Trauma Med-Surg IV

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Sample questions from Trauma Med-Surg IV

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.In the emergency department, a 19-year-old client with a penetrating chest injury becomes restless and pale. The heart rate is 132/min, blood pressure is 82/48 mm Hg, and the skin is cool and clammy. Which action should the nurse take first?

   • A.Administer an oral analgesic and reassess the blood pressure in 30 minutes.
   • B.Obtain a complete medication history before initiating treatment.
   • C.Place the client in a sitting position to reduce cardiac workload.
   • D.Establish large-bore intravenous access and begin isotonic fluid resuscitation as prescribed.

   Rationale: The hypotension, tachycardia, pallor, and cool skin indicate inadequate perfusion and possible hemorrhagic shock, so rapid vascular access and prescribed resuscitation are priorities. A medication history is useful but must not delay treatment of shock. Sitting the client upright may worsen venous return, and an oral medication is inappropriate for an unstable client.

2. 2.Refer to the client's chart. Which findings support concern for ongoing blood loss and impaired tissue perfusion? Select all that apply.

   • A.The oxygen saturation remains 97% on 2 L/min by nasal cannula.
   • B.The heart rate rises from 118/min to 136/min.
   • C.The blood pressure falls from 96/60 mm Hg to 78/44 mm Hg.
   • D.The client reports increasing thirst and restlessness.
   • E.Urine output is 15 mL during the last hour.

   Rationale: The rising heart rate and falling blood pressure show worsening hemodynamic instability, while urine output of 15 mL/hour suggests inadequate renal perfusion. Increasing thirst and restlessness are additional possible signs of hypovolemia and declining perfusion. An oxygen saturation of 97% on supplemental oxygen does not rule out blood loss, but by itself it does not support the specific concern as strongly as the other findings.

3. 3.A client states, "My chest feels tight, and I feel faint," 6 hours after a femoral cardiac catheterization. The affected leg is cool, and the pedal pulse is weaker than it was at the last assessment. Which action is the priority?

   • A.Notify the provider immediately and maintain the client on bed rest.
   • B.Assist the client to walk to improve circulation in the leg.
   • C.Apply a heating pad to the affected leg and reassess in 1 hour.
   • D.Document the finding as an expected effect of the procedure.

   Rationale: A cool extremity and diminished pulse after femoral access can indicate arterial occlusion, while chest tightness and faintness may signal a serious complication requiring prompt assessment. The provider should be notified immediately, and the client should remain at rest while further evaluation is arranged. Heat and ambulation are unsafe, and these findings are not an expected routine effect to simply document.

4. 4.A client's potassium is 6.4 mEq/L (reference range 3.5-5.0 mEq/L), and the electrocardiogram shows peaked T waves. Which prescribed intervention should the nurse anticipate to stabilize the myocardium?

   • A.Intravenous magnesium sulfate
   • B.Intravenous calcium gluconate
   • C.A loop diuretic as the sole immediate intervention
   • D.Oral potassium chloride

   Answer and rationale are in the full material.

5. 5.Refer to the client's chart. Which finding requires the most immediate action?

   • A.The client's heart rate rises from 104/min to 128/min.
   • B.The client's systolic blood pressure decreases by 18 mm Hg from the initial measurement.
   • C.The client reports new shortness of breath and has a respiratory rate of 30/min.
   • D.The client's oxygen saturation is 93% on room air.

   Answer and rationale are in the full material.