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A patient is brought by friends to the ED after being involved in a motor vehicle accident. The patient sustained blunt trauma to the abdomen. What nursing action would be most appropriate for this patient?
- A. Ambulate the patient to expel flatus.
- B. Place the patient in a high Fowler's position.
- C. Immobilize the patient on a backboard.
- D. Place the patient in a left lateral position.
Correct Answer: C
Rationale: Immobilization on a backboard is necessary until spinal injury is ruled out in blunt trauma. Ambulation, Fowler's, or lateral positions risk worsening undiagnosed spinal injuries.
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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.
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.
The ED nurse is planning the care of a patient who has been admitted following a sexual assault. The nurse knows that all of the nursing interventions are aimed at what goal?
- A. Encouraging the patient to gain a sense of control over his or her life
- B. Collecting sufficient evidence to secure a criminal conviction
- C. Helping the patient understand that this will not happen again
- D. Encouraging the patient to verbalize what happened during the assault
Correct Answer: A
Rationale: Nursing interventions post-sexual assault focus on empowering the patient to regain control, prioritizing emotional recovery over legal outcomes, future safety guarantees, or forced verbalization.
A patient is being treated for bites that she suffered during an assault. After the bites have been examined and documented by a forensic examiner, the nurse should perform what action?
- A. Apply a dressing saturated with chlorhexidine.
- B. Wash the bites with soap and water.
- C. Arrange for the patient to receive a hepatitis B vaccination.
- D. Assess the patient's immunization history.
Correct Answer: B
Rationale: Washing bites with soap and water after forensic documentation prevents infection. Chlorhexidine dressings, hepatitis B vaccination, or immunization history are not immediate priorities.
A patient with multiple trauma is brought to the ED by ambulance after a fall while rock climbing. What is a responsibility of the ED nurse in this patient's care?
- A. Intubating the patient
- B. Notifying family members
- C. Ensuring IV access
- D. Delivering specimens to the laboratory
Correct Answer: C
Rationale: Ensuring IV access is a key ED nursing role for administering fluids or medications. Intubation is for specialized providers, family notification is not a nurse's role, and specimen delivery is handled by others.