ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 71 Questions
Question 1 of 5
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?
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.
Question 2 of 5
The nurse is conducting a primary survey of a patient with multiple traumatic injuries and observes that the patient's right pedal pulses are absent and the leg is swollen. Which of the following actions will the nurse take next?
Correct Answer: D
Rationale: Absent pedal pulses and leg swelling suggest arterial trauma or hemorrhage, a life-threatening condition. Initiating IV fluid infusion immediately addresses potential hypovolemia, taking precedence over further assessment or completing the survey.
Question 3 of 5
The nurse is assessing a patient with hypothermia. Which of the following assessments should the nurse expect to find?
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.
Question 4 of 5
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?
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.
Question 5 of 5
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?
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.