Deck 27: Trauma Surgery

Question 1

Sherita Noonan,a 9-year-old girl,is admitted to the operating room for elevation of a depressed skull fracture without evidence of a hematoma.She has a history of seizure disorders.The anesthesia provider administers a loading dose of medication to prevent seizure activity under anesthesia.What is the appropriate medication to give and what nursing actions would be indicated?

A) Phenobarbital 15-20 mg/kg IV,monitor cardio/respiratory function during loading dose
B) Phenytoin 15-20 mg/kg IV;monitor for hypotension and drug interactions
C) Phenobarbital 15-20 mg/kg IV,monitor cardio/respiratory function during loading dose and phenytoin 15-20 mg/kg IV;monitor for hypotension and drug interactions
D) Neither phenobarbital 15-20 mg/kg IV,monitor cardio/respiratory function during loading dose nor phenytoin 15-20 mg/kg IV;monitor for hypotension and drug interactions

Answer 1

C
Phenobarbital can be used in combination (adjunct)with phenytoin for seizure control in patients with head trauma.Phenytoin (Dilantin):Assess patient for hypotension;monitor for interaction with other medications because it interacts and may precipitate in the presence of some medications or fluids;it is a prophylactic measure for patients at increased risk for seizure activity following head trauma;it may act on the motor cortex to inhibit spread of seizure activity.Phenobarbital (Luminal):Pediatric loading dose is 15-20 mg/kg IV in single or divided doses;monitor respiratory and cardiac function during loading dose;used as an adjunct for seizure control in patients with head trauma.

Question 2

Traumatic deaths may occur in three phases,or time frames.The first phase occurs immediately after the injury,the second phase within the first 1 to 2 hours after the injury,and the third phase occurs days to weeks after the injury.Approximately 30% of total fatalities from trauma could be prevented with definitive trauma care,including appropriate and aggressive resuscitation with rapid transport to an appropriate facility.Which phase,or timeframe,of potential for trauma death,does this group represent?

A) Phase I
B) Phase II
C) Phase III
D) This represents all phases of trauma,not one distinct phase.

Answer 2

B
The second phase occurs within the first 1 to 2 hours after the injury,representing approximately 30% of total fatalities.These patients have injuries to the spleen,liver,lung,or other organs that result in significant blood loss.This is the group in which definitive trauma care (i.e.,appropriate and aggressive resuscitation with adequate volume replacement)may have the most significant effect (the golden hour).

Question 3

If cervical spine precautions were not implemented before arrival at the hospital,the emergency department team initiates them before performing any other procedures on the patient.A trauma team member can stabilize the head and neck,if necessary,until a cervical collar is placed.What event needs to take place before the team removes the cervical collar and continues care?

A) A halo traction apparatus is applied.
B) A cervical radiograph is obtained to rule out injury to the neck.
C) A CT scan with contrast of the upper body is obtained to rule out vascular involvement.
D) A myelogram of the cervical spinal canal is obtained to rule out injury to the spinal cord.

Answer 3

B
Once placed,the team does not remove the collar until a cervical radiograph clears the neck of injury.

Question 4

Blunt force to the larynx can result in a fracture and impose immediate airway obstruction.These patients are at risk for a lost airway and may require immediate tracheotomy followed by repair of the fracture when the fracture is unstable or displaced.It is also important to consider that a trauma patient is assumed to have a full stomach;thus these patients are at high risk for aspiration and resultant pneumonia.What is an appropriate nursing action in the event of a lost airway after anesthesia induction and before intubation?

A) Assist the anesthesia provider with securing the airway while applying cricoid pressure.
B) Assist the anesthesia provider by inserting a nasogastric tube and connecting to suction.
C) Leave the room to get the emergency tracheostomy tray and trach tubes.
D) Increase the oxygen delivery and perform a head tilt-chin lift.

Question 5

A 26-year-old female is rushed to the operating room after a primary and secondary survey in the emergency department.She was hit by a small truck as she was riding her bicycle through a busy intersection.She has sustained rib fractures and several fractured transverse vertebral processes.Renal injury is suspected.As the perioperative nurse prepares to insert a urinary catheter,she notices blood at the urinary meatus.What should the nurse's next action be?

A) Place a gauze dressing over the perineum after inserting the urinary catheter.
B) Insert the catheter and notify the surgeon.
C) Discontinue the catheter insertion.
D) Insert a latex-free straight catheter to empty the bladder and then remove it.

Question 6

The perioperative nurse may not be able to assess the trauma patient until the patient arrives in the OR for surgical intervention.If the patient's condition permits,the perioperative nurse should obtain a brief,precise report from the ED nurse.One component of this report is the AMPLE history.What are the components of the AMPLE mnemonic?

A) Assessment,MOI,Pulse,Level of consciousness,Electrolytes
B) Available family,Medical history,Problem,Language,Environmental conditions of event
C) Allergies,Medications,Past medical history,Last meal,Event leading to injury
D) Additional diseases,Mean arterial pressure,Prior surgeries,Labs,Extraneous injuries

Question 7

Focused assessment with sonography in trauma (FAST)may assist with diagnosis in difficult situations.What group of scans is performed and what do they identify?

A) A chest,pelvic,and four abdominal scans;collections of fluid and free air
B) A chest,abdominal,and cervical spine scans;hemorrhage
C) A full body scan;midline shifts
D) A full body CT,MRI,and PET scans;life-threatening and secondary injuries

Question 8

Morbidity and mortality may be greater with penetrating trauma because identification of injuries may be more difficult when injuries are less obvious.In the case of an adult victim with a low-velocity,low-caliber gunshot wound,at far range,of the anterior left quadrant of the lower abdomen,what is the MOI and description of the possible injuries?

A) Acceleration;small entrance wound with blast injury to the left sigmoid colon and large exit wound
B) Deceleration;large entrance wound with complete transection of the left colon and no exit wound
C) Blunt force;disruption of left quadrant vessels,contusion of anterior sigmoid colon,and no exit wound
D) Penetrating;small entrance wound,puncture of the anterior wall of the sigmoid colon,no disruption of vessels,and bullet not found in pelvis

Question 9

When the patient arrives in the ED,the trauma team initiates a primary assessment.This is a logical,orderly process of patient assessment for potential life threats.These assessment activities are based on established protocols for advanced trauma life support (ATLS).The mnemonic "ABCDE" is used,representing assessment of the following:Airway,Breathing,Circulation,Disability,and Exposure.The D and E represent what degree of investigation?

A) D = musculoskeletal impairments;E = environmental issues
B) D = a brief reflex examination;E = extraneous sensory impairments
C) D = history of prior impairments;E = events that contributed to the injury
D) D = a brief neurologic examination;E = exposure to reveal all life-threatening injuries

Question 10

Trauma to the chest area is the primary cause of death in approximately 25% of trauma victims.Involvement of the heart,great vessels,lungs,and diaphragm,attributable to penetrating or blunt injury,can provide multiple unexpected findings when the chest is opened.Because of the nature of the potential findings and expected surgical intervention,what would be an appropriate preparatory nursing action?

A) Set up the autotransfusion system and resuscitation equipment.
B) Prepare the rapid response team and chaplain to be on alert.
C) Call for the small fragment set for rib fracture fixation at closure.
D) Prep the patient from the xiphoid to mid-thigh.

Question 11

Morgan Fairlawn is a 7-year-old female who fell off of the swing at school and landed on her head.She is alert.She does not have a history of seizures and does not take any medications.The ED team would like to keep her awake for further monitoring of level of consciousness,and are not yet considering intracranial pressure monitoring.Morgan is very anxious.What sedative and nursing action would be appropriate for Morgan?

A) Lorazepam 0.05-0.1 mg/kg IV over 2-5 min;monitor for continuing seizure activity
B) Propofol 100-200 mcg/kg/min for general anesthesia;monitor for respiratory depression
C) Diphenhydramine 25 mg PO;monitor for drowsiness
D) Midazolam 0.05-0.1 mg/kg IV;monitor for hypersensitivity,hypotension

Question 12

What is the description of damage control surgery,and what conditions may be present?

A) Trauma surgery performed by a nontrauma surgeon;lack of specialty training
B) Surgery performed during ambulance or helicopter transfer;patient movement
C) Surgery at a non-level I center before transfer to a level I;intentional retained sponges
D) Surgery performed in the emergency department;inadequate sterile technique

Question 13

With injury to the brain,swelling may occur quickly,requiring aggressive decisions to manage increasing intracranial pressure (ICP).What is an appropriate diuretic medication to give and what nursing actions would be indicated for an older adult patient with traumatic brain injury,increased ICP,and a history of congestive heart failure (CHF)?

A) Mannitol (Osmitrol) 1.5 /kg IV;monitor cardiovascular status
B) Furosemide (Lasix) 20-80 mg IV;monitor for hypotension and note extent of diuresis
C) Mannitol (Osmitrol) 1.5 /kg IV;monitor cardiovascular status and furosemide (Lasix) 20-80 mg IV;monitor for hypotension and note extent of diuresis
D) Neither mannitol (Osmitrol) 1.5 /kg IV;monitor cardiovascular status nor furosemide (Lasix) 20-80 mg IV;monitor for hypotension and note extent of diuresis

Question 14

If the injury to the patient is a result of a violent crime,the team must give special attention to preservation of evidence during the course of patient care.When clothing is removed from the patient,why must it be placed and secured in a paper bag rather than a plastic bag?

A) Plastic bags may trap moisture and allow mold growth,destroying evidence.
B) It is easier to write identifying information on paper rather than plastic.
C) Plastic bags trap air,which could kill anaerobic microorganisms needed as evidence.
D) Paper bags are more secure as they cannot be untied and retied.

Question 15

What statement regarding level I and level II trauma centers best describes the difference between the two types of centers?

A) A level I trauma center is staffed 24 hours/7 days,while a level II has many support services that are open and staffed 8 hours/5 days.
B) A level I trauma center has a transplant program,while a level II is only able to complete organ procurements.
C) A level I trauma center provides care for every type of injury,while a level II lacks some specialized resources.
D) A level I trauma center requires trauma certification and 8 hours of annual trauma education for all staff,while a level II does not.

Question 16

Mandibular fractures are highly associated with assault as the MOI.The goals of operative intervention are to reduce and immobilize the fracture,prevent infection,and restore facial cosmesis and function.What might be an appropriate nursing action and a nursing outcome statement for a patient with a mandibular fracture caused by assault?

A) Orient the patient to his/her surroundings;the patient will have the ability to verbalize concerns and ask questions.
B) Provide support and explain interventions;the patient will have decreased fear-related behaviors.
C) Provide caring behaviors and offer comfort to allay fear and anxiety;the patient and family will experience decreasing anxiety and fear.
D) All of the options are appropriate and desirable for this patient.

Question 17

Mechanism of injury (MOI),or kinematics,involves the action of forces on the human body and their effects.Motor vehicle collisions (MVCs)account for a high degree of blunt trauma.In the case of an adult trauma victim who is the driver in a head-on MVC at high speed,where the head hits the windshield and the chest impacts the steering wheel,what is the MOI and description of the possible injuries?

A) Acceleration;contusion of the occipital lobe of the brain and posterior chest wall
B) Deceleration;contusion of the frontal lobe of the brain and anterior chest wall
C) Acceleration/deceleration;injury to the anterior and posterior brain and internal thoracic organs and vessels
D) Blast force trauma;impact force causes subdural and epidural hemorrhage and transaction of the thoracic aorta and great vessels

Question 18

Blunt trauma injuries may not fully reveal the degree or depth of injury.What noninvasive diagnostic test is critical to diagnosis in potential traumatic brain injury?

A) Pupil reflex and response to light
B) Skull radiograph
C) CT scan of the head
D) Neurovascular arteriography

Question 19

A trauma patient is rushed to the OR after a primary survey is completed in the emergency department.He is a 36-year-old male with multiple penetrating gunshot and knife wounds to the abdomen.He is bleeding profusely.What appropriate nursing actions are critical in the rapid preparation for this procedure?

A) Set up the autotransfusion system.
B) Prep the patient from the suprasternal notch to the mid-thigh.
C) Place the aortic cross-clamp on the Mayo stand.
D) Open a silo-bag closure system on the sterile field.

Question 20

Which statement regarding level III and level IV trauma centers best describes the difference between the two types of centers?

A) A level III trauma center provides advanced cardiac life support (ACLS),surgery,stabilization,and transfer,while a level IV only provides ACLS services before immediate transfer to a higher level center.
B) A level III trauma center immediately transfers to a higher level center,while a level IV does not accept trauma patients.
C) A level III trauma center determines severity of injury and provides ACLS support before transfer to a level IV center,while a level IV provides all comprehensive services.
D) A level III trauma center provides all types of trauma services but is located in a rural setting,while a level IV provides post-hospital convalescent care for trauma patients.

Question 21

What special consideration should be made when assessing a pediatric trauma patient for level of consciousness?

A) Use the modified Glasgow Coma Scale for children.
B) Use the Broslow tape.
C) Stimulate the child gently in case he or she is a victim of shaken baby syndrome.
D) Use the universal Glasgow Coma Scale for all ages.

Question 22

Autotransfusion can present a vital asset in trauma care,when considering the high blood loss associated with many traumatic injuries.This process provides immediate volume replacement,decreases the amount of bank blood used,and reduces the possibility of transfusion reactions or risk of transfusion with bloodborne pathogens.What are the contraindications to using autotransfusion as a blood replacement source?

A) Clean,hemodiluted blood
B) Blood contaminated with food,bowel contents,or antibiotic irrigation
C) Blood and fluids squeezed out of sterile bloody sponges
D) Pooled blood from a ruptured aortic aneurysm

Question 23

What special consideration should be made when assessing a geriatric trauma patient before surgery?

A) They may have preexisting diseases and conditions.
B) They may take many prescription and nonprescription drugs.
C) They have decreased physiologic reserves.
D) All of the options can negatively impact the geriatric patient's perioperative experience.

Question 24

The emergency medical services system consists of trained prehospital personnel who arrive at the scene and perform definitive interventions designed to reduce morbidity and mortality.What is the primary role of the prehospital personnel? Select all that apply.

A) Scoop and run to the nearest hospital emergency department while performing ABCs.
B) Deliver the victim to the hospital before the end of the golden hour.
C) Determine the severity of injury and initiate medical treatment.
D) Identify the most appropriate facility to which to transport the victim.

Question 25

What special consideration should be made when operating on bariatric trauma patients that could negatively impact their surgical outcome?

A) They may have decreased self-esteem and suffer from societal prejudice.
B) They are at risk for retained foreign bodies related to the size of the abdominal cavity.
C) Several persons will be needed to position the patient.
D) They may not be able to fit into the CT or MRI scanner.