Nokea
An unresponsive older-adult patient is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 41.2°C (106.1°F), blood pressure (BP) 86/52, and pulse 102. Which of the following actions should the nurse implement initially?
- A. Administer an Aspirin suppository
- B. Start O2 at 6 L/minute with a nasal cannula
- C. Apply a cooling blanket to the patient
- D. Infuse Lactated Ringer's solution at 1000 mL/hour
Correct Answer: C
Rationale: Applying a cooling blanket is the priority to rapidly lower the core temperature in heat stroke, which is life-threatening at 41.2°C. Aspirin is ineffective, high-flow oxygen via non-rebreather is preferred, and rapid fluid infusion risks pulmonary edema in older adults.
You may also like to solve these questions
Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 diazepam tablets. Which of the following actions will the nurse plan to take first?
- A. Administer activated charcoal
- B. Insert a large-bore orogastric tube
- C. Prepare a 60-mL syringe with saline
- D. Assist with intubation of the patient
Correct Answer: D
Rationale: Intubation is the first priority in an unconscious patient to protect the airway and prevent aspiration during gastric lavage and activated charcoal administration, which follow after airway security is ensured.
The nurse is rewarming a patient who arrived in the emergency department (ED) with a temperature of 29°C (84.2°F) and no audible heart sounds. Which of the following temperatures should the nurse rewarm the patient to, prior to a pronouncement of death?
- A. 30°C (86.0°F)
- B. 32°C (89.6°F)
- C. 34°C (93.2°F)
- D. 36°C (96.8°F)
Correct Answer: B
Rationale: Patients with severe hypothermia must be rewarmed to at least 32°C (89.6°F) before pronouncing death, as hypothermia can mimic death by suppressing vital signs, and ventricular fibrillation is a common cause of apparent death.
The nurse is assessing a patient with hypothermia. Which of the following assessments should the nurse expect to find?
- A. Hypertension
- B. Reddened, swollen extremities
- C. Hyperventilation
- D. Bradycardia
Correct Answer: D
Rationale: Hypothermia causes bradycardia due to slowed metabolic processes. Hypotension, blue or white extremities, and hypoventilation are more typical, not hypertension, reddened extremities, or hyperventilation.
The nurse is conducting a primary survey of a patient with multiple traumatic injuries and observes that the patient's right pedal pulses are absent and the leg is swollen. Which of the following actions will the nurse take next?
- A. Assess further for a cause of the decreased circulation
- B. Send blood to the lab for a complete blood count (CBC)
- C. Finish the airway, breathing, circulation, disability survey
- D. Initiate isotonic fluid infusion through two large-bore IV lines
Correct Answer: D
Rationale: Absent pedal pulses and leg swelling suggest arterial trauma or hemorrhage, a life-threatening condition. Initiating IV fluid infusion immediately addresses potential hypovolemia, taking precedence over further assessment or completing the survey.
A patient who is unconscious after a fall from a ladder is transported to the emergency department by family members. During the primary survey of the patient, which of the following actions should the nurse implement?
- A. Assess the patient's vital signs
- B. Attach a cardiac electrocardiogram (ECG) monitor
- C. Obtain a Glasgow Coma Scale score
- D. Ask about chronic medical conditions
Correct Answer: C
Rationale: The Glasgow Coma Scale score assesses neurological disability during the primary survey, prioritizing evaluation of consciousness in an unconscious trauma patient. Vital signs and medical history are part of the secondary survey.