Chapter 68: Emergency and Disaster Nursing Lewis:
Medical-Surgical Nursing, 10th Edition
1. During the primary assessment of a victim of a motor vehicle collision, the
nurse determines that the patient has an unobstructed airway. Which action
should the nurse take next?
a. Palpate extremities for bilateral pulses.
b. Observe the patient's respiratory effort.
c. Check the patient's level of consciousness.
d. Examine the patient for any external bleeding.: ANS: B
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 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)
2. During the primary survey of a patient with severe leg trauma, the nurse
observes that the patient's left pedal and posterior tibial pulses are absent
and the entire 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.: 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: Analyze (analysis)
3. 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. Initiate cooling per protocol.
b. Avoid the use of sedative drugs.
, Chapter 68: Emergency and Disaster Nursing Lewis:
Medical-Surgical Nursing, 10th Edition
c. Check mental status every 15 minutes.
d. Rewarm if temperature is below 91° F (32.8° C).: 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 done at this stage. Sedative
drugs are given during therapeutic hypothermia.
DIF: Cognitive Level: Apply (application)
4. 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. attach an electrocardiogram monitor.
d. ask about chronic medical conditions.: 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)
5. A 19-yr-old patient 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
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).: ANS: D
For an adult with no previous tetanus immunizations, TIG and Tdap are
recommended. The other immunizations are not sufficient for this patient.
DIF: Cognitive Level: Apply (application)
6. A patient who has experienced blunt abdominal trauma during a motor
vehicle collision is complaining of increasing abdominal pain. The nurse
will plan to teach the patient about the purpose of
Medical-Surgical Nursing, 10th Edition
1. During the primary assessment of a victim of a motor vehicle collision, the
nurse determines that the patient has an unobstructed airway. Which action
should the nurse take next?
a. Palpate extremities for bilateral pulses.
b. Observe the patient's respiratory effort.
c. Check the patient's level of consciousness.
d. Examine the patient for any external bleeding.: ANS: B
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 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)
2. During the primary survey of a patient with severe leg trauma, the nurse
observes that the patient's left pedal and posterior tibial pulses are absent
and the entire 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.: 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: Analyze (analysis)
3. 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. Initiate cooling per protocol.
b. Avoid the use of sedative drugs.
, Chapter 68: Emergency and Disaster Nursing Lewis:
Medical-Surgical Nursing, 10th Edition
c. Check mental status every 15 minutes.
d. Rewarm if temperature is below 91° F (32.8° C).: 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 done at this stage. Sedative
drugs are given during therapeutic hypothermia.
DIF: Cognitive Level: Apply (application)
4. 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. attach an electrocardiogram monitor.
d. ask about chronic medical conditions.: 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)
5. A 19-yr-old patient 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
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).: ANS: D
For an adult with no previous tetanus immunizations, TIG and Tdap are
recommended. The other immunizations are not sufficient for this patient.
DIF: Cognitive Level: Apply (application)
6. A patient who has experienced blunt abdominal trauma during a motor
vehicle collision is complaining of increasing abdominal pain. The nurse
will plan to teach the patient about the purpose of
