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: Concepts of Emergency and Trauma Nursing
— Triage & Prioritization
Question Stem: A 64-year-old man arrives at the emergency
department after a fall from standing with hip pain and external
rotation of the left leg. He is alert, breathing spontaneously, and
hemodynamically stable. Which action should the nurse
perform first?
A. Administer IV analgesia as ordered.
B. Obtain AP and lateral pelvis radiographs.
C. Perform neurovascular assessment of the left lower
,extremity.
D. Prepare the patient for urgent reduction under sedation.
Correct Answer: C
Rationale (Correct): A focused neurovascular assessment
(circulation, sensation, movement) is the immediate nursing
priority to detect limb ischemia or nerve injury and guide
urgent actions. Early assessment identifies complications before
imaging or analgesia. (Application — Ch.10: Triage & Initial
Assessment)
Rationales (Incorrect):
A. Analgesia is important but should follow assessment and
stabilization; analgesia without knowing neurovascular status
may mask deterioration.
B. Imaging is necessary for definitive diagnosis but comes after
initial assessment and stabilization.
D. Urgent reduction is indicated only if neurovascular
compromise or dislocation is confirmed; preparing for reduction
before assessment is premature.
Teaching Point: Always perform neurovascular checks before
interventions that may mask changes.
Citation: Ignatavicius et al., 2023, Ch. 10: Concepts of
Emergency and Trauma Nursing.
2
,Reference: Ch. 10: Concepts of Emergency and Trauma Nursing
— Primary and Secondary Survey / Airway Management
Question Stem: A multisystem trauma patient arrives with noisy
respirations and facial burns. The nurse recognizes signs of
inhalation injury. Which action takes highest priority?
A. Administer humidified oxygen via nasal cannula.
B. Prepare for early endotracheal intubation.
C. Apply moist sterile dressings to facial burns.
D. Order a chest x-ray and carboxyhemoglobin level.
Correct Answer: B
Rationale (Correct): Early airway protection with endotracheal
intubation is the priority if inhalation injury or impending
airway compromise is suspected (facial burns, singed nasal
hairs, hoarseness). Delaying intubation risks airway edema and
difficult airway management. (Analysis — Ch.10: Airway &
Breathing)
Rationales (Incorrect):
A. Humidified oxygen is supportive but may be inadequate if
edema progresses.
C. Dressings for burns do not secure airway or prevent
respiratory compromise.
D. Diagnostics are useful but should not delay securing the
airway.
Teaching Point: Suspected inhalation injury → secure airway
early, before edema makes intubation difficult.
, Citation: Ignatavicius et al., 2023, Ch. 10: Concepts of
Emergency and Trauma Nursing.
3
Reference: Ch. 10: Concepts of Emergency and Trauma Nursing
— Trauma Shock Assessment & Hemorrhage Control
Question Stem: A patient with penetrating abdominal trauma
becomes hypotensive and tachycardic in triage. Which action
should the triage nurse expect to take immediately?
A. Apply direct pressure and rapid transport to the trauma bay.
B. Obtain complete laboratory studies including type and
crossmatch.
C. Prepare the patient for CT abdomen with contrast.
D. Monitor and wait for the on-call surgeon to arrive.
Correct Answer: A
Rationale (Correct): For active hemorrhage with hemodynamic
instability, immediate hemorrhage control (direct pressure) and
rapid transfer to definitive care (trauma bay/OR) are priorities.
Time-sensitive actions outrank diagnostics in unstable patients.
(Application — Ch.10: Hemorrhage Control & Shock)
Rationales (Incorrect):
B. Labs are important but should not delay hemorrhage
control/transfer.
C. CT is contraindicated in hemodynamic instability — delays
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: Concepts of Emergency and Trauma Nursing
— Triage & Prioritization
Question Stem: A 64-year-old man arrives at the emergency
department after a fall from standing with hip pain and external
rotation of the left leg. He is alert, breathing spontaneously, and
hemodynamically stable. Which action should the nurse
perform first?
A. Administer IV analgesia as ordered.
B. Obtain AP and lateral pelvis radiographs.
C. Perform neurovascular assessment of the left lower
,extremity.
D. Prepare the patient for urgent reduction under sedation.
Correct Answer: C
Rationale (Correct): A focused neurovascular assessment
(circulation, sensation, movement) is the immediate nursing
priority to detect limb ischemia or nerve injury and guide
urgent actions. Early assessment identifies complications before
imaging or analgesia. (Application — Ch.10: Triage & Initial
Assessment)
Rationales (Incorrect):
A. Analgesia is important but should follow assessment and
stabilization; analgesia without knowing neurovascular status
may mask deterioration.
B. Imaging is necessary for definitive diagnosis but comes after
initial assessment and stabilization.
D. Urgent reduction is indicated only if neurovascular
compromise or dislocation is confirmed; preparing for reduction
before assessment is premature.
Teaching Point: Always perform neurovascular checks before
interventions that may mask changes.
Citation: Ignatavicius et al., 2023, Ch. 10: Concepts of
Emergency and Trauma Nursing.
2
,Reference: Ch. 10: Concepts of Emergency and Trauma Nursing
— Primary and Secondary Survey / Airway Management
Question Stem: A multisystem trauma patient arrives with noisy
respirations and facial burns. The nurse recognizes signs of
inhalation injury. Which action takes highest priority?
A. Administer humidified oxygen via nasal cannula.
B. Prepare for early endotracheal intubation.
C. Apply moist sterile dressings to facial burns.
D. Order a chest x-ray and carboxyhemoglobin level.
Correct Answer: B
Rationale (Correct): Early airway protection with endotracheal
intubation is the priority if inhalation injury or impending
airway compromise is suspected (facial burns, singed nasal
hairs, hoarseness). Delaying intubation risks airway edema and
difficult airway management. (Analysis — Ch.10: Airway &
Breathing)
Rationales (Incorrect):
A. Humidified oxygen is supportive but may be inadequate if
edema progresses.
C. Dressings for burns do not secure airway or prevent
respiratory compromise.
D. Diagnostics are useful but should not delay securing the
airway.
Teaching Point: Suspected inhalation injury → secure airway
early, before edema makes intubation difficult.
, Citation: Ignatavicius et al., 2023, Ch. 10: Concepts of
Emergency and Trauma Nursing.
3
Reference: Ch. 10: Concepts of Emergency and Trauma Nursing
— Trauma Shock Assessment & Hemorrhage Control
Question Stem: A patient with penetrating abdominal trauma
becomes hypotensive and tachycardic in triage. Which action
should the triage nurse expect to take immediately?
A. Apply direct pressure and rapid transport to the trauma bay.
B. Obtain complete laboratory studies including type and
crossmatch.
C. Prepare the patient for CT abdomen with contrast.
D. Monitor and wait for the on-call surgeon to arrive.
Correct Answer: A
Rationale (Correct): For active hemorrhage with hemodynamic
instability, immediate hemorrhage control (direct pressure) and
rapid transfer to definitive care (trauma bay/OR) are priorities.
Time-sensitive actions outrank diagnostics in unstable patients.
(Application — Ch.10: Hemorrhage Control & Shock)
Rationales (Incorrect):
B. Labs are important but should not delay hemorrhage
control/transfer.
C. CT is contraindicated in hemodynamic instability — delays
