NUR 417 Exam 3 | Answered with Rationales (Complete Solutions)
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Course
NUR 417
Institution
NUR 417
NUR 417 Exam 3 | Answered with Rationales (Complete Solutions) The nurse is doing the primary survey of an adult who was in a motor vehicle collision. After the nurse determines that the patient has an unobstructed airway, which action would the nurse take next? 1. Palpate extremities for bilate...
The nurse is doing the primary survey of an adult who was in a motor vehicle collision.
After the nurse determines that the patient has an unobstructed airway, which action
would the nurse take next?
1. Palpate extremities for bilateral pulses.
2. Observe the patient's respiratory effort.
3. Check the patient's level of consciousness.
4. Examine the patient for external bleeding.
Even with a patent airway, patients can have other problems that compromise
ventilation, so the next action is to assess the patient's breathing. the other actions are
also part of the initial survey, but assessment of breathing should be done immediately
after assessing for airway patency.
During the primary survey of a patient with severe leg trauma, the nurse observes that
the patient's left pedal and posterior tibial pulses are absent, and the entire leg is
swollen. Which action will the nurse take next?
1. Send blood to the lab for a complete blood count.
2. Assess further for a cause of the decreased circulation.
3. Finish the airway, breathing, circulation, disability survey.
4. Start normal saline fluid infusion with two large-bore IV lines.
The assessment data indicate that the patient may have arterial trauma and
hemorrhage. When a life-threatening injury is found during the primary survey, the
nurse should immediately start interventions before proceeding with the survey.
Although sending off blood for 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.
A patient who had a cardiac arrest has been resuscitated and therapeutic hypothermia
is prescribed. Which action will the nurse include in the plan of care?
1. Hold the prescribed sedative drugs.
2. Check mental status every 15 minutes.
3. Initiate protocol for temperature management.
4. Rewarm if temperature is below 91 F (32.8 C).
Therapeutic hypothermia, also called targeted temperature management (TTM), uses
external cooling devices or cold normal saline infusions to rapidly lower body
,temperature to 89.6 to 93.2 F (32 to 34 C). Because hypothermia will decrease brain
activity, assessing mental status every 15 minutes is not done at this stage. Sedative
drugs are given during therapeutic hypothermia.
A patient who is unconscious after a fall from a ladder is transported to the emergency
department by emergency medical personnel. Which action would the nurse complete
during the primary survey of the patient?
1. Obtain a complete set of vital signs.
2. Check a Glasgow Coma Scale score.
3. Attach an electrocardiogram monitor.
4. Ask about chronic medical conditions.
The Glasgow Coma Scale is included when assessing for disability during the primary
survey. the other information is part of the secondary survey.
A 19-yr-old patient presents to the emergency department (ED) with multiple lacerations
and tissue avulsion of the left hand. The patient denies having any previous
vaccinations. What would the nurse anticipate administering?
1. Tetanus immunoglobulin (TIG) only
2. TIG and tetanus-diphtheria toxoid (Td)
3. Tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only
4. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap)
For an adult with no previous tetanus immunizations, TIG and Tdap are recommended.
the other immunizations are not sufficient for this patient.
A patient who experienced blunt abdominal trauma during a motor vehicle collision
reports increasing abdominal pain. For which procedure would the nurse expect to
prepare the patient?
For patients who are at risk for intraabdominal bleeding, focused abdominal
ultrasonography is the preferred method to assess for intraperitoneal bleeding. An MRI
or CT scan would not be used unless retroperitoneal bleeding is suspected, Peritoneal
lavage is an alternative, but it is more invasive. An NG tube would not be helpful in the
diagnosis of intraabdominal bleeding.
A patient with hypotension and an elevated temperature after working outside on a hot
day is treated in the emergency department (ED). Which patient statement indicates to
the nurse that discharge teaching has been effective?
, 1. "I'll take salt tablets when I work outdoors in the summer."
2. "I should take acetaminophen (Tylenol) if I start to feel too warm."
3. "I need to drink extra fluids when working outside in hot weather."
4. "I'll move to a cool environment if I notice that I'm feeling confused."
Water and oral electrolyte replacement solutions such as sports drinks help replace fluid
and electrolytes lost when exercising in hot weather. Salt tablets are not recommended
because of the risks of gastric irritation and hypernatremia. Antipyretic drugs are not
effective in lowering body temperature elevations caused by excessive exposure to
heat. A patient who is confused is likely to have more severe hyperthermia and will be
unable to remember to take appropriate action.
A 22-yr-old patient who experienced a drowning accident in a local pool, but now is
awake and breathing spontaneously, is admitted for observation. Which assessment will
be most important for the nurse to take during the observation period?
Because pulmonary edema is a common complication after drowning, the nurse should
assess the breath sounds frequently. the other information also will be obtained by the
nurse, but it is not as pertinent to the patient's risks for complications.
The emergency department (ED) nurse is requested to plan for a response to the
potential use of smallpox as a biological weapon. Which resource would the nurse
recommend be obtained?
Smallpox infection can be prevented or ameliorated by the administration of vaccine
given rapidly after exposure. the other interventions would be helpful for other agents of
terrorism but not for smallpox.
Which finding indicates that the nurse should discontinue active rewarming of a patient
admitted with hypothermia?
1. The patient begins to shiver.
2. The BP decreases to 86/42 mm Hg.
3. The patient develops atrial fibrillation.
4. The core temperature is 94 F (34.4 C).
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