Chapter 68: Emergency and Disaster Nursing Lewis:
Medical-Surgical Nursing, 10th Edition || Expert-Verified
Questions with Correct Answers.
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. 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.
DIF: Cognitive Level: Apply (application)
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.
DIF: Cognitive Level: Apply (application)
A 22-yr-old patient who experienced a drowning accident in a local pool, but now is awake and
breathing spontaneously, is admitted for observation. Which assessment will be most important
for the nurse to take during the observation period?
a. Auscultate heart sounds. c. Auscultate breath sounds.
b. Palpate peripheral pulses. d. Check mental orientation. correct answers ANS: C
Because pulmonary edema is a common complication after drowning, the nurse should assess the
breath sounds frequently. The other information also will be obtained by the nurse, but it is not
as pertinent to the patient's admission diagnosis.
DIF: Cognitive Level: Analyze (analysis)
A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10
abdominal pain and states, "I had a temperature of 103.9° F (39.9° C) at home." The nurse's first
action should be to
a. assess the patient's current vital signs.
b. give acetaminophen (Tylenol) per agency protocol.
c. ask the patient to provide a clean-catch urine for urinalysis.
,d. tell the patient that it will be 1 to 2 hours before seeing a health care provider. correct answers
ANS: A
The patient's pain and statement about an elevated temperature indicate that the nurse should
obtain vital signs before deciding how rapidly the patient should be seen by the health care
provider. A urinalysis may be appropriate, but this would be done after the vital signs are taken.
The nurse will not give acetaminophen before confirming a current temperature elevation.
DIF: Cognitive Level: Analyze (analysis)
The emergency department (ED) triage nurse is assessing four victims involved in a motor
vehicle collision. Which patient has the highest priority for treatment?
a. A patient with no pedal pulses
b. A patient with an open femur fracture
c. A patient with bleeding facial lacerations
d. A patient with paradoxical chest movement correct answers ANS: D
Most immediate deaths from trauma occur because of problems with ventilation, so the patient
with paradoxical chest movements should be treated first. Face and head fractures can obstruct
the airway, but the patient with facial injuries only has lacerations. The other two patients also
need rapid intervention but do not have airway or breathing problems.
DIF: Cognitive Level: Analyze (analysis)
Gastric lavage and administration of activated charcoal are ordered for an unconscious patient
who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan)
tablets. Which prescribed action should the nurse plan to do first?
a. Insert a large-bore orogastric tube.
b. Assist with intubation of the patient.
c. Prepare a 60-mL syringe with saline.
d. Give first dose of activated charcoal. correct answers ANS: B
In an unresponsive patient, intubation is done before gastric lavage and activated charcoal
administration to prevent aspiration. The other actions will be implemented after intubation.
DIF: Cognitive Level: Analyze (analysis)
An unresponsive patient is admitted to the emergency department (ED) after falling through the
ice while ice skating. Which assessment will the nurse obtain first?
a. Pulse c. Breath sounds
b. Heart rhythm d. Body temperature correct answers ANS: A
The priority assessment in an unresponsive patient relates to CAB (circulation, airway,
breathing) so a pulse check should be performed first. While assessing the pulse, the nurse
should look for signs of breathing. The other data will also be collected rapidly but are not as
essential as determining if there is a pulse.
DIF: Cognitive Level: Apply (application)
, The emergency department (ED) nurse is starting therapeutic hypothermia in a patient who has
been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be
delegated to an experienced licensed practical/vocational nurse (LPN/LVN) (select all that
apply)?
a. Continuously monitor heart rhythm.
b. Assess neurologic status every 2 hours.
c. Give acetaminophen (Tylenol) 650 mg.
d. Place cooling blankets above and below patient.
e. Attach rectal temperature probe to cooling blanket control panel. correct answers ANS: C, D,
E
Experienced LPN/LVNs have the education and scope of practice to implement hypothermia
measures (e.g., cooling blanket, temperature probe) and administer medications under the
supervision of a registered nurse (RN). Assessment of neurologic status and monitoring the heart
rhythm require RN-level education and scope of practice and should be done by the RN.
DIF: Cognitive Level: Apply (application)
The following four patients arrive in the emergency department (ED) after a motor vehicle
collision. In which order should the nurse assess them? (Put a comma and a space between each
answer choice [A, B, C, D, E].)
a. A 74-yr-old patient with palpitations and chest pain
b. A 43-yr-old patient complaining of 7/10 abdominal pain
c. A 21-yr-old patient with multiple fractures of the face and jaw
d. A 37-yr-old patient with a misaligned lower left leg with intact pulses correct answers ANS:
C, A, B, D
The highest priority is to assess the 21-yr-old patient for airway obstruction, which is the most
life-threatening injury. The 74-yr-old patient may have chest pain from cardiac ischemia and
should be assessed and have diagnostic testing for this pain. The 43-yr-old patient may have
abdominal trauma or bleeding and should be seen next to assess circulatory status. The 37-yr-old
patient appears to have a possible fracture of the left leg and should be seen soon, but this patient
has the least life-threatening injury.
DIF: Cognitive Level: Analyze (analysis)
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. 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.
Medical-Surgical Nursing, 10th Edition || Expert-Verified
Questions with Correct Answers.
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. 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.
DIF: Cognitive Level: Apply (application)
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.
DIF: Cognitive Level: Apply (application)
A 22-yr-old patient who experienced a drowning accident in a local pool, but now is awake and
breathing spontaneously, is admitted for observation. Which assessment will be most important
for the nurse to take during the observation period?
a. Auscultate heart sounds. c. Auscultate breath sounds.
b. Palpate peripheral pulses. d. Check mental orientation. correct answers ANS: C
Because pulmonary edema is a common complication after drowning, the nurse should assess the
breath sounds frequently. The other information also will be obtained by the nurse, but it is not
as pertinent to the patient's admission diagnosis.
DIF: Cognitive Level: Analyze (analysis)
A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10
abdominal pain and states, "I had a temperature of 103.9° F (39.9° C) at home." The nurse's first
action should be to
a. assess the patient's current vital signs.
b. give acetaminophen (Tylenol) per agency protocol.
c. ask the patient to provide a clean-catch urine for urinalysis.
,d. tell the patient that it will be 1 to 2 hours before seeing a health care provider. correct answers
ANS: A
The patient's pain and statement about an elevated temperature indicate that the nurse should
obtain vital signs before deciding how rapidly the patient should be seen by the health care
provider. A urinalysis may be appropriate, but this would be done after the vital signs are taken.
The nurse will not give acetaminophen before confirming a current temperature elevation.
DIF: Cognitive Level: Analyze (analysis)
The emergency department (ED) triage nurse is assessing four victims involved in a motor
vehicle collision. Which patient has the highest priority for treatment?
a. A patient with no pedal pulses
b. A patient with an open femur fracture
c. A patient with bleeding facial lacerations
d. A patient with paradoxical chest movement correct answers ANS: D
Most immediate deaths from trauma occur because of problems with ventilation, so the patient
with paradoxical chest movements should be treated first. Face and head fractures can obstruct
the airway, but the patient with facial injuries only has lacerations. The other two patients also
need rapid intervention but do not have airway or breathing problems.
DIF: Cognitive Level: Analyze (analysis)
Gastric lavage and administration of activated charcoal are ordered for an unconscious patient
who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan)
tablets. Which prescribed action should the nurse plan to do first?
a. Insert a large-bore orogastric tube.
b. Assist with intubation of the patient.
c. Prepare a 60-mL syringe with saline.
d. Give first dose of activated charcoal. correct answers ANS: B
In an unresponsive patient, intubation is done before gastric lavage and activated charcoal
administration to prevent aspiration. The other actions will be implemented after intubation.
DIF: Cognitive Level: Analyze (analysis)
An unresponsive patient is admitted to the emergency department (ED) after falling through the
ice while ice skating. Which assessment will the nurse obtain first?
a. Pulse c. Breath sounds
b. Heart rhythm d. Body temperature correct answers ANS: A
The priority assessment in an unresponsive patient relates to CAB (circulation, airway,
breathing) so a pulse check should be performed first. While assessing the pulse, the nurse
should look for signs of breathing. The other data will also be collected rapidly but are not as
essential as determining if there is a pulse.
DIF: Cognitive Level: Apply (application)
, The emergency department (ED) nurse is starting therapeutic hypothermia in a patient who has
been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be
delegated to an experienced licensed practical/vocational nurse (LPN/LVN) (select all that
apply)?
a. Continuously monitor heart rhythm.
b. Assess neurologic status every 2 hours.
c. Give acetaminophen (Tylenol) 650 mg.
d. Place cooling blankets above and below patient.
e. Attach rectal temperature probe to cooling blanket control panel. correct answers ANS: C, D,
E
Experienced LPN/LVNs have the education and scope of practice to implement hypothermia
measures (e.g., cooling blanket, temperature probe) and administer medications under the
supervision of a registered nurse (RN). Assessment of neurologic status and monitoring the heart
rhythm require RN-level education and scope of practice and should be done by the RN.
DIF: Cognitive Level: Apply (application)
The following four patients arrive in the emergency department (ED) after a motor vehicle
collision. In which order should the nurse assess them? (Put a comma and a space between each
answer choice [A, B, C, D, E].)
a. A 74-yr-old patient with palpitations and chest pain
b. A 43-yr-old patient complaining of 7/10 abdominal pain
c. A 21-yr-old patient with multiple fractures of the face and jaw
d. A 37-yr-old patient with a misaligned lower left leg with intact pulses correct answers ANS:
C, A, B, D
The highest priority is to assess the 21-yr-old patient for airway obstruction, which is the most
life-threatening injury. The 74-yr-old patient may have chest pain from cardiac ischemia and
should be assessed and have diagnostic testing for this pain. The 43-yr-old patient may have
abdominal trauma or bleeding and should be seen next to assess circulatory status. The 37-yr-old
patient appears to have a possible fracture of the left leg and should be seen soon, but this patient
has the least life-threatening injury.
DIF: Cognitive Level: Analyze (analysis)
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. 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.
