Trauma Exam UPDATED QUESTIONS
AND CORRECT ANSWERS
The health care provider in the emergency department prescribes an infusion of 1 liter of
normal saline over an hour for a client with a traumatic injury, and no peripheral intravenous
(IV) line is available. Which action would the nurse anticipate taking next?
1
Ask the health care provider to insert a central line.
2
Use hypodermoclysis to infuse the prescribed fluids.
3
Insert an intraosseous line and start the prescribed infusion.
4
Continue to attempt to insert a large-gauge peripheral IV line. - CORRECT
ANSWER 3 (When rapid fluid infusion is needed and no IV access is available,
intraosseous (IO) infusion of fluids results in the same rate of absorption as IV infusion.
Although a central line could be inserted, this will take time and the client needs immediate
fluid resuscitation. Hypodermoclysis is used to slowly infuse fluids through the subcutaneous
route, and IV fluids would not be absorbed rapidly enough for this client. The nurse will
continue to insert a peripheral IV line, but this will take time and IO infusion should be
started for the client until an adequate IV line is available.)
When a client is admitted to the unit with a crushed chest, abdominal trauma, a probable head
injury, and multiple fractures, which actions would the nurse take first?
1
Establish an airway and stabilize the cervical spine.
2
Assess heart sounds and find carotid and femoral pulses.
3
Check for alertness, orientation, and pupil reaction to light.
4
,Remove clothing to enable further assessment of injuries. - CORRECT ANSWER 1
(The initial actions after a traumatic injury are based on the ABCDE mnemonic:
Airway/Cervical Spine, Breathing, Circulation, Disability, Exposure. The first action by the
nurse would be to establish a patent airway and ensure that the cervical spine is stabilized.
Assessment of heart sounds and pulses would be done after breath sounds and ventilation
were assessed. Assessment of neurological status is done as part of the disability assessment,
after circulation is assessed. Removal of clothing to enable assessment of other injuries is part
of the exposure assessment, after assessment for disability.)
Which condition of the client with laryngeal trauma and hemoptysis stands first in the priority
list?
1
Dyspnea
2
Aphonia
3
Hoarseness
4
Subcutaneous emphysema - CORRECT ANSWER 1 (Bleeding from the airway,
aphonia, hoarseness, and subcutaneous emphysema are the clinical manifestations of
laryngeal trauma. Maintaining a patent airway is a priority; therefore dyspnea should be
corrected to prevent life-threatening consequences. Aphonia is of moderate priority and can
be corrected by clearing the throat. Hoarseness can be cleared slowly because it does not
threaten the client's life. Subcutaneous emphysema is of moderate priority because it does not
affect the client's life directly.)
A client with a recent history of head trauma is at risk for orthostatic hypotension. Which
assessment finding(s) observed by the nurse would relate to this diagnosis? Select all that
apply. One, some, or all responses may be correct.
1
Fainting
2
Headache
3
,Weakness
4
Lightheadedness
5
Shortness of breath - CORRECT ANSWER 1, 3, 4 (Head trauma may cause blood loss,
and clients with recent blood loss are at risk for orthostatic hypotension. Symptoms of
hypotension include fainting, lightheadedness, and weakness. Headaches and shortness of
breath are symptoms of hypertension.)
Which assessment would the nurse perform first for a client with severe trauma?
1
Airway
2
Disability
3
Breathing
4
Circulation - CORRECT ANSWER 1 (Airway is assessed first in a client with severe
trauma because inadequate oxygen supply can lead to brain injury that can progress to anoxic
brain death. Disability is assessed after the vital signs are assessed. Breathing is assessed after
the airway is assessed and cleared. Circulation is assessed after effective breathing is
ensured.)
In which order based on priority would the emergency department nurse perform
interventions for a severely traumatized client with difficulty breathing because of debris in
the mouth, external hemorrhaging, symptoms of severe hypoglycemia, and bruises on the
skin?
1.
Apply bandages on the bruises.
2.
Administer intravenous glucose.
3.
, Remove the debris from the mouth.
4.
Apply pressure bandages to the bleeding areas. - CORRECT ANSWER 3, 4, 2, 1
(The highest priority intervention for a severely traumatized client is to establish a patent
airway because inadequate oxygen supply to the brain may cause brain death. The priority
nursing intervention is to remove the debris from the client's mouth to ensure a patent airway.
After ensuring a patent airway, the priority is to ensure effective circulation. External
hemorrhage may cause shock and pressure bandages are applied to manage severe bleeding.
After ensuring effective breathing and circulation, metabolic abnormalities are assessed. The
nurse administers intravenous glucose to correct hypoglycemia. A bruise on the skin is
considered to be a minor injury and application of bandages on the bruises is given the lowest
priority.)
In which order would the assessments of a client who is severely injured with burns and has
sustained major trauma from a fire incident occur according to priority?
1.
Monitoring systolic blood pressure
2.
Assessing the score of eye opening
3.
Removing the clothing with scissors
4.
Palpating for the presence of a radial pulse
5.
Providing bag-valve-mask (BVM) ventilation
6.
Using a jaw-thrust maneuver to establish an airway - CORRECT ANSWER 6, 5, 4, 2,
1, 3 (A client with trauma should be assessed for ABCDE—airway-breathing-circulation-
disability-exposure. A jaw-thrust maneuver helps establish an airway and breathing, and
BVM ventilation with a 100% oxygen source ensures ventilatory assistance. After respiratory
assessment is the circulation assessment. The pulse of the client is palpated at the radial,
femoral, and carotid areas, and the systolic blood pressure is monitored. Disability is assessed
using the Glasgow Coma Scale to find out the eye opening, voice, and pain status. The
clothes of the client are removed with scissors to prevent fabric melting into the skin.)
AND CORRECT ANSWERS
The health care provider in the emergency department prescribes an infusion of 1 liter of
normal saline over an hour for a client with a traumatic injury, and no peripheral intravenous
(IV) line is available. Which action would the nurse anticipate taking next?
1
Ask the health care provider to insert a central line.
2
Use hypodermoclysis to infuse the prescribed fluids.
3
Insert an intraosseous line and start the prescribed infusion.
4
Continue to attempt to insert a large-gauge peripheral IV line. - CORRECT
ANSWER 3 (When rapid fluid infusion is needed and no IV access is available,
intraosseous (IO) infusion of fluids results in the same rate of absorption as IV infusion.
Although a central line could be inserted, this will take time and the client needs immediate
fluid resuscitation. Hypodermoclysis is used to slowly infuse fluids through the subcutaneous
route, and IV fluids would not be absorbed rapidly enough for this client. The nurse will
continue to insert a peripheral IV line, but this will take time and IO infusion should be
started for the client until an adequate IV line is available.)
When a client is admitted to the unit with a crushed chest, abdominal trauma, a probable head
injury, and multiple fractures, which actions would the nurse take first?
1
Establish an airway and stabilize the cervical spine.
2
Assess heart sounds and find carotid and femoral pulses.
3
Check for alertness, orientation, and pupil reaction to light.
4
,Remove clothing to enable further assessment of injuries. - CORRECT ANSWER 1
(The initial actions after a traumatic injury are based on the ABCDE mnemonic:
Airway/Cervical Spine, Breathing, Circulation, Disability, Exposure. The first action by the
nurse would be to establish a patent airway and ensure that the cervical spine is stabilized.
Assessment of heart sounds and pulses would be done after breath sounds and ventilation
were assessed. Assessment of neurological status is done as part of the disability assessment,
after circulation is assessed. Removal of clothing to enable assessment of other injuries is part
of the exposure assessment, after assessment for disability.)
Which condition of the client with laryngeal trauma and hemoptysis stands first in the priority
list?
1
Dyspnea
2
Aphonia
3
Hoarseness
4
Subcutaneous emphysema - CORRECT ANSWER 1 (Bleeding from the airway,
aphonia, hoarseness, and subcutaneous emphysema are the clinical manifestations of
laryngeal trauma. Maintaining a patent airway is a priority; therefore dyspnea should be
corrected to prevent life-threatening consequences. Aphonia is of moderate priority and can
be corrected by clearing the throat. Hoarseness can be cleared slowly because it does not
threaten the client's life. Subcutaneous emphysema is of moderate priority because it does not
affect the client's life directly.)
A client with a recent history of head trauma is at risk for orthostatic hypotension. Which
assessment finding(s) observed by the nurse would relate to this diagnosis? Select all that
apply. One, some, or all responses may be correct.
1
Fainting
2
Headache
3
,Weakness
4
Lightheadedness
5
Shortness of breath - CORRECT ANSWER 1, 3, 4 (Head trauma may cause blood loss,
and clients with recent blood loss are at risk for orthostatic hypotension. Symptoms of
hypotension include fainting, lightheadedness, and weakness. Headaches and shortness of
breath are symptoms of hypertension.)
Which assessment would the nurse perform first for a client with severe trauma?
1
Airway
2
Disability
3
Breathing
4
Circulation - CORRECT ANSWER 1 (Airway is assessed first in a client with severe
trauma because inadequate oxygen supply can lead to brain injury that can progress to anoxic
brain death. Disability is assessed after the vital signs are assessed. Breathing is assessed after
the airway is assessed and cleared. Circulation is assessed after effective breathing is
ensured.)
In which order based on priority would the emergency department nurse perform
interventions for a severely traumatized client with difficulty breathing because of debris in
the mouth, external hemorrhaging, symptoms of severe hypoglycemia, and bruises on the
skin?
1.
Apply bandages on the bruises.
2.
Administer intravenous glucose.
3.
, Remove the debris from the mouth.
4.
Apply pressure bandages to the bleeding areas. - CORRECT ANSWER 3, 4, 2, 1
(The highest priority intervention for a severely traumatized client is to establish a patent
airway because inadequate oxygen supply to the brain may cause brain death. The priority
nursing intervention is to remove the debris from the client's mouth to ensure a patent airway.
After ensuring a patent airway, the priority is to ensure effective circulation. External
hemorrhage may cause shock and pressure bandages are applied to manage severe bleeding.
After ensuring effective breathing and circulation, metabolic abnormalities are assessed. The
nurse administers intravenous glucose to correct hypoglycemia. A bruise on the skin is
considered to be a minor injury and application of bandages on the bruises is given the lowest
priority.)
In which order would the assessments of a client who is severely injured with burns and has
sustained major trauma from a fire incident occur according to priority?
1.
Monitoring systolic blood pressure
2.
Assessing the score of eye opening
3.
Removing the clothing with scissors
4.
Palpating for the presence of a radial pulse
5.
Providing bag-valve-mask (BVM) ventilation
6.
Using a jaw-thrust maneuver to establish an airway - CORRECT ANSWER 6, 5, 4, 2,
1, 3 (A client with trauma should be assessed for ABCDE—airway-breathing-circulation-
disability-exposure. A jaw-thrust maneuver helps establish an airway and breathing, and
BVM ventilation with a 100% oxygen source ensures ventilatory assistance. After respiratory
assessment is the circulation assessment. The pulse of the client is palpated at the radial,
femoral, and carotid areas, and the systolic blood pressure is monitored. Disability is assessed
using the Glasgow Coma Scale to find out the eye opening, voice, and pain status. The
clothes of the client are removed with scissors to prevent fabric melting into the skin.)
