Trauma

The nurse assesses for which client symptoms that indicate hyperthermia? Select all that apply. One, some, or all responses may be correct. 1 Vasodilation 2 Dry and flushed skin 3 Pale and cyanotic skin 4 Decreased capillary refill 5 Decreased urinary output

1, 2, 5 (During hyperthermia, vasodilation occurs that causes the flushed appearance of the skin; as a result, the skin may be warm to the touch. Hyperthermia causes loss of water from the body and results in dry skin and mucous membranes, decreased urinary output, and other signs of dehydration and electrolyte imbalance. Clients with hyperthermia may not have pale and cyanotic skin; instead, they have dry, flushed skin. Clients with hyperthermia may not have decreased capillary refill; instead, they have increased capillary refill.

Which assessment in a traumatized client does the nurse make with the Glasgow Coma Scale? 1 Patency of airway 2 Level of consciousness 3 Breathing abnormalities 4 Circulatory abnormalities

2 (The nurse uses the Glasgow Coma Scale while performing a primary survey of a traumatized client to assess the level of consciousness. Patency of airway is assessed by manually checking the client's oral cavity. Breathing abnormalities are assessed by checking the chest wall of the client. Circulatory abnormalities are assessed by checking the blood volume.)

Which statement by the student nurse requires further teaching about which action would be provided for a client who survived an earthquake and presents with abdominal trauma to the emergency department? 1 "I should ensure a patent airway." 2 "I should provide fluid replacement therapy." 3 "I should remove an impaled object immediately." 4 "I should insert a nasogastric tube to decompress the stomach."

3 (An impaled object should not be removed until skilled care is provided because it may increase the risk of bleeding. A patent airway should be established to ensure adequate breathing. The client should be provided with fluid replacement to prevent hypotension. A nasogastric tube is inserted to decompress the stomach and to prevent aspiration.)

6. Which is the correct ordering sequence for assessment in the primary survey a. Airway, breathing, circulation, expose, disability b. Airway/c-spine, breathing, circulation, disability, expose c. Airway, circulation, breathing, disability, expose d. Airway, breathing, circulation, disability, expose

B

16. In which patient should you consider intubation? a. Localizes pain, disoriented, opens eyes only to pain b. Opens eyes to verbal command, uses inappropriate words, withdrawls from pain c. Opens eyes to pain, incomprehensible sounds, displays abnormal flexion d. Opens eyes to pain, disoriented, localizes to pain

C

14. Patient with rib fractures, 02 sat of 78%, and no breath sounds on the L chest. You anticipate need for... a. Needle thoracostomy and chest tube placement b. Two large bore IVs and LR c. Chest CT d. endotracheal tube and ventilation

a

10. A patient with a displaced fracture is a _____ triage tier level a. Emergent b. Urgent c. Nonurgent

b

15. The fluid of choice for the initial resucitation for a poly-trauma patient is... a. 0.45% normal saline b. 0.9% normal saline c. Blood d. Plasma expanders (Hespan)

b

11. In the ED who should you treat first? a. Pneumonia b. Multiple fractures c. Active hemorrhage d. Rash

c

18. What is the priority for managing spinal cord injuries a. Vasopressin for neurogenic shock b. Methylprednisolone started within 8 hours of injury c. Immobilization d. Preventing hypothermia blow level of injury

c

A health care provider prescribes dexamethasone for a client with head trauma. The nurse recognizes that it reduces swelling in the brain by which process? 1 Acts as a hyperosmotic diuretic 2 Increases resistance to infection 3 Reduces the inflammatory response of tissues 4 Decreases the formation of cerebrospinal fluid

3 (Corticosteroids act to decrease inflammation, which decreases edema. Dexamethasone is an anti-inflammatory agent, not a diuretic. Resistance to infection is decreased, not increased, with a corticosteroid. The client's problem is not with increased cerebrospinal fluid.)

A client arrived in the emergency department with a posttraumatic brain injury and multiple fractures. The client's eyes remain closed, and there is no evidence of verbalization or movement when the nurse changes the client's position. Which score on the Glasgow Coma Scale (GCS) would the nurse document? Record your answer using a whole number. _______ Total GCS score

3 (The score is 3. The score on the GCS ranges from 3 to 15. The client's lack of response earns the minimum of 1 point in each of the categories: eye opening response, best verbal response, and best motor response.)

A patient in the ED complains of itching and rash. What triage tier are they? a. Urgent b. Nonurgent c. Emergent d. Expectant

B

Your patient arrives via ambulance with a GCS of less than 8. what do you need to do first a. Check his/her pupils b. Check for posturing c. Check his/her airway d. Assess for head injury

C

17. What are two early and reliable indications for compartment syndrome a. Pain, paresthesia b. Pulselessness below injury, pain c. Swelling, pain d. Paresthesia, swelling

a

A client with a recent history of head trauma is at risk for orthostatic hypotension. Which assessment finding(s) observed by the nurse would relate to this diagnosis? Select all that apply. One, some, or all responses may be correct. 1 Fainting 2 Headache 3 Weakness 4 Lightheadedness 5 Shortness of breath

1, 3, 4 (Head trauma may cause blood loss, and clients with recent blood loss are at risk for orthostatic hypotension. Symptoms of hypotension include fainting, lightheadedness, and weakness. Headaches and shortness of breath are symptoms of hypertension.)

Which is the correct order of steps the nurse will implement when providing care to a client who has experienced trauma? 1. Clear the airway. 2. Perform chest compressions. 3. Provide supplemental oxygen to trauma client (O2). 4. Protect the cervical spine.

1, 4, 3, 2 (The first step the nurse takes when providing care to a trauma client is to clear the airway. The second step is to protect the cervical spine. The third step is to provide supplemental O2. The fourth step is to perform chest compressions.)

When the chest x-ray for a client who has arrived at the emergency department with chest trauma shows multiple fractured ribs, which action will the nurse take next? 1 Administer the prescribed morphine sulfate. 2 Assist the client to take deep breaths and cough. 3 Check for paradoxical movement of the chest wall. 4 Teach the client about ways to manage rib pain.

3 (Flail chest can occur when multiple ribs are fractured and can compromise breathing efforts because of paradoxical movement during inspiration and expiration. Flail chest may require intubation and mechanical ventilation. Analgesic medication administration will be needed, because rib fractures make breathing painful, but further assessment of the client's ventilatory effort is needed prior to giving narcotic pain medications. The client with fractured ribs will need to deep breathe and cough to prevent atelectasis and pneumonia, but assessing for possible flail chest would be done first. Education about management of pain is needed, but this would be done after assessing for possible respiratory distress caused by flail chest.)

Which nursing action allows for a thorough assessment of a trauma client to prioritize the client's care? 1 Avoiding manipulation of the client's limbs 2 Asking a family member about any client medication allergies 3 Cutting fabric that is stuck to the client's skin with scissors 4 Auscultating heart and lung sounds through the client's clothing

3 (The nurse would remove all clothing to allow for a thorough assessment of the trauma client to accurately prioritize care. Cutting fabric that is stuck to the client's skin with scissors is the appropriate action by the nurse. It is necessary to avoid manipulation of the client's limbs during the trauma assessment. Although it is important to ask a family member about any client medication allergies, this is done after the initial assessment of the client. Clothing is always removed to allow for an accurate trauma assessment.)

A client is en route to the emergency department after sustaining a gunshot wound to the chest. Which priority nursing action would the nurse take to prepare for the arrival of the client? 1 Reserve an operating room. 2 Organize equipment for a tracheotomy. 3 Prepare equipment for chest tube insertion. 4 Arrange for a portable chest x-ray examination.

3 (The priority is to reinflate the lungs and stabilize the client's respiratory status. Reserving an operating room may be necessary later but is premature at this time. Organizing equipment for a tracheotomy is unnecessary; an endotracheal tube should be used for maintenance of the airway if necessary. Arranging for a portable chest x-ray examination is not the priority at this time; this may be done later.)

Which type of shock would the nurse suspect when a client is admitted to the emergency department after a motor vehicle accident with abdominal pain, a blood pressure decrease from 120/76 mm Hg to 60/40 mm Hg, and a heart rate increase from 82 beats/minute to 121 beats/minute? 1 Septic shock 2 Cardiogenic shock 3 Hemorrhagic shock 4 Neurogenic shock

3 (With a history of a traumatic injury and abdominal pain associated with assessment findings of hypotension and tachycardia, the most likely type of shock is hemorrhagic. A client with septic shock would have tachycardia and hypotension, but symptoms would also include fever and warm, flushed skin. Cardiogenic shock might also present with tachycardia and hypotension, but the client would report chest discomfort and dyspnea. Neurogenic shock presents with hypotension and bradycardia.)

In which order based on priority would the emergency department nurse perform interventions for a severely traumatized client with difficulty breathing because of debris in the mouth, external hemorrhaging, symptoms of severe hypoglycemia, and bruises on the skin? 1. Apply bandages on the bruises. 2. Administer intravenous glucose. 3. Remove the debris from the mouth. 4. Apply pressure bandages to the bleeding areas.

3, 4, 2, 1 (The highest priority intervention for a severely traumatized client is to establish a patent airway because inadequate oxygen supply to the brain may cause brain death. The priority nursing intervention is to remove the debris from the client's mouth to ensure a patent airway. After ensuring a patent airway, the priority is to ensure effective circulation. External hemorrhage may cause shock and pressure bandages are applied to manage severe bleeding. After ensuring effective breathing and circulation, metabolic abnormalities are assessed. The nurse administers intravenous glucose to correct hypoglycemia. A bruise on the skin is considered to be a minor injury and application of bandages on the bruises is given the lowest priority.)

Which rewarming method is appropriate specifically for a client suffering from severe hypothermia? 1 Using radiant lights 2 Using air-filled warming blankets 3 Immersing the client in warm water 4 Applying heated humidified oxygen

4 (Active internal or core rewarming is recommended for moderate to severe hypothermia. Application of humidified oxygen, heated up to 111.2°F (44°C), is a type of active internal or core rewarming method. Using radiant lights is a method of passive or spontaneous rewarming. Using air-filled warming blankets and immersing the client in warm water are methods of active external or surface rewarming. Both passive and active external rewarming methods are used for mild hypothermia)

7. You would place an NG tube and foley during the ____ survey a. Primary b. Secondary

b

8. Which is more life-threatening? A pneumothorax or a tension pneumothorax a. Pneumothorax b. Tension pneumothorax

b

20. In a mass casualty situation which category of patients do you triage first a. Expectant (black) b. Urgent (yellow) c. Emergent (red) d. Nonurgent (green)

d

9. Which of the following patients is most likely to develop renal failure secondary to injury a. A pt with a history of heart disease b. The patient requiring fluid resuscitation for 1 hour after trauma c. The patient with a urine output of 50ml/hr d. The patient who suffered a crush injury to the lower extremities

d

3. What level trauma center is UAB a. 1 b. 2 c. 3 d. 4

A

1. A patient enters the ED with respiratory distress. What triage tier are they? a. Back of the line b. Nonurgent c. Urgent d. Emergent

D

Which condition of the client with laryngeal trauma and hemoptysis stands first in the priority list? 1 Dyspnea 2 Aphonia 3 Hoarseness 4 Subcutaneous emphysema

1 (Bleeding from the airway, aphonia, hoarseness, and subcutaneous emphysema are the clinical manifestations of laryngeal trauma. Maintaining a patent airway is a priority; therefore dyspnea should be corrected to prevent life-threatening consequences. Aphonia is of moderate priority and can be corrected by clearing the throat. Hoarseness can be cleared slowly because it does not threaten the client's life. Subcutaneous emphysema is of moderate priority because it does not affect the client's life directly.)

A client with hypothermia is brought to the emergency department. Which treatment would the nurse anticipate? 1 Core rewarming with warm fluids 2 Ambulation to increase metabolism 3 Frequent oral temperature assessments 4 Gastric tube feedings to increase fluid volume

1 (Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is the preferred method of treatment. The client will be too weak to ambulate. Oral temperatures are not the most accurate assessment of core temperature because of environmental influences. Warmed oral feedings are advised; gavage feedings are unnecessary.)

Which assessment finding of a client being treated in the emergency department after a motor vehicle collision indicates the need for immediate health care provider intervention? Select all that apply. One, some, or all responses may be correct. 1 Facial edema 2 Septal deviation 3 Clear nasal drainage 4 Oxygen saturation 89% 5 Bilateral periorbital bruising

1, 2, 3, 4, 5 (Facial edema and septal deviation indicate that the client has sustained facial injuries. Clear nasal drainage is an indication of a cerebrospinal fluid leak, and the nurse would immediately report the finding and send the drainage to be tested for glucose. An oxygen level of 89% would be reported to the health care provider as it could indicate nonvisible injuries. "Raccoon eyes" or bilateral periorbital bruising indicates a basilar skull fracture and requires immediate medical treatment.)

A client is admitted to the emergency department with extensive wounds after a motor vehicle accident. Which member of the health care team is best suited to care for this client in the emergency department? 1 Charge nurse 2 Registered nurse 3 Licensed practical nurse 4 Unlicensed nursing personnel

2 (A registered nurse would be the health care team member to care for the client in the emergency department. The charge nurse's role includes making client assignments, scheduling breaks for staff members, and serving as a staff resource person. The licensed practical nurse is involved in fast-track emergency care. Unlicensed nursing personnel perform all hygienic tasks and are not required in the emergency care unit.)

Which intervention would the nurse implement to help prevent atelectasis in a client with fractured ribs as a result of chest trauma? 1 Apply a thoracic binder for support. 2 Encourage coughing and deep breathing. 3 Defer pain medication the first day after injury. 4 Position the client face-down on a soft mattress.

2 (Atelectasis with impaired gas exchange is a major complication when clients use shallow breathing to avoid pain; coughing and deep breathing help mobilize secretions. Applying a thoracic binder for support may impede deep breathing and coughing, which help prevent atelectasis. Analgesics are essential to diminish pain caused by breathing and to help motivate the client to cough and to breathe deeply. The prone position may diminish breathing for both lungs and is contraindicated.)

In which order would the nurse perform interventions for an emergency department client with facial trauma presenting with dyspnea, cyanosis, and external bleeding? 1. Administer supplemental oxygen (O2). 2. Perform jaw-thrust maneuver. 3. Remove the client's clothing to perform a thorough physical examination. 4. Measure client's level of consciousness. 5. Apply direct pressure with a sterile dressing.

2, 1, 5, 4, 3 (Facial trauma can obstruct the airway and cause respiratory compromise. Opening the airway using the jaw-thrust maneuver is priority for this client. Once the airway is opened, adequate ventilation should be ensured by administering supplemental O2. After ensuring the airway patency, circulation should be assessed and direct pressure applied with a sterile dressing on the bleeding site. After ensuring respiration and circulation, the client's level of consciousness should be determined. Then all clothing should be removed to perform thorough physical assessment. Topics)

Which nursing interventions are most appropriate for a client who survived a fire in the hospital and is found to have neck trauma, dyspnea, gasping breathing, and is unable to speak? Select all that apply. One, some, or all responses may be correct. 1 Placing a nasogastric tube 2 Performing jaw-thrust maneuver 3 Prepare assist in performing endotracheal intubation 4 Monitoring respiratory rate and oxygen saturation 5 Monitoring the heart rate and rhythm continuously

2, 3 (The jaw-thrust maneuver may help in opening a client's airway. Endotracheal intubation may assist the client in obtaining proper breathing. A nasogastric tube should not be placed in the client with neck trauma because it could enter the brain. Monitoring the respiratory rate and oxygen saturation is required after performing the jaw-thrust maneuver and endotracheal intubation may be required in this situation. Heart rate and rhythm should be monitored continuously in an emergency condition to assess the condition after the client has stabilized breathing.)

In which order, from the most to the least urgent, would the emergency department nurse triage clients based on the clients' conditions? 1. Multiple trauma 2. Minor burns 3. Simple laceration 4. Gynecological disorder 5. Overdose and bradypnea

5, 1, 4, 3, 2

Which activity places a client at risk for hyperthermia? 1 Snowmobiling 2 Skiing in the winter 3 Hiking Alaskan mountains 4 Performing strenuous activity in high humidity

4 (When a client performs strenuous activity in high humidity, it reduces heat loss from the body and results in hyperthermia. Activities such as snowmobiling, skiing, and hiking in cold weather may cause hypothermia because they occur in cold temperatures and may lower the body temperature.)

What is the Glasgow Coma Scale score for a client who, after a trauma, has difficulty opening his or her eyes to pain, has an abnormal flexion motor response, and speaks inappropriate words? Record your answer using a whole number. _________

8 (The client having pain opening the eyes scores 2 points, abnormal flexion motor response scores 3 points, and inappropriate words scores 3 points, which adds up to 8. A client scoring 8 points on the Glasgow Coma Scale after trauma requires medium priority.)

The purpose of a primary survey in a trauma situation is a. Identify and treat life-threatening conditions b. Identify life-threatening conditions c. Collect a good patient history d. Collect patient health info

A

12. In a mass casualty situation, what triage category would you triage first? a. Emergent (red) b. Expectant (black) c. Urgent (yellow) d. Non-urgent (green)

d

Which nursing action has the highest priority when the nurse is providing care to a trauma client whose primary survey indicates a Glasgow Coma Scale (GCS) score of 7? 1 Preparing for intubation 2 Observing for chest wall trauma 3 Covering the client with a blanket 4 Applying direct pressure to the client's wound

1 (If the Glasgow Coma Scale (GCS) score is 8 or less, the priority action by the nurse is to prepare for endotracheal intubation because the client is at risk for airway compromise. Observing for chest wall trauma, covering the client with a blanket, and applying direct pressure to a bleeding wound are all appropriate actions but not the priority.)

Which intervention would the nurse perform when caring for a client in the emergency department reporting chest pain? Select all that apply. One, some, or all responses may be correct. 1 Providing oxygen 2 Assessing vital signs 3 Obtaining a 12-lead EKG 4 Drawing blood for cardiac enzymes 5 Auscultating heart sounds 6 Administering nitroglycerin

1, 2, 3, 4, 5, 6 (The nurse would provide oxygen to a client with chest pain, as the heart may be getting insufficient oxygen as a result of occluded coronary vessels. The nurse would also assess the client's vital signs, obtain a 12-lead EKG, and auscultate heart sounds to determine rhythm changes related to cardiac ischemia. The nurse would need to draw blood for evaluation of cardiac enzymes. Changes in the levels of these enzymes (including troponin, creatine kinase, and myoglobin) can indicate damage to heart tissue. Nitroglycerin is administered to promote coronary vasodilation.)

Which are the priority nursing actions when providing care to a trauma client? Select all that apply. One, some, or all responses may be correct. 1 Starting a large-bore intravenous (IV) line 2 Immobilizing any obvious deformities 3 Providing emotional support to the client 4 Assigning team members to support caregivers 5 Removing clothing to allow for an adequate examination

1, 2, 5 (The priority nursing actions when providing care for a trauma client include starting a large-bore IV, immobilizing any obvious deformities, and removing clothing to allow for an adequate examination. Although providing emotional support to the client and assigning team members to support the caregivers are appropriate interventions, these are not the priorities at this time.)

Which nursing actions are the priority actions after the completion of the secondary survey when providing care for a trauma client with a penetrating wound? Select all that apply. One, some, or all responses may be correct. 1 Documenting the client's care 2 Formulating the client's plan of care 3 Reassessing the client's level of consciousness 4 Administering tetanus prophylaxis to the client 5 Transferring the client to the general medical unit

1, 4 (The priority nursing actions after completion of the secondary survey during the emergency assessment include documenting all client care and administering tetanus prophylaxis. Formulating the client's plan of care, reassessing level of consciousness, and transferring the client to the general medical unit are nursing actions implemented once the client is stable.)

Which disaster triage tag would the nurse apply to the group of clients who have extensive full-thickness body burns and severe head trauma after an apartment building fire and clients who require mechanical ventilation for survival? 1 Red 2 Black 3 Green 4 Yellow

2 (Clients with extensive full-thickness body burns, severe head trauma, and high cervical spinal cord injury requiring mechanical ventilation are given black tags because they are expected to die. Clients with airway obstruction or shock are given red tags because they require immediate attention. Clients with open fractures with a distal pulse and large wounds that need treatment within 30 minutes to 2 hours are given yellow tags. Green tags are issued to clients with minor injuries.)

A client who is admitted to the emergency department with a blood pressure of 240/150 mm Hg reports severe headache, blurred vision, and swelling of the ankles. Which prescribed action would the nurse take first? 1 Obtain a glucose blood sample. 2 Collect urine and blood samples. 3 Assess the client's pulse and respirations. 4 Determine the amount of ankle edema.

3 (Baseline pulse and respiratory rates are needed rapidly to help detect complications of hypertension such as heart failure and dysrhythmias. Because changes in glucose level are not likely to have caused the client's current hypertension, checking the glucose level is not needed immediately. Collecting urine and blood samples is not the priority at this time; this may be done later. The nurse will need to assess and document the amount of ankle edema, but this is not a life-threatening symptom.)

In which order would the nurse perform interventions for the jaw-thrust maneuver on an unconscious client admitted in the emergency unit with traumatic injuries and a suspected a spinal injury? 1. Stand or kneel at the top of the client's head. 2. Rest elbows on the surface. 3. Lay the client in the supine position. 4. Grasp the client's lower jaw and lift forward with both hands without tilting the head. 5. Place one hand on each side of the client's head.

3, 1, 2, 5, 4 (Jaw-thrust maneuver is performed to open the airway of an unconscious client with possible spinal or neck injury. The client should be laid in supine position and the nurse would kneel at the top of the client's head to initiate the procedure. This position allows access to the peritoneal, thoracic, and pericardial regions. This should be followed by resting the elbows on the surface and placing one hand on each side of the client's head. Grasping the client's lower jaw and lifting forward with both hands without tilting the head helps lift of the epiglottis and enlarge the laryngeal inlet and the pharynx, thereby resulting in improved ventilation.)

When categorizing victims of hypothermia as having mild, moderate, and severe hypothermia, which assessment findings will help the nurse identify the clients with moderate hypothermia? Select all that apply. One, some, or all responses may be correct. 1 Asystole 2 Lethargy 3 Hypovolemia 4 Respiratory acidosis 5 Fixed and dilated pupils

3, 4 (Moderate hypothermia causes hypovolemia and metabolic and respiratory acidosis. Asystole may be present in severe hypothermia; in fact, metabolic rate, heart rate, and respirations are so slow in severe hypothermia that they may be difficult to detect. Lethargy is a characteristic of mild hypothermia. Reflexes are absent in severe hypothermia, and the pupils are fixed and dilated.)

Which health concern has the highest priority for the nurse to monitor for after removing clothing from a client with burn trauma? 1 Bradypnea 2 Bradycardia 3 Hypotension 4 Hypothermia

4 (After the removal of the burn client's clothing, the priority for the nurse is to monitor for hypothermia because burn trauma clients lose their ability to maintain body temperature because of the loss of skin, which acts as an insulator. Although the nurse will monitor for bradypnea, bradycardia, and hypotension, hypothermia is the priority for a client with burn trauma.)

The emergency department nurse would provide immediate care based on priority to the client with which condition? 1 Second-degree burns 2 Blunt abdominal trauma 3 Closed fracture of the right arm 4 Repeated tonic-clonic seizures

4 (The client with tonic-clonic seizures may experience severe muscle contractions, which is a life-threatening complication. This client should be provided with immediate care. Clients with second-degree burns should be given second priority of care because their conditions may worsen if treatment is not provided as early as possible. Blunt abdominal trauma can be a serious condition if internal bleeding is found, but still does not require as immediate care as the seizures. Clients with closed arm fractures can be provided with care later, depending on the other clients in the emergency department.)

19. Which of the following patients would NOT be classified as emergent a. Patient with unstable vital signs b. Patient with severe abdominal pain c. Patient experiencing a stroke d. Patient in respiratory distress

b

Which assessment would the nurse perform first for a client with severe trauma? 1 Airway 2 Disability 3 Breathing 4 Circulation

1 (Airway is assessed first in a client with severe trauma because inadequate oxygen supply can lead to brain injury that can progress to anoxic brain death. Disability is assessed after the vital signs are assessed. Breathing is assessed after the airway is assessed and cleared. Circulation is assessed after effective breathing is ensured.)

Which causative agent is common to both hyperthermia and hypothermia? 1 Alcohol 2 Barbiturates 3 Phenothiazines 4 Cardiovascular disease

1 (Alcohol is the causative agent that is common to both hyperthermia and hypothermia. Barbiturates and phenothiazines can cause hypothermia. Cardiovascular disease can cause hyperthermia.)

How will the nurse document this rhythm for a client in the emergency department? . 1 Normal sinus rhythm 2 Sinus tachycardia 3 Sinus bradycardia 4 Sinus arrhythmia

1 (In normal sinus rhythm, atrial and ventricular rhythms are regular, there is a P wave before every QRS complex and all the P waves have the same shape. The rate is between 60 beats/minute to 100 beats/minute. Sinus tachycardia also has regular atrial and ventricular rates, with P waves before each QRS complex, but the rate is higher than 100. In sinus bradycardia, the atrial and ventricular rhythms are regular, there is a P wave before each QRS complex, and the rate is less than 60 beats/minute. Sinus arrhythmia is a variant of normal sinus rhythm and results from changes in intrathoracic pressure with respiration. The rate increases slightly with inspiration and slows slightly with expiration. There is a P wave before each QRS.)

Which level of trauma center would provide these to a group of clients who sustained severe injuries in an earthquake and need a full continuum of trauma services? 1 Level I 2 Level II 3 Level III 4 Level IV

1 (Level I trauma centers are usually located in large teaching hospital systems in densely populated areas and they provide a full continuum of trauma services for all clients. Level III trauma centers are typically located in community hospitals and are able to provide care for clients with major injuries up to stabilization before transporting them to higher-level centers if they require more resources for treatment. Level II trauma centers are community-based trauma centers that can provide care to most injured clients. However, if needs exceed resource capabilities, these centers transport the clients to higher level trauma centers. Level IV trauma centers provide basic trauma client stabilization and advanced life support within resource capabilities.)

Which client in the emergency department would the nurse assess first? 1 Client with chest pressure and ST segment elevation on the electrocardiogram 2 Client who reports a sharp chest pain with deep inspiration for the past week 3 Client who has history of heart failure with ascites and bilateral 4+ ankle swelling 4 Client with palpitations and paroxysmal atrial fibrillation at a rate of 136 beats/minute

1 (The client with chest pressure and ST segment elevation on the electrocardiogram will need emergency treatment for ST segment elevation myocardial infarction (STEMI), including transport to the cardiac catheterization laboratory for percutaneous coronary intervention within 90 minutes, and should be seen first. The client with sharp pain with deep inspiration has symptoms consistent with pericarditis or pleural effusion and does need rapid assessment and treatment, but is not at risk for life-threatening complications. The client with heart failure and ascites and ankle swelling has symptoms of right ventricular failure that are not life-threatening. The client with palpitations and rapid atrial fibrillation will need assessment and evaluation, but the client experiencing myocardial infarction has a more life-threatening diagnosis.)

When a client is admitted to the unit with a crushed chest, abdominal trauma, a probable head injury, and multiple fractures, which actions would the nurse take first? 1 Establish an airway and stabilize the cervical spine. 2 Assess heart sounds and find carotid and femoral pulses. 3 Check for alertness, orientation, and pupil reaction to light. 4 Remove clothing to enable further assessment of injuries.

1 (The initial actions after a traumatic injury are based on the ABCDE mnemonic: Airway/Cervical Spine, Breathing, Circulation, Disability, Exposure. The first action by the nurse would be to establish a patent airway and ensure that the cervical spine is stabilized. Assessment of heart sounds and pulses would be done after breath sounds and ventilation were assessed. Assessment of neurological status is done as part of the disability assessment, after circulation is assessed. Removal of clothing to enable assessment of other injuries is part of the exposure assessment, after assessment for disability.)

Which action would the nurse initiate first for the client admitted to the emergency department due to blunt abdominal trauma? 1 Ensure a patent airway. 2 Monitor the level of consciousness. 3 Infuse warm normal saline solution. 4 Maintain client warmth using blankets.

1 (The nurse would first ensure a patent airway and administer oxygen via a nonrebreather mask to the client with abdominal trauma. The client's level of consciousness should be monitored after providing the initial treatment. The client should be administered normal saline intravenously once the airway has been stabilized. The client should be provided with blankets to maintain warmth after immediate care is provided.)

Which trauma center will the nurse recommend transfer for the most critical clients involved in a multiple-vehicle accident? 1 Level I 2 Level II 3 Level III 4 Level IV

1 (The nurse would recommend transport of the most critical clients after a multiple motor vehicle accident to a level I trauma center because it provides a full continuum of trauma services for all clients. Level II and III trauma centers can stabilize critical clients but will usually have to transfer them to level I trauma centers. A level IV trauma center is only capable of providing basic stabilization before transfer to a level I trauma center.)

Which are the priority nursing actions related to breathing assessments in a primary survey during an emergency assessment? Select all that apply. One, some, or all responses may be correct. 1 Having suction available 2 Giving supplemental oxygen 3 Assessing pupil size and reactivity 4 Immobilizing any obvious deformities 5 Obtaining blood samples for type and crossmatch

1, 2 (The priority nursing actions related to breathing when conducting a primary survey during an emergency assessment include having suction available and giving supplemental oxygen. The critical words in this stem are breathing assessment. Assessing pupil size and reactivity is an appropriate nursing action during the brief neurologic assessment. Immobilization of any obvious deformities is a nursing action appropriate in response to data obtained during the disability portion of the assessment. Obtaining blood samples for a type and crossmatch is a nursing action appropriate in response to data obtained during the circulation portion of the assessment.)

When preparing to admit a near-drowning victim to the emergency department, which action by the nurse has the highest priority? 1 Obtain equipment for nasogastric tube insertion to decompress the stomach. 2 Get the endotracheal intubation tray ready for insertion of an artificial airway. 3 Have warming blankets and hyperthermia machine available to warm the client. 4 Call for laboratory personnel to be in the emergency department to draw blood.

2 (Because the duration and severity of hypoxia are the most important factors in determining outcomes for near-drowning victims, the highest priority is to ensure rapid treatment of hypoxemia with intubation and mechanical ventilation. The other actions are also needed. Gastric distension decreases the ability of the lungs to fully expand and nasogastric suctions is usually needed for near-drowning victims, but is not as high a priority as intubation and mechanical ventilation. Hypothermia frequently accompanies submersion and warming of the client should begin as quickly as possible once intubation and mechanical ventilation are initiated. Multiple laboratory tests are needed to determine treatments and blood specimens should be obtained as soon as possible after the client's gas exchange is addressed.)

Which sign of compartment syndrome would the nurse assess for in the client who has sustained blunt trauma to the forearm? 1 Warm skin at the site of injury 2 Escalating pain in the fingers 3 Rapid capillary refill in affected hand 4 Bounding radial pulse in the injured arm

2 (Elevated tissue pressure restricts blood flow, causing increasing ischemia and increasing pain; it is the cardinal early symptom of compartment syndrome. The arm will feel cool, not warm, because of a decrease in circulation. Sluggish, not rapid, capillary refill is a sign of compartment syndrome. The pulse will be diminished, not bounding; increasing edema impairs circulation.)

Which client condition would the nurse keep in mind while performing a rewarming procedure in a client with severe hypothermia? 1 The client is at risk for hypertension from rewarming shock. 2 The client should be monitored for after drop during rewarming. 3 The cold myocardium should be stimulated in a hypothermic client. 4 The core of the client with severe hypothermia should be warmed after the extremities.

2 (Rewarming places the client at risk for after drop, a further drop in core temperature. This occurs when cold peripheral blood returns to the central circulation. So, the core temperature of the client should be monitored carefully during rewarming. Rewarming shock can produce hypotension, not hypertension. The cold myocardium is extremely irritable, making it vulnerable to dysrhythmias. Gentle handling is essential to prevent the myocardium from being stimulated. Clients with moderate to severe hypothermia should have the core warmed before the extremities to prevent rewarming shock.)

MVA, compound femur fracture, BP: 92/50, R: 30 After reviewing the chart for a client who was recently admitted to the emergency department, which intervention will the nurse anticipate implementing immediately? 1 Pain medication 2 Intravenous fluids 3 Multiple antibiotics 4 Packed red blood cells

2 (The client probably is experiencing hypovolemic shock, as evidenced by the vital signs (elevated pulse and respirations and low blood pressure). Intravenous fluids will help correct the hypovolemia. Analgesics should not be administered until after the client is assessed fully, particularly for a head injury. Antibiotics may be prescribed eventually, but this is not the initial intervention. Packed red blood cells eventually may be administered, but this depends on an additional physical assessment and hematologic laboratory tests.)

When a client in the emergency department has a blood pressure of 90/60 mm Hg, weak quality radial pulse of 108 beats/minute, and reports working outside for several hours on a hot day, which prescribed action would the nurse take first? 1 Complete a head-to-toe assessment. 2 Start infusion of normal saline 500 mL. 3 Ask the client about current medications. 4 Obtain blood samples for laboratory testing.

2 (The low blood pressure, tachycardia, and report of being outside for several hours on a hot day suggest hypovolemia, indicating a need for immediate fluid replacement. The head-to-toe assessment is important, but can be completed after the intravenous fluids are started. Asking about the client's usual medications is necessary, but this information would not affect the decision for fluid infusion in this hypovolemic client. The client will need to have blood drawn to check electrolytes and renal function, but the infusion of fluids to prevent complications such as acute kidney injury is the priority.)

A client was admitted to the hospital with blunt trauma to the abdomen. The client was treated for a lacerated liver and abdominal hemorrhage. During the recovery period, the nurse would monitor the client for which indications of peritonitis? Select all that apply. One, some, or all responses may be correct. 1 Jaundice 2 Boardlike abdomen 3 Abdominal tenderness 4 Decreased bowel sounds 5 Rapid decrease in coagulation ability

2, 3, 4 (A boardlike abdomen is associated with the inflammatory process in the peritoneum. Abdominal tenderness is caused by the local inflammatory process and resulting bowel distention and irritation of the peritoneum. A decrease or absence of bowel sounds occurs in response to bowel distention caused by gas and shifting of fluid into the bowel. Jaundice is not a sign of peritonitis; it is caused by a disturbance in bilirubin metabolism. A rapid decrease in coagulation ability is associated with acute liver failure, not peritonitis.)

When a client comes to the emergency department with moderate substernal chest pain that is unrelieved by rest and nitroglycerin, which prescribed action has the highest priority? 1 Administer morphine sulfate. 2 Transfer to the coronary care unit. 3 Obtain a 12-lead electrocardiogram (ECG). 4 Have a blood specimen drawn for troponin studies.

3 (Current guidelines state that an ECG should be done and reviewed by the health care provider within 10 minutes of the arrival of a client with possible acute coronary syndrome. The other actions are also essential. Administration of morphine sulfate will be done to relieve pain, but the ECG has priority, because the presence or absence of ECG changes will determine whether the client needs immediate interventions such as percutaneous coronary intervention or thrombolysis. The client will be transferred as quickly as possible to the coronary care unit, but the ECG would be done in the emergency department. Obtaining blood for troponin should be done as quickly as possible, but presence or absence of elevated troponin will not affect decision-making about the client's immediate care.)

When a client with blunt trauma to the nose is noted to have nasal swelling, ecchymosis around the eyes, and watery pink-tinged nasal drainage, which action will the nurse take? 1 Assist the client to the supine position with no pillow. 2 Have the client squeeze the lower nose for 10 minutes. 3 Send a specimen of the fluid to the laboratory for analysis. 4 Apply warm moist packs to the client's nose and eyes.

3 (Pink-tinged nasal drainage after blunt nasal trauma indicates a possible cerebrospinal fluid leak, and the fluid would be sent to the laboratory to check for glucose. Clients who have nasal trauma are maintained in an upright position to reduce swelling. Squeezing the lower nose would be done for nosebleed, but watery pink nasal drainage is not characteristic of epistaxis. Cold packs would be used to minimize swelling and bleeding.)

After the initial assessment, which earthquake survivor with chest trauma would the disaster management nurse treat first? 1 Client A with muffled, distant heart sounds, neck vein distention 2 Client B with paradoxical movement of chest wall, respiratory distress 3 Client C with cyanosis, air hunger, violent agitation, tracheal deviation away from affected side 4 Client D with hyper-resonance to percussion, diminished or absent breath sounds on the affected side

3 (The assessment findings of cyanosis, air hunger, violent agitation, and tracheal deviation away from affected side indicate tension pneumothorax. This is a medical emergency and intervening by needle decompression is appropriate. Muffled, distant heart sounds and neck vein distention indicate cardiac tamponade; pericardiocentesis with surgical repair may be appropriate. Paradoxical movement of chest wall and respiratory distress indicate flail chest. Stabilizing flail segment with positive pressure ventilation is appropriate. Hyper-resonance to percussion and diminished or absent breath sounds on the affected side indicate pneumothorax. The treatment for this includes chest tube insertion with a flutter valve or chest drainage system.)

Which condition will be given the highest priority for a client admitted in the emergency department who has airway obstruction, chest wall trauma, external hemorrhage, and hypoglycemia? 1 Hypoglycemia 2 Chest wall trauma 3 Airway obstruction 4 External hemorrhage

3 (The highest priority intervention is to establish a patent airway because inadequate oxygen supply to the brain may cause brain death. Assessing the metabolic conditions is done after the airway is cleared. Once the airway is cleared, then the chest wall of the client is assessed. Hemorrhage is assessed after the airway of the client is cleared.)

Which action would the nurse perform as the highest priority for a client with trauma in the emergency unit? 1 Applying dry dressing 2 Evaluating chest expansion 3 Providing adequate oxygen (O2) supply. 4 Applying direct pressure on a bleeding site

3 (The nurse would prioritize care while caring for a client with trauma in the emergency department. Evaluation of chest expansion and respiratory effort, as well as evidence of chest wall trauma, helps assess breathing, a primary survey. The highest priority intervention is to establish a patent airway by providing adequate O2 supply, thereby reducing the brain injury and progression to anoxic brain death. Direct application of pressure on the bleeding site with thick, dry dressing material helps reduce external hemorrhage.)

Which nursing action is the priority when providing care to a trauma client? 1 Monitoring vital signs 2 Maintaining vascular access 3 Assessing respiratory effort 4 Evaluating level of consciousness

3 (When providing care during the primary survey of a trauma client, the priority action is assessing respiratory effort. The nurse prioritizes care by assessing the ABCs—airway-breathing-circulation. Once this is completed, the nurse will monitor vital signs, maintain vascular access, and then evaluate level of consciousness.)

The health care provider in the emergency department prescribes an infusion of 1 liter of normal saline over an hour for a client with a traumatic injury, and no peripheral intravenous (IV) line is available. Which action would the nurse anticipate taking next? 1 Ask the health care provider to insert a central line. 2 Use hypodermoclysis to infuse the prescribed fluids. 3 Insert an intraosseous line and start the prescribed infusion. 4 Continue to attempt to insert a large-gauge peripheral IV line.

3 (When rapid fluid infusion is needed and no IV access is available, intraosseous (IO) infusion of fluids results in the same rate of absorption as IV infusion. Although a central line could be inserted, this will take time and the client needs immediate fluid resuscitation. Hypodermoclysis is used to slowly infuse fluids through the subcutaneous route, and IV fluids would not be absorbed rapidly enough for this client. The nurse will continue to insert a peripheral IV line, but this will take time and IO infusion should be started for the client until an adequate IV line is available.)

In which order would the emergency department nurse triage the clients based on the threat to organs? 1. Cystitis 2. Hip fracture 3. Intubated trauma 4. Chest pain resulting from ischemia 5. Minor burns

3, 4, 2, 1, 5 (A client with intubated trauma is categorized as emergency severity index 1 (ESI-1), which indicates that the life or organ threat is obvious, and the client needs to be seen immediately. The client with chest pain resulting from ischemia is categorized under the ESI-2, which indicates the organ condition is likely to be life-threatening but is not obvious. The client with a hip fracture is categorized under ESI-3, which describes that the threat to organs is low, and the client can be seen after 1 hour. The client with cystitis is categorized under ESI-4 because there is no threat to life or organs, and the assessment could be delayed. The client with minor burns is categorized under ESI-5 because there is no threat to life or organs and assessment could be delayed.)

How will the nurse position a client who presents to the emergency department with severe epistaxis? 1 Trendelenburg position 2 Semi-Fowler position on a stretcher 3 Sitting in a chair with head tilted back 4 Sitting with head tilted slightly forward

4 (The sitting position will reduce bleeding and allow for assessment of the quantity of bleeding; leaning forward will prevent blood from entering the stomach and possible aspiration. Placing the client in the Trendelenburg position will increase pressure to the area of the nosebleed. Semi-Fowler position is better than flat but may lead to blood draining down the throat. Sitting upright is appropriate, but tilting the head back increases the risk of swallowing blood and possible aspiration.)

Which nursing action has the highest priority when preparing to transfer an unconscious client who sustained a head injury from the emergency department to a neurological trauma unit? 1 Notifying the receiving unit of the transfer 2 Having the client's records ready for the transfer 3 Verifying that the family has been notified of the transfer 4 Validating availability of a bag-valve-mask during the transfer

4 (Validating availability of a bag-valve-mask during the transfer is vital in case of respiratory distress; increased intracranial pressure compresses the brainstem, which contains the medulla, the respiratory center. Notifying the receiving unit of the transfer is important, but not of primary urgency; the respiratory status is the priority. Having the client's records ready for the transfer is important, but not of primary urgency; the respiratory status is the priority. Verifying notification of the family regarding the transfer is important, but not of primary urgency; the respiratory status is the priority.)

In which order would the nurse perform interventions for a client in a trauma condition with an open fracture? 1. Applying direct pressure on the injured area 2. Administering morphine sulfate intravenously 3. Cutting away the clothing from the fracture site 4. Assessing for airway-breathing-circulation (ABC)

4, 3, 1, 2 (The priority nursing intervention for a client in a trauma condition is to assess for ABC. Next priority is to cut away clothing from the fractured site. After clothing is removed, direct pressure is applied on the injured area to prevent bleeding. After stabilizing the client, pain is managed by administering morphine sulfate through the intravenous route.)

In which order would the assessments of a client who is severely injured with burns and has sustained major trauma from a fire incident occur according to priority? 1. Monitoring systolic blood pressure 2. Assessing the score of eye opening 3. Removing the clothing with scissors 4. Palpating for the presence of a radial pulse 5. Providing bag-valve-mask (BVM) ventilation 6. Using a jaw-thrust maneuver to establish an airway

6, 5, 4, 2, 1, 3 (A client with trauma should be assessed for ABCDE—airway-breathing-circulation-disability-exposure. A jaw-thrust maneuver helps establish an airway and breathing, and BVM ventilation with a 100% oxygen source ensures ventilatory assistance. After respiratory assessment is the circulation assessment. The pulse of the client is palpated at the radial, femoral, and carotid areas, and the systolic blood pressure is monitored. Disability is assessed using the Glasgow Coma Scale to find out the eye opening, voice, and pain status. The clothes of the client are removed with scissors to prevent fabric melting into the skin.)

13. Compartment syndrome can be caused by... a. Fracture b. Crush injury c. Running/exertion d. All of these

d