Chapter 70. Emergency, Trauma, and Environmental Injuries

10. A medical-surgical unit is expecting a large volume of patient admissions after a train derailment. Which member of the nursing care team will prioritize care for the unit? 1) Charge nurse 2) Nurse supervisor 3) Licensed practical nurse 4) Unlicensed assistive personnel

ANS: 1

13. Which member of the health-care team, when using the team nursing approach, is responsible for prioritizing patient care? 1) Team leader 2) Charge nurse 3) Licensed practical nurse 4) Unlicensed assistive personnel

ANS: 1

15. The nurse is conducting a primary survey during an emergency assessment. Which is the priority nursing action related to breathing in response to this assessment? 1) Having suction available 2) Assessing pupil size and reactivity 3) Immobilizing any obvious deformities 4) Obtaining blood samples for type and crossmatch

ANS: 1

16. The nurse is conducting a secondary survey as part of the emergency assessment. Which is the priority nursing action during the health history portion of the assessment? 1) Determining drug allergies 2) Noting the general appearance 3) Examining the neck for stiffness 4) Auscultating for heart and lung sounds

ANS: 1

20. Which are the priority nursing actions after the completion of the secondary survey when providing care for a trauma patient with a penetrating wound? 1) Documenting the patient's care 2) Formulating the patient's plan of care 3) Reassessing the patient's level of consciousness 4) Transferring the patient to the general medical unit

ANS: 1

24. The nurse secures the airway of a trauma patient in the emergency department (ED). Which action does the nurse implement next when conducting the primary survey? 1) Assess the patient's respiratory rate. 2) Monitor the patient's blood pressure. 3) Assess the patient's pupillary reaction. 4) Cover the patient with a warm blanket.

ANS: 1

9. The registered nurse (RN) is the team leader for a group of patients using the functional model of nursing. The team of nurses includes two licensed practical nurses (LPNs) and an unlicensed assistive personnel (UAP). Which task will the RN delegate to the UAP? 1) Taking vital signs 2) Providing wound care 3) Conducting discharge teaching 4) Administering oral medications

ANS: 1

29. What would the nurse working in the emergency department identify as clinical priorities for the treatment of a patient with a gunshot wound? Select all that apply. 1) Airway maintenance 2) Obtaining medical history 3) Ventilation assistance 4) Hemorrhage control 5) Hypothermia prevention

ANS: 1, 3, 4, 5

30. Which are the top priorities when conducting a primary patient survey during the emergency assessment? Select all that apply. 1) Airway 2) Disability 3) Breathing 4) Circulation 5) Cervical spine

ANS: 1, 5

33. The nurse is providing care to a trauma patient. What is the correct order of steps the nurse will implement when providing care to this patient? Select all that apply. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) Clear the airway 2) Protect the cervical spine 3) Perform chest compressions 4) Provide supplemental oxygen

ANS: 1243

11. Which is a potentially life-threatening condition found during the primary triage survey that would necessitate priority nursing care? 1) Cystitis 2) Concussion 3) Lacerated arm 4) Fractured femur

ANS: 2

14. The nurse is conducting a primary survey during the emergency assessment. Which nursing action is appropriate during the breathing assessment? 1) Assessing for edema 2) Counting respiratory rate 3) Checking for foreign bodies 4) Monitoring for respiratory distress

ANS: 2

17. Which is the essential nursing skill for the triage process in the emergency department? 1) Evaluating care 2) Setting priorities 3) Formulating diagnoses 4) Implementing interventions

ANS: 2

21. Which is the priority nursing action when providing care to a patient with a penetrating abdominal wound? 1) Assessing bowel sounds 2) Stabilizing the impaled object 3) Administering prescribed pain medication 4) Scheduling a CT scan to determine retroperitoneal bleeding

ANS: 2

22. Which treatment should the nurse prepare to administer when providing care to a toddler who presents after an accidental overdose of aspirin? 1) Gastric lavage 2) Activated charcoal 3) Peritoneal dialysis 4) Vitamin D injection

ANS: 2

4. Which observation indicates that interventions provided to a patient with neck injuries from a motor vehicle crash have been successful? 1) Urine is clear and odorless from indwelling catheter 2) Moves all four extremities independently, feeds self, and participates in partial bath 3) Unable to move independently in bed 4) Rests in bed with lights and television turned off

ANS: 2

31. Which interventions does the nurse implement when providing care to a patient who is at risk for hypothermia? Select all that apply. 1) Keeping wet clothing on the patient 2) Placing a warming blanket on the patient 3) Infusing warm intravenous fluids to the patient 4) Increasing the temperature in the patient's room 5) Providing the patient with room temperature oral fluids

ANS: 2, 3, 4

28. Which nursing actions are appropriate during the primary survey of the emergency assessment process? Select all that apply. 1) Inserting a nasogastric tube 2) Immobilizing the cervical spine 3) Arranging for diagnostic studies 4) Preparing for chest tube insertion 5) Applying direct pressure to a wound

ANS: 2, 4, 5

18. The nurse is providing care to several patients in the emergency department. Which patient would require priority care from the nurse? 1) An adult patient with an ankle sprain 2) An infant with a rash of unknown origin 3) An adult patient with unstable vital signs and chest pain 4) A pediatric patient with multiple fractures following a motor vehicle accident

ANS: 3

25. The nurse conducts a Glasgow Coma Scale (GCS) assessment for a patient who presents in the emergency department after a motor vehicle crash (MVC). The patient opens the eyes spontaneously, is confused, and withdrawals from pain. Which score does the nurse document for this patient? 1) 10 2) 11 3) 12 4) 13

ANS: 3

26. The nurse provides care to a patient who presents with a probable rib fracture. Radiology results confirm a lower rib injury. Which injury does the nurse prepare to assess this patient for based on these results? 1) Hemothorax 2) Pneumothorax 3) Liver laceration 4) Pulmonary contusion

ANS: 3

6. A nurse is developing a plan of care for a patient with traumatic injuries from a motor vehicle crash. Which nursing intervention does the nurse include in the plan of care to reduce the risk of integumentary complications? 1) Provide active or passive exercises at least once every eight hours 2) Encourage coughing, deep breathing, and incentive spirometry 3) Assist the patient in turning at least every two hours 4) Assist the patient in turning at least every eight hours

ANS: 3

1. What should the nurse do to assist a patient brought to the emergency department as a victim of a gunshot wound? 1) Ask the patient who shot him 2) Bathe the patient and provide a clean gown 3) Ask the patient where the weapon is 4) Preserve the chain of evidence

ANS: 4

12. Which nursing action is appropriate when conducting a secondary survey during the emergency assessment? 1) Maintaining privacy 2) Having suction available 3) Giving supplemental oxygen 4) Assigning a nurse to support family members

ANS: 4

19. The nurse is providing care to several patients in the emergency department. Which patient is the priority when using the three-tiered triage system? 1) A patient with a simple fracture 2) A patient experiencing renal colic 3) A patient with severe abdominal pain 4) A patient with chest pain and diaphoresis

ANS: 4

2. A patient is brought into the emergency department after being assaulted. It is suspected that the patient has a spinal cord injury. Which diagnostic test does the nurse anticipate based on the data collected? 1) Computed tomography (CT) scan 2) X-ray 3) Ultrasound 4) Magnetic resonance imaging (MRI)

ANS: 4

23. Which assessment data related to the patient's airway would indicate the need for priority intervention by the nurse? 1) Eupnea 2) Tachycardia 3) Hypotension 4) Agonal breaths

ANS: 4

27. The nurse provides education to a family on how to decrease the risk of accidental drowning. Which patient statement indicates a need for additional teaching? 1) "We will all wear life preservers when in our boat." 2) "It is a good idea for everyone in our family to take swimming lessons." 3) "We will ensure that our children are always with an adult when near water." 4) "I will allow those who are guests on our boat to drink alcohol since I won't be drinking."

ANS: 4

3. A patient recovering from a motor vehicle crash develops hypotension and jugular distension with a tracheal deviation. Based on this data, which should the nurse suspect occurred? 1) Hemorrhage 2) Compensatory shock 3) Hypovolemic shock 4) Tension pneumothorax

ANS: 4

5. Which intervention would be a priority when providing care to a patient recovering from thoracic injuries sustained from a motor vehicle crash? 1) Monitor urine output 2) Assess vital signs 3) Perform passive range of motion to all extremities 4) Assist to deep breathe and cough every two hours

ANS: 4

7. Which assessment data indicates the patient is experiencing a late symptom associated with chronic aspirin overdose? 1) Emesis 2) Nausea 3) Tinnitus 4) Ecchymosis

ANS: 4

8. The emergency department nurse is triaging patients. Which patient should be prioritized? 1) An adult patient experiencing mild chest pain 2) An adolescent patient with a possible fractured wrist 3) An older adult patient with a hip fracture who is in pain 4) A school-age patient with asthma presenting with dyspnea

ANS: 4

32. The nurse is providing care to several patients in the emergency department. In which order should the nurse assess and provide care to the patients? (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) A patient with a leg laceration requiring sutures 2) A patient with abdominal pain rated as a 7 on a numeric pain scale 3) A patient who has multiple trauma due to a motor vehicle accident 4) A patient who took an overdose of opioids with a respiratory rate of eight breaths per minute

ANS: 4321