Nokea
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.
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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.
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.
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.
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.
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.