Nokea
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.
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The nurse is conducting a primary survey on a patient in the emergency department (ED) and notes motor posturing in response to noxious stimuli. Which of the following actions should the nurse implement immediately?
- A. Hyperventilate the client
- B. Decrease the IV fluid rate
- C. Prepare for intubation
- D. Continue with the triage assessment
Correct Answer: C
Rationale: Motor posturing (e.g., decorticate or decerebrate) suggests possible brain herniation, requiring immediate preparation for intubation to secure the airway and support oxygenation. Hyperventilation may be considered later, but airway management is the priority.
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 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.
The nurse is caring for a patient who has experienced blunt abdominal trauma during a car accident and has increasing abdominal pain. Which of the following diagnostic tests should the nurse prepare the patient for?
- A. Ultrasonography
- B. Peritoneal lavage
- C. X-ray
- D. Magnetic resonance imaging (MRI)
Correct Answer: A
Rationale: Focused abdominal ultrasonography (FAST) is the preferred, non-invasive method to detect intraperitoneal bleeding in trauma patients. Peritoneal lavage is more invasive, and X-ray or MRI are less effective for this purpose.
A triage nurse is assessing a patient who complains of 6/10 abdominal pain and states, 'I had a temperature of 40.3°C (104.5°F) last night.' Which of the following triage categories should the nurse assign?
- A. Emergent
- B. Urgent
- C. Nonurgent
- D. Expectant
Correct Answer: B
Rationale: A temperature of 40.3°C and 6/10 abdominal pain suggest a potentially serious condition requiring prompt evaluation (urgent), but not immediate life-threatening intervention (emergent). Nonurgent indicates minor issues, and expectant is for unsalvageable patients.