Question 1

Levin, age 27, was driving home when his car collided with another moving vehicle. He obtained multiple injuries and a concussion. The paramedics placed a hard neck brace to immobilize the spine. Upon arriving at the hospital, X-rays are inconclusive because of swelling. To assess and care for the skin under the collar, the nurse should:

Accepted Answer

The head and neck are maintained in an aligned position at all times and supported. The collar is hard and can cause skin breakdown. The collar liner should be changed daily and the underlying skin cleansed. Turning the head from side to side may cause injury to the spine (Choice A). Choice B is incorrect because the client may be experiencing weakness and there is no support for the neck if the collar is removed. The collar liner must be changed and the skin cleaned daily to prevent breakdown (Choice D). The presence or absence of a spinal injury may not be determined in less than 24 hours.

Question 2

Troy, 27 years old, suffered from multiple injuries after his car crashed into a moving vehicle. He was then rushed to a nearby hospital where his left leg was amputated below the knee. After surgery, the physician's orders include elevation of the foot of the bed for 24 hours. The nurse observes that the nursing assistant has placed a pillow under Troy's amputated limb. The nursing action is to:

Accepted Answer

The orders call for bed elevation (this is done to reduce edema and prevent hemorrhage). A pillow under the stump may lead to a flexion contracture of the hip joint, so this is contraindicated. Also, further teaching is indicated so that the nursing assistant understands why the pillow is contraindicated.

Question 3

A client is scheduled for an electroencephalogram (EEG) early in the morning. The nurse working the night shift prior to the procedure would write a note to do which of the following per protocol order in the early morning on the day of the test?

Accepted Answer

Antidepressants, tranquilizers, and anticonvulsants are generally withheld for 24 to 48 hours before an EEG. The client does not have to be on NPO, but should avoid stimulants such as coffee, tea, cola, alcohol, and cigarettes. Pre-procedure care for EEG involves teaching that there is no discomfort and shampooing the hair.

Question 4

S) McCormick, R.N., is one of several persons who witness a vehicle hit a pedestrian at fairly low speed on a street. The person is dazed and tries to get up. The leg appears fractured. Ms. McCormick would plan to:

Accepted Answer

With a suspected fracture, the client is not moved unless it is dangerous to remain in that spot. A fracture is not reduced at the scene (Choice A). Choice B is incorrect because before the client is moved, the site of fracture is immobilized to prevent further injury. Choice C is incorrect because the nurse should remain with client and have someone else call for emergency help.

Quiz 1: Medical Surgical Nursing Practice

A client is scheduled for an electroencephalogram (EEG) early in the morning. The nurse working the night shift prior to the procedure would write a note to do which of the following per protocol order in the early morning on the day of the test?

S) McCormick, R.N., is one of several persons who witness a vehicle hit a pedestrian at fairly low speed on a street. The person is dazed and tries to get up. The leg appears fractured. Ms. McCormick would plan to: