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The nurse is observing a patient who experienced a near drowning accident in a local lake, but now is awake and breathing spontaneously. Which of the following actions will be most important for the nurse to take during the observation period?
- A. Listen to heart sounds
- B. Palpate peripheral pulses
- C. Auscultate breath sounds
- D. Check pupil reaction to light
Correct Answer: C
Rationale: Pulmonary edema is a common delayed complication of near-drowning, making frequent auscultation of breath sounds critical to detect respiratory compromise. Other assessments are relevant but less specific to the patient's condition.
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The nurse is conducting a primary assessment of a trauma victim and determines that the patient is breathing and has an unobstructed airway. Which of the following actions should the nurse take next?
- A. Observe the patient's respiratory effort
- B. Check the patient's level of consciousness
- C. Palpate extremities for capillary refill time
- D. Examine the patient for any external bleeding
Correct Answer: A
Rationale: Even with a patent airway, ineffective breathing can compromise ventilation. Assessing respiratory effort ensures adequate oxygenation and ventilation, which is the next priority after confirming airway patency in the primary survey.
A patient arrives at the emergency department with complaints of being bitten by a cat. Which of the following parameters should the nurse assess? (Select all that apply.)
- A. Septic arthritis
- B. Hypotension
- C. Osteomyelitis
- D. Tenosynovitis
- E. Cyanosis
Correct Answer: A,C,D
Rationale: Cat bites carry a high risk of infection, leading to septic arthritis, osteomyelitis, and tenosynovitis due to deep tissue penetration. Hypotension and cyanosis are not typically associated unless systemic infection develops later.
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.
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.
A patient's family members are in the patient room when the patient has a cardiac arrest and emergency personnel start resuscitation measures. Which of the following actions should the nurse take first?
- A. Have the family wait outside the patient room with a designated staff member to provide emotional support
- B. Keep the family in the room and assign a member of the team to explain the care given and answer questions
- C. Ask the family members about whether they would prefer to remain in the patient room or wait outside the room
- D. Advise the family members that patients are comforted by having family members present during resuscitation efforts
Correct Answer: C
Rationale: Assessing family preferences first respects their emotional needs and informs subsequent actions. Some families benefit from staying, while others prefer to leave, and this decision guides whether to provide support in or out of the room.