Chapter 68: Emergency and Disaster Nursing || Questions
with Complete Solutions.
During the primary assessment of a victim of a motor vehicle collision, the nurse determines that
the patient is breathing and has an unobstructed airway. Which action should the nurse take next?
A. Palpate extremities for bilateral pulses.
B. Observe the patients respiratory effort.
C. Check the patients level of consciousness.
D. Examine the patient for any external bleeding. correct answers ANS: B
Even with a patent airway, patients can have other problems that compromise ventilation, so the
next action is to assess the patients breathing. The other actions are also part of the initial survey
but assessment of breathing should be done immediately after assessing for airway patency.
DIF: Cognitive Level: Apply (application) REF: 1630
TOP: Nursing Process: Assessment
During the primary survey of a patient with severe leg trauma, the nurse observes that the
patients left pedal pulse is absent and the leg is swollen. Which action will the nurse take next?
A. Send blood to the lab for a complete blood count.
B. Assess further for a cause of the decreased circulation.
C. Finish the airway, breathing, circulation, disability survey.
D. Start normal saline fluid infusion with a large-bore IV line. correct answers 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 complete blood
count 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.
DIF: Cognitive Level: Apply (application) REF: 1630
TOP: Nursing Process: Implementation
, After the return of spontaneous circulation following the resuscitation of a patient who had a
cardiac arrest, therapeutic hypothermia is ordered. Which action will the nurse include in the
plan of care?
A. Apply external cooling device.
B. Check mental status every 15 minutes.
C. Avoid the use of sedative medications.
D. Rewarm if temperature is <91 F (32.8 C). correct answers ANS: A
When therapeutic hypothermia is used postresuscitation, external cooling devices or cold normal
saline infusions are used to rapidly lower body temperature to 89.6 F to 93.2 F (32 C to 34 C).
Because hypothermia will decrease brain activity, assessing mental status every 15 minutes is not
needed at this stage. Sedative medications are administered during therapeutic hypothermia.
DIF: Cognitive Level: Apply (application) REF: 1635
TOP: Nursing Process: Planning
A patient who is unconscious after a fall from a ladder is transported to the emergency
department by emergency medical personnel. During the primary survey of the patient, the nurse
should
A. obtain a complete set of vital signs.
B. obtain a Glasgow Coma Scale score.
C. ask about chronic medical conditions.
D. attach a cardiac electrocardiogram monitor. correct answers ANS: B
The Glasgow Coma Scale is included when assessing for disability during the primary survey.
The other information is part of the secondary survey.
DIF: Cognitive Level: Apply (application) REF: 1630
TOP: Nursing Process: Assessment
A 19-year-old is brought to the emergency department (ED) with multiple lacerations and tissue
avulsion of the left hand. When asked about tetanus immunization, the patient denies having any
previous vaccinations.
The nurse will anticipate giving
with Complete Solutions.
During the primary assessment of a victim of a motor vehicle collision, the nurse determines that
the patient is breathing and has an unobstructed airway. Which action should the nurse take next?
A. Palpate extremities for bilateral pulses.
B. Observe the patients respiratory effort.
C. Check the patients level of consciousness.
D. Examine the patient for any external bleeding. correct answers ANS: B
Even with a patent airway, patients can have other problems that compromise ventilation, so the
next action is to assess the patients breathing. The other actions are also part of the initial survey
but assessment of breathing should be done immediately after assessing for airway patency.
DIF: Cognitive Level: Apply (application) REF: 1630
TOP: Nursing Process: Assessment
During the primary survey of a patient with severe leg trauma, the nurse observes that the
patients left pedal pulse is absent and the leg is swollen. Which action will the nurse take next?
A. Send blood to the lab for a complete blood count.
B. Assess further for a cause of the decreased circulation.
C. Finish the airway, breathing, circulation, disability survey.
D. Start normal saline fluid infusion with a large-bore IV line. correct answers 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 complete blood
count 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.
DIF: Cognitive Level: Apply (application) REF: 1630
TOP: Nursing Process: Implementation
, After the return of spontaneous circulation following the resuscitation of a patient who had a
cardiac arrest, therapeutic hypothermia is ordered. Which action will the nurse include in the
plan of care?
A. Apply external cooling device.
B. Check mental status every 15 minutes.
C. Avoid the use of sedative medications.
D. Rewarm if temperature is <91 F (32.8 C). correct answers ANS: A
When therapeutic hypothermia is used postresuscitation, external cooling devices or cold normal
saline infusions are used to rapidly lower body temperature to 89.6 F to 93.2 F (32 C to 34 C).
Because hypothermia will decrease brain activity, assessing mental status every 15 minutes is not
needed at this stage. Sedative medications are administered during therapeutic hypothermia.
DIF: Cognitive Level: Apply (application) REF: 1635
TOP: Nursing Process: Planning
A patient who is unconscious after a fall from a ladder is transported to the emergency
department by emergency medical personnel. During the primary survey of the patient, the nurse
should
A. obtain a complete set of vital signs.
B. obtain a Glasgow Coma Scale score.
C. ask about chronic medical conditions.
D. attach a cardiac electrocardiogram monitor. correct answers ANS: B
The Glasgow Coma Scale is included when assessing for disability during the primary survey.
The other information is part of the secondary survey.
DIF: Cognitive Level: Apply (application) REF: 1630
TOP: Nursing Process: Assessment
A 19-year-old is brought to the emergency department (ED) with multiple lacerations and tissue
avulsion of the left hand. When asked about tetanus immunization, the patient denies having any
previous vaccinations.
The nurse will anticipate giving
