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A 6-year-old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming the patient?
- A. Assessing the patient's oral temperature frequently
- B. Ensuring continuous ECG monitoring
- C. Massaging the patient's skin surfaces to promote circulation
- D. Administering bronchodilators by nebulizer
Correct Answer: B
Rationale: Continuous ECG monitoring is essential during hypothermia rewarming to detect arrhythmias. Oral temperatures are unreliable, massage risks tissue damage, and bronchodilators are not indicated.
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The paramedics bring a patient who has suffered a sexual assault to the ED. What is important for the sexual assault nurse examiner to do when assessing a sexual assault victim?
- A. Respect the patient's privacy during assessment.
- B. Shave all pubic hair for laboratory analysis.
- C. Place items for evidence in plastic bags.
- D. Bathe the patient before the examination.
Correct Answer: A
Rationale: Respecting privacy minimizes trauma during a sexual assault assessment. Pubic hair is combed, not shaved; evidence goes in paper bags to avoid moisture; and bathing destroys evidence.
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 admitted to the ED with severe diarrhea and vomiting is subsequently diagnosed with food poisoning. The nurse caring for this patient assesses for signs and symptoms of fluid and electrolyte imbalances. For what signs and symptoms would this nurse assess? Select all that apply.
- A. Dysrhythmias
- B. Hypothermia
- C. Hypotension
- D. Hyperglycemia
- E. Delirium
Correct Answer: A,C,E
Rationale: Fluid and electrolyte imbalances from food poisoning cause dysrhythmias, hypotension, and delirium. Hypothermia and hyperglycemia are not typically associated.
A patient who attempted suicide being treated in the ED is accompanied by his mother, father, and brother. When planning the nursing care of this family, the nurse should perform which of the following action?
- A. Refer the family to psychiatry in order to provide them with support.
- B. Explore the causes of the patient's suicide attempt with the family.
- C. Encourage the family to participate in the bedside care of the patient.
- D. Ensure that the family receives appropriate crisis intervention services.
Correct Answer: D
Rationale: Crisis intervention services support the family after a suicide attempt. Exploring causes is insensitive, bedside care is impractical, and psychiatry isn't the primary support source.
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.