1. During the primary assessment of a trauma victim, the nurse determines that the patient is breathing and has an unobstructed airway. Which

action should the nurse take next?

a. Observe the patient’s respiratory effort.

b. Check the patient’s level of consciousness.

c. Palpate extremities for capillary refill time.

d. Examine the patient for any external bleeding.

ANS: A

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 also are 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 multiple traumatic injuries, the nurse observes that the patient’s right pedal pulses are absent and

the leg is swollen. Which of these 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.

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 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.

4.A patient who is unconscious after a fall from a ladder is transported to the emergency department by family members. During the primary

survey of the patient, the nurse should

a. assess the patient’s vital signs.

b. attach a cardiac electrocardiogram (ECG) monitor.

c. obtain a Glasgow Coma Scale score.

d. ask about chronic medical conditions.

ANS: C

The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the

secondary survey.

6.A patient who has experienced blunt abdominal trauma during a car accident is complaining of increasing abdominal pain. The nurse will plan

to teach the patient about the purpose of

a. ultrasonography.

b. peritoneal lavage.

c. nasogastric (NG) tube placement.

d. magnetic resonance imaging (MRI).

ANS: A

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.

7.A patient with hypotension and temperature elevation after doing yard work on a hot day is treated in the ED. After the nurse has completed

discharge teaching, which statement by the patient indicates that the teaching has been effective?

a. ―I will take salt tablets when I work outdoors in the summer.‖

b. ―Ishould take acetaminophen (Tylenol) if I start to feel too warm.‖

c. ―Ishould have sports drinks when exercising outside in hot weather.‖