Nokea
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.
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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 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.
A patient is brought to the ED by ambulance after swallowing highly acidic toilet bowl cleaner 2 hours earlier. The patient is alert and oriented. What is the care team's most appropriate treatment?
- A. Administering syrup of ipecac
- B. Performing a gastric lavage
- C. Giving milk to drink
- D. Referring to psychiatry
Correct Answer: C
Rationale: Diluting an acidic ingestion with milk or water is appropriate after 2 hours, as gastric lavage is ineffective beyond 1 hour. Ipecac is obsolete, and psychiatric referral follows physical stabilization.
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.
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.