IV.
Critical thinking
1.Based on the findings from the initial survey, indicate what interventions the emergency nurse would
expect the provider to order in the emergency department. Select all that apply.
a. Administer 500 ml of 0.9% NS IV over 1 hour.
b. Apply sequential compression device (SCD) to the uninjured leg.
c. Prepare the client for a STST MRI of the portable x-ray of the legs.
d. Remove the cervical spine immobilization then turn the client on their side.
e. Setup suction equipment at the bedside.
f. Insertion of endotracheal intubation.
Answer: A, B, C, E
Multiple Choice Question: (2 points)
2. When assessing Don, the nurse notices a strong order of alcohol on his breath. Lab results indicate
that his blood alcohol concentration (BAC) is 0.15% (150 mg/dL). The nurse’s immediate concern
for Don is the possibility of
a. a need for larger doses of opioids
b. onset of psychological symptoms
c. respiratory arrest
d. vomiting with aspirations
Answer: D
3. The secondary survey to identify all of Don’s injuries is quickly started. Don’s clothes are removed for
a thorough physical assessment, and vital signs are taken once again. Because Donhas sustained
significant trauma, additional interventions are required at this time. Select the interventions that
would be indicated for this client. Place an “X” by the correct answers.There are five (5) correct
statements. (5 points)
_X_Blood draw for hemoglobin & hematocrit
_X_Cardiac monitoring
_X_Insertion of indwelling urinary catheter
__IV Naloxone (Narcan)
_X_Neurovascular assessment of lower extremities
_X_Pain assessment
__Placement of a central line for venous access
_X_Pulse oximetry with SpO2 monitoring
Multiple Choice Question: (3 points)
4. It is determined that Don requires immediate surgery to reduce and immobilize the fractures of his
tibia, femur and jaw. The orthopedic surgeon discusses the risks of surgery with the client and his wife.
The nurse recognizes that surgical risks for this client are increased due to:
a. alcohol can increase the risk for respiratory complications
b. acute alcohol withdrawal may be triggered by surgery
c. physiological and psychological responses are slowed down by recent alcohol intake
d. alcohol can affect the client’s response to anesthesia and surgery
Answer: D
5. As the orthopedic nurse admits Don to the orthopedic unit, there are necessary assessments and
interventions needed to manage his newly repaired jaw, left tibia and femur fractures. Place an “X’ by
the correct answers (Select all that apply). There are five (5) correct statements.
_X_Assess the client’s airway and monitor for signs of respiratory distress
__Assess the client’s level of pain every 8 hours
__Encourage the client to eat finger foods to provide needed nutrition
_X_Obtain a tracheostomy tray kit and have it ready at the bedside
_X_Obtain wire cutters and have it available at the bedside
_X_Perform neurovascular checks to both legs every 2 hours
_X_Setup suction equipment at the bedside
6. The nurse caring for Don prepares to closely monitor for possible complications related to his
fractures and surgical repairs. The nurse would suspect a neurovascular complication based on the
assessment finding of:
a. Decreased sensation distal to the fracture site
b. Increased redness and warmth below the injury
c. Increased pain levels at the surgical sites
d. Purulent drainage at the site of the open fracture
Answer: A
7. Don is prescribed Heparin 6,000 units subcutaneously every 12 hours for deep vein thrombosis. The
pharmacy dispenses a vial containing 10,000 units/1 ml. How many milliliter(s) of heparin should the
nurse administer? Round answer to the nearest tenth (10 ) or first decimal place and show your work.
th
Since the prescribed is 6,000 units then the available in 10,000 units
the nurse should administer 0.6ml of heparin cause per 10,000 units is
1ml
8. The nurse knows that Don’s open tibial fracture places him at risk for developing osteomyelitis. Which of
the following classic symptoms would the nurse assess to detect the development of this complication?
a. Acute respiratory distress
b. Elevated temperature
c. High pain levels at the surgical site
d. Shortening of the left leg
Answer: B
9. The nurse caring for Don would assess for which of the following symptoms consistent with morphine
overdose?
a. Slow respiration, dilated pupils and restlessness
b. Profuse sweating, pinpoint pupils, and deep sleep
c. Slow respiration, constricted pupils, and sedation
d. Slow pulse, slow respiration and sedation
Answer: C
