Chapter 68: Emergency and Disaster Nursing

Lewis: Medical-Surgical Nursing, 10th Edition

MULTIPLE CHOICE

1. During the primary assessment of a victim of a motor vehicle

collision, the nurse determines that the patient has an unobstructed

airway. Which action should the nurse take next?

a. Palpate extremities for bilateral pulses.

b. Observe the patient’s respiratory effort.

c. Check the patient’s level of consciousness.

d. Examine the patient for any external bleeding.

ANS: B

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.

2. During the primary survey of a patient with severe leg trauma, the

nurse observes that the patient’s left pedal and posterior tibial pulses

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are absent and the entire leg is swollen. Which action will the nurse

take next?

a. Send blood to the lab for a complete blood count.

b. Assess further for a cause of the decreased circulation.

c. Finish the airway, breathing, circulation, disability survey.

d. Start normal saline fluid infusion with a large-bore IV line.

ANS: D

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The assessment data indicate that the patient 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 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.

DIF: Cognitive Level: Analyze (analysis) REF: 1630

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological

Integrity

3. After the return of spontaneous circulation following the resuscitation

of a patient who had a cardiac arrest, therapeutic hypothermia is

ordered. Which action will the nurse include in the plan of care?

a. Initiate cooling per protocol.

b. Avoid the use of sedative drugs.

c. Check mental status every 15 minutes.

d. Rewarm if temperature is below 91° F (32.8° C).

ANS: A

When therapeutic hypothermia is used postresuscitation, external

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