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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.
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A patient is brought to the ED by two police officers. The patient was found unconscious on the sidewalk, with his face and hands covered in blood. At present, the patient is verbally abusive and is fighting the staff in the ED, but appears medically stable. The decision is made to place the patient in restraints. What action should the nurse perform when the patient is restrained?
- A. Frequently assess the patient's skin integrity.
- B. Inform the patient that he is likely to be charged with assault.
- C. Avoid interacting with the patient until the restraints are removed.
- D. Take the opportunity to perform a full physical assessment.
Correct Answer: A
Rationale: Frequent skin integrity checks prevent injury from restraints. Legal charges are not the nurse's role, interaction should continue, and a full assessment may be unsafe while combative.
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 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.
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.
A 23-year-old woman is brought to the ED complaining of stomach cramps, nausea, vomiting, and diarrhea. The care team suspects food poisoning. What is the key to treatment in food poisoning?
- A. Administering IV antibiotics
- B. Assessing immunization status
- C. Determining the source and type of food poisoning
- D. Determining if anyone else in the family is ill
Correct Answer: C
Rationale: Identifying the source and type of food poisoning guides specific treatment, such as fluid replacement or antitoxins. Antibiotics are rarely needed, and immunization or family illness are secondary.