Test Bank - Lewis Medical Surgical Nursing, 11th Edition (Harding, 2020),
Chapter 1-68 | All Chapters
1. During the primary assessment of a victim of a motor vehicle collision, the
nurse determines that the patient is breathing and has an unobstructed airway.
Which action should the nurse take next?
a) Palpate extremities for bilateral pulses.
b) Observe the patients respiratory effort.
c) Check the patients level of consciousness.
d) Examine the patient for any external bleeding. - ANSWER ;ANS: B
Even with a patent airway, patients can have other problems that compromise
ventilation, so the next action is to assess the patients breathing. The other
actions are also part of the initial survey but assessment of breathing should be
done immediately after assessing for airway patency.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. During the primary survey of a patient with severe leg trauma, the nurse
observes that the patients left pedal pulse is absent and the leg is swollen. Which
action will the nurse take next?
a) Send blood to the lab for a complete blood count.
b) Assess further for a cause of the decreased circulation.
c) Finish the airway, breathing, circulation, disability survey.
d) Start normal saline fluid infusion with a large-bore IV line. - ANSWER ANS: D
The assessment data indicate that the patient may have arterial trauma and
hemorrhage. When a possibly life- threatening injury is found during the primary
survey, the nurse should immediately start interventions before proceeding with
the survey. Although a complete blood count is indicated, administration of IV
fluids should be started first. Completion of the primary survey and further
assessment should be completed after the IV fluids are initiated.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
, 3. After the return of spontaneous circulation following the resuscitation of a
patient who had a cardiac arrest, therapeutic hypothermia is ordered. Which
action will the nurse include in the plan of care?
a) Apply external cooling device.
b) Check mental status every 15 minutes.
c) Avoid the use of sedative medications.
d) Rewarm if temperature is <91 F (32.8 C). - ANSWER ANS: A
When therapeutic hypothermia is used postresuscitation, external cooling devices
or cold normal saline infusions are used to rapidly lower body temperature to 89.6
F to 93.2 F (32 C to 34 C). Because hypothermia will decrease brain activity,
assessing mental status every 15 minutes is not needed at this stage. Sedative
medications are administered during therapeutic hypothermia.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
4. A patient who is unconscious after a fall from a ladder is transported to the
emergency department by emergency medical personnel. During the primary
survey of the patient, the nurse should
a) obtain a complete set of vital signs.
b) obtain a Glasgow Coma Scale score.
c) ask about chronic medical conditions.
d) attach a cardiac electrocardiogram monitor. - ANSWER ANS: B
The Glasgow Coma Scale is included when assessing for disability during the
primary survey. The other information is part of the secondary survey.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
5. A 19-year-old is brought to the emergency department (ED) with multiple
lacerations and tissue avulsion of the left hand. When asked about tetanus
immunization, the patient denies having any previous vaccinations. The nurse will
anticipate giving
a) tetanus immunoglobulin (TIG) only.
Chapter 1-68 | All Chapters
1. During the primary assessment of a victim of a motor vehicle collision, the
nurse determines that the patient is breathing and has an unobstructed airway.
Which action should the nurse take next?
a) Palpate extremities for bilateral pulses.
b) Observe the patients respiratory effort.
c) Check the patients level of consciousness.
d) Examine the patient for any external bleeding. - ANSWER ;ANS: B
Even with a patent airway, patients can have other problems that compromise
ventilation, so the next action is to assess the patients breathing. The other
actions are also part of the initial survey but assessment of breathing should be
done immediately after assessing for airway patency.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. During the primary survey of a patient with severe leg trauma, the nurse
observes that the patients left pedal pulse is absent and the leg is swollen. Which
action will the nurse take next?
a) Send blood to the lab for a complete blood count.
b) Assess further for a cause of the decreased circulation.
c) Finish the airway, breathing, circulation, disability survey.
d) Start normal saline fluid infusion with a large-bore IV line. - ANSWER ANS: D
The assessment data indicate that the patient may have arterial trauma and
hemorrhage. When a possibly life- threatening injury is found during the primary
survey, the nurse should immediately start interventions before proceeding with
the survey. Although a complete blood count is indicated, administration of IV
fluids should be started first. Completion of the primary survey and further
assessment should be completed after the IV fluids are initiated.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
, 3. After the return of spontaneous circulation following the resuscitation of a
patient who had a cardiac arrest, therapeutic hypothermia is ordered. Which
action will the nurse include in the plan of care?
a) Apply external cooling device.
b) Check mental status every 15 minutes.
c) Avoid the use of sedative medications.
d) Rewarm if temperature is <91 F (32.8 C). - ANSWER ANS: A
When therapeutic hypothermia is used postresuscitation, external cooling devices
or cold normal saline infusions are used to rapidly lower body temperature to 89.6
F to 93.2 F (32 C to 34 C). Because hypothermia will decrease brain activity,
assessing mental status every 15 minutes is not needed at this stage. Sedative
medications are administered during therapeutic hypothermia.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
4. A patient who is unconscious after a fall from a ladder is transported to the
emergency department by emergency medical personnel. During the primary
survey of the patient, the nurse should
a) obtain a complete set of vital signs.
b) obtain a Glasgow Coma Scale score.
c) ask about chronic medical conditions.
d) attach a cardiac electrocardiogram monitor. - ANSWER ANS: B
The Glasgow Coma Scale is included when assessing for disability during the
primary survey. The other information is part of the secondary survey.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
5. A 19-year-old is brought to the emergency department (ED) with multiple
lacerations and tissue avulsion of the left hand. When asked about tetanus
immunization, the patient denies having any previous vaccinations. The nurse will
anticipate giving
a) tetanus immunoglobulin (TIG) only.
