Chapter 68: Emergency and Disaster Nursing
Lewis: Medical-Surgical Nursing, 10th
Edition Exam Questions And 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 answer ✅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.
,Chapter 68: Emergency and Disaster Nursing
Lewis: Medical-Surgical Nursing, 10th
Edition Exam Questions And Answers
b. obtain a Glasgow Coma Scale score.
c. attach an electrocardiogram monitor.
d. ask about chronic medical conditions. - - -
correct answer ✅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 answer ✅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.
, Chapter 68: Emergency and Disaster Nursing
Lewis: Medical-Surgical Nursing, 10th
Edition Exam Questions And Answers
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 answer ✅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)
Lewis: Medical-Surgical Nursing, 10th
Edition Exam Questions And 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 answer ✅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.
,Chapter 68: Emergency and Disaster Nursing
Lewis: Medical-Surgical Nursing, 10th
Edition Exam Questions And Answers
b. obtain a Glasgow Coma Scale score.
c. attach an electrocardiogram monitor.
d. ask about chronic medical conditions. - - -
correct answer ✅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 answer ✅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.
, Chapter 68: Emergency and Disaster Nursing
Lewis: Medical-Surgical Nursing, 10th
Edition Exam Questions And Answers
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 answer ✅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)
