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A 23-year-old woman is brought to the ED complaining of stomach cramps, nausea, vomiting, and diarrhea. The care team suspects food poisoning. What is the key to treatment in food poisoning?
- A. Administering IV antibiotics
- B. Assessing immunization status
- C. Determining the source and type of food poisoning
- D. Determining if anyone else in the family is ill
Correct Answer: C
Rationale: Identifying the source and type of food poisoning guides specific treatment, such as fluid replacement or antitoxins. Antibiotics are rarely needed, and immunization or family illness are secondary.
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A patient is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the physician will perform which of the following actions?
- A. Insert an oropharyngeal airway.
- B. Perform the jaw thrust maneuver.
- C. Perform endotracheal intubation.
- D. Perform a cricothyroidotomy.
Correct Answer: C
Rationale: Endotracheal intubation ensures airway patency in respiratory insufficiency. Oropharyngeal airways are for spontaneous breathing, jaw thrust doesn't secure an airway, and cricothyroidotomy is a last resort.
You are a floor nurse caring for a patient with alcohol withdrawal syndrome. What would be an appropriate nursing action to minimize the potential for hallucinations?
- A. Engage the patient in a process of health education.
- B. Administer opioid analgesics as ordered.
- C. Place the patient in a private, well-lit room.
- D. Provide television or a radio as therapeutic distraction
Correct Answer: C
Rationale: A quiet, well-lit private room reduces sensory overload, minimizing hallucinations in alcohol withdrawal. Analgesics or media may worsen symptoms, and education is inappropriate during acute withdrawal.
A patient is admitted to the ED with suspected alcohol intoxication. The ED nurse is aware of the need to assess for conditions that can mimic acute alcohol intoxication. In light of this need, the nurse should perform what action?
- A. Check the patient's blood glucose level.
- B. Assess for a documented history of major depression.
- C. Determine whether the patient has ingested a corrosive substance.
- D. Arrange for assessment of serum potassium levels.
Correct Answer: A
Rationale: Hypoglycemia can mimic alcohol intoxication symptoms like confusion and slurred speech, so checking blood glucose is critical. Depression, corrosive ingestion, or potassium levels are less likely mimics.
An obtunded patient is admitted to the ED after ingesting bleach. The nurse should prepare to assist with what intervention?
- A. Prompt administration of an antidote
- B. Gastric lavage
- C. Administration of activated charcoal
- D. Helping the patient drink large amounts of water
Correct Answer: D
Rationale: Diluting bleach ingestion with water is appropriate for corrosive substances. There's no antidote, lavage is contraindicated, and charcoal is ineffective for corrosives.
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.