Nokea
The nurse is caring for a patient admitted with a drug overdose. What is the nurse's priority responsibility in caring for this patient?
- A. Support the patient's respiratory and cardiovascular function.
- B. Provide for the safety of the patient.
- C. Enhance clearance of the offending agent.
- D. Ensure the safety of the staff.
Correct Answer: A
Rationale: Supporting respiratory and cardiovascular function is the priority in drug overdose to sustain life. Safety and agent clearance are important but secondary.
You may also like to solve these questions
A patient is brought to the ED by ambulance with a gunshot wound to the abdomen. The nurse knows that the most common hollow organ injured in this type of injury is what?
- A. Liver
- B. Small bowel
- C. Stomach
- D. Large bowel
Correct Answer: B
Rationale: Penetrating abdominal injuries, like gunshot wounds, frequently damage hollow organs, with the small bowel being most common due to its large surface area. The liver is a solid organ.
The ED nurse admitting a patient with a history of depression is screening the patient for suicide risk. What assessment question should the nurse ask when screening the patient?
- A. How would you describe your mood over the past few days?
- B. Have you ever thought about taking your own life?
- C. How do you think that your life is most likely to end?
- D. How would you rate the severity of your depression right now on a 10-point scale?
Correct Answer: B
Rationale: Directly asking about suicidal thoughts is essential for risk assessment in depression. Mood, life expectancy, or severity ratings are less specific for suicide screening.
A patient is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the physician will perform which of the following actions?
- A. Insert an oropharyngeal airway.
- B. Perform the jaw thrust maneuver.
- C. Perform endotracheal intubation.
- D. Perform a cricothyroidotomy.
Correct Answer: C
Rationale: Endotracheal intubation ensures airway patency in respiratory insufficiency. Oropharyngeal airways are for spontaneous breathing, jaw thrust doesn't secure an airway, and cricothyroidotomy is a last resort.
An ED nurse is triaging patients according to the Emergency Severity Index (ESI). When assigning patients to a triage level, the nurse will consider the patient's acuity as well as what other variable?
- A. The likelihood of a repeat visit to the ED in the next 7 days
- B. The resources that the patient is likely to require
- C. The patient's or insurer's ability to pay for care
- D. Whether the patient is known to ED staff from previous visits
Correct Answer: B
Rationale: ESI triage considers acuity and anticipated resource needs, such as diagnostics or consultations. Repeat visits, payment ability, or prior ED history are not triage factors.
A patient is admitted to the ED complaining of abdominal pain. Further assessment of the abdomen reveals signs of peritoneal irritation. What assessment findings would corroborate this diagnosis? Select all that apply.
- A. Ascites
- B. Rebound tenderness
- C. Changes in bowel sounds
- D. Muscular rigidity
- E. Copious diarrhea
Correct Answer: B,C,D
Rationale: Rebound tenderness, altered bowel sounds, and muscular rigidity indicate peritoneal irritation. Ascites and diarrhea are not specific to this condition.