Medical-Surgical Nursing: Concepts for Interprofessional
Collaborative Care (11th Ed.),
Unit II: Emergency Care & Disaster Preparedness.
Medical-Surgical Nursing
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
Reference: Ch. 10: Primary Survey
(Airway/Breathing/Circulation) — Emergency Nursing
Question Stem:
A 34-year-old motor vehicle crash victim arrives with labored
respirations, obvious neck trauma, and snoring sounds. Which
action should the nurse perform first?
A. Apply a cervical collar and logroll to full spinal precautions.
B. Open the airway using the jaw-thrust maneuver while
maintaining cervical stabilization.
C. Insert a nasopharyngeal airway to relieve the snoring.
D. Prepare for rapid sequence intubation (RSI).
Correct Answer: B
,Rationales:
• Correct (B): Jaw-thrust maintains cervical stabilization
while opening the airway — the immediate priority in
trauma is airway with cervical spine protection.
• A: Cervical collar application is important but does not
open the airway; airway maneuvers come first.
• C: Nasopharyngeal airway is contraindicated with
suspected basal skull fracture/penetrating facial trauma
and may not protect the airway.
• D: RSI may be needed, but initial airway opening and
stabilization should occur immediately before preparing for
definitive airway.
Teaching Point:
Airway first — open airway while protecting C-spine in trauma.
Citation:
Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 10: Primary
Survey — Airway/Breathing/Circulation
2.
Reference: Ch. 10: Hemorrhage Control and Shock — Trauma
Nursing
Question Stem:
A patient with penetrating thigh trauma has bright red spurting
,blood and weak rapid pulses. The nurse’s immediate priority is
to:
A. Apply direct pressure and elevate the limb.
B. Start two large-bore IVs proximal to the wound.
C. Apply a pneumatic tourniquet proximal to the wound.
D. Administer IV isotonic crystalloids.
Correct Answer: A
Rationales:
• Correct (A): Immediate direct pressure (and elevation if
appropriate) controls arterial hemorrhage; stopping blood
loss is the first priority to prevent exsanguination.
• B: Establishing IV access is essential but occurs after
hemorrhage control.
• C: A tourniquet may be used if direct pressure fails or in
catastrophic limb hemorrhage, but direct pressure is the
first step.
• D: Fluid resuscitation supports perfusion but should follow
attempts to control active bleeding.
Teaching Point:
Stop external bleeding with direct pressure before other
interventions.
Citation:
Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 10: Hemorrhage
Control and Shock
, 3.
Reference: Ch. 10: Chest Trauma — Emergency Interventions
Question Stem:
A 50-year-old man presents after a fall with asymmetric chest
rise, absent breath sounds on the left, hypotension, and
distended neck veins. Which immediate intervention should the
nurse anticipate?
A. Needle decompression of the left chest.
B. Emergent chest tube placement with underwater seal.
C. High-flow oxygen and observation.
D. Immediate intubation without other interventions.
Correct Answer: A
Rationales:
• Correct (A): Signs suggest tension pneumothorax
(hypotension, JVD, absent breath sounds, asymmetry);
immediate needle decompression relieves pressure and is
lifesaving.
• B: Chest tube is definitive but needle decompression is
performed immediately if tension pneumothorax is
suspected and chest tube cannot be placed instantly.
• C: Oxygen alone is insufficient for tension physiology.
Collaborative Care (11th Ed.),
Unit II: Emergency Care & Disaster Preparedness.
Medical-Surgical Nursing
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
Reference: Ch. 10: Primary Survey
(Airway/Breathing/Circulation) — Emergency Nursing
Question Stem:
A 34-year-old motor vehicle crash victim arrives with labored
respirations, obvious neck trauma, and snoring sounds. Which
action should the nurse perform first?
A. Apply a cervical collar and logroll to full spinal precautions.
B. Open the airway using the jaw-thrust maneuver while
maintaining cervical stabilization.
C. Insert a nasopharyngeal airway to relieve the snoring.
D. Prepare for rapid sequence intubation (RSI).
Correct Answer: B
,Rationales:
• Correct (B): Jaw-thrust maintains cervical stabilization
while opening the airway — the immediate priority in
trauma is airway with cervical spine protection.
• A: Cervical collar application is important but does not
open the airway; airway maneuvers come first.
• C: Nasopharyngeal airway is contraindicated with
suspected basal skull fracture/penetrating facial trauma
and may not protect the airway.
• D: RSI may be needed, but initial airway opening and
stabilization should occur immediately before preparing for
definitive airway.
Teaching Point:
Airway first — open airway while protecting C-spine in trauma.
Citation:
Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 10: Primary
Survey — Airway/Breathing/Circulation
2.
Reference: Ch. 10: Hemorrhage Control and Shock — Trauma
Nursing
Question Stem:
A patient with penetrating thigh trauma has bright red spurting
,blood and weak rapid pulses. The nurse’s immediate priority is
to:
A. Apply direct pressure and elevate the limb.
B. Start two large-bore IVs proximal to the wound.
C. Apply a pneumatic tourniquet proximal to the wound.
D. Administer IV isotonic crystalloids.
Correct Answer: A
Rationales:
• Correct (A): Immediate direct pressure (and elevation if
appropriate) controls arterial hemorrhage; stopping blood
loss is the first priority to prevent exsanguination.
• B: Establishing IV access is essential but occurs after
hemorrhage control.
• C: A tourniquet may be used if direct pressure fails or in
catastrophic limb hemorrhage, but direct pressure is the
first step.
• D: Fluid resuscitation supports perfusion but should follow
attempts to control active bleeding.
Teaching Point:
Stop external bleeding with direct pressure before other
interventions.
Citation:
Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 10: Hemorrhage
Control and Shock
, 3.
Reference: Ch. 10: Chest Trauma — Emergency Interventions
Question Stem:
A 50-year-old man presents after a fall with asymmetric chest
rise, absent breath sounds on the left, hypotension, and
distended neck veins. Which immediate intervention should the
nurse anticipate?
A. Needle decompression of the left chest.
B. Emergent chest tube placement with underwater seal.
C. High-flow oxygen and observation.
D. Immediate intubation without other interventions.
Correct Answer: A
Rationales:
• Correct (A): Signs suggest tension pneumothorax
(hypotension, JVD, absent breath sounds, asymmetry);
immediate needle decompression relieves pressure and is
lifesaving.
• B: Chest tube is definitive but needle decompression is
performed immediately if tension pneumothorax is
suspected and chest tube cannot be placed instantly.
• C: Oxygen alone is insufficient for tension physiology.
