Chapter 21: Emergency and Disaster Nursing || Questions
Answered with Absolute Accuracy.
The nurse is doing the primary survey of an adult who was in a motor vehicle collision. After the
nurse determines that the patient has an unobstructed airway, which action would 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 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 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.
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 two large-bore IV lines. 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.
A patient who had a cardiac arrest has been resuscitated and therapeutic hypothermia is
prescribed. Which action will the nurse include in the plan of care?
a. Hold the prescribed sedative drugs.
b. Check mental status every 15 minutes.
c. Initiate protocol for temperature management.
d. Rewarm if temperature is below 91F correct answers ANS: C
Therapeutic hypothermia, also called targeted temperature management (TTM), uses external
cooling devices or cold normal saline infusions to rapidly lower body temperature to 89.6 to
93.2F (32 to 34C). 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.
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. 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.
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). correct answers ANS: D
For an adult with no previous tetanus immunizations, TIG and Tdap are recommended. The other
immunizations are not sufficient for this patient.
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
a.
peritoneal lavage.
b.
abdominal ultrasonography.
c.
nasogastric (NG) tube placement.
d.
magnetic resonance imaging (MRI). correct answers ANS: B
For patients who are at risk for intraabdominal bleeding, focused abdominal ultrasonography is
the preferred method to assess for intraperitoneal bleeding. An MRI would not be used.
Peritoneal lavage is an alternative, but it is more invasive. An NG tube would not be helpful in
the diagnosis of intraabdominal bleeding.
A patient with hypotension and an elevated temperature after working outside on a hot day is
treated in the emergency department (ED). The nurse determines that discharge teaching has
been effective when the patient makes which statement?
a.
"I'll take salt tablets when I work outdoors in the summer."
b.
"I should take acetaminophen (Tylenol) if I start to feel too warm."
c.
"I need to drink extra fluids when working outside in hot weather."
Answered with Absolute Accuracy.
The nurse is doing the primary survey of an adult who was in a motor vehicle collision. After the
nurse determines that the patient has an unobstructed airway, which action would 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 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 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.
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 two large-bore IV lines. 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.
A patient who had a cardiac arrest has been resuscitated and therapeutic hypothermia is
prescribed. Which action will the nurse include in the plan of care?
a. Hold the prescribed sedative drugs.
b. Check mental status every 15 minutes.
c. Initiate protocol for temperature management.
d. Rewarm if temperature is below 91F correct answers ANS: C
Therapeutic hypothermia, also called targeted temperature management (TTM), uses external
cooling devices or cold normal saline infusions to rapidly lower body temperature to 89.6 to
93.2F (32 to 34C). 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.
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. 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.
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). correct answers ANS: D
For an adult with no previous tetanus immunizations, TIG and Tdap are recommended. The other
immunizations are not sufficient for this patient.
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
a.
peritoneal lavage.
b.
abdominal ultrasonography.
c.
nasogastric (NG) tube placement.
d.
magnetic resonance imaging (MRI). correct answers ANS: B
For patients who are at risk for intraabdominal bleeding, focused abdominal ultrasonography is
the preferred method to assess for intraperitoneal bleeding. An MRI would not be used.
Peritoneal lavage is an alternative, but it is more invasive. An NG tube would not be helpful in
the diagnosis of intraabdominal bleeding.
A patient with hypotension and an elevated temperature after working outside on a hot day is
treated in the emergency department (ED). The nurse determines that discharge teaching has
been effective when the patient makes which statement?
a.
"I'll take salt tablets when I work outdoors in the summer."
b.
"I should take acetaminophen (Tylenol) if I start to feel too warm."
c.
"I need to drink extra fluids when working outside in hot weather."
