An emergency room nurse is performing secondary triage on clients transported from the scene of a chemical spill. After caring for the clients, the EMS workers complained of nausea and dizziness. Which immediate interventions need to be taken by the triage nurse? SELECT ALL THAT APPLY

Continue with the triage process.

Evacuate the emergency department.

Place the client in a private room.

Treat the client after contaminated items are removed.

Send the client and EMS crew to decontamination.

Answer and Explanation

Correct Answer : B,E

Choice A reason: Continuing with the triage process is not an immediate intervention that needs to be taken by the triage nurse, as it may expose more people to the chemical hazard and worsen the situation. The triage nurse should stop the triage process and alert the emergency department staff and management about the potential contamination. The triage nurse should also follow the facility's emergency preparedness plan and protocols for dealing with chemical spills.

Choice B reason: Evacuating the emergency department is an immediate intervention that needs to be taken by the triage nurse, as it helps to protect the safety and health of the staff, clients, and visitors. The triage nurse should assist with evacuating everyone from the emergency department to a safe and designated area, away from the source of contamination. The triage nurse should also ensure that everyone is accounted for and that no one re-enters the emergency department until it is cleared by the authorities.

Choice C reason: Placing the client in a private room is not an immediate intervention that needs to be taken by the triage nurse, as it may not prevent the spread of contamination or provide adequate care to the client. The client who have been exposed to a chemical spill should not be moved to another area of the facility, as they may contaminate other people or surfaces along the way. The client should be kept in a separate and isolated area until they are decontaminated and assessed.

Choice D reason: Treating the client after contaminated items are removed is not an immediate intervention that needs to be taken by the triage nurse, as it may delay or compromise the care of the client. The client who has been exposed to a chemical spill should be treated as soon as possible, as some chemicals can cause serious or irreversible damage to the skin, eyes, lungs, or other organs. The triage nurse should provide basic life support measures, such as airway management, oxygen therapy, or bleeding control while wearing appropriate personal protective equipment (PPE). The triage nurse should also remove any contaminated clothing or jewelry from the client and place them in a sealed bag.

Choice E reason: Sending the client and EMS crew to decontamination is an immediate intervention that needs to be taken by the triage nurse, as it helps to remove or neutralize any harmful chemicals from their skin, hair, or clothing. The triage nurse should direct or escort the client and EMS crew to a designated decontamination area or unit, where they will undergo a thorough washing process with water and soap or other solutions. The triage nurse should also monitor their vital signs and symptoms during and after decontamination.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Administering an antipyretic is not the next action that the nurse should initiate. An antipyretic is a medication that lowers fever, which is a common symptom of meningococcal meningitis. However, fever is not a life-threatening condition, and it may have some beneficial effects on fighting infection. The nurse should first prioritize other actions that are more urgent or critical for the client's safety and outcome.

Choice B reason: Decreasing environmental stimuli is not the next action that the nurse should initiate. Decreasing environmental stimuli is a nursing intervention that can help reduce agitation, confusion, or seizures in clients with meningococcal meningitis. However, it is not an immediate or essential action, and it may not be effective if the client's condition worsens or progresses to coma.

Choice C reason: Assessing the cranial nerves is the next action that the nurse should initiate. Cranial nerve assessment is a neurological examination that evaluates the function of 12 pairs of nerves that originate from the brainstem and control various sensory and motor functions, such as vision, hearing, smell, taste, facial expression, eye movement, swallowing, speech, and balance. Meningococcal meningitis is an inflammation of the meninges, which are the membranes that cover and protect the brain and spinal cord. Meningeal inflammation can compress or damage the cranial nerves, causing various signs and symptoms, such as headache, photophobia, diplopia, facial palsy, dysphagia, dysarthria, or nystagmus. Assessing the cranial nerves can help detect any neurological deficits or complications early, and guide appropriate interventions or referrals.

Choice D reason: Completing a vascular assessment is not the next action that the nurse should initiate. A vascular assessment is a physical examination that evaluates the blood flow and circulation in different parts of the body, such as the arms, legs, abdomen, or neck. It may include checking pulses, blood pressure, capillary refill, skin color, temperature, or edema. A vascular assessment may be relevant for some clients with meningococcal meningitis who develop septic shock or disseminated intravascular coagulation (DIC), which are serious conditions that affect blood vessels and clotting factors. However, these are not common or early manifestations of meningococcal meningitis, and they require more advanced or specialized assessments and treatments.

A. Mitigation B. Security C. Preparedness D. Response phase

Correct Answer is C

Explanation

Choice A reason: Mitigation is not the correct level of the National Response Framework, as it refers to the actions taken to reduce or eliminate the long-term risk to human life and property from natural or man-made hazards. Mitigation activities include implementing building codes, zoning ordinances, land use planning, and flood insurance programs. Mitigation is a continuous process that occurs before, during, and after a disaster.

Choice B reason: Security is not the correct level of the National Response Framework, as it refers to the actions taken to protect the nation from threats or attacks by terrorists, criminals, or hostile states. Security activities include conducting intelligence operations, screening travelers and cargo, enforcing laws and regulations, and preventing cyberattacks. Security is a shared responsibility among federal, state, local, tribal, territorial, and private sector partners.

Choice C reason: Preparedness is the correct level of the National Response Framework, as it refers to the actions taken to plan, organize, equip, train, and exercise to build and sustain the capabilities necessary to prevent, protect against, mitigate the effects of, respond to, and recover from those threats that pose the greatest risk. Preparedness activities include developing emergency plans, conducting drills and exercises, educating the public, and establishing partnerships and coordination mechanisms. Preparedness is a continuous cycle of improvement that involves assessing needs, setting goals, implementing plans, and evaluating outcomes.

Choice D reason: The response phase is not the correct level of the National Response Framework, as it refers to the actions taken to save lives, protect property and the environment, stabilize the situation, and meet basic human needs in the immediate aftermath of a disaster. Response activities include activating emergency operations centers, deploying resources and personnel, providing mass care and sheltering, restoring critical infrastructure and services, and conducting search and rescue operations. Response is a short-term process that aims to restore normalcy as soon as possible.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

An emergency room nurse is performing secondary triage on clients transported from the scene of a chemical spill. After caring for the clients, the EMS workers complained of nausea and dizziness. Which immediate interventions need to be taken by the triage nurse? SELECT ALL THAT APPLY

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse has identified a community at risk for flooding. The nurse understands that educating the residents about evacuation routes and emergency shelters is an example of what level of the National Response Framework.

Correct Answer is C

Explanation

Discharge plans are being made for a 25-year-old hospitalized client diagnosed with multiple sclerosis. The client has significant muscle weakness in the lower extremities bilaterally. Which of the following facilities should the nurse expect this client to be discharged to?

A nurse is caring for a client who has experienced a hemorrhagic stroke. Which intervention should the nurse prioritize when providing care to the client?

A nurse is caring for a client with a myocardial infarction. The client questions the need for cardiac rehabilitation since "my heart is already damaged." Which of the following is the appropriate nursing response?

The hospital's Emergency Operations Committee is working on their disaster plan. In which components should nurses be included? SELECT ALL THAT APPLY

A client diagnosed with trigeminal neuralgia is experiencing intermittent, sudden, severe pain on the left side of the face. The nurse identifies which classification of medications is most effective in treating this pain.

A nurse advises a client with osteoporosis to have three servings of milk or dairy products daily. Which of the following levels of prevention is being used by the nurse?

A nurse enters the room of a client and discovers the client with new right-sided weakness and slurred speech. Which of the following actions should the nurse take?

A client is brought to the Emergency Department as one of the first victims of a train accident. The client reports light-headedness, a weak pulse, and uncontrolled bleeding. Which priority tag should a triage nurse use to categorize this client?