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what must the Emergency Room Nurse do FIRST?
- A. Start an intravenous line at once.
- B. Position with head lower than extremities.
- C. Request for laboratory examinations.
- D. Stop the bleeding immediately.
Correct Answer: B
Rationale: When a patient arrives in the emergency room, the nurse's first priority is to assess the patient's airway, breathing, and circulation, following the ABCs of emergency care. In this scenario, positioning the patient with the head lower than the extremities ensures proper blood flow to vital organs, especially the brain. This position helps to maintain perfusion to the brain and prevent complications such as hypotension and shock. Once the patient's position is optimized, the nurse can proceed with further interventions such as starting an intravenous line, stopping bleeding, and requesting laboratory examinations as needed.
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A patient presents with painless, progressive visual field loss, particularly in the peripheral vision, in both eyes. Gonioscopy reveals an open iridocorneal angle. Which of the following conditions is most likely responsible for this presentation?
- A. Open-angle glaucoma
- B. Closed-angle glaucoma
- C. Age-related macular degeneration
- D. Diabetic retinopathy
Correct Answer: A
Rationale: The presentation of painless, progressive visual field loss, especially in the peripheral vision, along with an open iridocorneal angle is characteristic of open-angle glaucoma. Open-angle glaucoma is a type of glaucoma where there is no physical obstruction to the outflow of aqueous humor from the eye, but there is gradual damage to the optic nerve over time. The gradual loss of peripheral vision is a common early symptom of open-angle glaucoma. It is essential to diagnose and manage open-angle glaucoma promptly to prevent irreversible vision loss.
The MOST significant contributory factor to the development of lung cancer is ________.
- A. being a cigarette smoker
- B. belonging to the male sex
- C. Being extremely obese
- D. age over 4 0years
Correct Answer: A
Rationale: The most significant contributory factor to the development of lung cancer is being a cigarette smoker. Cigarette smoking is directly linked to approximately 85% of lung cancer cases. The harmful substances in tobacco smoke, such as carcinogens, damage the cells in the lungs, leading to the development of cancer over time. Smokers are at a significantly higher risk of developing lung cancer compared to non-smokers. Therefore, being a cigarette smoker is the primary and most influential risk factor for developing lung cancer.
A woman in active labor demonstrates signs of cephalopelvic disproportion (CPD), with the fetal head failing to descend despite strong contractions. What nursing action should be prioritized to address this abnormal labor presentation?
- A. Perform a pelvic exam to assess for CPD.
- B. Assist the mother into a hands-and-knees position.
- C. Administer intravenous oxytocin to augment contractions.
- D. Prepare for immediate instrumental delivery.
Correct Answer: D
Rationale: When a woman in active labor demonstrates signs of cephalopelvic disproportion (CPD) with the fetal head failing to descend despite strong contractions, the nursing action that should be prioritized is to prepare for immediate instrumental delivery. CPD can lead to a prolonged and difficult labor, increasing the risks for both the mother and the fetus. In cases where the fetal head is not descending adequately and the mother's contractions are strong, instrumental delivery, like forceps or vacuum extraction, may be necessary to facilitate the safe delivery of the baby. It is important to act promptly to avoid potential complications associated with prolonged labor. Other actions, such as performing a pelvic exam, changing maternal positions, or administering oxytocin, may be considered but addressing the issue of CPD efficiently through instrumental delivery should take precedence in this scenario.
The immunity conferred by tetanus toxoid is best described as:
- A. Lifelong passive
- B. Temporary passive
- C. Long-lasting active
- D. Lifelong active
Correct Answer: C
Rationale: Tetanus toxoid provides long-lasting active immunity. When a person is vaccinated with tetanus toxoid, their immune system is stimulated to produce antibodies against the tetanus toxin. These antibodies provide protection against tetanus infection by recognizing and neutralizing the toxin if the person is exposed to the bacteria that causes tetanus in the future. This active immune response can last for many years, providing ongoing protection against tetanus. However, booster doses are recommended every 10 years to maintain adequate levels of protection.
A patient admitted to the ICU develops acute pancreatitis with severe abdominal pain and elevated pancreatic enzymes. What intervention should the healthcare team prioritize to manage the patient's pancreatitis?
- A. Administer intravenous fluids to maintain adequate hydration.
- B. Perform an abdominal ultrasound to assess pancreatic morphology.
- C. Implement total parenteral nutrition (TPN) to meet nutritional needs.
- D. Recommend proton pump inhibitors (PPIs) for gastric acid suppression.
Correct Answer: A
Rationale: The priority intervention in managing acute pancreatitis is to administer intravenous fluids to maintain adequate hydration. Acute pancreatitis can lead to significant fluid loss and dehydration due to factors such as vomiting and third-spacing of fluids into the retroperitoneal space. Adequate hydration helps to optimize perfusion to the pancreas, prevent hypovolemic shock, and support overall organ function. This intervention also aids in flushing out inflammatory mediators and preventing complications such as acute kidney injury. Monitoring fluid status and adjusting the rate of intravenous fluid administration based on the patient's response is crucial in the management of acute pancreatitis. While other interventions such as imaging studies, nutritional support, and gastric acid suppression may be important in managing acute pancreatitis, ensuring adequate hydration is the most critical initial step.