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NUR 417
NUR 417: Exam3 Care of Adult II – Concordia
University St. Paul 2025/2026.
1. Four victims of an automobile crash are brought by ambulance to the
emergency department. The triage nurse determines that the victim who has
the highest priority for treatment is the one with
a. severe bleeding of facial and head lacerations.
b. an open femur fracture with profuse bleeding.
c. a sucking chest wound.
d. absence of peripheral pulses.: C
Rationale: Most immediate deaths from trauma occur because of problems
with ventilation, so the patient with a sucking chest wound should be treated
first. Face and head fractures can obstruct the airway, but the patient with
facial injuries has lacerations only. The other two patients also need rapid
intervention but do not have airway or breathing problems.
NUR 417
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NUR 417
2. The triage nurse is working in the ED. A homeless person is admitted during
a blizzard with complaints
of being unable to feel his feet and lower legs. Core temperature is noted at
3. 2C (91.8F). The patient is intoxicated with alcohol at the time of admission
and is visibly malnourished. What is the triage nurses priority in the care of
this patient?
A) Addressing the patients hypothermia
B) Addressing the patients frostbite in his lower extremities
C) Addressing the patients alcohol intoxication
D) Addressing the patients malnutrition: A
Feedback:
The patient may also have frostbite, but hypothermia takes
precedence in treatment because it is systemic rather than localized.
The alcohol abuse and the alteration in nutrition do not take
precedence
NUR 417
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NUR 417
over the treatment of hypothermia because both problems are a less acute
threat to the patients survival
4. A hospitals emergency operations plan has been enacted following an
industrial accident. While one nurse performs the initial triage, what should
other emergency medical services personnel do?
A. Perform life-saving measures.
B. Classify patients according to acuity.
C. Provide health promotion education.
D. Modify the emergency operations plan.: A
Feedback:
In an emergency, patients are immediately tagged and transported or given
life-saving interventions. One person performs the initial triage while other
emergency medical services (EMS) personnel perform lifesaving measures and
transport patients. Health promotion is not a priority during the acute stage of
the crisis. Classifying patients is the task of the triage nurse. EMS personnel
prioritize life-saving measures; they do not modify the operations plan.
NUR 417
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NUR 417
5. Gastric lavage and administration of activated charcoal are ordered for an
unconscious patient who has been admitted to the emergency department
(ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action
should the nurse plan to do first?
a. Insert a large-bore orogastric tube.
b. Assist with intubation of the patient.
c. Prepare a 60-mL syringe with saline.
d. Give first dose of activated charcoal.: ANS: B
In an unresponsive patient, intubation is done before gastric lavage and
activated charcoal administration to prevent aspiration. The other actions will
be implemented after intubation.
DIF: Cognitive Level: Analyze (analysis)
6. An unresponsive 79-yr-old patient is admitted to the emergency
department
NUR 417
NUR 417
NUR 417: Exam3 Care of Adult II – Concordia
University St. Paul 2025/2026.
1. Four victims of an automobile crash are brought by ambulance to the
emergency department. The triage nurse determines that the victim who has
the highest priority for treatment is the one with
a. severe bleeding of facial and head lacerations.
b. an open femur fracture with profuse bleeding.
c. a sucking chest wound.
d. absence of peripheral pulses.: C
Rationale: Most immediate deaths from trauma occur because of problems
with ventilation, so the patient with a sucking chest wound should be treated
first. Face and head fractures can obstruct the airway, but the patient with
facial injuries has lacerations only. The other two patients also need rapid
intervention but do not have airway or breathing problems.
NUR 417
, 2
NUR 417
2. The triage nurse is working in the ED. A homeless person is admitted during
a blizzard with complaints
of being unable to feel his feet and lower legs. Core temperature is noted at
3. 2C (91.8F). The patient is intoxicated with alcohol at the time of admission
and is visibly malnourished. What is the triage nurses priority in the care of
this patient?
A) Addressing the patients hypothermia
B) Addressing the patients frostbite in his lower extremities
C) Addressing the patients alcohol intoxication
D) Addressing the patients malnutrition: A
Feedback:
The patient may also have frostbite, but hypothermia takes
precedence in treatment because it is systemic rather than localized.
The alcohol abuse and the alteration in nutrition do not take
precedence
NUR 417
, 3
NUR 417
over the treatment of hypothermia because both problems are a less acute
threat to the patients survival
4. A hospitals emergency operations plan has been enacted following an
industrial accident. While one nurse performs the initial triage, what should
other emergency medical services personnel do?
A. Perform life-saving measures.
B. Classify patients according to acuity.
C. Provide health promotion education.
D. Modify the emergency operations plan.: A
Feedback:
In an emergency, patients are immediately tagged and transported or given
life-saving interventions. One person performs the initial triage while other
emergency medical services (EMS) personnel perform lifesaving measures and
transport patients. Health promotion is not a priority during the acute stage of
the crisis. Classifying patients is the task of the triage nurse. EMS personnel
prioritize life-saving measures; they do not modify the operations plan.
NUR 417
, 4
NUR 417
5. Gastric lavage and administration of activated charcoal are ordered for an
unconscious patient who has been admitted to the emergency department
(ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action
should the nurse plan to do first?
a. Insert a large-bore orogastric tube.
b. Assist with intubation of the patient.
c. Prepare a 60-mL syringe with saline.
d. Give first dose of activated charcoal.: ANS: B
In an unresponsive patient, intubation is done before gastric lavage and
activated charcoal administration to prevent aspiration. The other actions will
be implemented after intubation.
DIF: Cognitive Level: Analyze (analysis)
6. An unresponsive 79-yr-old patient is admitted to the emergency
department
NUR 417
