ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 71 Questions
Question 1 of 5
An unresponsive older-adult patient is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 41.2°C (106.1°F), blood pressure (BP) 86/52, and pulse 102. Which of the following actions should the nurse implement initially?
Correct Answer: C
Rationale: Applying a cooling blanket is the priority to rapidly lower the core temperature in heat stroke, which is life-threatening at 41.2°C. Aspirin is ineffective, high-flow oxygen via non-rebreather is preferred, and rapid fluid infusion risks pulmonary edema in older adults.
Question 2 of 5
The nurse is admitting a patient to the emergency department after a submersion injury. Which of the following assessments is priority?
Correct Answer: B
Rationale: Lung sounds are the priority assessment after a submersion injury to evaluate for pulmonary edema or aspiration, which can compromise oxygenation. Other assessments like pulse, temperature, and consciousness are important but secondary to ensuring adequate ventilation.
Question 3 of 5
A patient arrives in the emergency department (ED) a few hours after taking '20-30' acetaminophen (Tylenol) tablets. Which of the following actions will the nurse plan to take?
Correct Answer: A
Rationale: N-acetylcysteine is the antidote for acetaminophen overdose, preventing liver damage by restoring glutathione levels. Chelation therapy, water dilution, and oxygen are not appropriate treatments for acetaminophen toxicity.
Question 4 of 5
A patient's family members are in the patient room when the patient has a cardiac arrest and emergency personnel start resuscitation measures. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: Assessing family preferences first respects their emotional needs and informs subsequent actions. Some families benefit from staying, while others prefer to leave, and this decision guides whether to provide support in or out of the room.
Question 5 of 5
Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 diazepam tablets. Which of the following actions will the nurse plan to take first?
Correct Answer: D
Rationale: Intubation is the first priority in an unconscious patient to protect the airway and prevent aspiration during gastric lavage and activated charcoal administration, which follow after airway security is ensured.