Nokea
The nurse is conducting a primary assessment of a trauma victim and determines that the patient is breathing and has an unobstructed airway. Which of the following actions 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
Correct Answer: A
Rationale: Even with a patent airway, ineffective breathing can compromise ventilation. Assessing respiratory effort ensures adequate oxygenation and ventilation, which is the next priority after confirming airway patency in the primary survey.
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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, which of the following actions should the nurse implement?
- 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
Correct Answer: C
Rationale: The Glasgow Coma Scale score assesses neurological disability during the primary survey, prioritizing evaluation of consciousness in an unconscious trauma patient. Vital signs and medical history are part of the secondary survey.
The nurse is assessing a patient with hypothermia. Which of the following assessments should the nurse expect to find?
- A. Hypertension
- B. Reddened, swollen extremities
- C. Hyperventilation
- D. Bradycardia
Correct Answer: D
Rationale: Hypothermia causes bradycardia due to slowed metabolic processes. Hypotension, blue or white extremities, and hypoventilation are more typical, not hypertension, reddened extremities, or hyperventilation.
The nurse is assessing a patient who 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. Which of the following should the nurse anticipate administering to the patient?
- A. Tetanus-diphtheria toxoid (TD) only
- B. Tetanus immunoglobulin (TIG) only
- C. Tetanus immunoglobulin (TIG) and tetanus-diphtheria (TD) toxoid
- D. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap)
Correct Answer: C
Rationale: For an unvaccinated patient with a tetanus-prone wound, both TIG (for immediate passive immunity) and TD (for long-term active immunity) are recommended. Tdap includes pertussis, which is not necessary in this context.
The nurse is caring for a patient who has experienced blunt abdominal trauma during a car accident and has increasing abdominal pain. Which of the following diagnostic tests should the nurse prepare the patient for?
- A. Ultrasonography
- B. Peritoneal lavage
- C. X-ray
- D. Magnetic resonance imaging (MRI)
Correct Answer: A
Rationale: Focused abdominal ultrasonography (FAST) is the preferred, non-invasive method to detect intraperitoneal bleeding in trauma patients. Peritoneal lavage is more invasive, and X-ray or MRI are less effective for this purpose.
The nurse is caring for a patient with hypotension and temperature elevation after doing yard work on a hot day and is being treated in the emergency department. After the nurse has completed discharge teaching, which of the following patient statements indicates that the teaching has been effective?
- A. I will take salt tablets when I work outdoors in the summer
- B. I should take acetaminophen if I start to feel too 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: Sports drinks replace fluids and electrolytes lost during heat exposure, preventing heat-related illnesses. Salt tablets risk gastric irritation, antipyretics like acetaminophen are ineffective for heat-induced hyperthermia, and confusion indicates severe heat stroke requiring immediate medical intervention.