Nokea
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.
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The nurse is admitting a patient to the emergency department after a submersion injury. Which of the following assessments is priority?
- A. Apical pulse
- B. Lung sounds
- C. Body temperature
- D. Level of consciousness
Correct Answer: B
Rationale: Lung sounds are the priority assessment after a submersion injury to evaluate for pulmonary edema or aspiration, which can compromise oxygenation. Other assessments like pulse, temperature, and consciousness are important but secondary to ensuring adequate ventilation.
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.
A patient's family members are in the patient room when the patient has a cardiac arrest and emergency personnel start resuscitation measures. Which of the following actions should the nurse take first?
- A. Have the family wait outside the patient room with a designated staff member to provide emotional support
- B. Keep the family in the room and assign a member of the team to explain the care given and answer questions
- C. Ask the family members about whether they would prefer to remain in the patient room or wait outside the room
- D. Advise the family members that patients are comforted by having family members present during resuscitation efforts
Correct Answer: C
Rationale: Assessing family preferences first respects their emotional needs and informs subsequent actions. Some families benefit from staying, while others prefer to leave, and this decision guides whether to provide support in or out of the room.
The nurse is preparing to rewarm a patient with hypothermia. Which of the following actions should the nurse implement?
- A. Attach a cardiac monitor
- B. Insert a urinary catheter
- C. Assist with endotracheal intubation
- D. Prepare sympathomimetic drugs for emergency administration
Correct Answer: A
Rationale: Rewarming can cause dysrhythmias in hypothermic patients, so cardiac monitoring is essential to detect and treat these complications. Urinary catheterization and intubation are not routinely required, and sympathomimetics increase dysrhythmia risk.
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.