Nursing Care: Trauma And Emergency – Qs And As
A nurse is performing a primary survey in the emergency department.
Identify components of the primary survey. Select all that apply.
Correct Ans - Circulation
Exposure
Disability
Breathing
Alertness
While conducting the primary survey, it may be necessary to gather
additional data. Which adjunct measures should be initiated? Select all that
apply. Correct Ans - Collect blood specimens for laboratory testing
Monitor oxygenation
Initiate continuous cardiac monitoring
Determine pain level
A client presents to the emergency department with periorbital bruising
and a dysconjugate gaze (failure of the eyes to turn together in the same
direction). Which intervention is contraindicated? Correct Ans -
Insert a nasogastric tube
A 28-year-old arrives to the emergency department stating, "I have been
vomiting all night. I think I ate some bad shellfish." The client reports
abdominal cramping with pain 4/10 and diarrhea but denies fever.
Vital Signs:
T 97.8ºF (36.6ºC)
HR 94
P 121/74
R 16 Correct Ans - Client 1 is assigned an ESI level of 5
A 22-year-old arrives to the emergency department in severe respiratory
distress stating, "I used my inhaler but it is not working". She has a history
of asthma.
Vital Signs:
T 98.6ºF (37ºC)
HR 125
BP 140/92
R 34 Correct Ans - Client 2 is assigned an ESI level of 1.
, A 50-year-old construction worker arrives to the emergency department
complaining of significant low back pain 8/10 and muscle spasms.
Vital Signs:
T 97.9ºF (36.6ºC)
HR 99
BP 135/82
R 20 Correct Ans - Client 3 is assigned an ESI level of 4
A mother brings her 10-month-old infant to the emergency department
reporting vomiting for 2 days. The infant appears lethargic and hypotonic.
Anterior fontanelle is depressed.
Vital Signs:
T 100.4ºF (38ºC)
HR 165
BP 72/40
R 40 Correct Ans - Client 4 is assigned an ESI level of 2
A client presents to the emergency department following a motor vehicle
accident. During the primary survey, the nurse found asymmetric chest
wall movement and absent breath sounds on the left side. What should be
the priority action by the nurse? Correct Ans - Begin ventilation
with 100% oxygen via bag-valve-mask
The body loses heat by four mechanisms: radiation, conduction, convection,
and evaporation. Match the type of heat loss to the example. Correct
Ans - Bed near a cold window = Radiation
Cold operating room table= Conduction
Wind chill= Convection
Wet clothing= Evaporation
The nurse is caring for a homeless client who arrived at the emergency
department with a core body temperature of 87ºF (30.5ºC). What
assessment findings should the nurse anticipate? Select all that apply.
Correct Ans - Kussmaul respirations
Hematocrit 55%
Bradypnea
Shivering
A nurse is performing a primary survey in the emergency department.
Identify components of the primary survey. Select all that apply.
Correct Ans - Circulation
Exposure
Disability
Breathing
Alertness
While conducting the primary survey, it may be necessary to gather
additional data. Which adjunct measures should be initiated? Select all that
apply. Correct Ans - Collect blood specimens for laboratory testing
Monitor oxygenation
Initiate continuous cardiac monitoring
Determine pain level
A client presents to the emergency department with periorbital bruising
and a dysconjugate gaze (failure of the eyes to turn together in the same
direction). Which intervention is contraindicated? Correct Ans -
Insert a nasogastric tube
A 28-year-old arrives to the emergency department stating, "I have been
vomiting all night. I think I ate some bad shellfish." The client reports
abdominal cramping with pain 4/10 and diarrhea but denies fever.
Vital Signs:
T 97.8ºF (36.6ºC)
HR 94
P 121/74
R 16 Correct Ans - Client 1 is assigned an ESI level of 5
A 22-year-old arrives to the emergency department in severe respiratory
distress stating, "I used my inhaler but it is not working". She has a history
of asthma.
Vital Signs:
T 98.6ºF (37ºC)
HR 125
BP 140/92
R 34 Correct Ans - Client 2 is assigned an ESI level of 1.
, A 50-year-old construction worker arrives to the emergency department
complaining of significant low back pain 8/10 and muscle spasms.
Vital Signs:
T 97.9ºF (36.6ºC)
HR 99
BP 135/82
R 20 Correct Ans - Client 3 is assigned an ESI level of 4
A mother brings her 10-month-old infant to the emergency department
reporting vomiting for 2 days. The infant appears lethargic and hypotonic.
Anterior fontanelle is depressed.
Vital Signs:
T 100.4ºF (38ºC)
HR 165
BP 72/40
R 40 Correct Ans - Client 4 is assigned an ESI level of 2
A client presents to the emergency department following a motor vehicle
accident. During the primary survey, the nurse found asymmetric chest
wall movement and absent breath sounds on the left side. What should be
the priority action by the nurse? Correct Ans - Begin ventilation
with 100% oxygen via bag-valve-mask
The body loses heat by four mechanisms: radiation, conduction, convection,
and evaporation. Match the type of heat loss to the example. Correct
Ans - Bed near a cold window = Radiation
Cold operating room table= Conduction
Wind chill= Convection
Wet clothing= Evaporation
The nurse is caring for a homeless client who arrived at the emergency
department with a core body temperature of 87ºF (30.5ºC). What
assessment findings should the nurse anticipate? Select all that apply.
Correct Ans - Kussmaul respirations
Hematocrit 55%
Bradypnea
Shivering
