TEST BANK - Lewis Medical Surgical Nursing, 12th Edition (Harding), Chapters 1 - 69 | All Chapters Verified Correct 2025 Updated Solution A+ Scored

1. The nurse is doing theprimary survey of an adult who was in a motor vehicle collision. After thenurse determines that thepatient has an unobstructed airway, which action would thenurs e take next? a. Palpate extremities for bilateral pulses. b. Observe thepatient‗s respiratory effort. c. Check thepatient‗s level of consciousness. d. Examine thepatient for external bleeding. ANSWER:T B Even with a patent airway, patients can have other problems that compromise ventilation, so then ext action is to assess thepatient‗s breathing. theother actions are also part of theinitial survey, b ut assessment of breathing should be done immediately after assessing for airway patency. DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Assessment MSC:NCLEX: Physiological Integrity 2. During theprimary survey of a patient with severe leg trauma, thenurse observes that th epatient‗s left pedal and posterior tibial pulses are absent, and theentire leg is swollen. Which action will thenurse take next? a. Send blood to thelab for a complete bloodTcount. b. Assess further for a cause of thedecreased circulation. c. Finish theairway, breathing, circulation, disability survey. d. Start normal saline fluid infusion with two large-bore IV lines. ANSWER:T D The assessment data indicate that thepatient may have arterial trauma and hemorrhage. When a life- threatening injury is found during theprimary survey, thenurse should immediately start inter ventions before proceeding with thesurvey. Although sending off blood for a complete blood count is indicated, administration of IV fluids should be started first. Completion of theprim ary survey and further assessment should be completed after theIV fluids are initiated. DIF:CognitiveLevel: Analyze (Analysis) TOP: NursingProcess: Implementation MSC:NCLEX: Physiological Integrity 3. A patient who had a cardiac arrest has been resuscitated and therapeutic hypothermia is prescribed. Which action will thenurse include in theplan of care? a. Hold theprescribed sedative drugs. b. Check mental status every 15 minutes. c. Initiate protocol for temperature management. d. Rewarm if temperature is below 91F (32.8C). ANSWER:T C Therapeutic hypothermia, also called targeted temperature management (TTM), uses external co oling devices or cold normal saline infusions to rapidly lower body temperature to 89.6 to 93.2F (32 to 34C). Because hypothermia will decrease brain activity, assessing mental stat us every 15 minutes is not done at this stage. Sedative drugs are given during therapeutic hyp othermia. DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: PlanningTMSC:NCLEX : Physiological Integrity 4. A patient who is unconscious after a fall from a ladder is transported to theemergency depa rtment by emergency medical personnel. Which action would thenurse complete during thep rimary survey of thepatient? a. Obtain a complete set of vital signs. b. Check a Glasgow Coma Scale score. c. Attach an electrocardiogram monitor. d. Ask about chronic medical conditions. ANSWER:T B The Glasgow Coma Scale is included when assessing for disability duringTtheprimary survey. the other information is part of thesecondary survey. DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Assessment MSC:NCLEX: Physiological Integrity 5. A 19-yr- old patient presents to theemergency department (ED) with multiple lacerations and tissue a vulsion of theleft hand. thepatient denies having any previous vaccinations. What would the nurse anticipate administering? a. Tetanus immunoglobulin (TIG) only b. TIG and tetanus-diphtheria toxoid (Td) c. Tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only d. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap) ANSWER:T D For an adult with no previous tetanus immunizations, TIG and Tdap are recommended. theoth er immunizations are not sufficient for this patient.