Nokea
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.
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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.
The nurse is assessing a patient who has experienced a possible snakebite on the left leg. Which of the following symptoms reported by the patient would be most helpful in confirming the diagnosis?
- A. Pain and swelling at the site
- B. Headache and blurred vision
- C. Abdominal pain and vomiting
- D. Fever and chills
Correct Answer: A
Rationale: Pain and swelling at the bite site are hallmark symptoms of a venomous snakebite due to local tissue reaction to the venom. Other symptoms like headache, abdominal pain, or fever are less specific and may occur in other conditions.
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.
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.