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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.
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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.
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 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.
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.
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.