,Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding)
889889889
Emergency and Disaster Nursing
Test Bank
MULTIPLE CHOICE
1. During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient
is breathing and has an unobstructed airway. Which action should the nurse take next?
a. Palpate extremities for bilateral pulses.
b. Observe the patients respiratory effort.
c. Check the patients 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 patients breathing. The other actions are also part of the initial survey but assessment of breathing
should be done immediately after assessing for airway patency.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. During the primary survey of a patient with severe leg trauma, the nurse observes that the patients left pedal
pulse is absent and the 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
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: Apply (application)
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?
,Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding)
890890890
a. Apply external cooling device.
b. Check mental status every 15 minutes.
c. Avoid the use of sedative medications.
d. Rewarm if temperature is <91 F (32.8 C).
ANS: A
When therapeutic hypothermia is used postresuscitation, external cooling devices or cold normal saline
infusions are used to rapidly lower body temperature to 89.6 F to 93.2 F (32 C to 34 C). Because hypothermia
will decrease brain activity, assessing mental status every 15 minutes is not needed at this stage. Sedative
medications are administered during therapeutic hypothermia.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
4. A patient who is unconscious after a fall from a ladder is transported to the emergency department by
emergency medical personnel. During the primary survey of the patient, the nurse should
a. obtain a complete set of vital signs. b.
obtain a Glasgow Coma Scale score. c.
ask about chronic medical conditions.
d. attach a cardiac electrocardiogram monitor.
ANS: B
The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other
information is part of the secondary survey.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
5. A 19-year-old is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of
the left hand. When asked about tetanus immunization, the patient denies having any previous vaccinations.
The nurse will anticipate giving
a. tetanus immunoglobulin (TIG) only.
b. TIG and tetanus-diphtheria toxoid (Td).
c. tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only.
, Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding)
891891891
d. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).
ANS: D
For an adult with no previous tetanus immunizations, TIG and Tdap are recommended. The other
immunizations are not sufficient for this patient.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance
6. A patient who has experienced blunt abdominal trauma during a motor vehicle collision is complaining of
increasing abdominal pain. The nurse will plan to teach the patient about the purpose of
a. peritoneal lavage.
b. abdominal ultrasonography.
c. nasogastric (NG) tube placement.
d. magnetic resonance imaging (MRI).
ANS: B
For patients who are at risk for intraabdominal bleeding, focused abdominal ultrasonography is the preferred
method to assess for intraperitoneal bleeding. An 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 intraabdominal bleeding.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
7. A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the
emergency department (ED). The nurse determines that discharge teaching has been effective when the patient
makes which statement?
a. I will take salt tablets when I work outdoors in the summer.
b. I should take acetaminophen (Tylenol) if I start to feel too warm.
c. I should drink sports drinks when working outside in hot weather.
d. I will move to a cool environment if I notice that I am feeling confused.
ANS: 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 patient who is confused is likely to have more severe hyperthermia and will be unable to
remember to take appropriate action.
889889889
Emergency and Disaster Nursing
Test Bank
MULTIPLE CHOICE
1. During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient
is breathing and has an unobstructed airway. Which action should the nurse take next?
a. Palpate extremities for bilateral pulses.
b. Observe the patients respiratory effort.
c. Check the patients 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 patients breathing. The other actions are also part of the initial survey but assessment of breathing
should be done immediately after assessing for airway patency.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. During the primary survey of a patient with severe leg trauma, the nurse observes that the patients left pedal
pulse is absent and the 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
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: Apply (application)
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?
,Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding)
890890890
a. Apply external cooling device.
b. Check mental status every 15 minutes.
c. Avoid the use of sedative medications.
d. Rewarm if temperature is <91 F (32.8 C).
ANS: A
When therapeutic hypothermia is used postresuscitation, external cooling devices or cold normal saline
infusions are used to rapidly lower body temperature to 89.6 F to 93.2 F (32 C to 34 C). Because hypothermia
will decrease brain activity, assessing mental status every 15 minutes is not needed at this stage. Sedative
medications are administered during therapeutic hypothermia.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
4. A patient who is unconscious after a fall from a ladder is transported to the emergency department by
emergency medical personnel. During the primary survey of the patient, the nurse should
a. obtain a complete set of vital signs. b.
obtain a Glasgow Coma Scale score. c.
ask about chronic medical conditions.
d. attach a cardiac electrocardiogram monitor.
ANS: B
The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other
information is part of the secondary survey.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
5. A 19-year-old is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of
the left hand. When asked about tetanus immunization, the patient denies having any previous vaccinations.
The nurse will anticipate giving
a. tetanus immunoglobulin (TIG) only.
b. TIG and tetanus-diphtheria toxoid (Td).
c. tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only.
, Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding)
891891891
d. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).
ANS: D
For an adult with no previous tetanus immunizations, TIG and Tdap are recommended. The other
immunizations are not sufficient for this patient.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance
6. A patient who has experienced blunt abdominal trauma during a motor vehicle collision is complaining of
increasing abdominal pain. The nurse will plan to teach the patient about the purpose of
a. peritoneal lavage.
b. abdominal ultrasonography.
c. nasogastric (NG) tube placement.
d. magnetic resonance imaging (MRI).
ANS: B
For patients who are at risk for intraabdominal bleeding, focused abdominal ultrasonography is the preferred
method to assess for intraperitoneal bleeding. An 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 intraabdominal bleeding.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
7. A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the
emergency department (ED). The nurse determines that discharge teaching has been effective when the patient
makes which statement?
a. I will take salt tablets when I work outdoors in the summer.
b. I should take acetaminophen (Tylenol) if I start to feel too warm.
c. I should drink sports drinks when working outside in hot weather.
d. I will move to a cool environment if I notice that I am feeling confused.
ANS: 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 patient who is confused is likely to have more severe hyperthermia and will be unable to
remember to take appropriate action.
