Nokea
The nurse is assessing a patient who has experienced a possible snakebite on the left leg. Which of the following symptoms reported by the patient would be most helpful in confirming the diagnosis?
- A. Pain and swelling at the site
- B. Headache and blurred vision
- C. Abdominal pain and vomiting
- D. Fever and chills
Correct Answer: A
Rationale: Pain and swelling at the bite site are hallmark symptoms of a venomous snakebite due to local tissue reaction to the venom. Other symptoms like headache, abdominal pain, or fever are less specific and may occur in other conditions.
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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.
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.
A patient arrives at the emergency department with complaints of being bitten by a cat. Which of the following parameters should the nurse assess? (Select all that apply.)
- A. Septic arthritis
- B. Hypotension
- C. Osteomyelitis
- D. Tenosynovitis
- E. Cyanosis
Correct Answer: A,C,D
Rationale: Cat bites carry a high risk of infection, leading to septic arthritis, osteomyelitis, and tenosynovitis due to deep tissue penetration. Hypotension and cyanosis are not typically associated unless systemic infection develops later.
The nurse is assessing a patient who is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the right hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. Which of the following should the nurse anticipate administering to the patient?
- A. Tetanus-diphtheria toxoid (TD) only
- B. Tetanus immunoglobulin (TIG) only
- C. Tetanus immunoglobulin (TIG) and tetanus-diphtheria (TD) toxoid
- D. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap)
Correct Answer: C
Rationale: For an unvaccinated patient with a tetanus-prone wound, both TIG (for immediate passive immunity) and TD (for long-term active immunity) are recommended. Tdap includes pertussis, which is not necessary in this context.
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.