Nokea
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.
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A patient arrives in the emergency department (ED) a few hours after taking '20-30' acetaminophen (Tylenol) tablets. Which of the following actions will the nurse plan to take?
- A. Give N-acetylcysteine
- B. Discuss the use of chelation therapy
- C. Have the patient drink large amounts of water
- D. Administer oxygen using a non-rebreather mask
Correct Answer: A
Rationale: N-acetylcysteine is the antidote for acetaminophen overdose, preventing liver damage by restoring glutathione levels. Chelation therapy, water dilution, and oxygen are not appropriate treatments for acetaminophen toxicity.
A patient who is unconscious after a fall from a ladder is transported to the emergency department by family members. During the primary survey of the patient, which of the following actions should the nurse implement?
- A. Assess the patient's vital signs
- B. Attach a cardiac electrocardiogram (ECG) monitor
- C. Obtain a Glasgow Coma Scale score
- D. Ask about chronic medical conditions
Correct Answer: C
Rationale: The Glasgow Coma Scale score assesses neurological disability during the primary survey, prioritizing evaluation of consciousness in an unconscious trauma patient. Vital signs and medical history are part of the secondary survey.
The nurse is assessing a patient admitted to the emergency department (ED) with a broken arm and facial bruises and notes multiple bruising in various stages of healing. Which of the following responses by the nurse is most appropriate?
- A. Is someone at home hurting you?
- B. You should not return to your home
- C. Would you like to see a social worker?
- D. I have to report this abuse to the police
Correct Answer: A
Rationale: Multiple bruises in various stages of healing suggest possible abuse. The nurse's initial response should be to assess further by asking about potential abuse sensitively, before taking other actions like reporting or involving social services.
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.
The nurse is rewarming a patient who arrived in the emergency department (ED) with a temperature of 29°C (84.2°F) and no audible heart sounds. Which of the following temperatures should the nurse rewarm the patient to, prior to a pronouncement of death?
- A. 30°C (86.0°F)
- B. 32°C (89.6°F)
- C. 34°C (93.2°F)
- D. 36°C (96.8°F)
Correct Answer: B
Rationale: Patients with severe hypothermia must be rewarmed to at least 32°C (89.6°F) before pronouncing death, as hypothermia can mimic death by suppressing vital signs, and ventricular fibrillation is a common cause of apparent death.