HESI 4 REVIEW - CRITICAL CARE - MCA 3
ANSWERED CORRECTLY WITH RATIONALES.
HESI 4 REVIEW - CRITICAL CARE - MCA 3
Which color-tagged clients usually make up the greatest number in most large-
scale multi-casualty situations, based on the disaster triage tag system?
Red
Black
Green
Yellow
Green
Rationale
Green-tags clients usually make up the greatest number in most large-scale
multicasualty
situations. These clients have minor injuries and they may actually evacuate themselves
from the mass casualty scene and go to the hospital in a private vehicle. Red-tagged
clients have major injuries, black-tagged clients are expected and allowed to die, and
yellow- tagged clients have major injuries. Clients belonging to these three categories
usually do not make up the greatest number in most large-scale multicasualty
situations.
Which color tag will be given by the triage nurse to a client assigned to class IV
during a mass casualty situation?
Red
Black
Green
Yellow
Black
Rationale
A client considered class IV during triage in a mass casualty situation will be given a
black tag. The red tag is associated with class I, green tag with class III, and yellow tag
with class II.
In a mass casualty situation, which is the facility-level organizational model for
disaster management used by the hospital or long-term care facility?
Emergency operations center (EOC)
Hospital Incident Command System (HICS)
National Incident Management System (NIMS)
Federal Emergency Management Agency (FEMA)
Hospital Incident Command System (HICS)
Rationale
,The facility-level organizational model for disaster management is the HICS. It attempts
to standardize disaster operations by formally structuring roles under the hospital or
long- term care facility incident commander with clear lines of authority and
accountability for specific resources. The EOC, NIMS, and FEMA are not facility-level
organizational models for disaster management. The EOC is established by the HICS
personnel in a designated location with accessible communication technology to
manage the overall incident. The NIMS is the overall system for incident management
of which the HICS is a part; it is implemented by the Department of Homeland Security
and FEMA. The FEMA provides numerous online resources so that people are better
prepared for disasters and are able to respond more self-sufficiently to incidents and
hazard situations in their own communities.
Which area of assessment is included in the Glasgow Coma Scale?
Breathing patterns
Deep tendon reflexes
Eye accommodation to light
Response to verbal commands
Response to verbal commands
Rationale
The three areas of assessment to determine the level of consciousness using the
Glasgow Coma Scale are motor response to verbal commands,
eye opening in response to speech,
and verbal response to speech.
Assessing breathing patterns, deep tendon reflexes, and eye accommodation are not
included in the Glasgow Coma Scale.
A group of bomb blast victims needs to be transported to the hospital
immediately. Which staff members of an emergency unit are most appropriate to
handle this situation?
Triage officer
Medical command physician
Prehospital care providers
Emergency medicine physician
Prehospital care providers
Rationale
Prehospital care providers are the first caregivers who provide transport to the
emergency department by ambulance or helicopter for clients in an emergency
situation. Triage officers are responsible for evaluating each client to determine priorities
for treatment. The medical command physician decides the number, acuity, and
resource needs of clients. Emergency medicine health care providers have specialized
education and training in emergency client management.
Which parameters would the nurse consider for proper rapid baseline
assessment using a disability mnemonic (AVPU) in a client with drug abuse?
Select all that apply. One, some, or all responses may be correct.
Level of anxiety
Reaction to pain
,Response to voice
Body temperature
Evidence of assault
Reaction to pain
Response to voice
Rationale
The disability examination provides a rapid baseline assessment of neurological status.
It helps evaluate level of consciousness by the AVPU mnemonic, which also helps
assess the responsiveness to pain and voice. Level of anxiety is not assessed by a
disability mnemonic. Body temperature and evidence of assault are assessed in a
primary survey of exposure.
The postanesthesia care unit nurse providing care for a client who had a
craniotomy for a meningioma would monitor for which specific clinical
manifestation in this client?
Dehydration
Blurred vision
Wound infection
Narrowing pulse pressure
Blurred vision
Rationale
Blurred vision is a sign of increasing intracranial pressure, which may follow a
craniotomy. Dehydration, wound infection, and narrowing pulse pressure require time to
develop; these clinical manifestations will not be observable immediately after surgery.
The pulse pressure widens with increased intracranial pressure.
Which action of the emergency department nurse caring for a group of clients
injured in a community disaster would need correction?
Triaging the victims
Supervising volunteers
Providing on-site first aid
Removing people from danger
Removing people from danger
Rationale
During a community disaster, removing people from danger is done by firefighters and
other disaster trained emergency personnel. Nurses would not be involved in this
process. After the removal of people from danger, the nurses triage the victims under
triage categories. The nurses supervise volunteers and provide on-site first aid to
victims.
A pregnant client is admitted with abdominal pain and heavy vaginal bleeding.
Which is the immediate nursing action?
Administering oxygen
Elevating the head of the bed
Drawing blood for a hematocrit level
Giving an intramuscular analgesic
, Administering oxygen
Rationale
Abdominal pain and heavy vaginal bleeding indicate significant blood loss. To
compensate for decreased cardiac output, oxygen is given to maintain the well-being of
both mother and fetus. Elevating the head of the bed will decrease blood flow to vital
centers in the brain. Drawing blood for a hematocrit level is not the priority. Giving an
intramuscular analgesic may mask abdominal pain and sedate an already compromised
fetus; also, it requires a primary health care provider's prescription.
Which personnel are responsible for identifying the need for and calling in
specialty trained providers in emergencies?
Triage officer
Public information officer
Medical command physician
Hospital incident commander
Medical command physician
Rationale
The medical command physician is responsible for identifying the resource needs of the
clients. The medical command physician identifies the need for and calls in the specialty
trained providers in emergencies. Triage officers are responsible for rapidly evaluating
each client to determine priorities for treatment. The public information officer serves as
a liaison between the health care facility and the media. The hospital incident
commander is the one who assumes overall leadership for implementing the emergency
plan.
Which is an example of an internal disaster in a hospital?
A hurricane
Oil spill from a marine oil tanker
Loss of communications capabilities
Malfunction of a nuclear reactor with radiation exposure
Loss of communications capabilities
Rationale
Loss of critical utilities, such as communications capabilities, is an internal disaster. A
hurricane is an external natural disaster. An oil spill from a marine oil tanker and
malfunction of a nuclear reactor with radiation exposure are examples of technological
external disasters
Which is the minimum length of time victims of a large scale near- drowning
incident brought to the emergency department would be kept under observation
in the hospital?
12 hours
18 hours
23 hours
48 hours
23 hours
ANSWERED CORRECTLY WITH RATIONALES.
HESI 4 REVIEW - CRITICAL CARE - MCA 3
Which color-tagged clients usually make up the greatest number in most large-
scale multi-casualty situations, based on the disaster triage tag system?
Red
Black
Green
Yellow
Green
Rationale
Green-tags clients usually make up the greatest number in most large-scale
multicasualty
situations. These clients have minor injuries and they may actually evacuate themselves
from the mass casualty scene and go to the hospital in a private vehicle. Red-tagged
clients have major injuries, black-tagged clients are expected and allowed to die, and
yellow- tagged clients have major injuries. Clients belonging to these three categories
usually do not make up the greatest number in most large-scale multicasualty
situations.
Which color tag will be given by the triage nurse to a client assigned to class IV
during a mass casualty situation?
Red
Black
Green
Yellow
Black
Rationale
A client considered class IV during triage in a mass casualty situation will be given a
black tag. The red tag is associated with class I, green tag with class III, and yellow tag
with class II.
In a mass casualty situation, which is the facility-level organizational model for
disaster management used by the hospital or long-term care facility?
Emergency operations center (EOC)
Hospital Incident Command System (HICS)
National Incident Management System (NIMS)
Federal Emergency Management Agency (FEMA)
Hospital Incident Command System (HICS)
Rationale
,The facility-level organizational model for disaster management is the HICS. It attempts
to standardize disaster operations by formally structuring roles under the hospital or
long- term care facility incident commander with clear lines of authority and
accountability for specific resources. The EOC, NIMS, and FEMA are not facility-level
organizational models for disaster management. The EOC is established by the HICS
personnel in a designated location with accessible communication technology to
manage the overall incident. The NIMS is the overall system for incident management
of which the HICS is a part; it is implemented by the Department of Homeland Security
and FEMA. The FEMA provides numerous online resources so that people are better
prepared for disasters and are able to respond more self-sufficiently to incidents and
hazard situations in their own communities.
Which area of assessment is included in the Glasgow Coma Scale?
Breathing patterns
Deep tendon reflexes
Eye accommodation to light
Response to verbal commands
Response to verbal commands
Rationale
The three areas of assessment to determine the level of consciousness using the
Glasgow Coma Scale are motor response to verbal commands,
eye opening in response to speech,
and verbal response to speech.
Assessing breathing patterns, deep tendon reflexes, and eye accommodation are not
included in the Glasgow Coma Scale.
A group of bomb blast victims needs to be transported to the hospital
immediately. Which staff members of an emergency unit are most appropriate to
handle this situation?
Triage officer
Medical command physician
Prehospital care providers
Emergency medicine physician
Prehospital care providers
Rationale
Prehospital care providers are the first caregivers who provide transport to the
emergency department by ambulance or helicopter for clients in an emergency
situation. Triage officers are responsible for evaluating each client to determine priorities
for treatment. The medical command physician decides the number, acuity, and
resource needs of clients. Emergency medicine health care providers have specialized
education and training in emergency client management.
Which parameters would the nurse consider for proper rapid baseline
assessment using a disability mnemonic (AVPU) in a client with drug abuse?
Select all that apply. One, some, or all responses may be correct.
Level of anxiety
Reaction to pain
,Response to voice
Body temperature
Evidence of assault
Reaction to pain
Response to voice
Rationale
The disability examination provides a rapid baseline assessment of neurological status.
It helps evaluate level of consciousness by the AVPU mnemonic, which also helps
assess the responsiveness to pain and voice. Level of anxiety is not assessed by a
disability mnemonic. Body temperature and evidence of assault are assessed in a
primary survey of exposure.
The postanesthesia care unit nurse providing care for a client who had a
craniotomy for a meningioma would monitor for which specific clinical
manifestation in this client?
Dehydration
Blurred vision
Wound infection
Narrowing pulse pressure
Blurred vision
Rationale
Blurred vision is a sign of increasing intracranial pressure, which may follow a
craniotomy. Dehydration, wound infection, and narrowing pulse pressure require time to
develop; these clinical manifestations will not be observable immediately after surgery.
The pulse pressure widens with increased intracranial pressure.
Which action of the emergency department nurse caring for a group of clients
injured in a community disaster would need correction?
Triaging the victims
Supervising volunteers
Providing on-site first aid
Removing people from danger
Removing people from danger
Rationale
During a community disaster, removing people from danger is done by firefighters and
other disaster trained emergency personnel. Nurses would not be involved in this
process. After the removal of people from danger, the nurses triage the victims under
triage categories. The nurses supervise volunteers and provide on-site first aid to
victims.
A pregnant client is admitted with abdominal pain and heavy vaginal bleeding.
Which is the immediate nursing action?
Administering oxygen
Elevating the head of the bed
Drawing blood for a hematocrit level
Giving an intramuscular analgesic
, Administering oxygen
Rationale
Abdominal pain and heavy vaginal bleeding indicate significant blood loss. To
compensate for decreased cardiac output, oxygen is given to maintain the well-being of
both mother and fetus. Elevating the head of the bed will decrease blood flow to vital
centers in the brain. Drawing blood for a hematocrit level is not the priority. Giving an
intramuscular analgesic may mask abdominal pain and sedate an already compromised
fetus; also, it requires a primary health care provider's prescription.
Which personnel are responsible for identifying the need for and calling in
specialty trained providers in emergencies?
Triage officer
Public information officer
Medical command physician
Hospital incident commander
Medical command physician
Rationale
The medical command physician is responsible for identifying the resource needs of the
clients. The medical command physician identifies the need for and calls in the specialty
trained providers in emergencies. Triage officers are responsible for rapidly evaluating
each client to determine priorities for treatment. The public information officer serves as
a liaison between the health care facility and the media. The hospital incident
commander is the one who assumes overall leadership for implementing the emergency
plan.
Which is an example of an internal disaster in a hospital?
A hurricane
Oil spill from a marine oil tanker
Loss of communications capabilities
Malfunction of a nuclear reactor with radiation exposure
Loss of communications capabilities
Rationale
Loss of critical utilities, such as communications capabilities, is an internal disaster. A
hurricane is an external natural disaster. An oil spill from a marine oil tanker and
malfunction of a nuclear reactor with radiation exposure are examples of technological
external disasters
Which is the minimum length of time victims of a large scale near- drowning
incident brought to the emergency department would be kept under observation
in the hospital?
12 hours
18 hours
23 hours
48 hours
23 hours
