Nokea
The triage nurse is working in an ED. A homeless person is admitted during a blizzard with complaints, being unable to reach his feet and lower legs. Core temperature is noted at 33.2°C (91.8°F). The patient is intoxicated with alcohol at the time of admission and is visibly malnourished. What is the triage priority for the nurse in the care of this patient?
- A. Addressing the patient
- B. Addressing hypothermia for the patient's frostbite in his lower extremities
- C. Addressing the patient's alcohol intoxication
- D. Addressing malnutrition in the patient
Correct Answer: A
Rationale: A) Addressing hypothermia is the priority. Hypothermia is a systemic, life-threatening condition requiring immediate treatment, while frostbite, intoxication, and alcohol abuse are less acute.
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A patient is admitted to the ED with suspected alcohol intoxication. The ED nurse is aware of the need to assess for conditions that can mimic acute alcohol intoxication. In light of this need, the nurse should perform what action?
- A. Check the patient's blood glucose level.
- B. Assess for a documented history of major depression.
- C. Determine whether the patient has ingested a corrosive substance.
- D. Arrange for assessment of serum potassium levels.
Correct Answer: A
Rationale: Hypoglycemia can mimic alcohol intoxication symptoms like confusion and slurred speech, so checking blood glucose is critical. Depression, corrosive ingestion, or potassium levels are less likely mimics.
A patient is brought to the ED by ambulance after swallowing highly acidic toilet bowl cleaner 2 hours earlier. The patient is alert and oriented. What is the care team's most appropriate treatment?
- A. Administering syrup of ipecac
- B. Performing a gastric lavage
- C. Giving milk to drink
- D. Referring to psychiatry
Correct Answer: C
Rationale: Diluting an acidic ingestion with milk or water is appropriate after 2 hours, as gastric lavage is ineffective beyond 1 hour. Ipecac is obsolete, and psychiatric referral follows physical stabilization.
Which patient should the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined below?
- A. A patient with a blunt chest trauma with some difficulty breathing
- B. A patient with a sore neck who was immobilized in the field on a backboard with a cervical collar
- C. A patient with a possible fractured tibia with adequate pedal pulses
- D. A patient with an acute onset of confusion
Correct Answer: A
Rationale: Blunt chest trauma with breathing difficulty suggests a compromised airway, which is a life-threatening emergency requiring immediate attention. Neck pain, a stable fracture, and confusion are less urgent.
A 13-year-old is being admitted to the ED after falling from a roof and sustaining blunt abdominal injuries. To assess for internal injury in the patient's peritoneum, the nurse should anticipate what diagnostic test?
- A. Radiograph
- B. Computed tomography (CT) scan
- C. Complete blood count (CBC)
- D. Barium swallow
Correct Answer: B
Rationale: CT scans effectively detect intraperitoneal injuries from blunt trauma. Radiographs are less detailed, CBC indicates blood loss but not location, and barium swallow is irrelevant.
A patient admitted to the ED with severe diarrhea and vomiting is subsequently diagnosed with food poisoning. The nurse caring for this patient assesses for signs and symptoms of fluid and electrolyte imbalances. For what signs and symptoms would this nurse assess? Select all that apply.
- A. Dysrhythmias
- B. Hypothermia
- C. Hypotension
- D. Hyperglycemia
- E. Delirium
Correct Answer: A,C,E
Rationale: Fluid and electrolyte imbalances from food poisoning cause dysrhythmias, hypotension, and delirium. Hypothermia and hyperglycemia are not typically associated.