Nokea
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.
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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.
After spending the previous weekend camping out with friends, a patient presents to the emergency department (ED) and is diagnosed with flaccid ascending paralysis. Based upon this information, the nurse concludes that the patient has been bitten by which of the following?
- A. Spider
- B. Wasp
- C. Tick
- D. Snake
Correct Answer: C
Rationale: Flaccid ascending paralysis developing 5-7 days after tick exposure is characteristic of tick paralysis, caused by a neurotoxin from wood or dog ticks. Removal of the tick typically reverses symptoms within 48-72 hours.
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 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.
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.