Nokea
A 13-year-old is being admitted to the ED after falling from a roof and sustaining blunt abdominal injuries. To assess for internal injury in the patient's peritoneum, the nurse should anticipate what diagnostic test?
- A. Radiograph
- B. Computed tomography (CT) scan
- C. Complete blood count (CBC)
- D. Barium swallow
Correct Answer: B
Rationale: CT scans effectively detect intraperitoneal injuries from blunt trauma. Radiographs are less detailed, CBC indicates blood loss but not location, and barium swallow is irrelevant.
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The nursing educator is reviewing the signs and symptoms of heat stroke with a group of nurses who provide care in a desert region. The educator should describe what sign or symptom?
- A. Hypertension with a wide pulse pressure
- B. Anhidrosis
- C. Copious diuresis
- D. Cheyne-Stokes respirations
Correct Answer: B
Rationale: Heat stroke is characterized by anhidrosis (lack of sweating), hot dry skin, and hyperthermia. It causes hypotension, not hypertension, and is not linked to diuresis or Cheyne-Stokes breathing.
The nurse is caring for a patient admitted with a drug overdose. What is the nurse's priority responsibility in caring for this patient?
- A. Support the patient's respiratory and cardiovascular function.
- B. Provide for the safety of the patient.
- C. Enhance clearance of the offending agent.
- D. Ensure the safety of the staff.
Correct Answer: A
Rationale: Supporting respiratory and cardiovascular function is the priority in drug overdose to sustain life. Safety and agent clearance are important but secondary.
A patient with multiple trauma is brought to the ED by ambulance after a fall while rock climbing. What is a responsibility of the ED nurse in this patient's care?
- A. Intubating the patient
- B. Notifying family members
- C. Ensuring IV access
- D. Delivering specimens to the laboratory
Correct Answer: C
Rationale: Ensuring IV access is a key ED nursing role for administering fluids or medications. Intubation is for specialized providers, family notification is not a nurse's role, and specimen delivery is handled by others.
An ED nurse is triaging patients according to the Emergency Severity Index (ESI). When assigning patients to a triage level, the nurse will consider the patient's acuity as well as what other variable?
- A. The likelihood of a repeat visit to the ED in the next 7 days
- B. The resources that the patient is likely to require
- C. The patient's or insurer's ability to pay for care
- D. Whether the patient is known to ED staff from previous visits
Correct Answer: B
Rationale: ESI triage considers acuity and anticipated resource needs, such as diagnostics or consultations. Repeat visits, payment ability, or prior ED history are not triage factors.
A patient with a fractured femur presenting to the ED exhibits cool, moist skin, increased heart rate, and falling BP. The care team should consider the possibility of what complication of the patient's injuries?
- A. Myocardial infarction
- B. Hypoglycemia
- C. Hemorrhage
- D. Peritonitis
Correct Answer: C
Rationale: Cool, moist skin, tachycardia, and hypotension suggest hemorrhage, a common complication of femur fractures due to significant blood loss. MI, hypoglycemia, and peritonitis are less likely.