Nokea
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.
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A patient who has been diagnosed with cholecystitis is being discharged home from the ED to be scheduled for surgery later. The patient received morphine during the present ED admission and is visibly drowsy. When providing health education to the patient, what would be the most appropriate nursing action?
- A. Give written instructions to patient.
- B. Give verbal instructions to one of the patient's family members.
- C. Telephone the patient the next day with verbal instructions.
- D. Give verbal and written instructions to patient and a family member.
Correct Answer: D
Rationale: Verbal and written instructions to both the patient and family ensure comprehension despite drowsiness. Written instructions alone or delayed calls risk misunderstanding.
A patient is brought to the ED by ambulance with a gunshot wound to the abdomen. The nurse knows that the most common hollow organ injured in this type of injury is what?
- A. Liver
- B. Small bowel
- C. Stomach
- D. Large bowel
Correct Answer: B
Rationale: Penetrating abdominal injuries, like gunshot wounds, frequently damage hollow organs, with the small bowel being most common due to its large surface area. The liver is a solid organ.
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.
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 nurse is caring for a patient who has been the victim of sexual assault. The nurse documents that the patient appears to be in a state of shock, verbalizing fear, guilt, and humiliation. What phase of rape trauma syndrome is this patient most likely experiencing?
- A. Reorganization phase
- B. Denial phase
- C. Heightened anxiety phase
- D. Acute disorganization phase
Correct Answer: D
Rationale: The acute disorganization phase of rape trauma syndrome involves shock, fear, guilt, and humiliation. Denial, heightened anxiety, and reorganization occur in different stages.