ATI MED SURG NURSING CARE QUESTI0N WITH ANSWERS 2023-2024
Trauma, Chest Injury, Abd. Trauma
1. During the primary assessment of a trauma victim, the
... [Show More] nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next?
a. Observe the patient’s respiratory effort.
b. Check the patient’s level of consciousness.
c. Palpate extremities for capillary refill time.
d. Examine the patient for any external bleeding.
ANS: A
Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient’s breathing. The other actions also are part of the initial survey but assessment of breathing should be done immediately after assessing for airway patency.
2. During the primary survey of a patient with multiple traumatic injuries, the nurse observes that the patient’s right pedal pulses are absent and the leg is swollen. Which of these actions will the nurse take next?
a. Assess further for a cause of the decreased circulation.
b. Send blood to the lab for a complete blood count (CBC).
c. Finish the airway, breathing, circulation, disability survey.
d. Initiate isotonic fluid infusion through two large-bore IV lines.
ANS: D
The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a possibly life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although a CBC is indicated, administration of IV fluids should be started first. Completion of the primary survey and further assessment should be completed after the IV fluids are initiated.
4.A patient who is unconscious after a fall from a ladder is transported to the emergency department by family members. During the primary survey of the patient, the nurse should
a. assess the patient’s vital signs.
b. attach a cardiac electrocardiogram (ECG) monitor.
c. obtain a Glasgow Coma Scale score.
d. ask about chronic medical conditions.
ANS: C
The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey.
6.A patient who has experienced blunt abdominal trauma during a car accident is complaining of increasing abdominal pain. The nurse will plan to teach the patient about the purpose of
a. ultrasonography.
b. peritoneal lavage.
c. nasogastric (NG) tube placement.
d. magnetic resonance imaging (MRI).
ANS: A
For patients who are at risk for intraabdominal bleeding, focused abdominal ultrasonography is the preferred method to assess for intraperitoneal bleeding. An MRI would not be used. Peritoneal lavage is an alternative, but it is more invasive. An NG tube would not be helpful in diagnosis of intraabdominal bleeding.
7.A patient with hypotension and temperature elevation after doing yard work on a hot day is treated in the ED. After the nurse has completed discharge teaching, which statement by the patient indicates that the teaching has been effective?
a. “I will take salt tablets when I work outdoors in the summer.”
b. “I should take acetaminophen (Tylenol) if I start to feel too warm.”
c. “I should have sports drinks when exercising outside in hot weather.”
d. “I will get into a cool environment if I notice that I am feeling confused.”
ANS: C
Electrolyte solutions such as sports drinks help replace fluid and electrolytes lost when exercising in hot weather. Salt tablets are not recommended because of the risks of gastric irritation and hypernatremia. Antipyretic medications are not effective in lowering body temperature elevations caused by excessive exposure to heat. A patient who is confused is likely to have more severe hyperthermia and will be unable to remember to take appropriate action.
8.When preparing to rewarm a patient with hypothermia, the nurse will plan to
a. attach a cardiac monitor.
b. insert a urinary catheter.
c. assist with endotracheal intubation.
d. have sympathomimetic drugs available.
ANS: A
Rewarming can produce dysrhythmias, so the patient should be monitored and treated if necessary. Urinary catheterization and endotracheal intubation are not needed for rewarming. Sympathomimetic drugs tend to stimulate the heart and increase the risk for fatal dysrhythmias such as ventricular fibrillation.
9.A patient who experienced a near drowning accident in a local lake, but now is awake and breathing spontaneously, is admitted for observation. Which action will be most important for the nurse to take during the observation period?
a. Listen to heart sounds.
b. Palpate peripheral pulses.
c. Auscultate breath sounds.
d. Check pupil reaction to light.
ANS: C
Since pulmonary edema is a common complication after near drowning, the nurse should assess the breath sounds frequently. The other information also will be collected by the nurse, but it is not as pertinent to the patient’s admission diagnosis.
14.A triage nurse in a busy emergency department assesses a patient who complains of 6/10 abdominal pain and states, “I had a temperature of 104.6º F (40.3º C) at home.” The nurse’s first action should be to
a. assess the patient’s current vital signs.
b. obtain a clean-catch urine for urinalysis.
c. tell the patient that it may be several hours before being seen by the doctor.
d. ask the health care provider to order an analgesic medication for the patient.
ANS: A
The patient’s pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how rapidly the patient should be seen by the health care provider. A urinalysis may be needed, but vital signs will provide the nurse with the data needed to determine this. The health care provider will not order a medication before assessing the patient.
15. The emergency department (ED) triage nurse is assessing four victims of an automobile accident. Which patient has the highest priority for treatment?
a. A patient with absent pedal pulses
b. A patient with an open femur fracture
c. A patient with a sucking chest wound
d. A patient with bleeding of facial lacerations
ANS: C
Most immediate deaths from trauma occur because of problems with ventilation, so the patient with a sucking chest wound should be treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries has lacerations only. The other two patients also need rapid intervention but do not have airway or breathing problems.
16. The following actions are part of the routine emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?
a. Remove the patient’s rings.
b. Place ice packs on both hands.
c. Apply calamine lotion to any itching areas.
d. Give diphenhydramine (Benadryl) 100 mg PO.
ANS: A
The patient’s rings should be removed first because it might not be possible to remove them if swelling develops. The other orders also should be implemented as rapidly as possible after the nurse has removed the jewelry.
20. When a patient is admitted to the emergency department after a submersion injury, which assessment will the nurse obtain first?
a. Apical pulse
b. Lung sounds
c. Body temperature [Show Less]