Nokea
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 Ipecac is obsolete, and psychiatric referral follows physical stabilization.
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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 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.
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.
A patient has been brought to the ED after suffering genitourinary trauma in an assault. Initial assessment reveals that the patient's bladder is distended. What is the nurse's most appropriate action?
- A. Withhold fluids from the patient.
- B. Perform intermittent urinary insertionization before.
- C. Insert a narrow-gauge indwelling in the urinary catheter.
- D. D) Await orders following the urologist's assessment.
Correct Answer: D
Rationale: Await orders following the urologist's assessment. Urethral injury may contraindicate catheterization, so urologic consultation is needed first. Withholding fluids is secondary.
A patient with a fractured femur presenting to the ED exhibits cool, moist skin, increased heart rate, and falling BP. The care team should consider the possibility of what complication of the patient's injuries?
- A. Myocardial infarction
- B. Hypoglycemia
- C. Hemorrhage
- D. Peritonitis
Correct Answer: C
Rationale: Cool, moist skin, tachycardia, and hypotension suggest hemorrhage, a common complication of femur fractures due to significant blood loss. MI, hypoglycemia, and peritonitis are less likely.