Chapter 069

Lewis: Medical-Surgical Nursing, 7th Edition
Test Bank
Chapter 69: Nursing Management: Emergency and Disaster Nursing
MULTIPLE CHOICE
1. Four victims of an automobile crash are brought by ambulance to the emergency

department (emergency department). The triage nurse determines that the victim who
has the highest priority for treatment is the one with
a. severe bleeding of facial and head lacerations.
b. an open femur fracture with profuse bleeding.
c. a sucking chest wound.
d. absence of peripheral pulses.
Correct Answer: C
Rationale: Most immediate deaths from trauma occur because of problems with
ventilation, so the patient with a sucking chest wound should be treated first. Face and
head fractures can obstruct the airway, but the patient with facial injuries has lacerations
only. The other two patients also need rapid intervention but do not have airway or
breathing problems.
Cognitive Level: Application Text Reference: p. 1823

Nursing Process: Assessment NCLEX: Physiological Integrity
2. A triage nurse in a busy emergency department assesses a patient who complains of

6/10 abdominal pain and states, “I had a temperature of 104.6º F (40.3º C) at home.”
The nurse’s first action should be to
a. tell the patient that it may be several hours before being seen by the doctor.
b. assess the patient’s current vital signs.
c. obtain a clean-catch urine for urinalysis.
d. ask the health care provider to order a nonopioid analgesic medication for the
patient.
Correct Answer: B
Rationale: The patient’s pain and statement about an elevated temperature indicate that
the nurse should obtain vital signs before deciding how rapidly the patient should be seen
by the health care provider. A urinalysis may be needed, but vital signs will provide the
nurse with more useful data for triage. The health care provider will not order a
medication before assessing the patient.
Cognitive Level: Application Text Reference: pp. 1822-1823

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Test Bank 69-3
3. During the primary assessment of a trauma victim, the nurse determines that the
patient has a patent airway. The next assessment by the nurse should be to
a. check the patient’s level of consciousness.
b. examine the patient for any external bleeding.
c. observe the patient’s respiratory effort.
d. palpate for the presence of peripheral pulses.
Correct Answer: C
Rationale: 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 are not accomplished as rapidly as the assessment of
breathing.

4. During the primary assessment of a patient with multiple trauma, the nurse observes
that the patient’s right pedal pulses are absent and the leg is swollen. The nurse’s first
action should be to
a. initiate isotonic fluid infusion through two large-bore IV lines.
b. send blood to the lab for a complete blood count (CBC).
c. finish the airway, breathing, circulation, disability survey.
d. assess further for a cause of the decreased circulation.
Correct Answer: A
Rationale: 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 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.

Nursing Process: Implementation NCLEX: Physiological Integrity
5. When caring for a patient with head and neck trauma after a motorcycle accident, the
emergency department nurse’s first action should be to
a. suction the mouth and oropharynx.
b. immobilize the cervical spine.
c. administer supplemental oxygen.
d. obtain venous access.
Correct Answer: B

Test Bank 69-4
Rationale: When there is a risk of spinal cord injury, the nurse’s initial action is
immobilization of the cervical spine during positioning of the head and neck for airway
management. Suctioning, supplemental oxygen administration, and venous access are
also necessary after the cervical spine is protected by immobilization.

6. A patient has been brought to the emergency department with a gunshot wound to the
abdomen. In obtaining a history of the incident to determine possible injuries, the
nurse asks
a. “Where did the incident occur?”
b. “What direction did the bullet enter the body?”
c. “How long ago did the incident happen?”
d. “What emergency care was started at the scene?”
Correct Answer: B
Rationale: The entry point and direction of the bullet will help to predict the type of
injuries the patient has. The other information is not as useful in determining which
diagnostic studies and care are needed immediately.

7. A 67-year-old patient who has fallen from a ladder is transported to the emergency
department by ambulance. The patient is unconscious on arrival and accompanied by
family members. During the primary survey of the patient, the nurse should
a. assess the patient’s vital signs.
b. obtain a Glasgow Coma Scale score.
c. attach a cardiac ECG monitor.
d. ask about chronic medical conditions.
Correct Answer: B
Rationale: The Glasgow Coma Scale is included when assessing for disability during the
primary survey. The other information is part of the secondary survey.

8. A 24-year-old is brought to the emergency department with multiple lacerations and

tissue avulsion of the right hand after catching the hand in a produce conveyor belt.
When asked about tetanus immunization, the patient says, “I’ve never had any
vaccinations.” The nurse will anticipate administration of tetanus

Test Bank 69-5
a. immunoglobulin.
b. and diphtheria toxoid.
c. immunoglobulin, tetanus-diphtheria toxoid, and pertussis vaccine.
d. immunoglobulin and tetanus-diphtheria toxoid.
Correct Answer: C
Rationale: For a patient with unknown immunization status, the tetanus immune globulin
is administered along with the Tdap (since the patient has not had pertussis vaccine
previously). The other immunizations are not sufficient for this patient.

Nursing Process: Planning
NCLEX: Health Promotion and Maintenance
9. A patient has experienced blunt abdominal trauma from a motor vehicle accident. The
nurse should explain to the patient the purpose of
a. magnetic resonance imaging (MRI).
b. ultrasonography.
c. peritoneal lavage.
d. nasogastric (NG) tube placement.
Correct Answer: B
Rationale: If intra-abdominal bleeding is suspected, focused abdominal ultrasonography
is obtained to look for intraperitoneal bleeding. MRI would not be used. Peritoneal lavage
is an alternative, but it is more invasive. An NG tube would not be helpful in diagnosis of
intra-abdominal bleeding.

Nursing Process: Planning NCLEX: Physiological Integrity
10. A patient is brought to the hospital in cardiac arrest by emergency personnel who are
performing resuscitation. The spouse arrives as the patient is taken into a treatment
room and asks to stay with the patient. The nurse should
a. have the spouse wait outside the treatment room with a designated staff member to
provide emotional support.
b. bring the spouse into the room and ensure him or her that a member of the team
will explain the care given and answer questions.
c. explain that the presence of family members is distracting to staff and might impair
the resuscitation efforts.
d. advise the spouse that if the resuscitation effort is unsuccessful, the memories may
have an adverse impact on grieving.
Correct Answer: B

Test Bank 69-6
Rationale: Family members and patients report benefits from family presence during
resuscitation efforts, so the nurse should try to accommodate the spouse. Having the
spouse wait outside the room is not as supportive to the spouse or patient. It would be
inappropriate to imply that the spouse’s presence would have adverse consequences for
the patient. Family members do not report problems with grieving caused by being
present during resuscitation efforts.

Nursing Process: Implementation NCLEX: Psychosocial Integrity
11. During the summer, a patient with heat cramps is treated in the emergency
department. The nurse determines that discharge teaching regarding the prevention of
another episode of heat cramps has been effective when the patient states,
a. “I will take salt tablets when I work outdoors in the summer.”
b. “I should double my water intake when the weather gets 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.”
Correct Answer: C
Rationale: 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. It is not necessary to double one’s water
intake simply when the weather is warm. A patient who is confused is likely to have more
severe hyperthermia and will be unable to remember to take appropriate action.

Nursing Process: Evaluation NCLEX: Physiological Integrity
12. An unresponsive 78-year-old patient is admitted to the emergency department in a

coma during a summer heat wave. The patient’s core temperature is 106.2° F (41.2°
C), blood pressure (BP) 86/52, and pulse 102. The nurse will plan to
a. apply wet sheets and a fan to the patient.
b. administer an acetaminophen (Tylenol) suppository.
c. start O2 at 6 L/min with a nasal cannula.
d. infuse lactated Ringer’s solution at 1000 ml/hr.
Correct Answer: A
Rationale: The priority intervention is to cool the patient. 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-rebreathing mask. An older patient would be at
risk for developing complications such as pulmonary edema if given fluids at 1000 ml/hr.


Test Bank 69-7
13. A 77-year-old patient is brought into the emergency department unconscious and with
a core temperature of 89° F (31.6° C). During rewarming measures, the nurse
determines that the goals of treatment are being met when the patient
a. has a core temperature of 95° F (35° C).
b. shivers involuntarily to raise body temperature.
c. regains consciousness.
d. has a blood pH within normal limits.
Correct Answer: A
Rationale: The improvement in the patient’s body temperature is the best indication that
the goals of rewarming are being met. Shivering, improvement in level of consciousness
(LOC), and normalization of pH all might confirm that the patient’s condition is
improving, but they are not as clear as the elevation in temperature.

Nursing Process: Evaluation NCLEX: Physiological Integrity
14. When preparing to rewarm a patient with hypothermia, the nurse will plan to
a. attach a cardiac monitor.
b. insert a urinary catheter.
c. assist with endotracheal intubation.
d. keep inotropic drugs available.
Correct Answer: A
Rationale: Rewarming can produce dysrhythmias, so the patient should be monitored
and treated if necessary. Urinary catheterization and endotracheal intubation are not
needed for rewarming. Cardiac inotropes tend to stimulate the heart and increase the risk
for fatal dysrhythmias such as ventricular fibrillation.

15. A patient is admitted to the emergency department after a near-drowning accident in a

local lake. The patient received rescue breathing at the site and now has spontaneous
respirations. The nurse will observe the patient for several hours to monitor for
symptoms of
a. hypernatremia.
b. pulmonary edema.
c. hypothermia.
d. head injury.
Correct Answer: B

Test Bank 69-8
Rationale: Pulmonary edema is a common complication after a near-drowning incident.

Hypernatremia would not occur in a freshwater submersion. Hypothermia and head
injury may be associated with near-drowning but would be apparent at the time of
admission and would not develop after several hours.

16. All of the following actions are needed for a patient admitted with multiple bee stings
to the hands. Which one will the nurse accomplish first?
a. Give diphenhydramine (Benadryl) 100 mg po.
b. Apply calamine lotion to any itching areas.
c. Place ice packs on both hands.
d. Remove the patient’s rings.
Correct Answer: D
Rationale: The patient’s rings should be removed first because it might not be possible to
remove them if swelling develops. The other orders should also be implemented as
rapidly as possible after the nurse has removed the jewelry.

17. An unconscious patient is admitted to the emergency department 45 minutes after

ingesting approximately 30 diazepam (Valium) tablets. The health care provider
prescribes gastric lavage. The first action the nurse will plan when implementing the
order is to
a. position the patient on his or her side.
b. insert a large-bore nasogastric tube.
c. assist the health care provider to intubate the patient.
d. prepare a 60-ml syringe with saline.
Correct Answer: C
Rationale: An unconscious patient cannot protect the airway and is at risk for aspiration
during gastric lavage, so intubation is done before starting the lavage. Positioning the
patient on his or her side will decrease the risk for aspiration, but the patient will need to
be supine for intubation. An orogastric tube is used for gastric lavage. The saline will be
injected after the intubation.

Nursing Process: Planning
NCLEX: Safe and Effective Care Environment

Test Bank 69-9
18. A patient is admitted to the emergency department with multiple bruises of the face
and arms and an obvious deformity of the right upper arm. A friend accompanying the
patient tells the nurse that the patient’s spouse was responsible for the injuries. The
nurse’s role in this patient’s care is
a. to inform the patient of safe houses and other options.
b. to encourage the friend to have the patient report the abuse.
c. to notify the local law enforcement agency.
d. limited to the treatment of the patient’s injuries.
Correct Answer: A
Rationale: The nurse’s role includes informing victims of domestic violence about
options and safe housing. The nurse should speak directly to the patient about the option
of reporting the abuse to the police (after further assessment of the patient). A competent
adult patient is responsible for reporting abuse to the police. The nurse is responsible for
assessing for domestic violence and making appropriate referrals in addition to providing
care for the physical injuries.
Cognitive Level: Comprehension Text Reference: p. 1838

19. When planning the response to the potential use of smallpox as a biologic weapon,
the emergency department manager will focus on obtaining sufficient quantities of
a. blood.
b. antibiotics.
c. vaccine.
d. antitoxin.
Correct Answer: C
Rationale: Smallpox infection can be prevented or ameliorated by the administration of
vaccine given rapidly after exposure. The other interventions would be helpful for other
biologic weapons, but not for smallpox.
Cognitive Level: Comprehension Text Reference: pp. 1838-1839

20. A patient arrives in the emergency department after exposure to radioactive dust.
Which action should the nurse take first?
a. Place the patient in a shower.
b. Obtain the patient’s vital signs.
c. Determine the type of radioactive agent.
d. Obtain a baseline complete blood count.
Correct Answer: A

Test Bank 69-10
Rationale: The initial action should be to protect staff members and decrease the
patient’s exposure to the radioactive agent by decontamination. The other actions can be
accomplished after the decontamination is completed.

21. When rewarming a patient who arrived in the emergency department with a
temperature of 87° F, which assessment indicates that rewarming should be stopped?
a. The patient develops atrial fibrillation.
b. The BP decreases to 85/40 mm Hg.
c. The core temperature is 95.2° F.
d. The axillary temperature reaches 96° F.
Correct Answer: C
Rationale: A core temperature of 95° F is an indication that sufficient rewarming has
occurred. Dysrhythmias and hypotension may occur during rewarming and should be
treated but are not an indication to stop rewarming the patient. The patient’s core
temperature, rather than the axillary temperature, is used to determine the success of
rewarming procedures.

22. When a patient is admitted to the emergency department after a submersion injury,
which assessment will the nurse obtain first?
a. Lung sounds
b. Oxygen saturation
c. Body temperature
d. Apical pulse
Correct Answer: B
Rationale: The priority assessment data are how well the patient is oxygenating, so O2
saturation should be obtained first because this measure gives the most direct
information. The other data will also be collected rapidly but are not as essential as the O2
saturation.

23. A patient arrives at the emergency department after being bitten by a poisonous
snake. Initially, the nurse will plan to
a. start a large-bore IV line.

Test Bank 69-11
b. administer analgesics.
c. draw blood for laboratory testing.
d. administer tetanus prophylaxis.
Correct Answer: A
Rationale: Because hypovolemic shock and hemolysis can occur with snakebite, it is
important to be able to administer large amounts of IV fluids rapidly. Analgesic
administration, drawing blood, and administration of tetanus prophylaxis can be
accomplished later.

24. When assessing a patient admitted to the emergency department with a broken arm
and facial bruises, the nurse notes multiple additional bruises in various stages of
healing. Which statement or question by the nurse is most appropriate?
a. “You should not return to your home.”
b. “I have to report this abuse to the police.”
c. “Would you like to see a social worker?”
d. “Is someone at home hurting you?”
Correct Answer: D
Rationale: The nurse’s initial response should be to further assess the patient’s situation.
Telling the patient not to return home may be an option once further assessment is done.
The patient, not the nurse, is responsible for reporting the abuse. A social worker may be
appropriate once further assessment is completed.

OTHER
1. These four patients arrive in the emergency department after a motor-vehicle crash. In
which order should they been assessed?
a. A 22-year-old with fractures of the face and jaw
b. A 30-year-old with a misaligned right leg
c. A 45-year-old complaining of 6/10 abdominal pain
d. A 72-year-old with palpitations and chest pain
Correct Answer: A, D, C, B

Test Bank 69-12
Rationale: The highest priority is to assess the 22-year-old patient for airway obstruction,
which is the most life-threatening injury. The 72-year-old patient may have chest pain
from cardiac ischemia and should be assessed and have diagnostic testing for this pains.
The 45-year-old patient may have abdominal trauma or bleeding and should be seen next
to assess circulatory status. The 30-year-old appears to have a possible fracture of the
right leg and should be seen soon, but this patient has the least life-threatening injury.


Chapter 069

Загружено:

Сведения о документе

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

Chapter 069

Загружено:

Авторское право:

Доступные форматы

Lewis: Medical-Surgical Nursing, 7th Edition

Chapter 69: Nursing Management: Emergency and Disaster Nursing

1. Four victims of an automobile crash are brought by ambulance to the emergency

Cognitive Level: Application Text Reference: p. 1823

2. A triage nurse in a busy emergency department assesses a patient who complains of

Cognitive Level: Application Text Reference: pp. 1822-1823

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Cognitive Level: Application Text Reference: p. 1823

Cognitive Level: Application Text Reference: pp. 1822-1824

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Cognitive Level: Application Text Reference: p. 1823

Cognitive Level: Application Text Reference: pp. 1825-1826

Cognitive Level: Application Text Reference: p. 1824

8. A 24-year-old is brought to the emergency department with multiple lacerations and

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Cognitive Level: Application Text Reference: p. 1828

Cognitive Level: Application Text Reference: p. 1827

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Cognitive Level: Application Text Reference: pp. 1825-1826

Cognitive Level: Application Text Reference: pp. 1829-1830

12. An unresponsive 78-year-old patient is admitted to the emergency department in a

Cognitive Level: Application Text Reference: pp. 1829-1830

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Cognitive Level: Application Text Reference: p. 1831

Cognitive Level: Application Text Reference: pp. 1831-1832

15. A patient is admitted to the emergency department after a near-drowning accident in a

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Rationale: Pulmonary edema is a common complication after a near-drowning incident.

Cognitive Level: Application Text Reference: p. 1832

Cognitive Level: Application Text Reference: p. 1834

17. An unconscious patient is admitted to the emergency department 45 minutes after

Cognitive Level: Application Text Reference: p. 1837

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Cognitive Level: Comprehension Text Reference: p. 1838

Cognitive Level: Comprehension Text Reference: pp. 1838-1839

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Cognitive Level: Application Text Reference: p. 1840

Cognitive Level: Application Text Reference: p. 1831

Cognitive Level: Application Text Reference: pp. 1832-1833

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Cognitive Level: Application Text Reference: p. 1836

Cognitive Level: Application Text Reference: p. 1838

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Cognitive Level: Application Text Reference: pp. 1822-1825

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Вам также может понравиться