Emergency Nursing & Triage NCLEX Practice (Part 2: 20 Questions)| 2022 update

Emergency Nursing & Triage NCLEX Practice (Part 2: 20 Questions) 1. 1. Question Michael works as a triage nurse, and four clients arrive at the emergency department at the same time. List the order in which he will assess these clients from first to last. View Answers: o An ambulatory dazed 25-year-old male with a bandaged head wound o A 35-year-old jogger with a twisted ankle, having a pedal pulse, and no deformity o A 50-year-old female with moderate abdominal pain and occasional vomiting o An irritable infant with a fever, petechiae, and nuchal rigidity Incorrect The correct order is shown above Rationale: 5. An irritable infant with fever and petechiae should be further assessed for other meningeal signs. Meningitis is a life-threatening disorder that is most often caused by bacteria or viruses. Before the era of antibiotics, the condition was universally fatal. Nevertheless, even with great innovations in healthcare, the condition still carries a mortality rate of close to 25%. 6. The patient with the head wound needs additional history and assessment for intracranial pressure. Traumatic brain injury (TBI) due to head trauma is a common presentation in emergency departments and usually accounts for more than one million visits annually. It is a common cause of death and disability among children and adults. 7. The patient with moderate abdominal pain is uncomfortable, but not unstable at this point. An acute abdomen is a condition that demands urgent attention and treatment. The acute abdomen may be caused by an infection, inflammation, vascular occlusion, or obstruction. The patient will usually present with sudden onset of abdominal pain with associated nausea or vomiting. 8. For the ankle injury, a medical evaluation can be delayed 24 – 48 hours if necessary. Acute ankle sprains are commonly seen in both primary care practices and emergency departments and can result in significant short-term morbidity, recurrent injuries, and functional instability. Appropriate initial evaluation and treatment can decrease the likelihood of these complications. 2. 2. Question In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? o A. Brief neurologic assessment o B. Client's allergy history o C. Initiation of pulse oximetry o D. Complete set of vital signs Incorrect Correct Answer: A. Brief neurologic assessment A brief neurologic assessment to determine the level of consciousness and pupil reaction is part of the primary survey. Once the patient is stabilized, a neurologic examination should be conducted. CT scan is the diagnostic modality of choice in the initial evaluation of patients with head trauma. • Option B: Primary injury includes injury upon the initial impact that causes displacement of the brain due to direct impact, rapid acceleration-deceleration, or penetration. These injuries may cause contusions, hematomas, or axonal injuries. • Option C: Identify any condition which might compromise the airway, such as pneumothorax. The cervical spine should be maintained in-line during intubation. Nasotracheal intubation should be avoided in patients with facial trauma or basilar skull fracture. • Option D: Vital signs are considered part of the secondary survey. Avoid hypotension. Normal blood pressure may not be adequate to maintain adequate flow and CPP if ICP is elevated. Isolated head trauma usually does not cause hypotension. Look for another cause if the patient is in shock. 3. 3. Question A 65-year-old patient arrived at the triage area with complaints of diaphoresis, dizziness, and left-sided chest pain. This patient should be prioritized into which category? • A. Non-urgent • B. Urgent • C. Emergent • D. High urgent Incorrect Correct Answer: C. Emergent Chest pain is considered an emergent priority, which is defined as potentially life-threatening. If the nurse can accurately diagnose the patient with these criteria and mark as a Level 1 trauma patient, the patient will need immediate life-saving therapy. Immediate physician involvement in the care of the patient is critical and is one of the differences between level 1 and level 2 patient designations. • Option A: Non-urgent conditions can wait for hours or even days. If the patient meets a certain group of discriminators, he or she is categorized into an urgency category that ranges from immediate to non-urgent. • Option B: Clients with urgent priority need treatment within 2 hours of triage (e.g. kidney stones). If the patient is not categorized as a level 1, the nurse then decides if the patient should wait or not. This is determined by three questions; is the patient in a high-risk situation, confused, lethargic, or disoriented? Or is the patient in severe pain or distress? • Option D: High urgency is not commonly used; however, in 5-tier triage systems, High urgent patients fall between emergent and urgent in terms of the time elapsing prior to treatment. The urgency categorization is tied to a maximum waiting time, with the immediate maximum waiting time being 0 minutes, very urgent is 10 minutes max. Urgent waiting time is maxed at 60 minutes, standard 120 minutes, and non-urgent waiting time is maxed at 240 minutes. 4. 4. Question You respond to a call for help from the ED waiting room. There is an elderly patient lying on the floor. List the order for the actions that you must perform. View Answers: • Establish unresponsiveness • Call for help and activate the code team • Initiate cardiopulmonary resuscitation (CPR) • Instruct a nursing assistant to get the emergency cart • Perform the chin lift or jaw thrust maneuver Incorrect The correct order is shown above: Rationale: 5. Establish unresponsiveness first. (The patient may have fallen and sustained a minor injury.) The Code Blue will follow the AHA/HSFC ACLS/PALS guidelines. It is recommended all members have current ACLS/PALS training and certification. 6. If the patient is unresponsive, get help, and have someone initiate the code. Any individual may call a code blue and certified staff will initiate BLS and AED if available until relieved by the Code Blue team. 7. Performing the chin lift or jaw thrust maneuver opens the airway. Staff trained in the use of the LifePak 20 Automatic External Defibrillator (AED) function, may initiate AED use prior to the arrival of the Code Blue Team. 8. The nurse is then responsible for starting CPR. CPR should not be interrupted until the patient recovers or it is determined that heroic efforts have been exhausted. 4 The Emergency Medical System (EMS) will be activated for all areas in the hospital not covered by the Code Blue team, as well as all arrests occurring outside the building. If the team is not able to transport the Code Blue Cart to the scene, the team will provide Basic Life Support (BLS) until EMS arrives. 9. A crash cart should be at the site when the code team arrives; however, basic CPR can be effectively performed until the team arrives. The units where the Code Blue carts are located are only responsible for transporting the cart to the unit where a Code Blue has been called. 5. 5. Question In caring for a victim of sexual assault, which task is most appropriate for an LPN/LVN? o A. Provide emotional support and supportive communication o B. Assess immediate emotional state and physical injuries o C. Ensure that the “chain of custody” is maintained o D. Collect hair samples, saliva swabs, and scrapings beneath fingernails Incorrect Correct Answer: A. Provide emotional support and supportive communication The LPN/LVN is able to listen and provide emotional support for her patients. The client is the center of care. The needs of the client must be competently met with the knowledge, skills, and abilities of the staff to meet these needs. In other words, the nurse who delegates aspects of care to other members of the nursing team must balance the needs of the client with the abilities of those to which the nurse is delegating tasks and aspects of care, among other things such as the scopes of practice and the policies and procedures within the particular healthcare facility. • Option B: Among the tasks that CANNOT be legally and appropriately delegated to nonprofessional, unlicensed assistive nursing personnel, such as nursing assistants, patient care technicians, and personal care aides, include assessments, nursing diagnosis, establishing expected outcomes, evaluating care and any and all other tasks and aspects of care including but not limited to those that entail sterile technique, critical thinking, professional judgment, and professional knowledge. • Option C: Part of supervision entails the ongoing evaluation of staff’s ability by the registered nurse to perform assigned tasks using direct observations and with indirect observations of patient safety, the quality of the care provided, the appropriateness of care provided, and the timeliness of care provided. • Option D: Scopes of practice are also considered prior to the assignment of care. All states have scopes of practice for advanced nurse practitioners, registered nurses, licensed practical nurses, and unlicensed assistive personnel like nursing assistants and patient care technicians. 6. 6. Question You are caring for a client with frostbite on the feet. Place the following interventions in the correct order. View Answers: • Apply a loose, sterile, bulky dressing • Remove the victim from the cold environment. • Monitor for signs of compartment syndrome • Administer pain medication • Immerse the feet in warm water 100° F to 105° F (40.6º C to 46.1° C) Incorrect The correct order is shown above: Rationale: Frostbite, also known as freezing cold injury, is tissue damage that occurs due to cold exposure, occurring at temperatures below zero degrees celsius. The victim should be removed from the cold environment first, and then the rewarming process can be initiated. It will be painful, so give pain medication prior to immersing the feet in warmed water. 1. Patients should have protection from further injury by covering exposed areas. Remove patients from the wind. Remove wet clothing and replace it with dry clothing. Avoid vigorous rubbing as this can cause further damage. 2. NSAIDS (ibuprofen) are indicated for controlling pain and preventing further inflammation, but stronger analgesics including narcotics may be necessary to achieve pain control. Frequent re-examination for sensation should accompany rewarming. 3. The care of patients with frostbite begins with rewarming in the field if there is no anticipation of refreezing, as thaw-refreezing may worsen injuries. In-hospital management includes warm water baths, approximately 40-42 degrees C. Patients with systemic hypothermia should be managed by raising core temperature above 35 degrees C using warm IV fluids, and this should precede warming of the affected extremity. 4. Apply a loose, bulky dressing to prevent infection. As with burn patients, particular care to prevent infections and dehydration should be a priority. Overly aggressive surgical debridement may remove skin that is otherwise viable, so complete rewarming should be achieved before surgical debridement. 5. Signs of compartment syndrome (edema, pulselessness, extreme pain) should prompt urgent surgery. Delayed amputation (up to 6 weeks following injury) until the determination of tissue viability may prevent surgical morbidity from unnecessary procedures. 7. 7. Question Following an emergency endotracheal intubation, nurses must verify tube placement and secure the tube. List in order the steps that are required to perform this function? View Answers: • Auscultate the chest during assisted ventilation • Secure the tube in place • Confirm that the breath sounds are equal and bilateral • Obtain an order for a chest x-ray to document tube placement Incorrect The correct order is shown above. Rationale: Auscultating and confirming equal bilateral breath sounds should be performed in rapid succession. If the sounds are not equal or if the sounds are heard over the mid-epigastric area, tube placement must be corrected immediately. Securing the tube is appropriate while waiting for the x-ray study. 1 and 2: After placing the endotracheal tube, it is essential to confirm its placement in the trachea and position proximal to the carina. The physician should auscultate for symmetric bilateral breath sounds, and the absence of breath sounds over the stomach. 3. After confirmation of breath sounds, the nurse may secure the tube in place. After the endotracheal tube is passed through the vocal cords, the cuff is inflated using a 5 cc or 10 cc syringe filled with air. The stylet is removed, and the proximal end of the endotracheal tube is connected to the carbon dioxide monitor and the ventilation device. 4. A post-intubation chest x-ray confirms the location of the endotracheal tube’s distal tip 2 to 4 cm proximal to the carina and rules out mainstem bronchus intubation. To avoid an unrecognized misplaced endotracheal tube, immediate confirmation of the tube position should take place. 8. 8. Question A 15-year-old male client arrives at the emergency department. He is conscious, coherent, and ambulatory, but his shirt and pants are covered with blood. He and his hysterical friends are yelling and trying to explain that they were goofing around and he got poked in the abdomen with a stick. Which of the following comments should be given first consideration? • A. “The stick was really dirty and covered with mud.” • B. “He pulled the stick out, just now, because it was hurting him.” • C. “He’s a diabetic, so he needs attention right away.” • D. “There was a lot of blood and we used three bandages.” Incorrect Correct Answer: B. “He pulled the stick out, just now, because it was hurting him.” An impaled object may be providing a tamponade effect, and removal can precipitate sudden hemodynamic decompensation. Additional history including a more definitive description of the blood loss, depth of penetration, and medical history should be obtained. Surgery is often required; impaled objects are secured in place so that they do not move and they should only be removed in an operating room. • Option A: Penetrating trauma often causes damage to internal organs resulting in shock and infection. The severity depends on the body organs involved, the characteristics of the object, and the amount of energy transmitted. • Option C: Other information, such as a history of diabetes, is important in the overall treatment plan, but can be addressed later. The indications for surgical intervention include a patient with hemodynamic instability, development of peritoneal findings such as involuntary guarding, point tenderness or rebound tenderness, and diffuse abdominal pain that does not resolve. • Option D: These injuries may be life-threatening because abdominal organs bleed profusely. If the pancreas is injured, further injury occurs from autodigestion. Injuries of the liver often present in shock because the liver tissue has a large blood supply. 9. 9. Question A prisoner, with a known history of alcohol abuse, has been in police custody for 48 hours. Initially, anxiety, sweating, and tremors were noted. Now, disorientation, hallucination, and hyper-reactivity are observed. The medical diagnosis is delirium tremens. What is the priority nursing diagnosis? • A. Risk for Injury related to seizures • B. Risk for Situational Low Self-esteem related to police custody • C. Risk for Nutritional Deficit related to chronic alcohol abuse • D. Risk for Other-Directed Violence related to hallucinations Incorrect Correct Answer: A. Risk for Injury related to seizures. The client shows neurologic hyperactivity and is on the verge of a seizure. Seizures can recur, though rarely lead to status epilepticus. Uncharacteristic signs of seizure activity should warrant further workup. Patient safety is the priority. The patient needs chlordiazepoxide (Librium) to decrease neurologic irritability and phenytoin (Dilantin) for seizures. Thiamine and haloperidol (Haldol) will also be ordered to address other problems. • Option B: Delirium tremens occurs in chronic alcohol abusers who abruptly discontinue alcohol use, often as early as 48 hours. The initial minor withdrawal symptoms are characterized by anxiety, insomnia, palpitations, headache, and gastrointestinal symptoms. These symptoms usually occur as early as 6 hours after cessation of alcohol use. More than 50% of those with a history of alcohol abuse can exhibit alcohol withdrawal symptoms at discontinuing or decreasing their alcohol use. • Option C: If withdrawal symptoms remain untreated, this can typically lead to DT. Additional evaluation of a patient with DT involves identifying electrolyte, nutrition, and fluid abnormalities. Most of these patients present with severe dehydration (up to 10 L fluid deficit) and severe electrolyte abnormalities, including hypoglycemia and severe hypomagnesemia, and hypophosphatemia. • Option D: After 12 hours, minor withdrawal symptoms can progress to alcohol hallucinosis, a condition characterized by visual hallucinations. It can typically resolve in 24 to 48 hours, and may also be associated with auditory and tactile hallucinations. 10. 10. Question In relation to submersion injuries, which task is most appropriate to delegate to an LPN/LVN? • A. Stabilize the cervical spine for an unconscious drowning victim • B. Talk to a community group about water safety issues • C. Monitor an asymptomatic near-drowning victim • D. Remove wet clothing and cover the victim with a warm blanket Incorrect Correct Answer: C. Monitor an asymptomatic near-drowning victim. The asymptomatic patient is currently stable but should be observed for delayed pulmonary edema, cerebral edema, or pneumonia. Appropriate decisions relating to the successful assignment of care are accurately based on the needs of the patient, the skills of the staff, the staffs’ position description or job descriptions, the employing facility’s policies and procedures, and legal aspects of care such as the states’ legal scopes of practice for nurses, nursing assistants and other members of the nursing team. • Option A: The care of critical patients is an RN’s responsibility. Some needs require high levels of professional judgment and skill, and other patient needs are somewhat routine and without the need for high levels of professional judgment and skill. Based on these characteristics and the total client needs for the group of clients that the registered nurse is responsible and accountable for, the registered nurse determines and analyzes all of the health care needs for a group of clients; the registered nurse delegates care that matches the skills of the person that the nurse is delegating to. • Option B: Teaching is an RN’s responsibility. Among the tasks that CANNOT be legally and appropriately delegated to nonprofessional, unlicensed assistive nursing personnel, such as nursing assistants, patient care technicians, and personal care aides, include assessments, nursing diagnosis, establishing expected outcomes, evaluating care, and any and all other tasks and aspects of care including but not limited to those that entail sterile technique, critical thinking, professional judgment, and professional knowledge. • Option D: Removing clothing can be delegated to a nursing assistant. The staff members’ levels of education, knowledge, past experiences, skills, abilities, and competencies are also evaluated and matched with the needs of all of the patients in the group of patients that will be cared for. 11. 11. Question You are assessing a patient who has sustained a cat bite to the left hand. The cat is up-to-date immunizations. The date of the patient’s last tetanus shot is unknown. Which of the following is the priority nursing diagnosis? • A. Impaired Skin Integrity related to puncture wounds • B. Ineffective Health Maintenance related to immunization status • C. Risk for Infection related to organisms specific to cat bites • D. Risk for Impaired Mobility related to potential tendon damage Incorrect Correct Answer: C. Risk for Infection related to organisms specific to cat bites. Cat’s mouths contain a virulent organism, Pasteurella multocida, that can lead to septic arthritis or bacteremia. Infections resulting from bites of all animal species are poly-microbial with aerobic and anaerobic bacteria; dogs and cats have an oral flora of Pasteurella, Staph, and Strep most commonly. In cat bites and scratches, Bartonella infections are an additional concern. • Option A: The initial injury is the result of the physical trauma of teeth puncturing and/or tearing soft tissue, and in the case of some dog bites, blunt force breaking bones. Cat bites are narrow and deep as the animal rarely pulls or shakes its head, simply biting and holding. Because the cat bite wound is deep and narrow, it is much more likely to seal itself relatively quickly, providing an anaerobic environment for the inoculated bacteria as well as initially appearing less consequential and prolonging time to seeking medical care. • Option B: A tetanus shot can be given before discharge. The patient’s TDaP status should be updated if necessary. Patients should be encouraged to get an updated tetanus vaccination. The prognosis for most animal bites is excellent. However, it is essential to know that, on average, about 30 to 50 people die from dog bites each year. • Option D: There is also a risk for tendon damage due to deep puncture wounds. Cat bites deeper than superficial need thorough irrigation under local anesthesia and the wound left open. The patient should be discharged with a week’s course of amoxicillin-clavulanate and given strict wound care precautions. 12. 12. Question A client in a one-car rollover presents with multiple injuries. Prioritize the interventions that must be initiated for this patient. View Answers: • Give supplemental oxygen per mask • Insert a Foley catheter if not contraindicated • Use the chin lift or jaw thrust method to open the airway • Assess for spontaneous respirations • Obtain a full set of vital signs • Remove the patient’s clothing • Secure/start two large-bore IVs with normal saline Incorrect The correct order is shown above: Rationale: For multiple trauma victims, a lot of interventions will occur simultaneously as team members assist in the resuscitation. Methods to open the airway such as the chin lift or jaw thrust can be used simultaneously while assessing for spontaneous respirations. However, airway and oxygenation are a priority. Starting IVs for fluid resuscitation is part of supporting circulation. (EMS will usually establish at least one IV in the field.) Nursing assistants can be directed to take vitals and remove clothing. A Foley catheter is necessary to closely monitor output. 1. Assessing the conscious patient’s airway starts with talking to the patient. Ask the patient their name to see if they respond clearly and appropriately. This will help assess the patency of the airway. Airway evaluation also includes a visual inspection of the patient. Look for signs of respiratory distress, listen for stridor, inspect the face, oral cavity, and neck, as well as palpate the patient’s neck and face. 2. Once the airway is secured or maintained by the patient, breathing and ventilation should be assessed. This involves visual inspection of the patient’s chest, looking for injury. Look for paradoxical chest movement, which indicates flail chest, penetrating injury, or tracheal deviation. Auscultate the lungs listening for decreased breath sounds. 3. Evaluate the patient’s oxygen saturation and give supplemental oxygen per mask. If the patient has signs of tension pneumothorax, immediate needle decompression or chest thoracostomy should be performed. Ultrasound or x-ray imaging of the chest should be considered as an adjunct to the physical exam. 4. In patients with shock, isotonic intravenous fluids can be initially administered, but blood products are preferred in a 1 to 1 to 1 ratio of red blood cells to plasma to platelets for patients with ongoing fluid requirements and concerns for hemorrhage. Establishing adequate IV access in trauma patients is also of critical importance. Two large-bore peripheral IVs, or functioning intraosseous access, should be established early in the evaluation period. 5. Emergency medical services (EMS) should provide information including mechanism of injury, patient vital signs, obvious injury, current interventions, and patient’s age and sex if available. After receiving this information, the healthcare team members should begin thinking of possible injuries that may be a threat to the patient’s life. 6. The fifth and final step of the primary survey includes removing all clothing to assess for signs of injury such as gunshot wounds, stab wounds, abrasions, lacerations, ecchymosis, or any other traumatic findings. During this stage, it is important to remember to keep the patient warm as hypothermia can lead to multiorgan failure. 7. Evaluate the patient’s rectum as well as a genitourinary exam. Evaluate the patient’s genitals looking for any bleeding, ecchymosis, or lacerations. Foley catheter may be placed as an adjunct but should be avoided without further evaluation if blood is noted at the meatus. 13. 13. Question A 33-year-old patient with a history of seizures and medication compliance of phenytoin (Dilantin) and carbamazepine (Tegretol) is brought to the ED by the MS personnel for repetitive seizure activity that started 45 minutes prior to arrival. You anticipate that the physician will order which drug for status epilepticus? • A. Phenytoin and Carbamazepine PO • B. Carbamazepine (Tegretol) IV • C. Magnesium sulfate IV • D. Lorazepam (Ativan) IV Incorrect Correct Answer: D. Lorazepam (Ativan) IV. IV Lorazepam (Ativan) is the drug of choice for status epilepticus. Benzodiazepines are the antiepileptic drug of choice for emergent control. Lorazepam is preferred because of its rapid onset of action and is dosed at 0.1 mg/kg IV. No more than 2 mg should be administered per minute. • Option A: PO (per os) medications are inappropriate for this emergency situation. Intravenous administration is preferred, but benzodiazepines can be administered via the intramuscular, rectal, nasal, or buccal route if vascular access is not available. • Option B: Tegretol is used in the management of generalized tonic-clonic, absence or mixed type seizures, but it does not come in an IV form. Carbamazepine is used to manage and treat epilepsy, trigeminal neuralgia, and acute manic and mixed episodes in bipolar I disorder. Indications for epilepsy are specifically for partial seizures with complex symptomatology (psychomotor, temporal lobe), generalized tonic seizures (grand mal), and mixed seizure patterns. • Option C: Magnesium sulfate is given to control seizures in toxemia of pregnancy. If eclampsia is suspected, intravenous magnesium sulfate is the antiepileptic drug of choice. Delivery of the fetus is the definitive treatment of eclampsia. 14. 14. Question A client arrived at the emergency department after suffering multiple physical injuries including a fractured pelvis from a vehicular accident. Upon assessment, the client is incoherent, pale, and diaphoretic. With vital signs as follows: temperature of 97°F (36.11° C), blood pressure of 60/40 mm Hg, heart rate of 143 beats/minute, and a respiratory rate of 30 breaths/minute. The client is mostly suffering from which of the following shock? • A. Distributive • B. Hypovolemic • C. Obstructive • D. Cardiogenic Incorrect Correct Answer: B. Hypovolemic Hypovolemic shock occurs when the volume of the circulatory system is too depleted to allow adequate circulation to the tissues of the body. A fractured pelvis will lose about one liter of blood hence symptoms such as hypotension, tachycardia, and tachypnea will occur. If left untreated, these patients can develop ischemic injury of vital organs, leading to multi-system organ failure. • Option A: Distributive shock results from a relative inadequate intravascular volume caused by arterial or venous vasodilation. In distributive shock, systemic vasodilation leads to decreased blood flow to the brain, heart, and kidneys damaging vital organs. Additionally, fluid leaks from the capillaries into the surrounding tissues, further complicating the clinical picture. further complicating the clinical picture. • Option C: An obstructive shock is a form of shock associated with physical obstruction of the major vessels of the heart itself. Obstructive shock is a less common, but important cause of shock in critically ill infants and children. It is caused by mechanical obstruction of blood flow to and/or from the heart and causes can include tension pneumothorax, cardiac tamponade, pulmonary embolism, or cardiac defects resulting in left-sided outflow tract obstruction. • Option D: Causes of cardiogenic include massive myocardial infarction or other causes of primary cardiac (pump) failure. Cardiogenic shock is a primary cardiac disorder characterized by a low cardiac output state of circulatory failure that results in end-organ hypoperfusion and tissue hypoxia. Clinical criteria include a systolic blood pressure of less than or equal to 90 mm Hg for greater than or equal to 30 minutes or support to maintain systolic blood pressure less than or equal to 90 mm Hg and urine output less than or equal to 30 mL/hr or cool extremities. 15. 15. Question Cole is an emergency nurse who encountered a patient who is a suspected carrier of a biologic agent. Which of these if found in the patient is not classified as a Category A biologic agent? • A. Bacillus anthracis (anthrax) • B. Francisella tularensis (tularemia) • C. Clostridium botulinum toxin (botulism) • D. Burkholderia pseudomallei (Melioidosis) • E. Yersinia petis (plague) Incorrect Correct Answer: D. Burkholderia pseudomallei (Melioidosis) Burkholderia pseudomallei (Melioidosis) belongs to the category B priority pathogen. These agents are moderately easy to be transmitted and can result in moderate morbidity rates. Melioidosis is endemic to southeast Asia and northern Australia but has also occurred in South America, Central America, Africa, and the Middle East. Melioidosis may present in an acute form with an incubation period of one day to three weeks. However, latent melioidosis may not present for decades. Melioidosis often infects those with underlying risk factors such as diabetes, kidney disease, alcohol abuse, and thalassemia, although healthy patients may also contract the disease. • Option A: Although B. anthracis is generally an environmentally stable and ubiquitous organism in nature, it has also been recognized as a potential pathogen that could be used as a biological weapon. Anthrax is categorized as a category A priority pathogen by the Centers for Disease Control and Prevention because it is potentially capable of being disseminated as a bioweapon. • Option B: Francisella tularensis organism is considered a category A biowarfare agent because of its high rate of infectivity, stability in a liquid environment, relative ease of growth, easy spread, and ability to cause significant illness and morbidity. Because of its ability to remain viable in the environment, this can also lead to repeat outbreaks and relapses that can last many months. The infection must be reported to the local authorities ASAP. • Option C: The Centre for Disease Control and Prevention (CDC) has been monitoring cases of botulism in the United States since 1973. From years 2011 through 2015, an average of 162 annual cases were reported. These primarily included infant botulism at 71% to 88%, followed by foodborne botulism, wound botulism, and botulism of unknown origin. • Option E: This biological agent belongs to Category A. This agent poses the highest risk to national security because they can easily transfer from one person to the other, which can lead to high mortality rates, and necessitate special measures for immediate preparation. Any patient suspected of plague should undergo until cleared. For pneumonic plague, the Centers for Disease Control recommend standard and droplet precautions for 48 hours after the initiation of appropriate antibiotic therapy. 16. 16. Question A 15-year-old male client was sent to the emergency unit following a small laceration on the forehead. The client says that he can’t move his legs. Upon assessment, respiratory rate of 20, strong pulses, and capillary refill time of less than 2 seconds. Which triage category would this client be assigned to? • A. Red • B. Black • C. Yellow • D. Green • E. White Incorrect Correct Answer: C. Yellow The client is possibly suffering from a spinal injury but otherwise, has a stable status and can communicate so the appropriate tag is yellow. If individuals can breathe spontaneously, follow simple commands, and have distal pulses with a normal capillary refill, they are tagged delayed and given the code yellow. • Option A: Red tags are for people with life-threatening conditions who need immediate emergency treatment. The rest of the individuals who have poor respirations or cannot protect their airway, have absent or decreased peripheral pulses, and are unable to follow simple commands are tagged immediately and given the color red. • Option B: Black tags are for deceased people and for those who are not expected to survive due to extensive injuries. Once the “minor” injuries are out of the area, responders should begin to move and triage patients with the RPM acronym; respirations, perfusion, and mental status. This includes making sure the individual has a manual respiration rate that is roughly greater than 30 breaths a minute, peripheral pulses are present with a capillary refill of fewer than 2 seconds, and can follow commands. If a patient has none of these, the patient is declared deceased, given a black tag, and moved to the black-coded area. • Option D: Green tags are for those people with non-urgent cases and can wait for their turn for assessment and treatment. Anyone who can follow these commands and walk to this area is designated as “minor” and given a green tag to signify minor injury status. • Option E: White tags are for those with minor injuries that don’t require any medical care. With this method, providers can quickly rule in and rule out individuals who require immediate medical attention, who can wait, and who nothing can be done for. 17. 17. Question An ER nurse is handling a 50-year-old woman complaining of dizziness and palpitations that occur from time to time. ECG confirms the diagnosis of paroxysmal supraventricular tachycardia. The client seems worried about it. Which of the following is an appropriate response of the nurse? • A. “You can be discharged now; this is a probable sign of anxiety.” • B. “The physician will prescribe you blood-thinning medications to lessen the episodes of palpitations.” • C. “We’ll need to keep you for further assessment; you may develop blood clots.” • D. "You have to stay here for a few hours to undergo blood tests to rule out myocardial infarction.” Incorrect Correct Answer: C. “We’ll need to keep you for further assessment; you may develop blood clots.” Paroxysmal supraventricular tachycardia (PSVT) is characterized by episodes of rapid heart rate that occur periodically and stop on their own. PSVT decreases cardiac output and can result in a thrombus. These clots could turn into an embolus, which could eventually lead to a stroke. Treatment of PSVT in a patient is dependent on the type of rhythm present on the electrocardiogram and the patient’s hemodynamic stability. • Option A: The patient should not be discharged yet. A significant component of evaluation for a patient who presents with signs and symptoms of PSVT is history and physical exam. These should include vital signs (respiratory rate, blood pressure, temperature, and heart rate), a review of the patient’s medication list, and a 12-lead electrocardiogram. • Option B: Patients who are hemodynamically stable and have an electrocardiogram that shows a regular rhythm with undetectable P waves, Valsalva maneuvers, carotid sinus massage, or intravenous adenosine might be used to slow the ventricular rate or convert the rhythm into sinus rhythm and thus aid in the diagnosis. If intravenous adenosine does not work, then intravenous or oral calcium channel blockers or beta-blockers should be used. • Option D: The most common symptoms are dizziness and palpitations. Patients with PSVT and a known history of coronary artery disease may present with a myocardial infarction secondary to the stress on the heart. Patients with PSVT and a known history of heart failure may come in with acute exacerbation. 18. 18. Question A client was brought to the ED due to an abdominal trauma caused by a motorcycle accident. During the assessment, the client complains of epigastric pain and back pain. Which of the following is true regarding the diagnosis of pancreatic injury? • A. Redness and bruising may indicate the site of the injury in blunt trauma • B. The client is symptom-free during the early post-injury period • C. Signs of peritoneal irritation may indicate pancreatic injury • D. All of the above Incorrect Correct Answer: D. All of the above Blunt injury resulting from vehicular accidents could cause pancreatic injury. Redness, bruising in the flank and severe peritoneal irritation are signs of a pancreatic injury. The client is usually pain-free during the early post-injury period, hence a comprehensive assessment and monitoring should be done. • Option A: Pancreatic injury is hidden in the shadows of coexisting intraabdominal injuries and its inherent retroperitoneal location. Symptoms of radiating epigastric pain to the back, nausea, and vomiting are also seen with the more commonly injured adjacent viscera. An abdominal exam is reported to have a false negative rate of 34% on initial evaluation. • Option B: Traumatic pancreatitis can be a difficult diagnosis to make and requires meticulous investigation. Damage to the pancreas is not very common and is seldom a solitary insult. As the signs and symptoms are nonspecific, a high index of suspicion is necessary to prevent delayed diagnosis. • Option C: Other complications include pancreatic pseudocyst which is a circumscribed collection of enzymes, blood, and necrotic tissue. Less frequent complications include peritonitis, intestinal obstruction, and gastrointestinal bleeding. Pancreatic trauma can disrupt the endocrine function for patients as well. 19. 19. Question A 20-year-old male client was brought to the emergency department with a gunshot wound to the chest. In obtaining a history of the incident to determine possible injuries, the nurse should ask which of the following? • A. "How long ago did the incident occur?" • B. "What was the initial first aid done?" • C. "Where did the incident happen?" • D. "What direction did the bullet enter into the body?" Incorrect Correct Answer: D. “What direction did the bullet enter into the body?” The entry point and direction of the bullet will predict the injuries of the client. In gunshot wounds, due to the high-intensity kinetic energy of the bullet, the pathway is often unpredictable in nature as well as the internal organs that may be affected. The most common organs injured are the small and large bowel at 50% and 40%, respectively. • Option A: Personnel such as paramedics, police officers, or fire rescue who may have arrived at the scene of the injury may be utilized as sources of essential history regarding the etiology of the injury. This is especially important if the patient has altered mental status and is unable to relay the history of the incident. • Option B: In penetrating abdominal injury due to a gunshot wound, initial treatment can be paramount for the prognosis and survival of the victim. The most important task for the initial assessment is to assess the airway, breathing, and circulation of the patient and stop the bleeding. • Option C: The other information is not as useful in determining which diagnostic studies and care are needed immediately. It is beneficial to gather information regarding the events surrounding the injury, including the environment, people involved, allergies, medications, and past medical history of the patient. Information about the caliber of the weapon, the number of shots heard, and any other extenuating circumstances may provide additional valuable information. 20. 20. Question When attending a client with a head and neck trauma following a vehicular accident, the nurse’s initial action is to? • A. Provide oxygen therapy • B. Initiate intravenous access • C. Immobilize the cervical area • D. Do oral and nasal suctioning Incorrect Correct Answer: C. Immobilize the cervical area Clients with suspected or possible cervical spine injury must have their neck immobilized until formal assessment occurs. Maintain cervical spine spinal immobilization and minimize neck movement particularly during transport. Beware that absence of neurologic findings does not eliminate the possibility of spinal cord injury. • Option A: Immediate measures are necessary to maintain breathing and hemodynamic stability, such as oxygen therapy. Hyperbaric oxygen (HBO) therapy has also been shown to exert neuroprotective effects when administered before or after SCI. Experimental studies have revealed various mechanisms that contribute to these neuroprotective effects, including improved spinal cord oxygen tension, decreased apoptosis, reduced inflammation, attenuation of oxidative stress, and improved angiogenesis and autophagy. • Option B: Rapid infusion as quickly as possible of large volumes of crystalloids to restore blood volume and blood pressure is now the standard treatment for patients with combined traumatic brain injury and hemorrhagic shock. The final goal of fluid management is to optimize the circulatory system to ensure the sufficient delivery of oxygen to organs. • Option D: Suctioning is also done after the cervical spine is immobilized. Patients with known or suspected cervical spine injury may require emergent intubation for airway protection and ventilatory support or elective intubation for surgery with or without rigid neck stabilization (i.e., halo).