Nokea
A patient arrives in the emergency department (ED) a few hours after taking '20-30' acetaminophen (Tylenol) tablets. Which of the following actions will the nurse plan to take?
- A. Give N-acetylcysteine
- B. Discuss the use of chelation therapy
- C. Have the patient drink large amounts of water
- D. Administer oxygen using a non-rebreather mask
Correct Answer: A
Rationale: N-acetylcysteine is the antidote for acetaminophen overdose, preventing liver damage by restoring glutathione levels. Chelation therapy, water dilution, and oxygen are not appropriate treatments for acetaminophen toxicity.
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The nurse is caring for a patient who has experienced blunt abdominal trauma during a car accident and has increasing abdominal pain. Which of the following diagnostic tests should the nurse prepare the patient for?
- A. Ultrasonography
- B. Peritoneal lavage
- C. X-ray
- D. Magnetic resonance imaging (MRI)
Correct Answer: A
Rationale: Focused abdominal ultrasonography (FAST) is the preferred, non-invasive method to detect intraperitoneal bleeding in trauma patients. Peritoneal lavage is more invasive, and X-ray or MRI are less effective for this purpose.
The nurse is assessing a patient with hypothermia. Which of the following assessments should the nurse expect to find?
- A. Hypertension
- B. Reddened, swollen extremities
- C. Hyperventilation
- D. Bradycardia
Correct Answer: D
Rationale: Hypothermia causes bradycardia due to slowed metabolic processes. Hypotension, blue or white extremities, and hypoventilation are more typical, not hypertension, reddened extremities, or hyperventilation.
The nurse is assessing a patient who is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the right hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. Which of the following should the nurse anticipate administering to the patient?
- A. Tetanus-diphtheria toxoid (TD) only
- B. Tetanus immunoglobulin (TIG) only
- C. Tetanus immunoglobulin (TIG) and tetanus-diphtheria (TD) toxoid
- D. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap)
Correct Answer: C
Rationale: For an unvaccinated patient with a tetanus-prone wound, both TIG (for immediate passive immunity) and TD (for long-term active immunity) are recommended. Tdap includes pertussis, which is not necessary in this context.
These four patients arrive in the emergency department after a motor vehicle crash. In which order should they be assessed?
- A. A 72-year-old with palpitations and chest pain
- B. A 45-year-old complaining of 6/10 abdominal pain
- C. A 22-year-old with multiple fractures of the face and jaw
- D. A 30-year-old with a misaligned right leg with intact pulses
Correct Answer: C,A,B,D
Rationale: The 22-year-old with facial and jaw fractures is assessed first due to potential airway compromise. The 72-year-old with chest pain (possible cardiac ischemia) is next, followed by the 45-year-old with abdominal pain (potential internal bleeding). The 30-year-old with a leg fracture and intact pulses is least urgent.
An unresponsive older-adult patient is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 41.2°C (106.1°F), blood pressure (BP) 86/52, and pulse 102. Which of the following actions should the nurse implement initially?
- A. Administer an Aspirin suppository
- B. Start O2 at 6 L/minute with a nasal cannula
- C. Apply a cooling blanket to the patient
- D. Infuse Lactated Ringer's solution at 1000 mL/hour
Correct Answer: C
Rationale: Applying a cooling blanket is the priority to rapidly lower the core temperature in heat stroke, which is life-threatening at 41.2°C. Aspirin is ineffective, high-flow oxygen via non-rebreather is preferred, and rapid fluid infusion risks pulmonary edema in older adults.