Nokea
A patient is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the physician will perform which of the following actions?
- A. Insert an oropharyngeal airway.
- B. Perform the jaw thrust maneuver.
- C. Perform endotracheal intubation.
- D. Perform a cricothyroidotomy.
Correct Answer: C
Rationale: Endotracheal intubation ensures airway patency in respiratory insufficiency. Oropharyngeal airways are for spontaneous breathing, jaw thrust doesn't secure an airway, and cricothyroidotomy is a last resort.
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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 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 to the ER in an unconscious state. The physician notes that the patient is in need of emergency surgery. No family members are present, and the patient does not have identification. What action by the nurse is most important regarding consent for treatment?
- A. Ask the social worker to come and sign the consent.
- B. Contact the police to obtain the patient's identity.
- C. Obtain a court order to treat the patient.
- D. Clearly document LOC and health status on the patient's chart.
Correct Answer: D
Rationale: Documenting the patient's unconscious state and critical condition justifies emergency treatment without consent. Social workers can't sign, police contact delays care, and court orders are too slow.
The ED nurse admitting a patient with a history of depression is screening the patient for suicide risk. What assessment question should the nurse ask when screening the patient?
- A. How would you describe your mood over the past few days?
- B. Have you ever thought about taking your own life?
- C. How do you think that your life is most likely to end?
- D. How would you rate the severity of your depression right now on a 10-point scale?
Correct Answer: B
Rationale: Directly asking about suicidal thoughts is essential for risk assessment in depression. Mood, life expectancy, or severity ratings are less specific for suicide screening.
A patient admitted to the ED with severe diarrhea and vomiting is subsequently diagnosed with food poisoning. The nurse caring for this patient assesses for signs and symptoms of fluid and electrolyte imbalances. For what signs and symptoms would this nurse assess? Select all that apply.
- A. Dysrhythmias
- B. Hypothermia
- C. Hypotension
- D. Hyperglycemia
- E. Delirium
Correct Answer: A,C,E
Rationale: Fluid and electrolyte imbalances from food poisoning cause dysrhythmias, hypotension, and delirium. Hypothermia and hyperglycemia are not typically associated.