POST TEST - EMERGENCY ROOM &

DISASTER NURSING
Total points 21/30

Prepared By: Ms. Haydee Soriano Bacani RM, RN, MAN

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rede.liberato.up@phinmaed.com

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LIBERATO

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RENZY
MIDDLE NAME: *

DELA CRUZ

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PHINMA - UNIVERSITY OF PANGASINAN

SECTION: *

4BSN-SA1

POST TEST 21 of 30 points

1. Carlos, a 32-year old male client arrives at the emergency department *0/1
who suffered multiple injuries from a head-on car collision. Which of the
following assessment should take the highest priority to take?

A. irregular pulse

B. ecchymosis in the flank area

C. a deviated trachea

D. unequal pupils
2. Nurse Kelly, a triage nurse encountered a client who complaints of mid- *0/1
sternal chest pain, dizziness, and diaphoresis. Which of the following
nursing action should take priority?

A. Complete history taking

B. Put the client on ECG monitoring

C. Notify the physician

D. Administer oxygen therapy via nasal cannula

3. In SALT triage, the letter S in SALT means * 1/1

A. Sign

B. Sort

C. Simple

D. Secret

4. In ESI triaging, a patient in 7/10 pain scale is categorized as? * 1/1

A. Level 1.

B. Level 2.

C. Level 3.

D. Level 4
5. A 56- yo patient presents in triage with left sided chest pain, *0/1
diaphoresis, and dizziness.This patient should be prioritized into which
category?

A. Dead on arrival

B. Urgent

C. Non-urgent

D. Emergent

6. A client with a known history of panic disorder comes to the *0/1

emergency department and states to the nurse, “Please help me. I think
I’m having a heart attack.” What is the priority nursing action?

A. Check the client’s vital signs.

B. Encourage the client to use relaxation techniques.

C. Identify the manifestations related to the panic disorder.

D. Determine what the client’s activity involved when the pain started.

7. The principles in Emergency Nursing are the following, except: * 1/1

A. Referral

B. Sorting according to management priorities

C. Primary Survey for Emergent patients

D. Secondary Survey
8. Aside from using Glasgow Coma Scale, In determining neurologic *1/1
disability of a patient, a quick neurologic assessment is by using AVPU
mnemonic. What does P stand for?

A. Pain

B. Planning

C. Precipitating Factors

D. Predisposing Factors

9. What is considered the universal distress sign for a person who is *0/1
choking?

A. Having an apprehensive appearance, refuse to lie supine, stridor

B. Labored breathing, use of accessory muscle to breathe

C. Clutches the neck between thumb and fingers

D. Cannot speak, breath, or cough

10. The Er nurse knows that when measuring an oropharyngeal airway *1/1
before insertion, he/she correctly measures the airway by doing which of
the following?

A. Measuring the airway alongside the neck, and should reach from corner of lip to
cricoid cartilage

B. Measuring the airway alongside the head, and should reach from nose tip to ear

C. Measuring the airway alongside the head, and should reach from nose tip to
earlobe to xyphoid process

D. Measuring the airway alongside the head, and should reach from lip to ear

11. In case of hypovolemic shock, the most essential to the care and *1/1
survival of patients in an emergency or disaster nursing?

A. Stopping the bleeding

B. Fluid resuscitation

C. Oxygenation

D. Prevention of Infection
12. After a building explode, EMS delivers 33 critically injured patients to *1/1
your hospital where you work as an ER nurse. Which type of leadership
would be the most effective in ER personnel?

A. Bureaucratic

B. Democratic

C. Autocratic

D. Laissez- Faire

13. The principle used in Routine Triaging: * 1/1

A. First come, First serve

B. Worst is First regardless of outcome

C. Greater good for greater number of people

D. Worst but survivable is assessed First

14. A decrease in circulating blood volume leads to decrease tissue *1/1
perfusion. Therefore, any condition producing a profound volume deficit
necessitates immediate intervention. Treatment is directed at preventing
further volume loss and Fluid volume replacement. Which is the fluid of
choice?

A. Crystalloids

B. Colloids

C. Hetastarch

D. Blood

15. If peripheral venous and central line access is not possible, which *1/1
route of parenteral access can be used to infuse fluids, blood and
medication?

A. Intrathecal

B. Buccal

C. Rectal

D. Intraosseus
16. The patient became agitated, tachypneic, tachycardic, diaphoretic, *0/1
with crackles and distended jugular vein during flid resuscitation. The
initial action you as a nurse will do is

A. Give oxygenation

B. Place in high-fowlers position

C. Establish venous access

D. Call Radiology Department for a stat portable Chest Xray

17 The following are the issues in Emergency Nursing, but not: * 0/1

A. consent and privacy

B. exposure to communicable disease

C. high risk of violence

D. lack of specialties and equipment

18. Mr. Rey, who is on an end-stage of life has an order of “Do Not *1/1
Resuscitate” and past away in your shift. He was declared dead by his
physician at 8:30 AM. What should be your PRIORITY nursing action in
this situation.

A. Prepare the death certificate for the physician to sign

B. Request your nurse attendant to all the funeral parlor at once.

C. Allow the family to have private moments with the deceased.

D. Clean the body and remove all the IV lines, tubes and other appliances.
19. After rapid assessment, the nurse categorizes emergency patients by *1/1
priority nursing diagnoses. Based on the following diagnoses, which
patient should be given priority attention?

A. Nobita, a 14-year-old with a suspected fractured femur

B. Mang Jose, a 60- year-old with burns of the face and neck

C. Marites a 25-year-old with a lacerated finger

D. Marife a 50-year-old complaining of “feelings of panic”

20.Airways obstruction is a life-threatening medical emergency. It can be *1/1

a partial or complete where in a complete obstruction, interventions have
to be done or permanent brain injury or even death can occur within?

A. 10-15 minutes

B. 5-8 minutes

C. 3-5 mins

D. 1-3 mins

21. Patient brought in who are unresponsive with penetrating head *1/1
wounds are tagged by the triage nurse in which color?

A. Black

B. Red

C. Green

D. Yellow
22. Those who suffered stable abdominal wounds without significant *1/1
bleeding will be tagged___

A. green

B. Red

C. Black

D. Yellow

23. A client involved in a one-car rollover comes in with multiple injuries. *1/1
What Is your priority?

A. Secure two large bore IV lines and infuse normal saline

B. Use the chin lift or jaw thrust maneuver to open airway

C. Assess for spontaneous respirations

D. Give supplemental oxygen via mask

24. Those who suffered unstable abdominal wounds in a disaster will be *1/1
tagged___

A. green

B. Red

C. Black

D. Yellow
25. Nurse Sophie checks the gauge of the patient’s intravenous catheter. *1/1
Which is the smallest gauge catheter that the nurse can use to
administer blood?

A. 22-gauge

B. 18-gauge

C. 20-guage

D. 24-guage

26. As a disaster triage Nurse, which of the following will be your *1/1
priority?

A. A non-responsive patient with sunken skull.

B. The patient with facial wounds and fracture.

C. patient with sucking chest wound.

D. A man with over 60 percent second and third degree burns.

27. Thirty people are injured in a bus accident. Which client should be *1/1
transported to the hospital first?

A. A 20-year-old who is unresponsive and has a high injury to his spinal cord.

B. An 80-year-old who has a compound fracture of the arm.

C. A 10-year-old with a laceration on his leg.

D. A 25-year-old with a sucking chest wound.

28. You are working in the triage area of an ED, and the following four *1/1
clients approach the triage desk at the same time. Who is your priority?

A. Ambulatory, dazed 25 year-old man with a bandaged head wound

B. Child who fell from a tree and is unresponsive to painful stimuli

C. 35-year-old jogger with a twisted ankle who has a pedal pulse and no deformity

D. 50-year-old woman with moderate abdominal pain and occasional vomiting

29. When a primary survey of a trauma client is conducted, what is *0/1

considered one of the priority actions?

A. Obtain a complete set of vital sign measurements

B. Palpate and auscultate the abdomen

C. Do a brief neurologic assessment

D. Perform wound management

30. Those who suffered stable abdominal wounds with significant *0/1
bleeding will be tagged___

A. green

B. Red

C. Black

D. Yellow

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