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These four patients arrive in the emergency department after a motor vehicle crash. In which order should they be assessed?
- A. A 72-year-old with palpitations and chest pain
- B. A 45-year-old complaining of 6/10 abdominal pain
- C. A 22-year-old with multiple fractures of the face and jaw
- D. A 30-year-old with a misaligned right leg with intact pulses
Correct Answer: C,A,B,D
Rationale: The 22-year-old with facial and jaw fractures is assessed first due to potential airway compromise. The 72-year-old with chest pain (possible cardiac ischemia) is next, followed by the 45-year-old with abdominal pain (potential internal bleeding). The 30-year-old with a leg fracture and intact pulses is least urgent.
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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.
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 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.
The nurse is caring for a patient with hypotension and temperature elevation after doing yard work on a hot day and is being treated in the emergency department. After the nurse has completed discharge teaching, which of the following patient statements indicates that the teaching has been effective?
- A. I will take salt tablets when I work outdoors in the summer
- B. I should take acetaminophen if I start to feel too warm
- C. I should have sports drinks when exercising outside in hot weather
- D. I will get into a cool environment if I notice that I am feeling confused
Correct Answer: C
Rationale: Sports drinks replace fluids and electrolytes lost during heat exposure, preventing heat-related illnesses. Salt tablets risk gastric irritation, antipyretics like acetaminophen are ineffective for heat-induced hyperthermia, and confusion indicates severe heat stroke requiring immediate medical intervention.
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.