PN3 EXAM 2 QUESTIONS AND ANSWERS
Primary Survey in E.R - CORRECT ANSWER✅✅(A) Airway/cervical spine
Establish a patent airway by positioning, suctioning, and oxygen as needed. Protect the cervical spine by
maintaining alignment; use a jaw-thrust maneuver if there is a risk for spinal injury. If the Glasgow Coma
Scale (GCS) score is 8 or less or the patient is at risk for airway compromise, prepare for endotracheal
intubation and mechanical ventilation.
(B) Breathing
Assess breath sounds and respiratory effort. Observe for chest wall trauma or other physical
abnormality. Prepare for chest decompression if needed. Prepare to assist ventilations if needed.
(C) Circulation
Monitor vital signs, especially blood pressure and pulse. Maintain vascular access with a large-bore
catheter. Use direct pressure for external bleeding; anticipate need for a tourniquet for severe,
uncontrollable extremity hemorrhage and use of a hemostatic dressing.
(D) Disability
Evaluate the patient's level of consciousness (LOC) using the GCS. Re-evaluate the patient's LOC
frequently.
(E) Exposure
Remove all clothing for a complete physical assessment. Prevent hypothermia (e.g., cover the patient
with blankets, use heating devices, infuse warm solutions).
Maintain airway - CORRECT ANSWER✅✅o Suction and/or remove foreign body
o Insert nasopharyngeal/oropharyngeal airway
o Endotracheal intubation
o Cricothyroidotomy or tracheostomy
Stabilize/immobilize cervical spine - CORRECT ANSWER✅✅Collar
Spinal precautions
Flat bedrest
Log roll
Breathing - CORRECT ANSWER✅✅Assessment
,Administer high-flow O2 via a nonrebreather mask
Bag-valve-mask (BVM) ventilation with 100% O2 and intubation for life-threatening conditions
Monitor patient response
Circulation - CORRECT ANSWER✅✅Check central pulse
Assess skin color, temperature, moisture
Assess mental status and capillary refill
Aggressive fluid resuscitation
· Insert two large-bore IV catheters
· NS or LR
Disability - CORRECT ANSWER✅✅LOC
AVPU
o A=alert
o V=responsive to voice
o P=responsive to pain
o U=unresponsive
GCS
Pupils
Exposure - CORRECT ANSWER✅✅clothing removal/temperature control
The nurse performing a primary survey in the ED is assessing - CORRECT ANSWER✅✅the acuity of the
patient's condition to determine priority of care
the status of airway, breathing, circulation, or presence of deformity.
whether the patient is responsive enough to provide needed information
whether the resources of the ED are adequate to treat the patient
Types of patients seen in E.R. - CORRECT ANSWER✅✅Abdominal pain
,Chest pain
Breathing difficulties
Injuries (especially falls in older adults)
Headache
Fever
Pain (the most common symptom)
Forensic nurse role - CORRECT ANSWER✅✅Are educated to obtain patients histories; collect forensic
evidence; and offer counseling and follow-up care for victims of rape, child abuse, and domestic violence
also known as intimate partner violence (IPV). They recognize evidence of abuse and when to intervene
on the patient's behalf. May include information about developing a safety plan or how to escape a
violent relationship. Forensic nurse examiners document injuries and collect physical and photographic
evidence. They may also provide testimony in court as to what was observed during the examination
and information about the type of care provided.
Emergent or class I (red tag) (immediate threat to life or limb) - CORRECT ANSWER✅✅Airway
obstruction
shock
Respiratory distress
Chest pain with diaphoresis
Stroke
Active hemorrhage
Unstable vital signs
Urgent or class II (yellow tag) (major injuries that require treatment) can wait a short time for care.
Treatment within 30 minutes to 2 hours. - CORRECT ANSWER✅✅o Patient should be treated quickly
but immediate threat to life does not exist at the moment
Severe abdominal pain
Renal colic
Open fractures with distal pulse
Large wounds
Displaced or multiple fractures
, Complex or multiple soft tissue injuries
New-onset respiratory infection, especially pneumonia in older adults
Nonurgent or class III (green tag) (walking wounded) (minor injuries that do not require immediate
treatment) delayed more than 2 hours - CORRECT ANSWER✅✅Skin rash
Strains and sprains
"Colds"
Simple closed fracture
Contusions
Black tag - CORRECT ANSWER✅✅Expectant or class IV (black tag) (expected and allowed to die)
massive head injuries, extensive full-thickness body burns, and high cervical spinal cord injury requiring
mechanical ventilation.
Level 1 - CORRECT ANSWER✅✅Usually located in large teaching hospital systems in densely populated
areas Provides a full continuum of trauma services for adult and/or pediatric patients Conducting
research is a requirement for trauma center verification
Level II and Level III - CORRECT ANSWER✅✅Both typically located in community hospitals Level II
Provides care to most injured patients. Transfers patient if needs exceed resource capabilities Level III
Stabilizes patients with major injuries. Transfers patient if needs exceed resource capabilities
Level IV - CORRECT ANSWER✅✅Usually located in rural and remote areas. Provides basic trauma
patient stabilization and advanced life support within resource capabilities. Arranges transfer to higher
trauma center levels as necessary
Penetrating trauma - CORRECT ANSWER✅✅caused by injury from sharp objects and projectiles.
Examples are wounds from knives, ice picks, other comparable implements, and bullets (gunshot
wounds [GSWs]) or pellets. Fragments of metal, glass, or other materials that become airborne in an
explosion (shrapnel) can also produce penetrating trauma.
Each mechanism has the risk for specific injury patterns and severity that the trauma team considers
when planning diagnostic evaluation and management strategies. Certain injury mechanisms such as a
gunshot wound to the chest or abdomen or a stab wound to the neck are so highly associated with life-
Primary Survey in E.R - CORRECT ANSWER✅✅(A) Airway/cervical spine
Establish a patent airway by positioning, suctioning, and oxygen as needed. Protect the cervical spine by
maintaining alignment; use a jaw-thrust maneuver if there is a risk for spinal injury. If the Glasgow Coma
Scale (GCS) score is 8 or less or the patient is at risk for airway compromise, prepare for endotracheal
intubation and mechanical ventilation.
(B) Breathing
Assess breath sounds and respiratory effort. Observe for chest wall trauma or other physical
abnormality. Prepare for chest decompression if needed. Prepare to assist ventilations if needed.
(C) Circulation
Monitor vital signs, especially blood pressure and pulse. Maintain vascular access with a large-bore
catheter. Use direct pressure for external bleeding; anticipate need for a tourniquet for severe,
uncontrollable extremity hemorrhage and use of a hemostatic dressing.
(D) Disability
Evaluate the patient's level of consciousness (LOC) using the GCS. Re-evaluate the patient's LOC
frequently.
(E) Exposure
Remove all clothing for a complete physical assessment. Prevent hypothermia (e.g., cover the patient
with blankets, use heating devices, infuse warm solutions).
Maintain airway - CORRECT ANSWER✅✅o Suction and/or remove foreign body
o Insert nasopharyngeal/oropharyngeal airway
o Endotracheal intubation
o Cricothyroidotomy or tracheostomy
Stabilize/immobilize cervical spine - CORRECT ANSWER✅✅Collar
Spinal precautions
Flat bedrest
Log roll
Breathing - CORRECT ANSWER✅✅Assessment
,Administer high-flow O2 via a nonrebreather mask
Bag-valve-mask (BVM) ventilation with 100% O2 and intubation for life-threatening conditions
Monitor patient response
Circulation - CORRECT ANSWER✅✅Check central pulse
Assess skin color, temperature, moisture
Assess mental status and capillary refill
Aggressive fluid resuscitation
· Insert two large-bore IV catheters
· NS or LR
Disability - CORRECT ANSWER✅✅LOC
AVPU
o A=alert
o V=responsive to voice
o P=responsive to pain
o U=unresponsive
GCS
Pupils
Exposure - CORRECT ANSWER✅✅clothing removal/temperature control
The nurse performing a primary survey in the ED is assessing - CORRECT ANSWER✅✅the acuity of the
patient's condition to determine priority of care
the status of airway, breathing, circulation, or presence of deformity.
whether the patient is responsive enough to provide needed information
whether the resources of the ED are adequate to treat the patient
Types of patients seen in E.R. - CORRECT ANSWER✅✅Abdominal pain
,Chest pain
Breathing difficulties
Injuries (especially falls in older adults)
Headache
Fever
Pain (the most common symptom)
Forensic nurse role - CORRECT ANSWER✅✅Are educated to obtain patients histories; collect forensic
evidence; and offer counseling and follow-up care for victims of rape, child abuse, and domestic violence
also known as intimate partner violence (IPV). They recognize evidence of abuse and when to intervene
on the patient's behalf. May include information about developing a safety plan or how to escape a
violent relationship. Forensic nurse examiners document injuries and collect physical and photographic
evidence. They may also provide testimony in court as to what was observed during the examination
and information about the type of care provided.
Emergent or class I (red tag) (immediate threat to life or limb) - CORRECT ANSWER✅✅Airway
obstruction
shock
Respiratory distress
Chest pain with diaphoresis
Stroke
Active hemorrhage
Unstable vital signs
Urgent or class II (yellow tag) (major injuries that require treatment) can wait a short time for care.
Treatment within 30 minutes to 2 hours. - CORRECT ANSWER✅✅o Patient should be treated quickly
but immediate threat to life does not exist at the moment
Severe abdominal pain
Renal colic
Open fractures with distal pulse
Large wounds
Displaced or multiple fractures
, Complex or multiple soft tissue injuries
New-onset respiratory infection, especially pneumonia in older adults
Nonurgent or class III (green tag) (walking wounded) (minor injuries that do not require immediate
treatment) delayed more than 2 hours - CORRECT ANSWER✅✅Skin rash
Strains and sprains
"Colds"
Simple closed fracture
Contusions
Black tag - CORRECT ANSWER✅✅Expectant or class IV (black tag) (expected and allowed to die)
massive head injuries, extensive full-thickness body burns, and high cervical spinal cord injury requiring
mechanical ventilation.
Level 1 - CORRECT ANSWER✅✅Usually located in large teaching hospital systems in densely populated
areas Provides a full continuum of trauma services for adult and/or pediatric patients Conducting
research is a requirement for trauma center verification
Level II and Level III - CORRECT ANSWER✅✅Both typically located in community hospitals Level II
Provides care to most injured patients. Transfers patient if needs exceed resource capabilities Level III
Stabilizes patients with major injuries. Transfers patient if needs exceed resource capabilities
Level IV - CORRECT ANSWER✅✅Usually located in rural and remote areas. Provides basic trauma
patient stabilization and advanced life support within resource capabilities. Arranges transfer to higher
trauma center levels as necessary
Penetrating trauma - CORRECT ANSWER✅✅caused by injury from sharp objects and projectiles.
Examples are wounds from knives, ice picks, other comparable implements, and bullets (gunshot
wounds [GSWs]) or pellets. Fragments of metal, glass, or other materials that become airborne in an
explosion (shrapnel) can also produce penetrating trauma.
Each mechanism has the risk for specific injury patterns and severity that the trauma team considers
when planning diagnostic evaluation and management strategies. Certain injury mechanisms such as a
gunshot wound to the chest or abdomen or a stab wound to the neck are so highly associated with life-
