Nokea
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.
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The nurse is caring for a patient with hypotension and temperature elevation after doing yard work on a hot day and is being treated in the emergency department. After the nurse has completed discharge teaching, which of the following patient statements indicates that the teaching has been effective?
- A. I will take salt tablets when I work outdoors in the summer
- B. I should take acetaminophen if I start to feel too warm
- C. I should have sports drinks when exercising outside in hot weather
- D. I will get into a cool environment if I notice that I am feeling confused
Correct Answer: C
Rationale: Sports drinks replace fluids and electrolytes lost during heat exposure, preventing heat-related illnesses. Salt tablets risk gastric irritation, antipyretics like acetaminophen are ineffective for heat-induced hyperthermia, and confusion indicates severe heat stroke requiring immediate medical intervention.
These four patients arrive in the emergency department after a motor vehicle crash. In which order should they be assessed?
- A. A 72-year-old with palpitations and chest pain
- B. A 45-year-old complaining of 6/10 abdominal pain
- C. A 22-year-old with multiple fractures of the face and jaw
- D. A 30-year-old with a misaligned right leg with intact pulses
Correct Answer: C,A,B,D
Rationale: The 22-year-old with facial and jaw fractures is assessed first due to potential airway compromise. The 72-year-old with chest pain (possible cardiac ischemia) is next, followed by the 45-year-old with abdominal pain (potential internal bleeding). The 30-year-old with a leg fracture and intact pulses is least urgent.
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.
The nurse is observing a patient who experienced a near drowning accident in a local lake, but now is awake and breathing spontaneously. Which of the following actions will be most important for the nurse to take during the observation period?
- A. Listen to heart sounds
- B. Palpate peripheral pulses
- C. Auscultate breath sounds
- D. Check pupil reaction to light
Correct Answer: C
Rationale: Pulmonary edema is a common delayed complication of near-drowning, making frequent auscultation of breath sounds critical to detect respiratory compromise. Other assessments are relevant but less specific to the patient's condition.
The nurse is caring for a patient who has sustained a black widow spider bite. When would the nurse expect the symptoms to peak?
- A. 30 minutes
- B. 2-3 hours
- C. 5-6 hours
- D. 9-10 hours
Correct Answer: B
Rationale: Symptoms of a black widow spider bite, caused by neurotoxic venom, typically peak within 2-3 hours as the venom affects the nervous system, causing muscle cramps and pain.