HESI 4 REVIEW - CRITICAL CARE - MCA 3 QUESTIONS AND
CORRECT ANSWERS VERIFIED 100%
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
Rationale
Complications can develop in victims who are essentially free of symptoms
immediately after a near-drowning episode. This secondary drowning refers to
delayed death from drowning due to pulmonary complications. Consequently, all
victims of near-drowning should be observed in a hospital for a minimum of 23
hours, and longer if they have comorbidities. Twelve hours and 18 hours are too
soon to rule out secondary drowning. The clients need not be kept under observation
for 48 hours if they do not have comorbidities.
As a surface rewarming measure for a client who is hypothermic, which is the
highest temperature up to which the fluid can be heated for peritoneal lavage?
98.6°F (37°C)
111.2°F (44°C)
113°F (45°C)
120.2°F (49°C)
CORRECT ANSWERS VERIFIED 100%
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
Rationale
Complications can develop in victims who are essentially free of symptoms
immediately after a near-drowning episode. This secondary drowning refers to
delayed death from drowning due to pulmonary complications. Consequently, all
victims of near-drowning should be observed in a hospital for a minimum of 23
hours, and longer if they have comorbidities. Twelve hours and 18 hours are too
soon to rule out secondary drowning. The clients need not be kept under observation
for 48 hours if they do not have comorbidities.
As a surface rewarming measure for a client who is hypothermic, which is the
highest temperature up to which the fluid can be heated for peritoneal lavage?
98.6°F (37°C)
111.2°F (44°C)
113°F (45°C)
120.2°F (49°C)
