The nurse is the first responder to the site of a disaster in which several people were injured in a train

crash. Which victim of the crash should the nurse attend to first?

a. A victim with a fractured arm

b. A victim with multiple bruises on the legs
c. A victim with a severe head injury who is not breathing
d. A victim with an upper leg injury who is bleeding profusely

D) The strategic word first. Focus on the data in the question, and note that the disaster site is outside
the hospital environment. Therefore, determine which victim has a life-threatening injury and requires
immediate treatment to sustain life. Think survivability. The victims described in options A and B
sustained injuries that are not critical or life threatening and could wait for care. Outside the hospital
environment, resources are limited. Therefore, it is unlikely that the nurse could help the victim with a
severe head injury who is not breathing. The nurse could apply pressure to the leg of the victim who is
bleeding profusely and could save this victim’s life.

The community health nurse is assisting residents involved in a hurricane and flood. Many of the older
residents are emotionally despondent and refuse to evacuate their homes. With regard to rescue and
relocation of the older residents, the nurse should plan to perform which action first?

a. Contact families.
b. Attend to emotional needs.
c. Attend to nutritional and basic needs.
d. Arrange for transportation to shelters.

C) Attending to people’s basic needs of food, shelter, and clothing is the priority. Options A, B, and D
may or may not be needed at a later time. Test-Taking Strategy: Note the strategic word, first, and use
Maslow’s Hierarchy of Needs theory. The correct option addresses basic physiological needs. Options A,
B, and D address psychosocial needs and may be appropriate at a later time.

In a telephone call from emergency medical services, the nurse in the emergency department is told
that several victims who survived a plane crash and are suffering from cold exposure will be transported
to the hospital. What is the initial nursing action by the emergency department nurse?

1. Call the nursing supervisor to activate the agency disaster plan.

2. Supply the trauma rooms with bottles of sterile water and normal saline.

3. Call the intensive care unit to request that nurses be sent to the emergency department.

4. Call the laundry department to request as many warm blankets as possible for the emergency
department.

1) Note the strategic word initial, and focus on the subject—the nursing action in the event of a disaster.
As you read each option, you will note that all options are correct. In this type of question, look for the
umbrella option. Option 1 is the umbrella option. Activating the agency disaster plan will ensure that the
interventions in options 2, 3, and 4 will occur. Remember that the umbrella option incorporates the
ideas of the other options within it.

Reference: Linda Anne Silvestri PhD RN FAAN, Angela Elizabeth Silvestri PhD - Saunders 2020-2021
Strategies for Test Success_ Passing Nursing School and the NCLEX Exam (2019, Saunders)

There is a train wreck causing 46 casualties. The nurse is asking personnel on the floor to suggest clients
who could be discharged to make room for casualties. Which client would be best for the LPN to
suggest?

1. A 77-year-old who had a fractured femur with hip replacement yesterday

2. A 58-year-old who had an open cholecystectomy two days ago

3. A 52-year-old who had a bowel resection with colostomy yesterday

4. A 44-year-old who is undergoing internal radiation for cancer of the cervix

2) The client who had an open cholecystectomy yesterday should be able to be safe if discharged home.
The client probably no longer has an indwelling urinary catheter in place. The client who had a fractured
femur with hip replacement yesterday is not likely to be ready for discharge. This client has probably not
yet done much ambulating. The client who had a colon resection with colostomy yesterday is not ready
for discharge. The client must learn how to care for the colostomy first. A person who is undergoing
internal radiation therapy should not be discharged. This person is radioactive and a danger to others.

An adult has injured her ankle and asks her neighbor, a nurse, for assistance. The ankle appears swollen,
and the client cannot move it without severe pain. Before arranging transport to the emergency room,
which action by the nurse would be most appropriate?

1. Applying a warm compress to the ankle

2. Keeping the ankle elevated

3. Performing range-of-motion exercises on the ankle

4. Seeing if the client can ambulate safely

2) The nurse should elevate the ankle. The nurse would apply ice or a cold compress, not a warm
compress. Cold will decrease bleeding and swelling. Heat increases circulation to the area. Range-of-
motion exercises and weight bearing are contraindicated. The data suggest that the client has either a
severe sprain or possibly a fracture.

The nurse is caring for an adult who was admitted for observation following an automobile accident. The
client has several lacerations that were sutured in the emergency room and a fractured leg that has
been casted. The baseline vital signs are BP = 120/72, P = 76, and R = 16. One hour after arriving on the
unit, the client’s vital signs are BP = 108/68, P = 90, and R = 22. The nurse most correctly interprets these
results to mean that the client may be developing which condition?

1. Shock

2. Increased intracranial pressure

3. Panic attack

4. Autonomic hyperreflexia

1) In shock, the systolic pressure drops faster than the diastolic and the pulse and respirations increase,
causing a narrowed pulse pressure. In increased intracranial pressure, the systolic pressure rises, and
the diastolic pressure either stays the same or decreases, causing a widened pulse pressure. A panic
attack would cause the blood pressure, pulse, and respirations to increase. Autonomic hyperreflexia
occurs in persons who have spinal cord injuries at T6 and higher and is characterized by hypertension,
headache, blurred vision, and nausea. That is very unlikely in this client.

An adult is admitted to the emergency department following a fall. A piece of bone is protruding
through the skin of the left thigh. In addition to assessing vital signs, what information is most essential
to obtain from the client at this time?

1. History of previous falls and fractures

2. Date of last tetanus shot

3. Type of environment where the fall took place

4. Any previous surgeries

2) The data indicate that the client has a compound fracture. Tetanus infections occur in persons who
have puncture wounds. The protruding piece of bone creates a puncture wound. It is essential for the
nurse to ask about tetanus immunization. A history of previous falls and fractures may be nice to know
but is not essential. It is helpful to know if the fall was in a dirty environment, but this is not as essential
to know as the date of the last tetanus immunization. Previous surgeries are nice to know but not
essential information.

An adult who was struck by lightning is brought to the emergency department. Which action is of
highest priority when the client is brought to the emergency room?

1. Obtain an ECG

2. Check blood gasses

3. Dress wounds

4. Check electrolytes
1) Electrical current is very apt to cause dysrhythmias; it is essential to monitor ECG initially. Electrolytes
will be checked but not initially. The wounds will be dressed but not initially. Blood gasses could be
checked but may not always be necessary. Smoke inhalation is not usually a factor with electrical burns.

The nurse is assisting at a disaster shelter setup following a devastating earthquake. What is the most
common problem the nurse is likely to see in those who come to the shelter?

1. Thirst

2. Traumatic injuries

3. Stress

4. Exacerbation of medical problems

3) Although all of the problems could be seen, the most common problem seen in a disaster shelter is
stress.

You are assigned to complete mass-casualty decontamination. Which group, according to triage
guidelines, will be decontaminated last?

1. Those closest to the point of release of the toxin.

2. Those that have serious medical conditions.

3. Those with liquid deposits on their skin.

4. Those with conventional injuries.

(4) When triaging casualties, you will first triage serious medical conditions, then those close to the point
of release with liquid on their skin or those who report exposure to the agent; you will then treat those
with conventional injuries. Last, you would treat those who do not have a serious medical condition.

If a disaster occurs, one example of how the disaster will impact the infrastructure of a city is by the
effect it will have on the?

1. People who live in the city.

2. Houses and land of the city.

3. Water supply of a city.

4. First responders.

(3) The infrastructure of a city includes transportation, electrical equipment, telephone connections, fuel
supplies, and water. People and housing are not part of the infrastructure. Water could be affected by
disruption of service, inadequate supply to fight a fire, and increased risk to public health if the supply is
not pure.
You are assigned to decontaminate casualties. Which decontamination material will you use as a first
step?

1. Bleach.

2. Hydrogen peroxide.

3. Tepid water.

4. Hot water.

(3) The primary decontamination material used is tepid water. Water is an effective decontaminant
because of the rapidity of application. Water should be tepid because cold water can cause hypothermia
and hot water will cause vasodilation, speeding distribution of the contaminants.

Which piece of equipment is not necessary when implementing standard precautions?

1. Soap or waterless antiseptic.

2. Gloves.

3. Gown.

4. Shoe covers.

(4) Shoe covers are not considered standard equipment for precautions, but a mask and eye or face
shield are included.

You are assigned to administer smallpox vaccinations to a group of people. Of the following groups,
which group would be appropriate to receive the vaccination?

1. Those with immunodeficiency, such as HIV infection or AIDS.

2. Those who have life-threatening allergies to antibiotics.

3. Those with flu, cold, or bronchitis.

4. Those who have been diagnosed with eczema.

(3) Persons who have a cold, flu, or bronchitis could receive a smallpox vaccination. Other categories of
conditions that are excluded (in addition to the ones mentioned in the question) are cardiac conditions,
leukemia, lymphoma, pregnancy, or burns.

When establishing a triage site following a major disaster, the area that will not be included is

1. Immediate care.

2. Intermediate care.
3. Delayed care.

4. The morgue or other designated area for the deceased.

(2) Triage sites will be set up in three areas. The area that is not included is intermediate care. Following
a disaster, the area sites are simple and straightforward—those who need immediate care, delayed care,
or no care (dead).

There is a suspected attack of anthrax. The precautions necessary to implement are

1. Strict isolation.

2. Isolation.

3. Droplet precautions.

4. Standard precautions.

(4) An attack of anthrax would require standard precautions. Isolation is not necessary because anthrax
is not transmitted via droplet or person to person.

The precaution protocol necessary to implement for the biohazard of pneumonic plague is

1. Standard precautions plus droplet.

2. Strict isolation with standard precautions.

3. Droplet precautions.

4. Contact precautions.

(1) Precautions include standard precautions plus droplet precautions (eye protection and surgical mask)
until 48–72 hours after antibiotic treatment.

The rationale for setting up a decontamination unit for radiological exposure prior to victims entering
the hospital is

1. That it is closer to medical care than a unit in the field.

2. To prevent contamination of clients and healthcare workers.

3. That it is preferable to decontamination at the site.

4. Protection for healthcare workers is better closer to the hospital.

(2) It is preferable to decontaminate at the site of radiological exposure, but if it cannot be done, the
next choice is to decontaminate prior to entering the hospital to prevent contamination of clients and
workers.
If a mass-casualty incident occurs and first responders do not know what type of personal protection
gear is needed, the team should

1. Wait until the type of equipment needed is known.

2. Decontaminate victims before intervening.

3. Choose the highest level of equipment available— full Level A protection.

4. Wear a radiation and biological device before entering the area.

(3) Because it is critical that the response team be fully protected, they must wear the highest level of
equipment; this includes SCBA full protection suit, shoe covers, double gloves, and biological detection
device, if available.

An earthquake has just occurred and the hospital has sustained a great deal of damage. The first action
is to

1. Call for help for the clients who are the most critical.

2. Find the disaster instructions posted on every unit in the hospital and follow instructions.

3. Return to the central staff room for instructions.

4. Wait until you receive instructions.

(2) The first action is to follow instructions posted in the disaster planning poster. If everyone follows
these guidelines, there will be less confusion and clients will receive the care they require. The other
options would all follow the first action.

Reference: Sandra Fucci Smith_ Marianne P. Barba - Sandra Smith's review for NCLEX-RN-Jones &
Bartlett Learning (2016)

An older adult, hospitalized with chest trauma following a motor vehicle accident, has a right femoral
arterial line. Because the client has been thrashing about in bed, a physician writes an order for wrist
restraints to be applied. Based on this information, which action by a nurse is correct?

1. Apply the wrist restraints as ordered

2. Request an order for a right ankle restraint also

3. Request an order for sedation instead of restraints

4. Question the order because restraints will increase the client’s agitation

ANSWER: 2 An ankle restraint will help prevent dislodgement of the arterial catheter and bleeding and
injury that could occur from thrashing in bed. While applying wrist restraints will prevent side-to-side
movement, it will not keep the client’s right leg straight to prevent catheter dislodgement. The client has
chest trauma. Sedation may compromise the client’s respiratory status. While restraints can increase
agitation, especially for an older adult, keeping one leg unrestrained may prevent this from occurring.
Safety of the client is priority.

A nurse sees smoke coming from a client’s hospital room. When entering the room, the nurse notes that
the client is standing on the far side of the room with clothing on fire. Which action should be taken by
the nurse immediately?

1. Go find the nearest fire alarm box

2. Tell the client to drop and roll on the floor

3. Grab a blanket to smother the fire

4. Obtain water to douse the clothes

ANSWER: 2 Rolling on the ground will smother the flames and put the fire out. The client is priority.
Those responding can locate and activate the alarm box. Smothering the fire is the next action. Finding
and obtaining water is too time-consuming and the fire will continue to burn.

A power outage occurs at a hospital and a backup generator, supplying power to a telemetry unit fails.
After obtaining a flashlight, what is a nurse’s next best action?

1. Call the nursing supervisor

2. Assess the most critically ill clients

3. Obtain oxygen tanks for clients on oxygen

4. Delegate which clients a nursing assistant should monitor

ANSWER: 3 When power is interrupted, the oxygen sources in the room will also fail. Oxygen will need
to be delivered by oxygen tanks. A call to the nursing supervisor may be necessary for assistance on the
unit, but is not the next action. Assessment of the most critical clients is also a priority, but those in need
of oxygen are the priority. A nurse should delegate activities, but rather than monitoring clients, the
nurse should delegate retrieving oxygen tanks.

A nurse has been asked to be a member of a hospital’s Emergency Operations Committee, which is
working on reviewing the components of the emergency plan in place. When reviewing the plan, which
components should the nurse expect to be included? SELECT ALL THAT APPLY.

1. Calling 911 to activate an emergency response

2. An internal and external communication plan

3. Identification of external resources

4. A plan for practice drills.

5. Identification of anticipated expendable resources needed

6. Methods for educating personnel

ANSWER: 2, 3, 4, 5, 6 Communication to and from the prehospital arena and to all parties involved is
needed for a rapid and orderly response to a disaster. Local, state, and federal resources should be
identified as well as how to activate these resources. Practice drills with community participation allows
for troubleshooting problems before an event happens and gives persons an opportunity to practice
their roles. Food, water, and supplies must be available and sources for these identified. Educating
personnel allows for improved readiness and additional input for refining the process. An activation
response defines where, how, and when the response is initiated. Calling 911 would not be an
appropriate activation.

A hospital is overloaded with victims from a tornado that leveled a nearby community of 75,000 people,
and the hospital is short staffed. Which actions might be necessary in this situation? SELECT ALL THAT
APPLY.

1. Nurses performing duties outside of the nurses’ area of expertise

2. Family members providing nonskilled interventions for their loved ones

3. Giving care to persons with extensive injuries and little chance of survival first

4. Setting up a hospital ward in a community shelter

5. Asking if anyone can interpret for clients that only speak a foreign language

6. Leaving victims to perform rituals required by another victim’s religion and culture

ANSWER: 1, 2, 4, 5 Nurses may be asked to take on responsibilities normally held by physicians or

advanced practice nurses. When insufficient health-care personnel are available, family members may
take on nonskilled responsibilities. Care may need to be provided outside of the hospital setting.
Although client confidentially is important, a medical emergency may require the services of lay persons.
Victims with extensive injuries and unlikely to survive should be triaged and treated as the last priority.
Nursing care in a disaster focuses on essential care from the perspective of what is best for all persons.
Treating physical injures should take priority over partaking in cultural rituals.

Which statement, if made by a community nurse teaching disaster-preparedness to a group of

community members, is accurate?

1. “Change stored bottled water every year.”

2. “Keep on hand a 3-day supply of water, 1 gallon per person per day.”

3. “Animals will be able to fend for themselves in a disaster.”

4. “Beside water, include in the disaster supply kit a 1-day supply of food and other necessities for each
person in the household.”

ANSWER: 2 The amount of water to keep on hand is calculated according to family size (1 gallon per
person per day) for a 3-day supply of water. Food that will not spoil should also be stored. Bottled water
that is stored for use in the event of an emergency should be replaced before it expires or, if self-
prepared, every 6 months. A disaster kit should also contain water, food, and other necessary items for
household pets. The disaster kit should contain a 3-day supply of food and necessities.

A school nurse is planning a school-based intervention program for children who lost their homes due to
a tornado and are now residing in temporary housing. With which group should the nurse initially focus
the intervention program because they are more likely to experience symptoms of mental health
distress?

1. Older age female children of higher socioeconomic status

2. Older age male children of higher socioeconomic status

3. Younger age female children of lower socioeconomic status

4. Younger age male children of lower socioeconomic status

ANSWER: 3 Posttraumatic stress syndrome is experienced more frequently in children than adults.
According to research conducted by members of the Department of Psychiatry and Pediatrics of Mount
Sinai School of Medicine and the National Center for Posttraumatic Stress Disorder, clients who are
female, younger age, and lower socioeconomic status are more likely to experience symptoms of mental
health distress. School-based intervention programs after disasters are considered to be cost-effective
and valid. While all individuals may experience symptoms of mental health distress, the initial focus
should be on the age and gender group that is most likely to be affected.

A nurse admits a male client to a hospital with exacerbation of asthma. During the admission history,
the nurse learns that the client has a history of chronic hepatitis C. Which precautions should the nurse
plan to implement based on the transmission of the hepatitis C virus?

1. Airborne

2. Contact

3. Droplet

4. Standard

ANSWER: 4 Standard precautions are infection preventive practices that protect against infectious
agents present in body fluids, including the blood. Hepatitis C is transmitted through body fluids,
principally the blood. Hepatitis C is not transmitted via the respiratory tract. Further precautions
included in contact precautions are not necessary.
A health-care agency has different receptacles for the various categories of institutional waste. Into
which container should a nurse dispose of a suction canister used to collect drainage from a client’s
nasogastric tube?

1. Injurious waste receptacle

2. Hazardous waste receptacle

3. Infectious waste receptacle

4. Wastebasket in the client’s bathroom

ANSWER: 3 Blood and body fluids are considered infectious waste. Therefore, the suction canister
should be placed in the infectious waste receptacle. Injurious wastes would include items such as
needles, scalpel blades, lancets, or other objects that could injure another person. Hazardous waste
includes radioactive material, chemotherapy agents, or caustic chemicals. Regular waste that does not
pose a health hazard to others can be placed in a regular wastebasket.

Five families of clients injured in an apartment fire have arrived at an emergency department to inquire
about the health status of their family members. Which is the nurse’s best action?

1. Take the families to the triage area so they can be with their loved ones

2. Ask the families to wait in the waiting area until information is available

3. Ensure that there is a designated area for family staffed by available social workers or clergy

4. Direct families to a lounge where a receptionist will be keeping families informed

ANSWER: 3 Families should be in a designated area where social service workers, counselors, therapists,
or clergy are available for support. Family members may be feeling intense anxiety, shock, or grief and
should be provided with information and updates as soon as possible. Families should not be in the
triage or treatment areas to protect the privacy of other clients and to prevent congestion or
interference with treatment measures. Support systems would be unavailable in a waiting area or in a
lounge.

Which injured client of a mass casualty disaster should a triage nurse in an emergency department
establish as the priority client?

1. An unresponsive client with a penetrating head injury.

2. A partially responsive client with a sucking chest wound.

3. A client with a maxilla fracture and facial wounds without airway compromise.

4. A client with third-degree burns over 65% of the body surface area.

ANSWER: 2 A sucking chest wound is a life-threatening but survivable emergency. The client would be
triaged as priority 1 (red) according to the NATO triage system. The unresponsive client with a
penetrating head injury and the severely burned client have a limited potential for survival, even with
definitive care, and would be categorized as a priority 4 level (black). The client with the facial wounds
would be classified as priority 2 (yellow) because injuries are significant and require medical care, but
can wait hours without threat to life.

A health-care provider (HCP) writes orders to transfuse a unit of red blood cells (RBCs) to a client
admitted to an emergency department after a disaster. A nurse is completing the compatibility checks
between the client’s blood type, noted to be blood type B-positive, and the unit of blood is blood type
O-positive, which had been donated by the client’s spouse and obtained from the blood bank. Which
clinical judgment by the nurse preparing to administer the unit of blood is correct?

1. The unit of blood is of a different blood type but compatible with the client’s blood.

2. The unit of blood is of a different blood type and incompatible with the client’s blood.

3. The unit of blood is not the blood component that the HCP prescribed for the client.

4. The unit of blood will cause a hemolytic transfusion reaction and cannot be administered to the client.

ANSWER: 1 Type O blood is compatible for persons with type A, B, or AB blood because it does not have
an antigen on the erythrocyte (RBC). A person with type O blood is considered a universal donor. The Rh
positive indicates that the Rhesus antigen is present on the cell, whereas Rh negative indicates that the
Rh factor is not present. Rh-positive RBCs can only be administered to persons who are Rh positive,
whereas Rh-negative RBCs can be administered to persons who are Rh positive or Rh negative. Although
the client and spouse have different blood types, the RBCs are compatible. The unit of blood states that
it is red blood cells (RBCs). A hemolytic transfusion reaction will occur if there are ABO or Rh
incompatibilities.

Reference: Ohman, Kathleen - Davis Q and A for the NCLEX-RN Examination-F.A. Davis (2010)

The nurse is selected to assist with emergency preparedness planning at the nurse’s place of
employment. The nurse knows that which action is most effective in this endeavor? Select all that apply.

A. Developing a response plan.

B. Developing different emergency response plans for each type of disaster.

C. Educating all individuals to specifics of the response plan.

D. Practicing the plan and evaluating the facility’s level of preparedness.

Answer: A, C, & D. Developing a response plan, educating individuals to the specifics of the response
plan, and practicing the plan and evaluating the facility’s level of preparedness are effective means of
implementing emergency preparedness. The basic principles of emergency preparedness are the same
for all types of disasters. Only the response interventions vary to address the specific needs of the
situation.

As a disaster relief nurse, you counsel parents of young clients (select all that apply):

A. To act as if things are normal.

B. That young children may exhibit separation fears and clinging.

C. To sedate the client until the crisis is resolved.

D. That nightmares and sleep disturbances may occur in young children.

Answer: B & D. Following a disaster, children exhibit a range of emotional and physiological reactions
including separation fear and sleep issues. They may also appear confused, passive, fearful, and have
somatic symptoms. They have difficulty talking about the event or identifying feelings. Acting as if
nothing happened is a nontherapeutic parental response. Sedation may be an emergent need but more
therapeutic responses are quickly warranted.

An elderly client from a long-term care facility arrives in the emergency department by ambulance with
altered level of consciousness. The physician instructs the respiratory therapist to prepare for
intubation. The nurse discovers a Do Not Resuscitate (DNR) bracelet on the client’s wrist during the
initial assessment. Which immediate action should the nurse take to appropriately advocate for this
client?

A. Assist the respiratory therapist to prepare the client for immediate intubation.

B. Attempt to contact the client’s family.

C. Notify the physician immediately of the client’s DNR bracelet.

D. Notify the dietician immediately of the client’s DNR bracelet.

Answer: C. The nurse should immediately notify the physician upon discovering the client’s DNR
bracelet. The DNR bracelet is an indicator that the client or their health care surrogate decisionmaker
desire the client’s wishes be known regarding health care treatment and resuscitation. Ignoring the DNR
bracelet and assisting the respiratory therapist to prepare for immediate intubation is incorrect because
the client has a DNR notification on their person and should not be intubated. Reaching the client’s
family allows the family to be with the client and to provide additional health history, but this should be
done after notifying the physician. Notifying the dietician of the client’s DNR bracelet is not appropriate
and delays addressing the immediate problem.

A client seen in the emergency department for a femur fracture is receiving discharge instructions for
cast care, use of crutches, and follow-up care. The client complains of chest heaviness to the nurse. The
nurse assures the client that the chest heaviness is probably caused by sore chest muscles from using
the crutches, and instructs the client to sign the discharge instructions. The nurse neglects to document
the complaints of chest heaviness nor does the nurse notify the physician. The nurse failed to implement
which measure to intervene on the client’s behalf? Select all that apply.

A. Failure to preserve client privacy.

B. Failure to act as a client advocate.

C. Failure to take appropriate action.

D. Failure to appropriately diagnose.

Answer: B & C. The nurse failed to act as a client advocate by neglecting to take appropriate action
regarding the client’s symptoms, neglecting to document the symptoms, and failing to report the client’s
complaints of chest heaviness to the physician for further evaluation. The client’s privacy is not an issue
in this question. Diagnosing the cause of the chest heaviness is not in the nurse’s scope of practice, but
notifying the physician of the client’s complaints and symptoms is the nurse’s responsibility.

A client is brought to the emergency department by ambulance with a head injury. The emergency
department physician calls the nurse to be present while addressing the client’s family. The physician
informs the client’s family that the hospital does not have a neurosurgeon on staff. In order to provide
the best possible care to the client, the emergency department will stabilize the client and then make
transfer arrangements to a nearby hospital with neurosurgical services. This action decision by the
physician member of the multidisciplinary team reflects (select all that apply):

A. Appropriate consultation.

B. Appropriate disclosure of client health information.

C. Appropriate continuity of care.

D. Poor continuity of care.

Answer: B & C. The physician appropriately disclosed client health information to the client’s family for
purposes of client care. The physician also provides appropriate continuity of care by arranging for the
head-injured client to be stabilized and transferred to a health care facility with the services necessary
to give the best care to the client.

During a mass casualty incident, the hospital is faced with the arrival of multiple clients. Which use of
gloves by the nurse during a mass casualty is appropriate? Select all that apply.

A. Placing spare gloves in uniform pockets for immediate use.

B. Donning 3 to 4 pairs of gloves at once.

C. If gloves become scarce, using a 4-by-4 gauze to wipe the accumulated fluids off the gloves to
decrease contamination between clients.
D. Wearing gloves during a mass casualty event is only required if the casualty event is precipitated by a
contagious illness.

Answer: A, B, & C. Placing spare gloves in uniform pockets for immediate use, donning 3 to 4 pairs of
gloves at once and using a shedding process to remove gloves as they become contaminated, and
cleaning gloves—if they become scarce—between clients are all effective uses for gloves during a mass
casualty. Gloves should be worn during all mass casualty events to prevent exposure to blood or body
fluids.

The nurse is selected to assist with emergency preparedness planning at the nurse’s place of
employment. The nurse knows that which action is most effective in this endeavor? Select all that apply.

A. Developing a response plan.

B. Developing different emergency response plans for each type of disaster.

C. Educating all individuals to specifics of the response plan.

D. Practicing the plan and evaluating the facility’s level of preparedness.

Answer: A, C, & D. Developing a response plan, educating individuals to the specifics of the response
plan, and practicing the plan and evaluating the facility’s level of preparedness are effective means of
implementing emergency preparedness. The basic principles of emergency preparedness are the same
for all types of disasters. Only the response interventions vary to address the specific needs of the
situation.

A nurse is working triage in an emergency department (ED). A client presents in the ED complaining of
“stomach pain.” The nurse palpates the abdomen and discovers that the client has right upper quadrant
tenderness. The physician suspects cholecystitis. Which symptoms should the nurse anticipate when
caring for a client with cholecystitis? Select all that apply.

A. Chills.

B. Fever.

C. Nausea and vomiting.

D. Right upper quadrant pain.

Answer: A, B, C, & D. Many clients with acute cholecystitis present with acute onset of right upper
quadrant pain associated with nausea and vomiting. Epigastric pain may also be present. Additional
symptoms may include fever, chills, and anorexia. A physical examination often reveals right upper
quadrant tenderness. Rebound and guarding are present in some cases.