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A patient has been brought to the ED with multiple trauma after a motor vehicle accident. After immediate threats to life have been addressed, the nurse and trauma team should take what action?
- A. Perform a rapid physical assessment.
- B. Initiate health education.
- C. Perform diagnostic imaging.
- D. Establish the circumstances of the accident.
Correct Answer: A
Rationale: After stabilizing life-threatening issues, a rapid physical assessment identifies injuries and guides treatment priorities. Education, imaging, and accident details follow later.
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A backcountry skier has been airlifted to the ED after becoming lost and developing hypothermia and frostbite. How should the nurse best manage the patient's frostbite?
- A. Immerse affected extremities in water slightly above normal body temperature.
- B. Immerse the patient's frostbitten extremities in the warmest water the patient can tolerate.
- C. Gently massage the patient's frozen extremities in between water baths.
- D. Perform passive range-of-motion exercises of the affected extremities to promote circulation.
Correct Answer: A
Rationale: Immersion in 37-40°C water safely rewarms frostbitten extremities. Hotter water risks burns, and massage or exercises cause further tissue damage.
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.
A patient is brought to the ED by two police officers. The patient was found unconscious on the sidewalk, with his face and hands covered in blood. At present, the patient is verbally abusive and is fighting the staff in the ED, but appears medically stable. The decision is made to place the patient in restraints. What action should the nurse perform when the patient is restrained?
- A. Frequently assess the patient's skin integrity.
- B. Inform the patient that he is likely to be charged with assault.
- C. Avoid interacting with the patient until the restraints are removed.
- D. Take the opportunity to perform a full physical assessment.
Correct Answer: A
Rationale: Frequent skin integrity checks prevent injury from restraints. Legal charges are not the nurse's role, interaction should continue, and a full assessment may be unsafe while combative.
A patient is brought to the ED by friends. The friends tell the nurse that the patient was using cocaine at a party. On arrival to the ED the patient is in visible distress with an axillary temperature of 40.1°C (104.2°F). What would be the priority nursing action for this patient?
- A. Monitor cardiovascular effects.
- B. Administer antipyretics.
- C. Ensure airway and ventilation.
- D. Prevent seizure activity.
Correct Answer: C
Rationale: Ensuring airway and ventilation is the priority in cocaine-induced hyperthermia, as respiratory compromise is life-threatening. Cardiovascular monitoring, antipyretics, and seizure prevention follow.
A triage nurse is talking to a patient when the patient begins choking on his lunch. The patient is coughing forcefully. What should the nurse do?
- A. Stand him up and perform the abdominal thrust maneuver from behind.
- B. Lay him down, straddle him, and perform the abdominal thrust maneuver.
- C. Leave him to get assistance.
- D. Stay with him and encourage him, but not intervene at this time.
Correct Answer: D
Rationale: A forcefully coughing patient may dislodge the obstruction, so the nurse should stay and encourage without intervening unless obstruction worsens. Abdominal thrusts are for complete obstruction.