1. During the primary assessment of a trauma victim, the nurse determines that the patient is breathing and has an unobstructed airway. Which action
... [Show More] 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.
3. After resuscitation, a patient who had a cardiac arrest is nonresponsive to commands and therapeutic hypothermia is prescribed. Which action will the nurse include in the plan of care?
a. Rapidly infuse cold normal saline.
b. Avoid the use of sedative medications.
c. Check neurologic status every 30 minutes. d. Rewarm if temperature is >91° F (32.8° C). ANS: A
When therapeutic hypothermia is used postresuscitation, cold normal saline is infused to rapidly lower body temperature to 89.6° F to 93.2° F (32° C to 34° C). Since hypothermia will decrease brain activity, neurologic assessment every 30 minutes is not needed. Sedative medications are administered during therapeutic hypothermia.
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.
5. An 18-year-old is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the right hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate administration of
a. tetanus-diphtheria toxoid (Td) only. b. tetanus immunoglobulin (TIG) only.
c. TIG and tetanus-diphtheria toxoid (Td).
d. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap). ANS: D
For an adult with no previous tetanus immunizations, TIG and Tdap are recommended. The other immunizations are not sufficient for this patient.
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. [Show Less]