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Chapter 71: Nursing Management: Emergency Care SituationsLewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is conducting a primary assessment of a trauma victim and determines that the
client is breathing and has an unobstructed airway. Which of the following actions should
the nurse take next?
a. Observe the client’s respiratory effort.
b. Check the client’s level of consciousness.
c. Palpate extremities for capillary refill time.
d. Examine the client for any external bleeding.
ANS: A
Even with a patent airway, clients can have other problems that compromise ventilation,
so the next action is to assess the client’s breathing. The evaluation of airway patency and
the effectiveness of breathing always assume highest priority. The other actions also are
part of the initial survey but assessment of breathing should be done immediately after
assessing for airway patency.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
2. The nurse is conducting a primary survey of a client with multiple traumatic injuries and
observes that the client’s right pedal pulses are absent and the leg is swollen. Which of the
following actions will the nurse take next?
a. Assess further for a cause of the decreased circulation.
b. Send blood to the lab for a complete blood count (CBC).
c. Finish the airway, breathing, circulation, disability survey.
d. Initiate isotonic fluid infusion through two large-bore IV lines.
ANS: D
The assessment data indicate that the client 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
CBC 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: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
3. The nurse is assessing a client with hypothermia. Which of the following assessments
should the nurse expect to find?
a. Hypertension
b. Reddened, swollen extremities
c. Hyperventilation
d. Bradycardia
ANS: D
, A client with hypothermia will have bradycardia. The other symptoms a client with
hypothermia may have are hypotension, blue or white extremities, and hypoventilation.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
4. A client who is unconscious after a fall from a ladder is transported to the emergency
department by family members. During the primary survey of the client, which of the
following actions should the nurse implement?
a. Assess the client’s vital signs.
b. Attach a cardiac electrocardiogram (ECG) monitor.
c. Obtain a Glasgow Coma Scale score.
d. Ask about chronic medical conditions.
ANS: C
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: Application TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
5. The nurse is assessing a client who is brought to the emergency department (ED) with
multiple lacerations and tissue avulsion of the right hand. When asked about tetanus
immunization, the client denies having any previous vaccinations. Which of the following
should the nurse anticipate administering to the client?
a. Tetanus-diphtheria toxoid (TD) only
b. Tetanus immunoglobulin (TIG) only
c. Tetanus immunoglobulin (TIG) and tetanus-diphtheria (TD) toxoid
d. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap)
ANS: C
For an adult with no previous tetanus immunizations, TIG and TD are recommended. The
other immunizations are not sufficient for this client.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
6. The nurse is caring for a client who has experienced blunt abdominal trauma during a car
accident and has increasing abdominal pain. Which of the following diagnostic tests
should the nurse prepare the client for?
a. Ultrasonography
b. Peritoneal lavage
c. X-ray
d. Magnetic resonance imaging (MRI)
ANS: A
For clients who are at risk for intra-abdominal bleeding, focused abdominal
ultrasonography is the preferred method to assess for intraperitoneal bleeding-focused
abdominal sonography for trauma (FAST). An MRI would not be used. Peritoneal lavage
is an alternative, but it is more invasive. An x-ray would not be helpful in diagnosis of
intra-abdominal bleeding.
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