Nokea
The patient with heatstroke has been undressed and treated with cold packs and a fan. The patient's temperature is now down to 101.2°F (38.4°C). The patient starts to shiver. What action should the emergency department nurse take?
- A. Raise the head of the bed.
- B. Offer warm liquids.
- C. Remove cold packs and fan.
- D. Continue with cooling interventions.
Correct Answer: C
Rationale: The cooling techniques have caused the patient to shiver, which will increase the patient's temperature.
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A nurse is assessing victims in an emergency situation. What will the nurse assess for first?
- A. Hemorrhage
- B. Fractures
- C. Mobility
- D. Abnormal breathing
Correct Answer: D
Rationale: A life-threatening situation of the highest priority is arrested or abnormal breathing.
A nurse assesses an accident victim who has bright red blood spurting from a laceration on his right forearm. Where will the nurse apply pressure after applying direct pressure and elevating the limb?
- A. Right subclavian artery
- B. Right radial artery
- C. Right ulnar artery
- D. Right brachial artery
Correct Answer: D
Rationale: Arterial bleeding is characterized by the spurting of bright red blood and can be controlled by direct pressure, elevation, and indirect pressure on the appropriate pressure point. The brachial artery is the closest pressure point to the injury.
A farm worker who has been kicked in the stomach by a mule passes a foul black tarry stool. What is this called?
- A. Loose stool
- B. Melena
- C. Hematuria
- D. Hemoptysis
Correct Answer: B
Rationale: When internal bleeding occurs, the patient may demonstrate hemoptysis (bloody sputum), hematemesis (bloody vomit), melena (foul black tarry stool), or hematuria (bloody urine).
When a patient suddenly experiences respiratory difficulty in the cafeteria the nurse begins assessment for foreign-body airway obstruction. What is the most appropriate question to ask the victim?
- A. What did you swallow?
- B. Are you choking?
- C. Are you OK?
- D. Can I help you?
Correct Answer: B
Rationale: With complete airway obstruction, the victim cannot speak. Ask, 'Are you choking?' With this question the nurse pinpoints the problem and can perform the Heimlich maneuver with no wasted time.
The nurse is assessing a patient who is severely bleeding and at risk for hypovolemic shock. What can the nurse anticipate?
- A. Slow labored breathing
- B. Hot flushed skin
- C. Edematous extremities
- D. Weak thready pulse
Correct Answer: D
Rationale: The pulse becomes weak and thready with hypovolemic shock.