chapter 71

Question 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.

Answer 1

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.

Question 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.

Answer 2

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.

Question 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

Answer 3

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.

Question 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.

Answer 4

C
The Glasgow Coma Scale is included when assessing for disability during the primary
survey. The other information is part of the secondary survey.

Question 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)

Answer 5

C
For an adult with no previous tetanus immunizations, TIG and TD are recommended. The
other immunizations are not sufficient for this client.

Question 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)

Answer 6

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.

Question 7

The nurse is caring for a client with hypotension and temperature elevation after doing
yard work on a hot day and is being treated in the emergency department. After the nurse
has completed discharge teaching, which of the following client statements indicates that
the teaching has been effective?
a. “I will take salt tablets when I work outdoors in the summer.”
b. “I should take acetaminophen if I start to feel too warm.”
c. “I should have sports drinks when exercising outside in hot weather.”
d. “I will get into a cool environment if I notice that I am feeling confused.”

Answer 7

C
Electrolyte 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 medications are not effective in lowering body
temperature elevations caused by excessive exposure to heat. A client who is confused is
likely to have more severe hyperthermia and will be unable to remember to take
appropriate action.

Question 8

The nurse is preparing to rewarm a client with hypothermia. Which of the following
actions should the nurse implement?
a. Attach a cardiac monitor.
b. Insert a urinary catheter.
c. Assist with endotracheal intubation.
d. Prepare sympathomimetic drugs for emergency administration.

Answer 8

A
Rewarming can produce dysrhythmias, so the client should be monitored and treated if
necessary. Urinary catheterization and endotracheal intubation are not needed for
rewarming. Sympathomimetic drugs tend to stimulate the heart and increase the risk for
fatal dysrhythmias such as ventricular fibrillation.

Question 9

The nurse is observing a client who experienced a near drowning accident in a local lake,
but now is awake and breathing spontaneously. Which of the following actions will be
most important for the nurse to take during the observation period?
a. Listen to heart sounds.
b. Palpate peripheral pulses.
c. Auscultate breath sounds.
d. Check pupil reaction to light.

Answer 9

C
Since pulmonary edema is a common delayed complication after near drowning, the nurse
should assess the breath sounds frequently. The other information also will be collected by
the nurse, but it is not as pertinent to the client’s admission diagnosis.

Question 10

The nurse is caring for a client that has sustained a black widow spider bite. Which of the
following times should the nurse be aware of that the symptoms usually peak?
a. 30 minutes
b. 2–3 hours
c. 5–6 hours
d. 9–10 hours

Answer 10

B
After a spider bite symptoms will peak in 2–3 hours.

Question 11

The nurse is rewarming a client who arrived in the emergency department (ED) with a
temperature of 29°C (84.2°F) and no audible pulse. Which of the following temperatures
should the nurse rewarm the client to, prior to a pronouncement of death?
a. 30°C (86°F)
b. 32°C (89.6°F)
c. 34°C (93.2°F)
d. 36°C (96.8°F)

Answer 11

B
Every effort is made to warm the client to at least 32°C (89.6°F) before the person is
pronounced dead. The cause of death is usually refractory ventricular fibrillation.

Question 12

The nurse is assessing a client admitted to the emergency department (ED) with a broken
arm and facial bruises and notes multiple additional bruises in various stages of healing.
Which of the following responses by the nurse is most appropriate?
a. “Is someone at home hurting you?”
b. “You should not return to your home.”
c. “Would you like to see a social worker?”
d. “I have to report this abuse to the police.”

Answer 12

A
The nurse’s initial response should be to further assess the client’s situation. Telling the
client not to return home may be an option once further assessment is done. The client, not
the nurse, is responsible for reporting the abuse. A social worker may be appropriate once
further assessment is completed.

Question 13

A client arrives in the emergency department (ED) a few hours after taking “20–30”
acetaminophen (Tylenol) tablets. Which of the following actions will the nurse plan to
take?
a. Give N-acetylcysteine.
b. Discuss the use of chelation therapy.
c. Have the client drink large amounts of water.
d. Administer oxygen using a non-rebreather mask.

Answer 13

A
N-acetylcysteine is the recommended treatment to prevent liver damage after
acetaminophen overdose. The other actions might be used for other types of poisoning, but
they will not be appropriate for a client with acetaminophen poisoning.

Question 14

A triage nurse is assessing a client who complains of 6/10 abdominal pain and states, “I
had a temperature of 40.3°C (104.5°F) at home.” Which of the following actions should
the nurse implement first?
a. Assess the client’s current vital signs.
b. Obtain a clean-catch urine for urinalysis.
c. Tell the client that it may be several hours before being seen by the doctor.
d. Ask the health care provider to order an analgesic medication for the client.

Answer 14

A
The client’s pain and statement about an elevated temperature indicate that the nurse
should obtain vital signs before deciding how rapidly the client should be seen by the
health care provider. A urinalysis may be needed, but vital signs will provide the nurse
with the data needed to determine this. The health care provider will not order a
medication before assessing the client.

Question 15

The triage nurse is assessing four victims of an automobile accident. Which of the
following clients has the highest priority for treatment?
a. A client with absent pedal pulses
b. A client with an open femur fracture
c. A client with a sucking chest wound
d. A client with bleeding of facial lacerations

Answer 15

C
Most immediate deaths from trauma occur because of problems with ventilation, so the
client with a sucking chest wound should be treated first. Face and head fractures can
obstruct the airway, but the client with facial injuries has lacerations only. The other two
clients also need rapid intervention but do not have airway or breathing problems.

Question 16

The following actions are part of the routine emergency department (ED) protocol for a
client who has been admitted with multiple bee stings to the hands. Which action should
the nurse take first?
a. Remove the client’s rings.
b. Place ice packs on both hands.
c. Apply calamine lotion to any itching areas.
d. Give diphenhydramine 100 mg PO.

Answer 16

A
The client’s rings should be removed first because it might not be possible to remove them
if swelling develops. The other orders also should be implemented as rapidly as possible
after the nurse has removed the jewellery.

Question 17

Gastric lavage and administration of activated charcoal are prescribed for an unconscious
client who has been admitted to the emergency department (ED) after ingesting 30
diazepam tablets. Which of the following actions will the nurse plan to take first?
a. Administer activated charcoal.
b. Insert a large-bore orogastric tube.
c. Prepare a 60-mL syringe with saline.
d. Assist with intubation of the client.

Answer 17

D
In an unresponsive client, intubation is done before gastric lavage and activated charcoal
administration to prevent aspiration. The other actions will be implemented after
intubation.

Question 18

After spending the previous weekend camping out with some friends, a client arrives at the
emergency department and is diagnosed with flaccid ascending paralysis. Based upon this
information, the nurse concludes that the client has been bitten by which of the following?
a. Spider
b. Wasp
c. Tick
d. Snake

Answer 18

C
Tick paralysis occurs 5–7 days after exposure to the wood or dog tick. Classic symptoms
are flaccid ascending paralysis, which develops over 1–2 days. Without tick removal, the
client dies as respiratory muscles become paralyzed. Tick removal leads to return of
muscle movement, usually within 48–72 hours.

Question 19

An unresponsive older-adult client is admitted to the emergency department (ED) during a
summer heat wave. The client’s core temperature is 41.2°C (106.1°F), blood pressure (BP)
86/52, and pulse 102. Which of the following actions should the nurse implement initially?
a. Administer an Aspirin rectal suppository.
b. Start O2 at 6 L/minute with a nasal cannula.
c. Apply wet sheets and a fan to the client.
d. Infuse lactated Ringer’s solution at 1 000 mL/hour.

Answer 19

C
The priority intervention is to cool the client. Antipyretics are not effective in decreasing
temperature in heat stroke, and 100% oxygen should be given, which requires a high flow
rate through a non-rebreather mask. An older client would be at risk for developing
complications such as pulmonary edema if given fluids at 1 000 mL/hour.

Question 20

The nurse is admitting a client to the emergency department after a submersion injury.
Which of the following assessments is priority?
a. Apical pulse
b. Lung sounds
c. Body temperature
d. Level of consciousness

Answer 20

B
The priority assessment data are how well the client is oxygenating, so lung sounds should
be assessed first. The other data also will be collected rapidly but are not as essential as the
lung sounds.

Question 21

A client’s family members are in the client room when the client has a cardiac arrest and
emergency personnel start resuscitation measures. Which of the following actions should
the nurse take first?
a. Have the family wait outside the client room with a designated staff member to
provide emotional support.
b. Keep the family in the room and assign a member of the team to explain the care
given and answer questions.
c. Ask the family members about whether they would prefer to remain in the client
room or wait outside the room.
d. Advise the family members that clients are comforted by having family members
present during resuscitation efforts.

Answer 21

C
Although many family members and clients report benefits from family presence during
resuscitation efforts, the nurse’s initial action should be to determine the preference of
these family members. The other actions may be appropriate, but this will depend on what
is learned when assessing family preferences.

Question 22

The nurse is conducting a primary survey on a client in the emergency department and
notes motor posturing. Which of the following actions should the nurse implement
immediately?
a. Hyperventilate the client.
b. Decrease the IV fluid rate.
c. Prepare for intubation.
d. Continue with the triage assessment.

Answer 22

A
Hyperventilation is implemented when signs of motor posturing are present as that may
indicate brain herniation and oxygen is required. The other actions are not appropriate at
this time.