Chapter 10: Concepts of Emergency and
Trauma Nursing
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A trauma client with multiple open wounds is brought to the emergency department in
cardiac arrest. Which action would the nurse take prior to providing advanced cardiac
life support?
a. Contact the on-call orthopedic surgeon.
b. Don personal protective equipment.
c. Notify the Rapid Response Team.
d. Obtain a complete history from the paramedic.
ANS: B
Nurses must recognize and plan for a high risk of contamination with blood and body
fluids when engaging in trauma resuscitation. Standard Precautions would be taken in
all resuscitation situations and at other times when exposure to blood and body fluids
is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a
facemask, a surgical cap, and shoe covers. It is not known if this client has orthopedic
injuries. The Rapid Response Team is not needed in the ED. A complete history is
needed but the staff’s protection comes first.
DIF: Applying TOP: Integrated Process: Nursing Process: Planning
KEY: Emergency nursing, Standard Precautions MSC: Client
Needs Category: Safe and Effective Care Environment: Safety and Infection
Control
, 2. A nurse is triaging clients in the emergency department. Which client would be
considered “urgent”?
a. A 20-year-old female with a chest stab wound and tachycardia
b. A 45-year-old homeless man with a skin rash and sore throat
c. A 75-year-old female with a cough and a temperature of 102° F (38.9° C)
d. A 50-year-old male with new-onset confusion and slurred speech
ANS: C
A client with a cough and a temperature of 102° F (38.9° C) is urgent. This client is at
risk for deterioration and needs to be seen quickly, but is not in an immediately life-
threatening situation. The client with a chest stab wound and tachycardia and the
client with new-onset confusion and slurred speech would be triaged as emergent. The
client with a skin rash and a sore throat is not at risk for deterioration and would be
triaged as nonurgent.
DIF: Applying TOP: Integrated Process: Nursing Process: Planning
KEY: Emergency nursing, Triage MSC: Client Needs Category:
Safe and Effective Care Environment: Management of Care
3. An emergency department nurse is caring for a client who has died from a suspected
homicide. Which action does the nurse take?
a. Remove all tubes and wires in preparation for the medical examiner.
b. Limit the number of visitors to minimize the family’s trauma.
c. Consult the bereavement committee to follow up with the grieving family.
d. Communicate the client’s death to the family in a simple and concrete manner.
ANS: D
When dealing with clients and families in crisis, communicate in a simple and
concrete manner to minimize confusion. Tubes must remain in place for the medical
examiner. Family would be allowed to view the body. Offering to call for additional
family support during the crisis is suggested. The bereavement committee would be
consulted, but this is not the priority at this time.
Trauma Nursing
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A trauma client with multiple open wounds is brought to the emergency department in
cardiac arrest. Which action would the nurse take prior to providing advanced cardiac
life support?
a. Contact the on-call orthopedic surgeon.
b. Don personal protective equipment.
c. Notify the Rapid Response Team.
d. Obtain a complete history from the paramedic.
ANS: B
Nurses must recognize and plan for a high risk of contamination with blood and body
fluids when engaging in trauma resuscitation. Standard Precautions would be taken in
all resuscitation situations and at other times when exposure to blood and body fluids
is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a
facemask, a surgical cap, and shoe covers. It is not known if this client has orthopedic
injuries. The Rapid Response Team is not needed in the ED. A complete history is
needed but the staff’s protection comes first.
DIF: Applying TOP: Integrated Process: Nursing Process: Planning
KEY: Emergency nursing, Standard Precautions MSC: Client
Needs Category: Safe and Effective Care Environment: Safety and Infection
Control
, 2. A nurse is triaging clients in the emergency department. Which client would be
considered “urgent”?
a. A 20-year-old female with a chest stab wound and tachycardia
b. A 45-year-old homeless man with a skin rash and sore throat
c. A 75-year-old female with a cough and a temperature of 102° F (38.9° C)
d. A 50-year-old male with new-onset confusion and slurred speech
ANS: C
A client with a cough and a temperature of 102° F (38.9° C) is urgent. This client is at
risk for deterioration and needs to be seen quickly, but is not in an immediately life-
threatening situation. The client with a chest stab wound and tachycardia and the
client with new-onset confusion and slurred speech would be triaged as emergent. The
client with a skin rash and a sore throat is not at risk for deterioration and would be
triaged as nonurgent.
DIF: Applying TOP: Integrated Process: Nursing Process: Planning
KEY: Emergency nursing, Triage MSC: Client Needs Category:
Safe and Effective Care Environment: Management of Care
3. An emergency department nurse is caring for a client who has died from a suspected
homicide. Which action does the nurse take?
a. Remove all tubes and wires in preparation for the medical examiner.
b. Limit the number of visitors to minimize the family’s trauma.
c. Consult the bereavement committee to follow up with the grieving family.
d. Communicate the client’s death to the family in a simple and concrete manner.
ANS: D
When dealing with clients and families in crisis, communicate in a simple and
concrete manner to minimize confusion. Tubes must remain in place for the medical
examiner. Family would be allowed to view the body. Offering to call for additional
family support during the crisis is suggested. The bereavement committee would be
consulted, but this is not the priority at this time.
