Chapter 69: Nursing Management: Emergency, Terrorism, and Disaster Nursing

Chapter 69: Nursing Management: Emergency, Terrorism, and Disaster Nursing

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE
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.
DIF: Cognitive Level: Application REF: 1769-1771
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
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.
DIF: Cognitive Level: Application REF: 1769-1771
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
3. After resuscitation, a patient who had a cardiac arrest is nonresponsive to commands and
therapeutic hypothermia is prescribed. Which action will the nurse include in the plan of
care?
a. Rapidly infuse cold normal saline.
b. Avoid the use of sedative medications.
Test Bank 69-2
c. Check neurologic status every 30 minutes.
d. Rewarm if temperature is >91° F (32.8° C).
ANS: A
When therapeutic hypothermia is used postresuscitation, cold normal saline is infused to
rapidly lower body temperature to 89.6° F to 93.2° F (32° C to 34° C). Since hypothermia
will decrease brain activity, neurologic assessment every 30 minutes is not needed.
Sedative medications are administered during therapeutic hypothermia.
DIF: Cognitive Level: Application REF: 1773-1774 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 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.
DIF: Cognitive Level: Application REF: 1769-1771
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
5. An 18-year-old is brought to the emergency department (ED) with multiple lacerations
and tissue avulsion of the right hand. When asked about tetanus immunization, the patient
denies having any previous vaccinations. The nurse will anticipate administration of
a. tetanus-diphtheria toxoid (Td) only.
b. tetanus immunoglobulin (TIG) only.
c. TIG and tetanus-diphtheria toxoid (Td).
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: Application REF: 1773-1774 TOP: Nursing Process:
Planning
MSC: NCLEX: Health Promotion and Maintenance