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. Observe the client’s respiratory effort.

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. Initiate isotonic fluid infusion through two large-bore IV lines.

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. Bradycardia

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. Obtain a Glasgow Coma Scale score.

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. Tetanus immunoglobulin (TIG) and tetanus-diphtheria (TD) toxoid

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. Ultrasonography

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. “I should have sports drinks when exercising outside in hot weather.”

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. Attach a cardiac monitor.

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. Auscultate breath sounds.

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. 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. 32°C (89.6°F)

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. “Is someone at home hurting you?”

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. Give N-acetylcysteine.

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. Assess the client’s current vital signs.

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. A client with a sucking chest wound

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. Remove the client’s rings.

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. Assist with intubation of the client.

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

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. Apply wet sheets and a fan to the client.

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. 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. Ask the family members about whether they would prefer to remain in the client room or wait outside the room.

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. Hyperventilate the client.