Chapter 21: Emergency and Disaster Nursing Harding: Lewis’s Medical-Surgical Nursing, 12th Edition

MULTIPLE CHOICE 1. 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. 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) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. 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. ANS: D The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although sending off blood for 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. DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 3. 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 91F (32.8C). 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 93.2F (32 to 34C). 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. DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 4. A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. Which action would the nurse complete during the primary survey of the patient? a. Obtain a complete set of vital signs. b. Check a Glasgow Coma Scale score. c. Attach an electrocardiogram monitor. d. Ask about chronic medical conditions. 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) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 5. A 19-yr-old patient presents to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand. The patient denies having any previous vaccinations. What would the nurse anticipate administering? 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)