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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.
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The nurse is assessing a patient with hypothermia. Which of the following assessments should the nurse expect to find?
- A. Hypertension
- B. Reddened, swollen extremities
- C. Hyperventilation
- D. Bradycardia
Correct Answer: D
Rationale: Hypothermia causes bradycardia due to slowed metabolic processes. Hypotension, blue or white extremities, and hypoventilation are more typical, not hypertension, reddened extremities, or hyperventilation.
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 emergency department (ED) nurse is admitting a patient with a left forearm laceration that is bleeding profusely. The health care provider has prescribed that the nurse remove the patient's rings from the left hand. Which of the following actions should the nurse take first?
- A. Apply a clean dressing to the laceration
- B. Elevate the left arm above heart level
- C. Remove the rings from the patient's hand
- D. Insert an 18-gauge IV in the right arm
Correct Answer: C
Rationale: Removing the rings first prevents complications from swelling, which could impair circulation if the rings are left in place. Other actions like dressing the wound or elevating the arm follow to control bleeding.
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 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.