DISASTER TRIAGE NURSING NCLEX QUESTIONS

DISASTER TRIAGE NURSING NCLEX QUESTIONS

• You’re working as a triage nurse during a disaster situation. Based on the triage color code

tags placed on each of the wounded, which tag color represents the wounded who have the highest priority of being treated first?* ○ A. Green ○ B. Yellow ○ C. Red ○ D. Black

• A catastrophic disaster has occurred 5 miles from the hospital you are working in. The

hospital’s disaster plan is activated and the wounded are brought to the hospital. You’re helping triage the survivors. One of the wounded is able to walk around and has minor lacerations on the arms, hands, chest, and legs. You would place what color tag on this survivor?* ○ A. Red ○ B. Yellow ○ C. Green ○ D. Black

• Which statement below is INCORRECT about the yellow triage tag color in regards to a

disaster situation?* ○ A. A survivor with this tag color is seen after patients with the green tag color.○ B. A survivor with this tag color can have treatment delayed for an hour or less.○ C. A survivor with this tag color has serious injuries that could eventually lead to the compromise of breathing, circulation, or mental status, especially if treatment is delayed more than an hour or so.○ D. A survivor with this tag color has second priority for treatment of injuries.

• For the next 7 questions, use the START method for adults to help triage the wounded that

have been involved in a disaster situation. Each question will give you details on what you have assessed and you will need to use those details to help you assign a color tag to the individual: The wounded victim is unable to walk, has respiratory rate of 40, capillary refill is 6 seconds, and can’t follow simple commands. The wounded victim is assigned what tag color?* ○ A. Green ○ B. Red ○ C. Yellow ○ D. Black

• While triaging the wounded from a disaster, you note that one of the wounded is not breathing,

radial pulse is absent, capillary refill >2 seconds, and does not respond to your commands. What color tag is assigned?* ○ A. Green ○ B. Red ○ C. Yellow ○ D. Black

• The wounded victim is unable to walk, has respiratory rate of 12, capillary refill is 8 seconds,

and is unresponsive. The wounded victim is assigned what tag color?*

○ A. Green ○ B. Red ○ C. Yellow ○ D. Black

• The wounded victim is unable to walk, has respiratory rate of 19, capillary refill of one second,

and is able to obey your commands. The wounded victim is assigned what tag color?* ○ A. Green ○ B. Red ○ C. Yellow ○ D. Black

• The wounded victim is unable to walk, respiratory rate is absent but when airway is

repositioned breathing is noted. The wounded victim is assigned what tag color?* ○ A. Green ○ B. Red ○ C. Yellow ○ D. Black

• The wounded victim is unable to walk, respiratory rate is absent and when airway is

repositioned breathing is still absent. The wounded victim is assigned what tag color?* ○ A. Green ○ B. Red ○ C. Yellow ○ D. Black

• The wounded victim is able to walk and obey commands. The wounded victim is assigned

what tag color?* ○ A. Green ○ B. Red ○ C. Yellow ○ D. Black

Hypovolemic Shock NCLEX Questions

• True or False: Hypovolemic shock occurs where there is low fluid volume in the interstitial

compartment.* ○ True ○ False

• As the nurse you know that in order for hypovolemic shock to occur the patient would need to

lose of their blood volume.* ○ A. <30% ○ B. >25% ○ C. >15% ○ D. >10%

• If a patient has a blood volume of 5 Liters and loses 2 Liters, what is the percentage amount of

volume loss this patient has experienced?*

○ A. 25%

○ B. 40%

○ C. 30%

○ D. 10%

• A patient who is experiencing hypovolemic shock has decreased cardiac output, which

contributes to ineffective tissue perfusion. The decrease in cardiac output occurs due to?* ○ A. An increase in cardiac preload ○ B. An increase in stroke volume ○ C. A decrease in cardiac preload ○ D. A decrease in cardiac contractility

• True or False: A patient with acute pancreatitis is presenting with Turner and Cullen's Sign.

This patient is at risk for absolute hypovolemic shock.* ○ True ○ False

• Select all the conditions below that increases a patient's risk for absolute hypovolemic shock:*

○ A. Burns ○ B. Vomiting ○ C. Long bone fracture ○ D. Surgery ○ E. Diarrhea ○ F. Sepsis

• A patient has a 10% loss of their blood volume. Select all the signs and symptoms this patient

may present with?* ○ A. Cool, clammy skin ○ B. Blood pressure within normal limits ○ C. Anxiety ○ D. Capillary refill less than 2 seconds ○ E. Urinary output greater than 30 mL/hr ○ F. Mild tachycardia

• During what stage (or class) of hypovolemic shock does the sympathetic nervous system

attempt to maintain cardiac output?*

○ A. I

○ B. III

○ C. IV

○ D. II

• One of your patients begins to vomit large amounts of bright red blood. The patient is taking

Warfarin. You call a rapid response. Which assessment findings indicate this patient is developing

hypovolemic shock? Select all that apply:*

○ A. Temperature 104.8 'F ○ B. Heart rate 40 bpm ○ C. Heart rate 140 bpm ○ D. Anxiety, restlessness ○ E. Urinary output 15 mL/hr

○ F. Blood pressure 70/56 ○ G. Pale, cool skin ○ H. Weak peripheral pulses ○ I. Blood pressure 220/106

• You're providing care to a patient who has experienced a 45% loss of their fluid volume and is

experiencing hypovolemic shock. The patient has hemodynamic monitoring and fluid resuscitation is being attempted. Which finding indicates the patient is still in hypovolemic shock?* ○ A. Low central venous pressure ○ B. High pulmonary artery wedge pressure ○ C. Elevated mean arterial pressure ○ D. Low systemic vascular resistance

• A patient is 1 hour post-op from abdominal surgery and had lost 20% of their blood volume

during surgery. The patient is experiencing signs and symptoms of hypovolemic shock. What position is best for this patient?* ○ A. Modified Trendelenburg ○ B. Trendelenburg ○ C. High Fowler's ○ D. Supine

• A 35-year-old male arrives to the emergency room with multiple long bone fractures and an

internal abdominal injury. The patient is anxious. Patient's vital signs are: Blood pressure 70/54, heart rate 125 bpm, respirations 30, oxygen saturation on 2 L nasal cannula 96%, temperature 99.3 'F, pain 6 on 1-10 scale. During assessment it is noted the skin is cool and clammy. The nurse will make it priority to?* ○ A. Collect a urine sample ○ B. Obtain an EKG ○ C. Establish 2 large-bore IV access sites ○ D. Place a warming blanket on the patient

• A patient in hypovolemic shock is receiving rapid infusions of crystalloid fluids. Which patient

finding requires immediate nursing action?* ○ A. Patient heart rate is 115 bpm ○ B. Patient experiences dyspnea and crackles in lung fields ○ C. Patient is anxious ○ D. Patient's urinary output is 35 mL/hr

• A patient has lost 750 mL of blood volume. The MD orders Normal Saline infusion. Using the

3:1 rule, how much crystalloid solution should be prescribed by the doctor?*

○ A. 2,250 mL of Normal Saline ○ B. 250 mL of Normal Saline ○ C. 375 mL of Normal Saline ○ C. 1,225 mL of Normal Saline

• You're providing an in-service to new nurse graduates on the fluid treatment for hypovolemic

shock. You ask the participants to list the types of crystalloid solutions used in hypovolemic

shock. Which responses are INCORRECT? Select all that apply:*