ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 72 : Emergency Nursing Questions
Question 1 of 5
A patient has been brought to the ED after suffering genitourinary trauma in an assault. Initial assessment reveals that the patient's bladder is distended. What is the nurse's most appropriate action?
Correct Answer: D
Rationale: Await orders following the urologist's assessment. Urethral injury may contraindicate catheterization, so urologic consultation is needed first. Withholding fluids is secondary.
Question 2 of 5
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?
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.
Question 3 of 5
A patient is brought to the ED by friends. The friends tell the nurse that the patient was using cocaine at a party. On arrival to the ED the patient is in visible distress with an axillary temperature of 40.1°C (104.2°F). What would be the priority nursing action for this patient?
Correct Answer: C
Rationale: Ensuring airway and ventilation is the priority in cocaine-induced hyperthermia, as respiratory compromise is life-threatening. Cardiovascular monitoring, antipyretics, and seizure prevention follow.
Question 4 of 5
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.
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.
Question 5 of 5
The nurse is caring for a patient admitted with a drug overdose. What is the nurse's priority responsibility in caring for this patient?
Correct Answer: A
Rationale: Supporting respiratory and cardiovascular function is the priority in drug overdose to sustain life. Safety and agent clearance are important but secondary.