ATI: MEDICAL SURGICAL (CHAPTER-2 TO 10)
CHAPTER 2
1. What are the five level system of triage?
a. Level 1: Resuscitation
b. Level 2: Emergent
c. Level 3: Urgent
d. Level 4: Less urgent
e. Level 5: Nonurgent
2. Resuscitation requires what?
a. Immediate treatment to prevent death
3. What is required for nonurgent triage (level 5)?
a. Non life threatening condition requiring simple evaluation and care
management
4. What is the standard precaution for primary survey during triage?
a. Gloves
b. Gowns
c. Eye protection
d. Face masks
e. Shoe covers
f. ABCDE guides the primary survey
5. What is the ABCDE principle?
a. Airway/Cervical Spine brain injury/death = 3-5 min. if airway not
patent.
b. Breathing assess presence & effectiveness of breathing.
c. Circulation
d. Disability
e. Exposure
6. How to implement airway for patients who is unresponsive without
suspicious of trauma?
a. Airway opened head tilt, chin lift maneuver
7. How to implement airway for patients who is unresponsive WITH
suspicious trauma?
a. Airway opened modified jaw thrust maneuver
8. How is the modified jaw thrust maneuver performed?
a. Nurse place both hands on either side of the client’s head. Locate the
connection between maxilla and mandible. Lift the jaw superiorly
while maintaining alignment of the cervical spine.
9. During triage, what mask is given to patient who are spontaneously
breathing?
a. Non-breather mask with 100% O2 source
10.What does the breathing assessment include?
, ATI: MEDICAL SURGICAL (CHAPTER-2 TO 10)
a. Auscultation of breath sounds
b. Observation of chest expansion and respiratory effort
c. Notation of rate and depth of respiration
d. Identification of chest trauma
e. Assessment of tracheal position
f. Assessment of JVD
11.How to assess for circulation?
a. Nurse assess HR, BP, peripheral pulses, and capillary refill for
adequate perfusion.
12.What are the precursor to shock that nurses need to be aware of?
a. Cardiac arrest
b. Myocardial dysfunction
c. Hemorrhage
13.What are some interventions that is geared toward restoring effective
circulation?
a. CPR
b. Assess for external bleeding.
c. Hemorrhage control
d. Obtain IV access using large-bore IV catheters inserted into the
antecubital fossa of both arms, unless there is obvious injury to the
extremity.
e. Infuse isotonic IV fluids such as Lactated Ringer’s & 0.9% NaCl &/or
Blood products.
14.What is shock?
a. Body response to inadequate tissue perfusion and oxygenation. It
manifests with an increase HR, hypotension and result in tissue
ischemia and necrosis.
15.What are some intervention that can alleviate shock?
a. Administer oxygen
b. Apply pressure to obvious bleeding
c. Elevate lower extremities to shunt blood to vital organs
d. Administer IV fluids and blood products
e. Monitor VS
f. Remain with client and provide reassurance and support for anxiety.
16.What is the D portion of the ABCDE protocol during triage?
a. Disability quick assessment to determine clients LOC
b. Ex: AVPU (Alert, Response to Voice, Responsive to pain,
Unresponsive), GCS
17.What is the E portion of the ABCDE protocol during triage?
a. Exposure
, ATI: MEDICAL SURGICAL (CHAPTER-2 TO 10)
18.What is the primary concern during the exposure phase during triage?
a. Hypothermia pt. core temperature 35 degree Celsius (95-degree F.)
or less.
i. Why hypothermia for trauma patients? Exposure, un-warmed
oxygen, cold IV fluids
19.What can hypothermia eventually lead to?
a. Coma, hypoxemia, and acidosis
20.What is a contraindication in the first 6-8 hours after the bite (poisoning)?
a. Ice
b. Tourniquets
c. Heparin
d. Corticosteroids
21.Antivenom is effective when?
a. Within 4-12 hour and is based on type and severity of a snake bite
22.What is considered cardiac emergency?
a. Cardiac arrest
b. V. Fib
c. Pulseless V. tach.
d. V. Asystole
e. Pulseless electrical activity (PEA)
23.What is a cardiac arrest?
a. Sudden cessation of cardiac function causes most commonly by V.
fib. or V. sys.
24.What is Ventricular fibrillation?
a. Fluttering of the ventricles causing LOC, pulselessness, no breathing.
Requires collaborative care to defibrillate immediately using ACLS
protocol.
25.What is pulseless V. tach.?
a. Irritable firing of ectopic ventricular beats at a rate of 140 to 180/min.
b. Pt. overtime become unconscious and deteriorate into V. fib.
26.What is v. asystole?
a. Complete absence of electrical activity and ventricular mvmt of heart.
b. Pt. complete cardiac arrest requires implementation of BLS/ACLS
protocol.
27.What is pulseless electrical activity (PEA)?
a. Rhythm appears to have electrical activity but is not sufficient to
stimulate effective cardiac contractions and requires implementation
of BLS/ACLS protocol
28.What are the most common causes of pulseless electrical activity?
5 H’s: 5 T’s:
1. Hypovolemia 1. Toxins
2. Hypoxia 2. Tamponade
3. H+ ion accumulation 3. Tension pneumothorax
acidosis 4. Thrombosis (coronary)
4. Hyperkalemia/hypokalemia 5. Thrombosis (pulmonary)
CHAPTER 2
1. What are the five level system of triage?
a. Level 1: Resuscitation
b. Level 2: Emergent
c. Level 3: Urgent
d. Level 4: Less urgent
e. Level 5: Nonurgent
2. Resuscitation requires what?
a. Immediate treatment to prevent death
3. What is required for nonurgent triage (level 5)?
a. Non life threatening condition requiring simple evaluation and care
management
4. What is the standard precaution for primary survey during triage?
a. Gloves
b. Gowns
c. Eye protection
d. Face masks
e. Shoe covers
f. ABCDE guides the primary survey
5. What is the ABCDE principle?
a. Airway/Cervical Spine brain injury/death = 3-5 min. if airway not
patent.
b. Breathing assess presence & effectiveness of breathing.
c. Circulation
d. Disability
e. Exposure
6. How to implement airway for patients who is unresponsive without
suspicious of trauma?
a. Airway opened head tilt, chin lift maneuver
7. How to implement airway for patients who is unresponsive WITH
suspicious trauma?
a. Airway opened modified jaw thrust maneuver
8. How is the modified jaw thrust maneuver performed?
a. Nurse place both hands on either side of the client’s head. Locate the
connection between maxilla and mandible. Lift the jaw superiorly
while maintaining alignment of the cervical spine.
9. During triage, what mask is given to patient who are spontaneously
breathing?
a. Non-breather mask with 100% O2 source
10.What does the breathing assessment include?
, ATI: MEDICAL SURGICAL (CHAPTER-2 TO 10)
a. Auscultation of breath sounds
b. Observation of chest expansion and respiratory effort
c. Notation of rate and depth of respiration
d. Identification of chest trauma
e. Assessment of tracheal position
f. Assessment of JVD
11.How to assess for circulation?
a. Nurse assess HR, BP, peripheral pulses, and capillary refill for
adequate perfusion.
12.What are the precursor to shock that nurses need to be aware of?
a. Cardiac arrest
b. Myocardial dysfunction
c. Hemorrhage
13.What are some interventions that is geared toward restoring effective
circulation?
a. CPR
b. Assess for external bleeding.
c. Hemorrhage control
d. Obtain IV access using large-bore IV catheters inserted into the
antecubital fossa of both arms, unless there is obvious injury to the
extremity.
e. Infuse isotonic IV fluids such as Lactated Ringer’s & 0.9% NaCl &/or
Blood products.
14.What is shock?
a. Body response to inadequate tissue perfusion and oxygenation. It
manifests with an increase HR, hypotension and result in tissue
ischemia and necrosis.
15.What are some intervention that can alleviate shock?
a. Administer oxygen
b. Apply pressure to obvious bleeding
c. Elevate lower extremities to shunt blood to vital organs
d. Administer IV fluids and blood products
e. Monitor VS
f. Remain with client and provide reassurance and support for anxiety.
16.What is the D portion of the ABCDE protocol during triage?
a. Disability quick assessment to determine clients LOC
b. Ex: AVPU (Alert, Response to Voice, Responsive to pain,
Unresponsive), GCS
17.What is the E portion of the ABCDE protocol during triage?
a. Exposure
, ATI: MEDICAL SURGICAL (CHAPTER-2 TO 10)
18.What is the primary concern during the exposure phase during triage?
a. Hypothermia pt. core temperature 35 degree Celsius (95-degree F.)
or less.
i. Why hypothermia for trauma patients? Exposure, un-warmed
oxygen, cold IV fluids
19.What can hypothermia eventually lead to?
a. Coma, hypoxemia, and acidosis
20.What is a contraindication in the first 6-8 hours after the bite (poisoning)?
a. Ice
b. Tourniquets
c. Heparin
d. Corticosteroids
21.Antivenom is effective when?
a. Within 4-12 hour and is based on type and severity of a snake bite
22.What is considered cardiac emergency?
a. Cardiac arrest
b. V. Fib
c. Pulseless V. tach.
d. V. Asystole
e. Pulseless electrical activity (PEA)
23.What is a cardiac arrest?
a. Sudden cessation of cardiac function causes most commonly by V.
fib. or V. sys.
24.What is Ventricular fibrillation?
a. Fluttering of the ventricles causing LOC, pulselessness, no breathing.
Requires collaborative care to defibrillate immediately using ACLS
protocol.
25.What is pulseless V. tach.?
a. Irritable firing of ectopic ventricular beats at a rate of 140 to 180/min.
b. Pt. overtime become unconscious and deteriorate into V. fib.
26.What is v. asystole?
a. Complete absence of electrical activity and ventricular mvmt of heart.
b. Pt. complete cardiac arrest requires implementation of BLS/ACLS
protocol.
27.What is pulseless electrical activity (PEA)?
a. Rhythm appears to have electrical activity but is not sufficient to
stimulate effective cardiac contractions and requires implementation
of BLS/ACLS protocol
28.What are the most common causes of pulseless electrical activity?
5 H’s: 5 T’s:
1. Hypovolemia 1. Toxins
2. Hypoxia 2. Tamponade
3. H+ ion accumulation 3. Tension pneumothorax
acidosis 4. Thrombosis (coronary)
4. Hyperkalemia/hypokalemia 5. Thrombosis (pulmonary)
