Test Bank for Medical Surgical Nursing 7th Edition by Linton

NURSING ATI: TEST BANK FOR MEDICAL SURGICAL NURSING 7TH EDITIO
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Chapter: First Aid, Emergency Care, and Disaster ManagementLinton:
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Medical-Surgical Nursing, 7th Edition u u u




I. A patient is present with signs of severe airway obstruction. What term accuratelyde
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scribes the high-pitched noise the patient is exhibiting with inhalation?
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a. Stridor
b. Tachypnea
c. Wheezing
d. Rhonchi

ANS: A u




Signs of severe airway obstruction are poor or no air exchange, poor or no cough,
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high-
pitched noise known as stridor on inhalation, respiratory distress, cyanosis, inabilityto spea
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k, inability to move air, and clutching the neck.
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DIF: Cognitive Level: Comprehension REF: p. 1246 u u uuu u OBJ: 3 u




TOP: Airway Obstruction
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KEY: Nursing Process Step: Knowled
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geMSC: NCLEX: Physiological Integrity: Physiological Adaptation
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II. Standing in a fast- u u u




food line, the person in front, while munching on a cookie, begins to cough heavily, takes dee
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p inspirations, and waves his arms around wildly. What should bethe nurse’s first action?
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a. Start rescue breathing as quickly as possible.
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b. Start chest compressions as quickly as possible.
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c. Perform abdominal thrusts. u u




d. Do nothing at this point as long as air is exchanged.
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ANS: D u




When a person is choking but alert enough to attempt to cough and force the obstructionup a
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nd out by himself, allowing him to do so alone is best because more expelling forceoccurs th
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at way. Only when the person shows signs of not being able to breathe beyond the obstructio
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n should abdominal thrusts be applied.
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DIF: Cognitive Level: Application u u REF: p. 1246 uuu u




OBJ: 4TOP: Immediate Intervention for a Choking Victim
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KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
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III. What is the initial intervention for an unconscious patient who is not breathing accordingto
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one-person CPR principles, as taught and practiced by professional nurses?
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a. Lift the jaw to clear the airway.
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b. Call for assistance. u u




c. Start chest compressions. u u




d. Remove patient clothing to visualize the chest.
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ANS: B u




With one-u




person CPR, when the patient is unconscious and not breathing, the first thing todo is to call f
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or help.
u

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DIF: Cognitive Level: Comprehension REF: p. 1245 u u uuu u OBJ: 3 | 4
u u u




TOP: CPR Guidelines u u




KEY: Nursing Process Step: Implementati
u u u u




onMSC: NCLEX: Physiological Integrity: Basic Care and Comfort
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IV. While ambulating, a patient gasps and drops to the floor unconscious with no pulse orres
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piration. When is the nurse aware that brain cells begin to die?
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a. 1 minute u



b. 2 minutes u



c. 3 minutes u




d. 4 minutes u




ANS: D u




Without adequate perfusion, the brain cells begin to die in 4 minutes.
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DIF: Cognitive Level: Comprehension REF: p. 1245 u u uuu u OBJ: 3 uuu




TOP: Brain Damage u u




KEY: Nursing Process Step: Assessm
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entMSC: NCLEX: Physiological Integrity: Physiological Adaptation
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V. A nurse follows the protocol of SAMPLE when speaking to a victim of a fall in thepar
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king lot of the hospital. What does the P stand for?
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a. Pills taken today u u



b. Personal physician u



c. Past illnesses u



d. Preference for emergency transportation u u u




ANS: C u




The acronym SAMPLE that guides the victim interview means allergies, medications, pastill
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ness or pregnancy, last food and drink, and events related to injury.
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DIF: Cognitive Level: Knowledge u u REF: p. 1244 uuu u OBJ: 3 uuu




TOP: SAMPLE Protocol u u




KEY: Nursing Process Step: Implementati
u u u u




onMSC: NCLEX: Physiological Integrity: Basic Care and Comfort
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VI. What instructions should the nurse provide for immediate treatment for epistaxis?
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a. “Stand still, lean your head back so that the blood won’t get all over everything,an
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d pinch your nose shut for at least 10 minutes.”
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b. “Stand still, lean your head forward, and pinch your nose tightly for at least 10mi
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nutes.”
c. “Sit down on a solid surface, lean your head forward to let the blood run out, andthe
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n pinch your nose closed for at least 30 minutes.”
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d. “Sit down on a solid surface, lean your head forward so you don’t choke on thebl
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ood, and pinch your nose shut for at least 10 minutes.”
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ANS: D u




Blood from a nosebleed in the anterior portion of the nasal cavity will usually stop withpin
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ch pressure within 10 minutes. Blood from a nosebleed should not be swallowed.
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DIF: Cognitive Level: Application u u REF: p. 1247 uuu u OBJ: 4 u




TOP: First Aid for a Nosebleed
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KEY: Nursing Process Step: Implementati
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onMSC: NCLEX: Physiological Integrity: Basic Care and Comfort
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