Nokea
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.
You may also like to solve these questions
An ED nurse is triaging patients according to the Emergency Severity Index (ESI). When assigning patients to a triage level, the nurse will consider the patient's acuity as well as what other variable?
- A. The likelihood of a repeat visit to the ED in the next 7 days
- B. The resources that the patient is likely to require
- C. The patient's or insurer's ability to pay for care
- D. Whether the patient is known to ED staff from previous visits
Correct Answer: B
Rationale: ESI triage considers acuity and anticipated resource needs, such as diagnostics or consultations. Repeat visits, payment ability, or prior ED history are not triage factors.
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 Ipecac is obsolete, and psychiatric referral follows physical stabilization.
A patient is brought to the ED by ambulance with a gunshot wound to the abdomen. The nurse knows that the most common hollow organ injured in this type of injury is what?
- A. Liver
- B. Small bowel
- C. Stomach
- D. Large bowel
Correct Answer: B
Rationale: Penetrating abdominal injuries, like gunshot wounds, frequently damage hollow organs, with the small bowel being most common due to its large surface area. The liver is a solid organ.
The ED nurse is planning the care of a patient who has been admitted following a sexual assault. The nurse knows that all of the nursing interventions are aimed at what goal?
- A. Encouraging the patient to gain a sense of control over his or her life
- B. Collecting sufficient evidence to secure a criminal conviction
- C. Helping the patient understand that this will not happen again
- D. Encouraging the patient to verbalize what happened during the assault
Correct Answer: A
Rationale: Nursing interventions post-sexual assault focus on empowering the patient to regain control, prioritizing emotional recovery over legal outcomes, future safety guarantees, or forced verbalization.
A 6-year-old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming the patient?
- A. Assessing the patient's oral temperature frequently
- B. Ensuring continuous ECG monitoring
- C. Massaging the patient's skin surfaces to promote circulation
- D. Administering bronchodilators by nebulizer
Correct Answer: B
Rationale: Continuous ECG monitoring is essential during hypothermia rewarming to detect arrhythmias. Oral temperatures are unreliable, massage risks tissue damage, and bronchodilators are not indicated.