TRAUMA NURSING PROCESS UPDATED
QUESTION BANK AND CLINICAL
RESPONSE FRAMEWORK REVIEW
MATERIAL
●● 2. Which should the nurse do to avoid patient accidents?
a. Provide a cane for walking if the patient is weak
b. Determine the strength of a patient before walking
c. Apply a vest restraint when a patient is using the wheelchair
d. Keep the overbed table in front of a patient sitting in a chair
Answer: b
●● 3. Which assessment by the nurse most likely indicates that a patient
is having difficulty breathing?
a. 18 breaths per minute and inhaled through the mouth
b. 20 breaths per minute and shallow in character
c. 16 breaths per minute and deep in character
d. 28 breaths per minute and noisy
Answer: d
●● 4. Which should a nurse always do when taking a rectal temperature?
a. Allow self-insertion of the thermometer
,b. Position the patient on the left side
c. Use an electronic thermometer
d. Lubricate the thermometer
Answer: d
●● 5. A nurse is assessing a patient's ideal body weight. Which
significant factor should be taken into consideration when performing
this assessment?
a. Daily intake
b. Body height
c. Clothing size
d. Food preference
Answer: b
●● 6. A nurse asks a patient's wife specific questions about the patient's
health status before admission. When collecting this information, the
nurse is seeking information for a:
a. Primary source
b. Tertiary source
c. Subjective source
d. Secondary source
Answer: d
,●● 7. A nurse is performing a physical assessment of a newly admitted
patient. Which patient statement communicates subjective data?
a. "I have sores between my toes"
b. "I dye my hair but it is really gray"
c. "My joints hurt when I get up in the morning"
d. "My left leg drags the floor when I am walking"
Answer: c
●● 8. Which is an example of nonverbal communications?
a. Letter
b. Holding hands
c. Noise in the room
d. Telephone message
Answer: b
●● 9. A nurse takes a patient's blood pressure and records a diastolic
pressure of 120 mm Hg. Which should the nurse do first?
a. Notify the primary health-care provider
b. Retake the blood pressure
c. Notify the nurse in charge
d. Take the other vital signs
Answer: b
, ●● 10. A patient returns to the surgical unit from the post anesthesia care
unit after abdominal surgery. The primary health-care provider orders
intravenous fluids, oxygen via nasal cannula at 2 L/min, I&O, and vital
signs every 2 hours. Two hours after surgery the patient voids 400 mL of
amber urine. What should the nurse do with this information?
a. Report this information to the primary health-care provider.
b. Record this amount on the patient's intake and output flow sheet
c. Document this information on the patient's vital signs flow sheet
d. Communicate this event verbally to the other members of the health-
care team.
Answer: b
●● 11. A patient had a brain attack (i.e., stroke, cerebrovascular
accident) that resulted in paralysis of the right side. When clustering
data, the nurse grouped the following data together: drooling of saliva
and slurred speech. Which information is most significant to include
with this clustered data.
a. Receptive aphasia
b. Inability to ambulate
c. Difficulty swallowing
d. Incontinence of bowel movements
Answer: c
●● 12. A nurse understands that pressure ulcers are most often
associated with patients who:
QUESTION BANK AND CLINICAL
RESPONSE FRAMEWORK REVIEW
MATERIAL
●● 2. Which should the nurse do to avoid patient accidents?
a. Provide a cane for walking if the patient is weak
b. Determine the strength of a patient before walking
c. Apply a vest restraint when a patient is using the wheelchair
d. Keep the overbed table in front of a patient sitting in a chair
Answer: b
●● 3. Which assessment by the nurse most likely indicates that a patient
is having difficulty breathing?
a. 18 breaths per minute and inhaled through the mouth
b. 20 breaths per minute and shallow in character
c. 16 breaths per minute and deep in character
d. 28 breaths per minute and noisy
Answer: d
●● 4. Which should a nurse always do when taking a rectal temperature?
a. Allow self-insertion of the thermometer
,b. Position the patient on the left side
c. Use an electronic thermometer
d. Lubricate the thermometer
Answer: d
●● 5. A nurse is assessing a patient's ideal body weight. Which
significant factor should be taken into consideration when performing
this assessment?
a. Daily intake
b. Body height
c. Clothing size
d. Food preference
Answer: b
●● 6. A nurse asks a patient's wife specific questions about the patient's
health status before admission. When collecting this information, the
nurse is seeking information for a:
a. Primary source
b. Tertiary source
c. Subjective source
d. Secondary source
Answer: d
,●● 7. A nurse is performing a physical assessment of a newly admitted
patient. Which patient statement communicates subjective data?
a. "I have sores between my toes"
b. "I dye my hair but it is really gray"
c. "My joints hurt when I get up in the morning"
d. "My left leg drags the floor when I am walking"
Answer: c
●● 8. Which is an example of nonverbal communications?
a. Letter
b. Holding hands
c. Noise in the room
d. Telephone message
Answer: b
●● 9. A nurse takes a patient's blood pressure and records a diastolic
pressure of 120 mm Hg. Which should the nurse do first?
a. Notify the primary health-care provider
b. Retake the blood pressure
c. Notify the nurse in charge
d. Take the other vital signs
Answer: b
, ●● 10. A patient returns to the surgical unit from the post anesthesia care
unit after abdominal surgery. The primary health-care provider orders
intravenous fluids, oxygen via nasal cannula at 2 L/min, I&O, and vital
signs every 2 hours. Two hours after surgery the patient voids 400 mL of
amber urine. What should the nurse do with this information?
a. Report this information to the primary health-care provider.
b. Record this amount on the patient's intake and output flow sheet
c. Document this information on the patient's vital signs flow sheet
d. Communicate this event verbally to the other members of the health-
care team.
Answer: b
●● 11. A patient had a brain attack (i.e., stroke, cerebrovascular
accident) that resulted in paralysis of the right side. When clustering
data, the nurse grouped the following data together: drooling of saliva
and slurred speech. Which information is most significant to include
with this clustered data.
a. Receptive aphasia
b. Inability to ambulate
c. Difficulty swallowing
d. Incontinence of bowel movements
Answer: c
●● 12. A nurse understands that pressure ulcers are most often
associated with patients who:
