Nokea
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.
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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 Ipecac is obsolete, and psychiatric referral follows physical stabilization.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 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.
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.
Which patient should the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined below?
- A. A patient with a blunt chest trauma with some difficulty breathing
- B. A patient with a sore neck who was immobilized in the field on a backboard with a cervical collar
- C. A patient with a possible fractured tibia with adequate pedal pulses
- D. A patient with an acute onset of confusion
Correct Answer: A
Rationale: Blunt chest trauma with breathing difficulty suggests a compromised airway, which is a life-threatening emergency requiring immediate attention. Neck pain, a stable fracture, and confusion are less urgent.
The nursing educator is reviewing the signs and symptoms of heat stroke with a group of nurses who provide care in a desert region. The educator should describe what sign or symptom?
- A. Hypertension with a wide pulse pressure
- B. Anhidrosis
- C. Copious diuresis
- D. Cheyne-Stokes respirations
Correct Answer: B
Rationale: Heat stroke is characterized by anhidrosis (lack of sweating), hot dry skin, and hyperthermia. It causes hypotension, not hypertension, and is not linked to diuresis or Cheyne-Stokes breathing.