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A year ago
Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which action should the nurse plan to do first?
 
  a. Insert a large-bore orogastric tube.
  b. Assist with intubation of the patient.
  c. Prepare a 60-mL syringe with saline.
  d. Give first dose of activated charcoal.

Question 2

The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment?
 
  a. A patient with no pedal pulses.
  b. A patient with an open femur fracture.
  c. A patient with bleeding facial lacerations.
  d. A patient with paradoxic chest movements.

Question 3

The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?
 
  a. Remove the patient's rings.
  b. Apply ice packs to both hands.
  c. Apply calamine lotion to any itching areas.
  d. Give diphenhydramine (Benadryl) 50 mg PO.

Question 4

A 20-year-old patient arrives in the emergency department (ED) several hours after taking 25 to 30 acetaminophen (Tylenol) tablets. Which action will the nurse plan to take?
 
  a. Give N-acetylcysteine (Mucomyst).
  b. Discuss the use of chelation therapy.
  c. Start oxygen using a non-rebreather mask.
  d. Have the patient drink large amounts of water.

Question 5

A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states, I had a temperature of 103.9 F (39.9 C) at home. The nurse's first action should be to
 
  a. assess the patient's current vital signs.
  b. give acetaminophen (Tylenol) per agency protocol.
  c. ask the patient to provide a clean-catch urine for urinalysis.
  d. tell the patient that it will 1 to 2 hours before being seen by the doctor.

Question 6

When assessing an older patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse observes several additional bruises in various stages of healing. Which statement or question by the nurse is most appropriate?
 
  a. Do you feel safe in your home?
  b. You should not return to your home.
  c. Would you like to see a social worker?
  d. I need to report my concerns to the police.
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wrote...
Posts: 464
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A year ago
The answer to question 1

ANS: B
In an unresponsive patient, intubation is done before gastric lavage and activated charcoal administration to prevent aspiration. The other actions will be implemented after intubation.

The answer to question 2

ANS: D
Most immediate deaths from trauma occur because of problems with ventilation, so the patient with paradoxic chest movements should be treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries only has lacerations. The other two patients also need rapid intervention but do not have airway or breathing problems.

The answer to question 3

ANS: A
The patient's rings should be removed first because it might not be possible to remove them if swelling develops. The other orders should also be implemented as rapidly as possible after the nurse has removed the jewelry.

The answer to question 4

ANS: A
N-acetylcysteine is the recommended treatment to prevent liver damage after acetaminophen overdose. The other actions might be used for other types of poisoning, but they will not be appropriate for a patient with acetaminophen poisoning.

The answer to question 5

ANS: A
The patient's pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how rapidly the patient should be seen by the health care provider. A urinalysis may be appropriate, but this would be done after the vital signs are taken. The nurse will not give acetaminophen before confirming a current temperature elevation.

The answer to question 6

ANS: A
The nurse's initial response should be to further assess the patient's situation. Telling the patient not to return home may be an option once further assessment is done. A social worker may be appropriate once further assessment is completed.
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A year ago
I've been struggling with this concept and going into a mild panic attack due to having an exam on this in the morning. Really wish I found this website a few weeks ago when I began studying for this exam, but better late than never I guess. Thank you so much!
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