A patient with chest pain has a 12-lead electrocardiogram that shows a new-onset left bundle branch block. There is > 1 mm concordant ST elevation in lead aVF. What is the priority intervention for this patient?
Serial troponin measurements
Continuous ST-segment monitoring
Preparing the patient for transport to the cardiac catheterization lab
✓
Admission to a telemetry unit for observation
Correct Answer
Preparing the patient for transport to the cardiac catheterization lab
A. A left bundle branch block can obscure ST-segment elevation. Continued monitoring for suspected ST-segment elevation would delay the patient's transport to the cardiac catheterization lab and myocardial reperfusion of tissue. According to modified Sgarbossa criteria, 1 or more leads (in leads with a positive QRS complex) with 1 mm or more of concordant ST elevation can diagnose a myocardial infarction in the presence of a left bundle branch block.
B. Serial troponin measurements may be beneficial in diagnosis, but the time needed for serial measurements would delay transport of this patient to the cardiac catheterization lab.
C. Concordant ST-segment elevation in the presence of a new-onset left bundle branch block is suggestive of an acute myocardial infarction. The goal is cardiac catheterization within 90 minutes, which is the same as for any STEMI. However, emergent reperfusion is recommended even if the time since onset of symptoms is uncertain.
D. Patients with a new-onset left bundle branch block in the presence of concordant ST-segment elevation require emergent cardiac catheterization, not observation on a telemetry unit.
Category: Cardiovascular Emergencies, Acute coronary syndrome
Question 2
During the completion of a 12-lead electrocardiogram, the nurse identifies excessive artifact in lead II and lead III. To resolve this technical difficulty, the nurse should:
check for cable movement.
change the left leg electrode.
✓
instruct the patient to momentarily hold their breath.
change the right arm electrode.
Correct Answer
change the left leg electrode.
A. The left leg electrode is common to both lead II and lead III. Changing the right arm electrode would not affect the appearance of lead III.
B. Cable movement could be the reason for excessive artifact; however, it would result in movement also being detected in other leads.
C. The left leg electrode is common to both lead II and lead III. The development of artifact and decreased conductivity results when the conducting gel in the electrode becomes dry.
D. Interference from respiration tends to reflect a wandering baseline and not generalized artifact in lead II and lead III. Lead II and lead III are limb leads, which are less affected by respiration.
Category: Cardiovascular Emergencies, Acute coronary syndrome
Question 3
A patient with ST elevation in leads II, III, and aVF is likely to experience an infarct in which location of the heart?
Inferior
✓
Anterior
Lateral
Posterior
Correct Answer
Inferior
A. ST elevation in leads II, III, and AVF indicates an inferior myocardial infarction.
B. ST elevation in leads V1, V2, V3, or V4 indicates an anterior myocardial infarction.
C. ST-elevation in leads I, aVL, V5, or V6 indicates a lateral myocardial infarction.
D. Posterior myocardial infarctions are noted by “reciprocal” V1 and V2, absence of Q-waves and tall R-waves, ST-segment depression, and upright T-waves.
Category: Cardiovascular Emergencies, Acute coronary syndrome
Question 4
A patient states they awoke from sleep with midsternal chest pain approximately 4–5 hours ago. In the presence of an acute myocardial infarction (AMI), the initial elevation of the troponin cardiac biomarkers occurs within:
24–30 hours of onset of an AMI.
10–24 hours of onset of an AMI.
3–12 hours of onset of an AMI.
✓
1–2 hours of onset of an AMI.
Correct Answer
3–12 hours of onset of an AMI.
A. 1–2 hours following onset of an AMI is too early to detect any rise in the troponin cardiac biomarkers.
B. Troponin (I and T) cardiac biomarkers provide a bioassay to measure proteins found in the myofibrils of the heart muscle. Troponins are detectable based on assay 3–12 hours after the AMI. Troponin levels will peak at 18–24 hours following AMI.
C. The troponin levels are beginning to fall within 24 hours of an AMI.
D. 10–24 hours following onset of an AMI is the mean peak time range for troponin I levels.
Category: Cardiovascular Emergencies, Acute coronary syndrome
Question 5
The nurse suspects a patient may have an acute aortic dissection when, during the history-taking process, the patient describes the pain as:
right upper quadrant pain referred to the right scapula and shoulder.
sudden, severe tearing or ripping chest, interscapular, or back pain.
✓
squeezing, burning epigastric pain that may radiate to the middle back area.
sharp, stabbing chest pain radiating to the neck, arms, or left shoulder.
Correct Answer
sudden, severe tearing or ripping chest, interscapular, or back pain.
A. Squeezing, burning epigastric pain that may radiate to the midback is characteristic of the discomfort associated with the presence of a gastric ulcer.
B. Right upper quadrant pain referred to the right scapula and shoulder is characteristic of cholecystitis.
C. Sudden, severe tearing or ripping chest, interscapular, or back pain is a classic presentation of an aortic dissection.
D. Sharp, stabbing chest pain radiating to the neck, arms, or left shoulder is characteristic of acute pericarditis.
Category: Cardiovascular Emergencies, Aneurysm and dissection
Question 6
You are assisting in the resuscitation of a patient in cardiac arrest. A waveform capnography is in place, and high-quality cardiopulmonary resuscitation is being performed. A sudden increase in the level of the end-tidal carbon dioxide indicates the:
need for an additional dose of a vasopressor.
need for deeper and faster chest compressions.
return of spontaneous circulation.
✓
presence of an irreversible cardiac arrest.
Correct Answer
return of spontaneous circulation.
A. A decrease in the end-tidal carbon dioxide (ETCO ) waveform would indicate the 2 possible need for deeper and faster compressions.
B. A decrease in the ETCO waveform would indicate the possible need for a dose 2 of a vasopressor such as epinephrine.
C. A sudden increase in the ETCO level indicates a return of spontaneous 2 circulation. A continued decrease in the level of ETCO would be an indicator of 2 failure to resuscitate, or respiratory compromise/misplaced endotracheal tube.
D. Although no clinical study has examined whether titrating resuscitative efforts to physiologic parameters during cardiopulmonary resuscitation (CPR) improves outcomes, it may be reasonable to use physiologic parameters (quantitative waveform capnography, arterial relaxation diastolic pressure, arterial pressure monitoring, and central venous oxygen saturation) when feasible to monitor and optimize CPR quality, guide vasopressor therapy, and detect return of spontaneous circulation.
Category: Cardiovascular Emergencies, Cardiopulmonary arrest
Question 7
The cardiac monitor of a patient in cardiac arrest displays sinus rhythm, but no palpable pulse can be detected. The most likely cause of this pulseless electrical activity (PEA) is:
magnesium level of 3.0 mg/dL.
potassium value of 1.3 mmol/L (1.3 mEq/L).
✓
glucose level of 145 mg/dL.
arterial pH of 7.36.
Correct Answer
potassium value of 1.3 mmol/L (1.3 mEq/L).
A. A normal glucose level ranges from 80 mg/dL to 120 mg/dL. Although a reading of 145 mg/dL is elevated, this would not be the cause of PEA.
B. Hypokalemia, or decreased potassium level, may be a cause of PEA in the cardiac arrest patient. Electrical activity may be present in the heart muscle with absence of contractility. A normal potassium level is 3.5 mmol/L to 5.0 mmol/L (3.5 mEq/L to 5.0 mEq/L). A potassium level of 1.3 mmol/L is severe hypokalemia and is considered a critical or life-threatening value.
C. A pH of 7.36 is within the normal pH range of 7.35–7.45 and would not be a cause of PEA.
D. A normal magnesium level is in the range of 1.7–2.1 mg/dL. Hypomagnesemia (level less than 1.7 mg/dL) can cause ventricular dysrhythmias. A level of 3.0 mg/dL would be considered elevated or hypermagnesemic.
Category: Cardiovascular Emergencies, Cardiopulmonary arrest
Question 8
Which of the following physiological conditions would result in the loss of ventricular capture for a patient with a transcutaneous pacemaker?
Lactic acidosis
✓
Metabolic alkalosis
Hypomagnesemia
Hypokalemia
Correct Answer
Lactic acidosis
A. The presence of lactic acidosis resulting from decreased tissue oxygenation alters myocardial contractility, leading to a decreased ability to achieve ventricular capture.
B. Hypomagnesemia may present with torsades de pointes, ventricular tachycardia, and ventricular fibrillation. Hypomagnesemia does not cause a lack of ventricular capture with transcutaneous pacing.
C. Metabolic alkalosis may present with atrial tachycardia, but it would not be responsible for the lack of ventricular capture with transcutaneous pacing.
D. Hypokalemia presents with U-waves on the electrocardiogram, ventricular dysrhythmias, or pulseless electrical activity. Hypokalemia does not prevent ventricular capture with transcutaneous pacing.
Category: Cardiovascular Emergencies, Dysrhythmias
Question 9
A patient presents complaining of shortness of breath and chest pain. Electrocardiogram reveals a ventricular rate of 210 with a regular rhythm. Which medication should the nurse anticipate administering?
Amiodarone
Adenosine
✓
Lidocaine
Moricizine
Correct Answer
Adenosine
A. A rapid ventricular rate greater than 180 with regular rhythm is likely supraventricular tachycardia. The specific treatment is administration of adenosine in three doses or synchronized cardioversion.
B. Amiodarone is not indicated in SVT because SVT is a rhythm that originates above the level of the ventricles. Amiodarone is indicated for ventricular dysrhythmias.
C. Lidocaine is not indicated in SVT because SVT is a rhythm that originates above the level of the ventricles. Lidocaine is indicated for ventricular dysrhythmias.
D. Moricizine is indicated for ventricular dysrhythmias.
Category: Cardiovascular Emergencies, Dysrhythmias
Question 10
On examination of a febrile patient presenting to the emergency department with a chief complaint of “flulike symptoms” and a history of intravenous drug use, the nurse notes a cardiac murmur, crackles in bilateral lung bases, subungual hemorrhages, nontender erythematous macules on the palms of the hands and soles of the feet, and painful erythematous nodules on the tips of the fingers and toes. Which is the priority intervention for this patient?
Antibiotics
✓
Surgery
Echocardiogram
Chest radiography
Correct Answer
Antibiotics
A. An echocardiogram is helpful in the diagnosis of infective endocarditis, but prompt initiation of antibiotic therapy is a crucial intervention. It is recommended that three sets of blood cultures be obtained before initiation of antibiotic therapy.
B. A chest radiograph may be helpful in ruling out pneumonia and determining the status of the lungs and heart size, but prompt initiation of antibiotic therapy is a crucial intervention for a patient with infective endocarditis.
C. Surgery may be indicated for a patient with infective endocarditis, but not before prompt initiation of antibiotic therapy. There is also a higher risk if surgery is performed on patients during the active phase of infective endocarditis.
D. Patients with a history of intravenous drug use are at risk for infective endocarditis. The impurities in the injectable substance can attach to and invade the heart valve leaflets, causing a murmur. Bacteria or fungi colonize (vegetations); these vegetations may embolize and be “showered” throughout the cardiovascular system, causing splinter hemorrhages under the fingernails, and nontender nodules on the palms and soles (Janeway lesions), and fingers and toes (Osler nodes). Empirical therapy for infective endocarditis includes prompt initiation of antibiotics.
Category: Cardiovascular Emergencies, Endocarditis
Question 11
A patient presents to the emergency department complaining of a severe headache. Vital signs reveal a BP of 270/170 mm Hg. The patient is alert and describes being recently diagnosed with high blood pressure. What is the priority intervention for this patient?
Initiate intravenous medication to lower the patient’s BP immediately
Consider emergency cardioversion for BP control
Obtain baseline laboratory data
Evaluate the BP cuff size for accuracy
✓
Correct Answer
Evaluate the BP cuff size for accuracy
A. Although lowering the patient’s BP is a priority, the BP should be lowered slowly, over several hours.
B. Baseline laboratory data are important for patient evaluation but are not a priority in treating their severe hypertension.
C. Cardioversion is used for emergency treatment of various cardiac dysrhythmias, including tachycardia. Cardioversion is not indicated for the presence of hypertension.
D. Accurate BP values must be ensured before instituting BP-lowering measures. Appropriate-size cuffs should be available and used for all patients. Using a blood pressure cuff that is too large will result in a blood pressure reading that is lower than the patient’s actual blood pressure, and using a cuff that is too small will result in a blood pressure reading that is higher than the patient’s actual blood pressure.
Category: Cardiovascular Emergencies, Hypertension
Question 12
Administration of nitroprusside (Nipride) to a patient in a hypertensive crisis without evidence of aortic dissection is considered effective when the patient demonstrates which of the following?
The systolic blood pressure reaches 160 mm Hg.
✓
The systolic blood pressure reaches 120 mm Hg.
The patient reports relief of chest pain.
The patient responds to verbal stimuli.
Correct Answer
The systolic blood pressure reaches 160 mm Hg.
A. The patient in hypertensive crisis may present with altered mental status and other neurological findings. This finding is not consistent with evidence of effective treatment of a patient in hypertensive crisis.
B. Evidence has shown that the systolic blood pressure (SBP) should be lowered 25% within the first hour, and then to 160 mm Hg over the next 2–6 hours; a lower SBP can compromise cerebral blood flow and cause organ hypoperfusion and tissue ischemia.
C. Evidence has shown that the SBP should be lowered 25% within the first hour, and then to about 160 mm Hg over hours 2–6; a lower SBP can compromise cerebral blood flow and cause organ hypoperfusion and tissue ischemia. The exception would be in aortic dissection, in which the blood pressure should be reduced more rapidly, with the recommendation to < 120 mm Hg. Nitroprusside (Nipride) is recommended after beta blocker administration with labetalol or esmolol to prevent reflex tachycardia.
D. The patient in hypertensive crisis may present with chest pain and other cardiovascular manifestations. The relief of chest pain is not consistent with effective treatment of a patient in hypertensive crisis.
Category: Cardiovascular Emergencies, Hypertension
Question 13
Which of the following is a symptom of pericardial tamponade?
Jugular vein flattening
Muffled heart tones
✓
Widening pulse pressure
Tracheal deviation
Correct Answer
Muffled heart tones
A. Beck’s triad—hypotension, muffled heart tones, and distended neck veins—is caused by blood filling the pericardial sac, usually as a result of a penetrating chest trauma. The heart is not able to relax enough to accommodate venous return. This causes a decrease in cardiac output and venous congestion in the jugular veins.
B. Pericardial tamponade causes decreased cardiac output; as the systolic blood pressure drops, systemic vascular resistance will increase to shunt blood to the vital organs, increasing the diastolic blood pressure. The pulse pressure will narrow, not widen.
C. Because of increased pressure within the heart impeding venous return, the patient may demonstrate jugular neck vein distention.
D. Tracheal deviation occurs as a late sign in the presence of tension pneumothorax; it is not associated with cardiac tamponade.
Category: Cardiovascular Emergencies, Pericardial tamponade
Question 14
A child with a recent diagnosis of hand, foot, and mouth disease complains of chest pain that hurts more while coughing and “when taking a deep breath.” The nurse notes that the child is sitting upright on the mother’s lap and is leaning forward. Based on the patient’s most recent illness history, the nurse knows this patient is at risk for developing:
pneumonia.
commotio cordis.
pericarditis.
✓
respiratory syncytial virus.
Correct Answer
pericarditis.
A. Pneumonia may cause pleuritic chest pain symptoms, but the patient’s symptoms and recent illness history indicate the presence of pericarditis.
B. Coxsackie virus (otherwise known as hand, foot, and mouth disease) is the most common cause of viral pericarditis. The common symptoms of pericarditis include sharp, pleuritic chest pain that improves when sitting up and leaning forward and worsens with coughing or inspiration. Tuberculosis is the most common cause of pericarditis worldwide.
C. Symptoms of respiratory syncytial virus include cough, congestion, and fever.
D. Commotio cordis is not related to any preexisting illness; it is the result of a direct blow to the chest directly over the heart, which often causes a lethal disruption in the cardiac rhythm. The patient would present in cardiac arrest.
Category: Cardiovascular Emergencies, Pericarditis
Question 15
Which of the following would further enhance the symptoms of peripheral vascular disease, causing the patient increased discomfort?
Smoking
✓
Calcium channel blockers
Alcohol use
Narcotics
Correct Answer
Smoking
A. Smoking has been proved to further enhance peripheral vascular disease because of the vasoconstrictive effect of nicotine. If a patient continues to smoke, the peripheral vascular disease may worsen.
B. Calcium channel blockers may be used as a therapy for peripheral vascular disease to decrease the presence of vasospasms.
C. Although alcohol use may cause disorientation and increase the patient’s risk for falling, the consumption of alcohol is not associated with development of peripheral vascular disease.
D. Narcotics may be used to treat pain caused by vasospasms or decreased blood flow, but narcotics will not contribute to worsening of the patient’s symptoms.
Category: Cardiovascular Emergencies, Peripheral vascular disease
Question 16
Assessment of a patient from a motor vehicle collision reveals a seat belt sign on the patient’s chest, premature ventricular contractions, chest pain, and hypotension. Oxygen, intravenous fluids, and pain medication have been administered. Which of the following reevaluation criteria would cause the nurse to be concerned?
Lactic acid of 3 mmol/L
Heart tones of S , S 1 2
Breath sounds with crackles
✓
Oxygen saturation of 95%
Correct Answer
Breath sounds with crackles
A. Lactic acid of 3 mmol/L is within normal limits.
B. Heart tones of S , S are normal. 1 2
C. This patient has a cardiac contusion, and cardiac function may be severely depressed. The right ventricle is at greatest risk for cardiac contusion because of its prominence; thus, volume replacement must proceed cautiously. Cell injury and bruising lead to decreased contractility, so the cautious use of fluid is recommended.
D. Oxygen saturation of 95% is within acceptable range of 94–98%.
Category: Cardiovascular Emergencies, Cardiovascular trauma
Question 17
What is a characteristic sign of chronic obstructive pulmonary disease?
Crackles on auscultation
Fever or hypothermia
Pursed lip breathing
✓
Pink frothy sputum
Correct Answer
Pursed lip breathing
A. Chronic hyperinflation and enlargement of the lungs results in changes in the shape of the chest. Pursed lip breathing is an effort to prevent airways from collapsing during expiration. It prolongs expiration and slows the rate of breathing.
B. Fever (or hypothermia) accompanied by purulent sputum can be a sign of pneumonia.
C. Crackles may indicate a variety of pulmonary and cardiovascular pathologies.
D. Blood-tinged or pink frothy sputum is a sign of pulmonary edema.
Category: Respiratory Emergencies, Chronic obstructive pulmonary disease
Question 18
A patient presents with a 2-day history of multiple watery diarrheal stools, low-grade fever, anorexia, nausea, and abdominal tenderness. He has a recent history of gastroesophageal reflux disease for which pantoprazole (Protonix) was prescribed. Which of the following disease processes is most likely occurring in this patient?
Norovirus
Escherichia coli
Clostridium difficile
✓
Salmonella
Correct Answer
Clostridium difficile
A. Patients with Escherichia coli (E. coli) infections experience diarrhea (which may be bloody), vomiting, severe abdominal cramps, and possible low-grade fever (less than 38.5°C). This is a bacterial infection causing inflammation of the small intestines and colon. E. coli infections are not associated with proton pump inhibitor use.
B. Patients with norovirus have symptoms similar to those for Clostridium difficile (C. difficile); however, the symptoms are not associated with the recent administration of proton pump inhibitors. Norovirus is a viral infection that causes symptoms of gastroenteritis.
C. The patient’s symptoms recently began after taking pantoprazole (Protonix), a proton pump inhibitor, suggesting C. difficile as the cause. C. difficile is characterized by symptoms of multiple watery diarrhea events, fever, loss of appetite, nausea, and abdominal pain/tenderness, and is associated with recent exposure to antibiotics or proton pump inhibitors, gastrointestinal surgery/manipulation, long length of stay in a healthcare setting, advanced age, or the presence of immunosuppression. C. difficile is a bacterium but has multiple etiologic factors.
D. Patients with Salmonella infections also experience diarrhea (which may be bloody), abdominal cramping, fever (almost always present), nausea, vomiting, and headaches. Salmonella infections are not associated with proton pump inhibitor use. This is a bacterial agent causing infectious diarrhea.
Category: Environment and Toxicology Emergencies, and Communicable
Question 19
A sentinel event prompts the organization to work with staff directly involved in the event to complete a(n):
incident report.
patient safety report.
investigation.
root cause analysis.
✓
Correct Answer
root cause analysis.
A. A root cause analysis of the event should be prepared to allow both staff members and the organization’s management to examine the event for system or process failures. The results of this proactive risk assessment will then be shared with all staff members to prevent similar incidents from occurring in the future.
B. Any sentinel event requires an incident or formal report to be filed with The Joint Commission or your institution’s accreditation organization. A root cause analysis will ideally lead to the correction of identified system failures.
C. An investigation will only identify how the incident occurred; it does not provide a corrective mechanism to prevent similar incidents from happening again in the future. A sentinel event is a threat to patient safety and may have led to permanent harm to, or death of, a patient. A root cause analysis will ensure that a complete comprehensive analysis takes place to prevent a recurrence of a similar event.
D. A patient safety report allows facility personnel involved in a situation to anonymously report a medical event that impacted the safety of patients. The patient safety report may not contain all the information needed to complete a formal root cause analysis.
Category: Professional Issues, System, Performance and process improvement
Question 20
A patient with hyperemesis gravidarum presents to the emergency department after 12 hours of retching and has noted some hematemesis. You would anticipate that the patient is presenting with:
esophageal stricture.
ruptured esophageal varices.
Mallory-Weiss syndrome.
✓
peptic ulcer disease.
Correct Answer
Mallory-Weiss syndrome.
A. When the intra-abdominal pressure suddenly and severely increases (as in cases of forceful retching and vomiting), the gastric contents rush proximally under pressure into the esophagus. This excess pressure from the gastric contents results in longitudinal mucosal tears, which may reach deep into the submucosal arteries and veins, resulting in upper GI bleeding.
B. Peptic ulcer disease is characterized by an onset of gnawing and burning pain that progressively worsens and may or may not be relieved by eating. Upper gastrointestinal bleeding may occur with peptic ulcer disease, but the history is more consistent with Mallory-Weiss syndrome.
C. Esophageal varices are the result of dilated esophageal veins formed when the portal veins are under pressure, secondary to severe liver disease, such as seen in individuals with alcoholism. Bleeding from ruptured esophageal varices is hemorrhagic in nature, leading to hypovolemic shock and even death.
D. The patient with an esophageal stricture will usually present with the chief complaint of trouble swallowing, or dysphagia.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 21
A patient is being prepared for discharge from the ED after being diagnosed with cholecystitis. You know that your patient understands your instructions when they make which statement?
“My mother said she is going to make me my favorite broccoli and cheese casserole with gravy and mashed potatoes when I get home.”
“My mother is going to make me some of her famous baked chicken with steamed carrots and rice when I get home.”
✓
“I am going to get a big thick steak with a baked potato with lots of butter and sour cream when I leave here.”
“I should eat small, frequent meals like sliders with french fries.”
Correct Answer
“My mother is going to make me some of her famous baked chicken with steamed carrots and rice when I get home.”
A. High-fat diets are discouraged with an inflamed gallbladder.
B. High-fat diets, which this meal represents, are discouraged in patients with cholecystitis.
C. Small, frequent meals will help to rest an irritated digestive system, but it is more important that the patient be aware of the foods that cause gallbladder pain and know to avoid them.
D. Treatment of cholecystitis depends on the severity of the condition and the presence or absence of complications. The symptoms associated with cholecystitis usually occur after consuming a meal high in fat content.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 22
A patient presents with complaints of cramping abdominal pain, nausea/vomiting, constipation, and anorexia that began 2 days prior to presentation. Vital signs are normal except for a temperature of 38.2°C (100.8°F). Assessment findings include LLQ abdominal tenderness and hyperactive bowel sounds. You are suspicious that this patient may be experiencing:
cholecystitis.
diverticulitis.
✓
pancreatitis.
appendicitis.
Correct Answer
diverticulitis.
A. The pain associated with appendicitis occurs in the right lower abdominal quadrant and is accompanied by nausea, vomiting, and rebound tenderness over the appendix. If perforation of the appendix has occurred, abdominal rigidity can result.
B. Diverticulitis is often referred to as “left-sided appendicitis.” Patients typically present with constant pain that is localized in the left lower quadrant. A low-grade fever, nausea, constipation, and anorexia are symptoms frequently associated with diverticulitis.
C. The discomfort associated with cholecystitis typically presents in the right upper quadrant, radiating to the back or right shoulder, and most often occurs after eating a meal high in fat content.
D. Patients with pancreatitis experience a sudden onset of severe left upper quadrant abdominal pain that may radiate to the back. Nausea, vomiting, tachycardia, and fever are commonly associated with the presence of pancreatitis.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 23
Your patient has been diagnosed with bleeding esophageal varices. The treatment plan, after initial stabilization, would consist of administration of which of the following medications?
Sulfasalazine (Azulfidine)
Somatostatin (Octreotide)
✓
Pantoprazole (Protonix)
Sucralfate (Carafate)
Correct Answer
Somatostatin (Octreotide)
A. Consensus guidelines continue to recommend proton pump inhibitors for patients with nonvariceal bleeding from peptic ulcer disease.
B. Sulfasalazine (Azulfidine) is a medication used to treat rheumatoid arthritis, ulcerative colitis. and Crohn’s disease.
C. Vasopressors such as somatostatin (Octreotide) reduce pressure in the portal circulation, which will slow bleeding from esophageal varices. Octreotide elicits several actions in patients with upper GI bleeding. It inhibits the secretion of gastric acid, reduces blood flow to the gastroduodenal mucosa, and causes splanchnic vasoconstriction. This is an important first step as the patient is prepared for an endoscopy.
D. Sucralfate (Carafate) creates a protective barrier to pepsin and bile, and inhibits the diffusion of gastric acid. Its therapeutic efficacy is in healing gastric and duodenal ulcers. Sucralfate is not indicated in the treatment of esophageal varices.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 24
A 60-year-old with a history of alcoholic cirrhosis presents after an episode of coffee-ground emesis. He had been drinking for the past few days and reports that he had not been eating properly. Physical exam notes diffuse abdominal tenderness, ascites, tachycardia, and hypotension. The anticipated diagnosis would be:
esophagitis.
gastritis.
cholecystitis.
esophageal varices.
✓
Correct Answer
esophageal varices.
A. Cholecystitis is an inflammation of the gallbladder and is most frequently caused by gallstones that obstruct the cystic duct or common bile duct.
B. Esophagitis is an inflammatory response of the mucosa of the esophagus; it is related to a variety of stimuli, including GERD, infection, medications, and trauma.
C. Gastritis is inflammation of the stomach that most often originates from ingestion of nonsteroidal anti-inflammatory drugs (NSAIDs), alcohol, or steroids; it can also be caused by emotional stress.
D. Esophageal varices are dilated, submucosal veins of the lower esophagus and are often a result of obstructed portal hypertension associated with liver cirrhosis due to alcoholism.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 25
A toddler is brought in after a witnessed ingestion of a button battery approximately 2 hours before arrival. The airway is patent, with drooling noted on arrival. Radiographs confirm that the battery is lodged in the child’s esophagus. You would anticipate which of the following interventions?
Discharge the patient to home and provide caregivers with instructions to examine the child’s stool for the battery
Administer intravenous glucagon
Prepare the patient for immediate endoscopy to remove the battery
✓
Provide the patient with popsicles and repeat the radiograph in 1 hour
Correct Answer
Prepare the patient for immediate endoscopy to remove the battery
A. Button batteries that are lodged in the esophagus for more than 2 hours can cause esophageal burns and erosion of tissue, leading to possible perforation of the esophagus. The battery must be removed before it results in tissue damage.
B. The patient should not be permitted to eat or drink prior to the removal of the battery because this may cause the battery to enter, and potentially cause damage to, the stomach. The priority is to remove the battery from the child’s esophagus before it causes esophageal burns.
C. The patient should not be discharged before the battery is removed. Allowing the battery to travel through the gastrointestinal tract can lead to further damage and injury to the child. The priority is to remove the battery from the child’s esophagus before it causes esophageal burns.
D. Intravenous glucagon is indicated for the adult patient who has a food bolus in the esophagus. The priority is to remove the battery from the child’s esophagus before it causes esophageal burns.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 26
A 63-year-old presents to the ED complaining of hematemesis. The vomiting began abruptly, with no other symptoms. They describe the vomiting as about a cup of bright red blood. The patient has a past medical history of alcoholic cirrhosis, with consumption of at least 12 beers daily. When initially evaluated, their vital signs are HR 125 with a BP of 76/40. After 1 liter of normal saline, BP is 92/56. Which of the following should be a part of the initial management of this patient?
Administration of propranolol
Administration of octreotide (Sandostatin)
✓
Ongoing fluid resuscitation with normal saline or lactated Ringer’s solution
Emergent GI consult for esophageal banding
Correct Answer
Administration of octreotide (Sandostatin)
A. While vasopressin was initially the agent of choice, cardiovascular ischemia can occur with the high doses used in GI bleeding. The currently preferred agent is octreotide by continuous infusion.
B. An emergent GI consultation for endoscopic evaluation should be obtained. Endoscopic treatment should include esophageal band ligation, but in the acute setting, sclerotherapy may be used to control local bleeding with band ligation occurring at a future point in time.
C. Volume resuscitation should be initiated with normal saline, and blood products should be administered when available.
D. Nonspecific beta blockers such as propranolol or nadolol are used for the primary or secondary prevention of variceal bleeding but are not prescribed in the acute setting because these agents could worsen hypotension.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 27
A patient presents with colicky abdominal pain and vomiting for several days. They have also noticed progressive abdominal distention, with no bowel movement for 3 days. On exam, you hear high-pitched, loud bowel sounds with diffuse tenderness and rigidity. Past medical history includes an exploratory laparoscopy 6 years ago, post gunshot wound. You suspect this patient to have:
bowel obstruction.
✓
pancreatitis.
appendicitis.
diverticulitis.
Correct Answer
bowel obstruction.
A. The patient with diverticulitis will usually present with anorexia, nausea, and vomiting. The pain associated with diverticulitis is located in the left lower abdominal quadrant.
B. The pain associated with pancreatitis is sharp and boring, with radiation to the back. It usually has an abrupt onset.
C. A patient with appendicitis typically presents with right lower abdominal pain, anorexia, vomiting, and a low-grade fever. Rebound tenderness is elicited over McBurney’s point in the right lower quadrant.
D. A bowel obstruction will usually have a gradual onset, with a past history of abdominal surgery, vomiting, abdominal distention, and constipation.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 28
A patient presents with right lower quadrant pain. While performing your assessment, you note that the patient has a fever of 101.8°F and tachycardia, and rates the abdominal pain as 9 out of 10. The abdomen is distended and rigid with no bowel sounds. The patient states, “I was feeling better last night, but it seems the pain has become worse—that’s why I came in.” Based on your assessment, what do you suspect the patient is experiencing?
Massive GI bleed
Peritonitis due to a ruptured appendix
✓
Ruptured abdominal aneurysm
Acute small bowel obstruction
Correct Answer
Peritonitis due to a ruptured appendix
A. A patient with peritonitis will have a fever, usually of low grade, that worsens over time. Tachycardia is common. Abdominal examination reveals diffuse guarding and rebound, and a “board-like” abdomen. Bowel sounds are decreased.
B. Small bowel obstructions will present with crampy, diffuse abdominal pain associated with vomiting.
C. In a massive GI bleed, you will see a nonfocal abdominal tenderness; large bleeds may result in tachycardia and hypotension with enough blood loss. Nausea and vomiting typically occur with upper GI bleeds, with hallmark coffee-grounds vomitus or hematemesis.
D. With a ruptured abdominal aneurysm, vital signs may be normal (in 70%) to severely abnormal. Palpation of a pulsatile mass is usually possible in aneurysms 5 cm or greater. The physical examination may be nonspecific. Bruits or inequality of femoral pulses may be evident. No fever is noted.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 29
An infant is brought by their parents, who state that the infant has been irritable and vomiting, and there has been a change in the color and consistency of the infant’s stools. The infant is diagnosed with intussusception. The parents tell the nurse they do not understand what is wrong with their child. The best explanation the nurse can give to the parents is:
“This happens when one portion of the bowel slides into the next. It’s similar to a telescope and results in a blockage within the bowel.”
✓
“These changes in the stool can happen when a child is transitioned from breastmilk to formula and cereal.”
“This can happen when the bowel pushes through the abdominal muscles. As long as the blood supply isn’t cut off, surgery isn’t needed.”
“Intussusception occurs when the muscle that controls how the stomach empties is too tight, so the stomach contents back up.”
Correct Answer
“This happens when one portion of the bowel slides into the next. It’s similar to a telescope and results in a blockage within the bowel.”
A. Constriction of the gastric outlet is usually due to pyloric stenosis. Pyloric stenosis usually occurs within the first weeks of life and is characterized by projectile vomiting; it usually does not cause pain.
B. Abdominal pain, vomiting, and red currant jelly-like stools are the classic symptoms associated with intussusception.
C. Intussusception occurs when a portion of the bowel telescopes into itself, resulting in an obstruction.
D. A hernia occurs when a loop of bowel protrudes through the abdominal muscle, most commonly in the inguinal and umbilical areas. Unless incarcerated, it is not a surgical emergency.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 30
A 17-year-old presents with an 8-hour history of repeated bouts of emesis. They have a history of chronic, recurrent headaches but have never seen a provider for these headaches and have been smoking cannabis to help with the headaches. No blood or bile is noted in the emesis. The patient reports minor abdominal cramping associated with the vomiting and denies fever or diarrhea. They state this has happened four times in the past year. The nurse administers ondansetron, 1 liter of normal saline, and obtains a basic metabolic panel. A mild headache persists but the patient is able to tolerate oral fluids. What is likely to be included in the discharge instructions?
Avoidance of cannabis with medication teaching for ondansetron (Zofran) or promethazine (Phergan); recommend hot showers if vomiting returns
✓
Continuation of cannabis with medication teaching for an opioid and ondansetron (Zofran)
Avoidance of cannabis with medication teaching for an opioid and ondansetron (Zofran); recommend hot showers if vomiting returns
Continuation of cannabis with medication teaching for droperidol (Inapsine) or promethazine (Phenergan)
Correct Answer
Avoidance of cannabis with medication teaching for ondansetron (Zofran) or promethazine (Phergan); recommend hot showers if vomiting returns
A. Ondansetron is a fairly safe and broad-spectrum antiemetic. Unlike many other antiemetic agents, there are no sedative or extrapyramidal side effects. Opioids are not the first-line drugs of choice for treating headaches. If this is thought to be hyperemesis related to cannabis use, avoidance of cannabis for at least 2 weeks is indicated.
B. Most other causes of nausea seem to involve several receptors (especially the 5HT-3 serotonin receptors, D dopamine receptors, M muscarinic acetylcholine 2 1 receptors, and the H histamine receptors). Consequently, most broad-spectrum 1 antiemetic drugs will inhibit one or more of these receptors. Ondansetron (Zofran) is a good choice, along with promethazine (Phenergan) for home use. If this is thought to be hyperemesis related to cannabis use, avoidance of cannabis for at least 2 weeks is indicated.
C. If this is thought to be hyperemesis related to cannabis use, avoidance of cannabis for at least 2 weeks is indicated. Opioids are not the first-line drugs of choice for treating headaches. Ondansetron is a fairly safe and broad-spectrum antiemetic. Unlike with many other antiemetic agents, there are no sedative or extrapyramidal side effects.
D. The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition describes cyclic vomiting as at least 5 episodes, or a minimum of 3, over 6 months, and episodes of nausea/vomiting lasting 1 hour to 10 days, with 1 week in between. The typical pattern and symptoms involve a return to baseline health in between episodes, and symptoms are not due to another disorder. Children usually have 12 cycles per year, and adults have 4 cycles per year. Nausea between episodes is more common in adults. Evaluation should be tailored to the patient and presentation. Treatment includes avoidance of triggers, aborting the acute episode, and supportive therapy. Triggers include psychological stress, infection, physical exhaustion, specific foods (cheese, chocolate), motion sickness, and sleep deprivation. With hyperemesis of cannabis use, the patient will admit to smoking medium to large amounts of marijuana chronically. They will note improvement of symptoms with bathing/showering using hot water. To differentiate cyclic vomiting syndrome and cannabis hyperemesis, the patient must stop using marijuana for at least one week. If symptoms resolve, cannabis hyperemesis is likely.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 31
A patient presents to triage noting that they were involved in a MVC the night before. They complain of shortness of breath with pain to the left upper quadrant, with pain referred to the left shoulder. This sign is referred to as:
psoas sign.
Rovsing’s sign.
Kehr’s sign.
✓
balance sign.
Correct Answer
Kehr’s sign.
A. Balance sign is dullness on percussion of the left upper quadrant in a ruptured spleen.
B. Rovsing’s sign is found when right lower quadrant pain is elicited on deep palpation of the left lower quadrant.
C. Kehr’s sign suggests diaphragmatic irritation by peritoneal blood, as seen in splenic injuries.
D. Psoas sign indicates irritation to the iliopsoas group of hip flexors in the abdomen.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 32
A patient presents with complaints of a painful penile erection for the past several hours that is not associated with sexual stimulation. The patient has a history of chronic back pain, depression, and hepatitis C. The prolonged erection is most likely due to the patient’s use of:
ribavirin (Virazole).
buprenorphine (Suboxone).
celecoxib (Celebrex).
trazodone (Desryl).
✓
Correct Answer
trazodone (Desryl).
A. Trazodone is a serotonin receptor antagonist and reuptake inhibitor used to treat depression. A side effect associated with the administration of trazodone is the presence of priapism.
B. Ribavirin is an antiviral used in the treatment of hepatitis C, but priapism is not a known side effect of this medication.
C. Celecoxib is a nonsteroidal anti-inflammatory agent used for the management of pain. Priapism is not a known side effect of this medication.
D. Buprenorphine is used for the treatment of opioid dependence, but priapism is not a known side effect of this medication.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 33
A patient with a diagnosis of renal calculi is being prepared for discharge from the emergency department. Which of the following statements made by the patient demonstrates their understanding of the discharge instructions?
“I should increase the amount of water I drink during the day.”
✓
“I can expect to run a fever until the stone passes.”
“I will eliminate all calcium-containing foods from my diet.”
“Once the pain resolves, I will no longer need to strain my urine.”
Correct Answer
“I should increase the amount of water I drink during the day.”
A. Renal calculi consist of 80% calcium, but calcium is a necessary nutrient, and eliminating it from the diet may result in a nutritional deficit. The patient should be encouraged to avoid consuming large amounts of calcium-containing foods, including milk, spinach coffee, tea, and chocolate, but should not totally eliminate calcium from their diet.
B. Increasing the amount of fluid intake, especially water, will dilute the urine and discourage the collection of stone-forming crystals.
C. The acute pain related to renal calculus is the result of the stone descending from the renal pelvis through the ureter. There is often little to no discomfort as the stone passes from the bladder through the urethra. The patient should continue to strain the urine for up to 72 hours after the pain is relieved in order to retrieve the stone for chemical analysis.
D. Fever is not a symptom associated with renal calculi unless an infection is present. The patient should be advised to return to the emergency department if fever is present because hospital admission is generally indicated.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 34
A young woman presents with a complaint of heavy, bright red vaginal bleeding for the past 2 months. She complains of feeling tired with mild dizziness and lightheadedness when she tries to exercise. Vital signs are normal, hemoglobin is 9.4 g/dL, and the pregnancy test is negative. A bimanual pelvic exam has been performed. The nurse should prepare the patient for a(n):
pelvic or transvaginal ultrasound.
✓
transfusion of packed red blood cells.
immediate exploratory laparotomy.
endometrial ablation.
Correct Answer
pelvic or transvaginal ultrasound.
A. A uterine dilation and curettage (D&C) may eventually be indicated, but the patient’s hemodynamic status does not suggest there is an immediate threat to her well-being.
B. Although anemic, this patient is hemodynamically stable and does not require a blood transfusion.
C. Because the patient is not pregnant, a vaginal exam should be performed. Ultrasonography can be used to examine the status of the endometrium. Endometrial hyperplasia, endometrial carcinoma, endometrial polyps, and uterine fibroids can be identified easily by this technology.
D. Endometrial ablation is not acceptable as a primary therapy, because the procedure can hamper the later use of other common methods for monitoring the endometrium.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 35
Your patient was just diagnosed with chlamydia. The patient demonstrates understanding of the diagnosis by stating:
“Once treated, a patient develops immunity against future chlamydia infections.”
“For men, the symptoms include a thick green penis discharge and pain or swelling of both testicles.”
“Symptoms of a chlamydia infection include a vaginal discharge with a ‘fishy’ odor and pain during intercourse.”
“There may not be any symptoms, but burning with urination may be a warning about 1–3 weeks after exposure.”
✓
Correct Answer
“There may not be any symptoms, but burning with urination may be a warning about 1–3 weeks after exposure.”
A. A vaginal discharge with a “fishy” odor is a symptom associated with a Trichomonas vaginalis infection.
B. Chlamydia can be transmitted through oral and anal sexual contact, so homosexual men are at risk for developing a chlamydia infection.
C. It is estimated that up to 75% of patients with chlamydia infection are asymptomatic. Symptoms may appear within 1–3 weeks after exposure. When they do occur, symptoms include vaginal discharge or burning with urination in women. For men, the symptoms include penis discharge, burning during urination, and pain or swelling in one or both testicles. If the rectum is infected in men or women, rectal pain, discharge, and bleeding can occur.
D. A patient who has been treated for chlamydia can become infected again if they have unprotected sex with a partner who is infected with chlamydia. Also, women with chlamydia are more likely to develop cervical cancer and to become HIV positive than women without the condition.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 36
A 26-year-old female presents with sudden onset of right lower abdominal pain, followed by a syncopal episode and heavy vaginal bleeding. Which of the following potential diagnoses is the highest probability?
Ruptured ovarian cyst
Acute exacerbation of endometriosis
Pelvic inflammatory disease (PID)
Ruptured ectopic pregnancy
✓
Correct Answer
Ruptured ectopic pregnancy
A. Early symptoms and signs of ectopic pregnancy include pelvic pain, vaginal bleeding, and cervical motion tenderness. Syncope or hemorrhagic shock can occur with rupture. This is a high-risk condition and, when suspected, should be given a high priority.
B. Symptoms of PID include lower abdominal pain, cervical discharge, and irregular vaginal bleeding. An associated history of a syncopal episode is unlikely in a patient with PID.
C. Most ovarian cysts are asymptomatic. Blood-filled corpus luteum cysts may rupture, resulting in abdominal pain and intraperitoneal bleeding. Although these symptoms may be confused with those of a ruptured ectopic pregnancy, the bleeding is intraperitoneal, not vaginal.
D. The symptoms of endometriosis are dependent on the location of the endometrial tissue implanted outside the uterine cavity. Symptoms may include dysmenorrhea, dyspareunia, infertility, dysuria, and pain during defecation. The symptoms presented in the stem of this question do not apply to endometriosis except for pain.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 37
Approximately 10 minutes after the vaginal delivery of a full-term neonate, the nurse observes a sudden gush of vaginal bleeding. Which of the following events would be the highest possibility for this new manifestation?
The placenta has separated from the uterine wall.
✓
A cervical tear occurred during delivery.
Delivery of an unanticipated second neonate is imminent.
Uterine rupture has occurred.
Correct Answer
The placenta has separated from the uterine wall.
A. Uterine rupture is a rare obstetric emergency that occurs before delivery. It is typically the result of blunt force, deceleration, or compression injury.
B. Following delivery of the placenta, vaginal bleeding should lessen. A cervical tear can be the cause of significant postpartum bleeding, but the bleeding is characterized by a steadier flow rather than a single gush.
C. Approximately 10 minutes after the birth of the infant, the patient enters the third stage of labor, placental delivery. This stage is preceded by a sudden gush of blood from the vagina as the placenta separates from the uterine wall.
D. Signs of an imminent delivery include a bulging of the perineum or visualization or palpation of the presenting fetal parts. A second neonate often has intact membranes, so a gush of amniotic fluid may occur, but not blood.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 38
Which of the following assessment findings would place a patient at risk for preterm labor?
Smoking during pregnancy
✓
Increased maternal body mass
Previous full-term birth
Maternal age between 30 and 35 years
Correct Answer
Smoking during pregnancy
A. Women with low body mass, not higher body mass indices, are at increased risk of premature birth.
B. Smoking during pregnancy is a common risk factor associated with premature birth and poor fetal outcomes.
C. Mothers who have had a previous preterm birth are at greater risk for experiencing preterm labor during subsequent pregnancies.
D. Women younger than 18 years and older than 40 years are more likely to experience premature labor.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 39
Following 8 hours of observation, a near-drowning victim is being discharged home. Which of the following statements made by the parent indicates an understanding of the discharge instructions?
“I will give my child a high-protein, low-fat diet to encourage the healing process.”
“I will provide plenty of liquids that will keep my child hydrated and aid in recovery.”
“I will observe my child closely for any difficulty breathing or other changes that occur.”
✓
“I will have my child lie down with feet elevated to help promote water drainage from the lungs.”
Correct Answer
“I will observe my child closely for any difficulty breathing or other changes that occur.”
A. There should be no dietary restrictions or changes in discharge instructions for a near-drowning victim.
B. Asymptomatic near-drowning patients should be closely observed for approximately 8 hours and admitted if any deterioration occurs. If vital signs, pulse oximetry, and all studies, including a chest radiograph obtained close to the end of the observation period, are normal and no clinical deterioration develops during this period, the patient may be discharged with appropriate follow-up. Clear verbal and written instructions to return to the emergency department immediately for any respiratory or other problems must be given, and the patient must be accompanied by a responsible adult.
C. No evidence is available that shows this is beneficial. Normal hydration would be encouraged, but not overhydration.
D. Raising the legs while in a supine position will not assist in removing drainage from the lungs of a near-drowning victim. If drainage were present or if the chest radiograph were abnormal, the patient would not be discharged.
Category: Environment and Toxicology Emergencies, and Communicable
Question 40
What is the main goal of treatment for patients with chronic obstructive pulmonary disease (COPD)?
Avoiding hospitalization
Healing lung tissue
Reducing the use of medications
Preventing further damage
✓
Correct Answer
Preventing further damage
A. COPD is a lung disease that progressively worsens with each exacerbation. To decrease the frequency of exacerbations, patients should avoid risk factors such as smoking, environmental pollution, and exposure to chemicals and dust.
B. COPD is a progressive illness that advances with each exacerbation. Currently there is no cure for COPD.
C. Early hospitalization may decrease the severity and duration of a COPD exacerbation.
D. As the disease progresses, adjusting the medication regimen may assist in reducing symptoms and limit the occurrence of acute exacerbations.
Category: Respiratory Emergencies, Chronic obstructive pulmonary disease
Question 41
A patient arrives via emergency medical services and is confused, febrile, and tachypneic, with the presence of crackles in the right lower lobe on auscultation of the lung fields. What medication would the nurse identify as the most appropriate to treat the underlying disease process?
Normal saline
Albuterol sulfate
Acetaminophen
Levofloxacin
✓
Correct Answer
Levofloxacin
A. The patient has clinical manifestations of pneumonia. Levofloxacin is the preferred monotherapy to treat community-acquired pneumonia.
B. Albuterol sulfate may be indicated for symptoms associated with pneumonia, but it alone has no direct treatment effect on the underlying disease process.
C. Normal saline bolus may benefit the patient by thinning respiratory secretions for expectoration, but it is not the specific treatment for pneumonia. Patients with congestive heart failure or renal problems should be given fluids cautiously.
D. Acetaminophen is the treatment for fever that is found in the client with pneumonia; however, it is not specifically targeted at treating the underlying pathology.
Category: Respiratory Emergencies, Infections
Question 42
A motorcyclist who was not wearing a helmet is involved in a collision. On arrival to the emergency department, the patient is assessed to have sustained significant facial injuries, and audible gurgling is heard. What is the priority intervention for this patient?
Suction the oropharynx
✓
Prepare for endotracheal intubation
Place the patient in high Fowler’s position
Control facial venous bleeding
Correct Answer
Suction the oropharynx
A. Ensuring a patent airway by suctioning the oropharynx is the priority intervention in this scenario. Airway is the first component of the trauma primary assessment, along with cervical spine stabilization.
B. Although controlling venous bleeding is an appropriate intervention, it is not the priority. Ensuring a patent airway is the initial priority intervention. Controlling facial venous bleeding would be initiated in the secondary assessment.
C. Ensuring a patent airway by suctioning the oropharynx is the initial priority intervention for this patient. Cervical spinal precautions should be in place in the trauma primary assessment. Placing the patient in high Fowler’s position is not indicated and may be harmful.
D. Although endotracheal intubation is an appropriate intervention, it is not the immediate priority. Ensuring a patent airway by suctioning the oropharynx is the priority intervention. Once the airway is patent and cervical spine protection has been established, breathing with endotracheal intubation is the next component of the trauma primary assessment.
Category: Respiratory Emergencies, Respiratory trauma
Question 43
A patient presents confused, lethargic, and vomiting, and has flushed skin. The patient was found in a vehicle parked in an enclosed house garage with the engine running. Which assessment is the most appropriate to determine the patient’s oxygenation status?
Glasgow Coma Scale score
Peak flow reading
Pulse oximetry reading
Arterial blood gas measurement
✓
Correct Answer
Arterial blood gas measurement
A. A patient with carbon monoxide poisoning may have changes in levels of consciousness, hypotension, “cherry red” skin, and cardiac changes. The most appropriate assessment to determine oxygenation is arterial blood gas measurement.
B. The Glasgow Coma Scale will evaluate the patient’s level of consciousness but not for the presence of carbon monoxide poisoning.
C. The pulse oximeter cannot differentiate between hemoglobin being bound to oxygen or carbon monoxide. An arterial blood gas measurement is necessary to differentiate between blood that is saturated with oxygen and blood that is saturated with carbon monoxide.
D. A peak flow reading is used to evaluate a patient’s response in the treatment of asthma but is not indicated in the treatment of carbon monoxide poisoning.
Category: Respiratory Emergencies, Inhalation injuries
Question 44
In assessing a patient for the presence of a suspected tracheobronchial injury, the nurse can expect to auscultate which of the following?
A crunching sound synchronous with heartbeats
✓
Pleural friction rub auscultated over the axilla
Rales auscultated at the bilateral lung bases
Bowel sounds heard in the thoracic cavity
Correct Answer
A crunching sound synchronous with heartbeats
A. Disruption of the tracheobronchial tree is usually the result of trauma. It leads to air leakage into the mediastinum, resulting in a crunching or bubbling sound that is produced by the heart beating against air-filled tissues. This phenomenon is called Hamman sign.
B. A pleural friction rub is a low-pitched, dry grating sound heard on both inspiration and expiration and can indicate the presence of pleurisy.
C. Rales is an assessment finding consistent with fluid in the lungs.
D. The presence of bowel sounds in the thoracic cavity is consistent with the presence of a diaphragm rupture, not a suspected tracheobronchial injury.
Category: Respiratory Emergencies, Obstruction
Question 45
A patient with a history of congestive heart failure who reports being noncompliant with prescribed medications presents with shortness of breath, cough, and chest pain that worsens with inspiration. Breath sounds are markedly diminished over the bilateral lung bases. What should the nurse anticipate as the cause?
Pleural effusion
✓
Pericardial effusion
Pneumothorax
Pulmonary contusion
Correct Answer
Pleural effusion
A. Pleural effusions are a result of another underlying pathology. The most frequent cause of pleural effusions is poorly managed congestive heart failure. The buildup of fluids in the lower thoracic cage impairs the lungs’ ability to expand to accommodate respirations.
B. Pulmonary contusion is a potentially life-threatening injury caused by chest trauma. This patient reported no chest trauma.
C. Pneumothorax is an accumulation of air in the pleural space that may be spontaneous or the result of trauma. A pneumothorax will produce pleuritic chest pain, dyspnea, cough, and decreased breath sounds but typically has a sudden onset and is hyperresonant to percussion. Depending on the size of the pneumothorax, symptoms may be mild to severe.
D. Pericardial effusion is the abnormal accumulation of fluid in the pericardial sac. As the fluid accumulates, pressure on the heart increases, limiting ventricular filling and decreasing cardiac output. This is known as a cardiac tamponade. The patient will exhibit muffled heart sounds and hemodynamic instability.
Category: Respiratory Emergencies, Pleural effusion
Question 46
A patient presents to the emergency department complaining of chest pain and dyspnea. A chest radiograph is obtained and shows a visible lung margin with air filling the pleural space. Supplemental oxygen has been administered, and intravenous access has been established. Which intervention should the emergency nurse anticipate next?
Needle thoracostomy
Bilevel positive airway pressure
Endotracheal intubation
Chest tube thoracostomy
✓
Correct Answer
Chest tube thoracostomy
A. The chest radiograph indicates a pneumothorax; the margin of the collapsed lung is visible, with air filling the space outside the lung. The appropriate treatment would be to release the trapped air through placement of a chest tube to water seal.
B. Needle thoracostomy is indicated only for the emergent treatment of a tension pneumothorax. In this scenario, a chest tube would be appropriate.
C. Supplemental oxygen must be administered to improve hypoxia in a pneumothorax. However, positive airway pressure will not improve ventilation until the trapped air is relieved and negative pressure in the pleural space is restored, allowing the lung to re-expand. Furthermore, in the presence of a pneumothorax, the positive pressure may cause the development of a tension pneumothorax, a medical emergency.
D. Supplemental oxygen must be administered to improve hypoxia in a pneumothorax. However, mechanical ventilation through endotracheal intubation will not improve ventilation until the trapped air is relieved and negative pressure in the pleural space is restored, allowing the lung to re-expand. Furthermore, in the presence of a pneumothorax, the positive pressure of mechanical ventilation may cause the development of a tension pneumothorax, a medical emergency.
Category: Respiratory Emergencies, Pneumothorax
Question 47
A patient presents pale and diaphoretic with initial vital signs as follows: BP 130/85 mm Hg, HR 135 beats/minute, RR 40 breaths/minute, SpO 48% room air, T 2 37.2°C (99.0°F). Lung sounds are diminished bilaterally throughout, with crackles at the bases. The patient has been visiting from Florida for the past 4 days, and the current elevation is 9500 feet. What is the priority action for this patient?
Administer dexamethasone by slow IV push
Place the patient on a nonrebreather mask
✓
Obtain an electrocardiogram (ECG)
Obtain a chest radiograph
Correct Answer
Place the patient on a nonrebreather mask
A. The patient is in an environment where less oxygen is available than what they are used to. This can cause high-altitude pulmonary edema. Placing the patient on supplemental oxygen is the priority. The use of a nonrebreather mask will increase the level of inspired oxygen to the patient. The patient may require an ECG and IV access, but the first priority is to maintain airway, breathing, and circulation, along with the correction of oxygenation.
B. After correcting the patient’s oxygenation and breathing, evaluation of the effects to their cardiovascular system will be necessary. An ECG should be obtained and evaluated for possible myocardial injury.
C. Administering dexamethasone (Decadron) should be considered in the plan of care for this patient; however, oxygen administration is lifesaving in this situation.
D. A chest radiograph will need to be completed on this patient. However, because of the emergent nature of the patient’s complaint, maintaining airway, breathing, and circulation, followed by supplemental oxygenation, is the priority intervention.
Category: Respiratory Emergencies, Noncardiac pulmonary edema
Question 48
A patient arrives complaining of dyspnea and mild right-sided chest pain that began the previous evening and increases in intensity with exertion. Initial vital signs are BP 108/56 mm Hg, HR 115 beats/minute, RR 28 breaths/minute, SpO 87% room 2 air, and T 36.6°C (97.8°F). Lung sounds have fine scattered crackles bilaterally. The patient states that 3 days ago, they sustained an injury to their right leg while playing tennis. Based on this information, what should the emergency nurse suspect as the cause of the patient’s symptoms?
Pleural effusion
Pneumonia
Pulmonary embolism
✓
Pneumothorax
Correct Answer
Pulmonary embolism
A. Risk factors for pulmonary embolism include venous stasis, recent trauma, obesity, pregnancy, and a history of thrombosis. The patient is tachycardic and tachypneic, with a room air SpO of 87%. In addition, the 2 patient had a recent trauma to their right leg, indicating a possible deep vein thrombus with possible dislodgement, resulting in a pulmonary embolus.
B. The patient is afebrile, with fine scattered crackles bilaterally. A patient with pneumonia would present with course crackles on auscultation and bronchial breath sounds over the affected area.
C. A patient with a pleural effusion would have diminished or absent breath sounds over the area of the effusion.
D. On assessment, the patient demonstrates bilateral lung sounds that are inconsistent with a pneumothorax. A patient with a pneumothorax would have absent or diminished breath sounds on the affected side.
Category: Respiratory Emergencies, Pulmonary embolus
Question 49
Which type of ventilator setting is most often used in the initial phase of acute respiratory distress syndrome?
Volume-controlled
Pressure support
Pressure-controlled
✓
Assist control
Correct Answer
Pressure-controlled
A. The patient with acute respiratory distress syndrome requires close monitoring of respiratory status. It is a delicate process to recruit more alveoli. This is done by carefully titrating pressure and positive end-expiratory pressure. Pressure-controlled settings deliver breaths until a certain pressure is reached. Tidal volume is variable.
B. A volume-controlled setting delivers a set tidal volume, which increases the risk for barotrauma and volutrauma in the client with decreased lung compliance.
C. An assist control setting delivers a set respiratory rate and set tidal volume. This setting should not be used in the initial phase because the patient has to initiate a breath. Patients are often sedated and given neuromuscular blockades to rest and recover.
D. A pressure support setting provides inspiratory support to a spontaneously breathing patient. This setting is used for ventilatory weaning, not initial management.
Category: Respiratory Emergencies, Respiratory distress syndrome
Question 50
A pneumothorax can be classified as a simple, open, or tension pneumothorax. In a tension pneumothorax, assessment findings may include which of the following?
Muffled heart tones
Tracheal deviation
✓
Symmetrical chest wall movement
Sucking chest wound
Correct Answer
Tracheal deviation
A. Tracheal deviation is an assessment finding in a patient with a tension pneumothorax when air enters the interpleural space but cannot escape on expiration. The air on the affected side causes a mediastinal shift, which pushes the contents toward the unaffected side.
B. Asymmetrical chest wall movement, not symmetrical chest wall movement, is an assessment finding with tension pneumothorax.
C. Muffled heart tones is an assessment finding consistent with a pericardial tamponade; it is not typically an assessment finding with tension pneumothorax.
D. A sucking chest wound is an assessment finding consistent with the presence of an open pneumothorax.
Category: Respiratory Emergencies, Pneumothorax
Question 51
A patient with a history of chronic obstructive pulmonary disease (COPD) presents with shortness of breath, distended jugular veins, abdominal pain, and dependent extremity edema. What is the suspected cause for these symptoms?
Cor pulmonale
✓
Pneumothorax
Pneumonia
Blood clot
Correct Answer
Cor pulmonale
A. Cor pulmonale is a complication associated with COPD. Not all patients with COPD will advance to cor pulmonale, but if they do, their prognosis worsens. Because of chronic hypoxia, there is an increased pulmonary vascular resistance that causes the right ventricle to work harder to pump blood into the pulmonary vasculature. That increased resistance causes right-sided heart failure.
B. Pneumonia is a common complication in COPD, but symptoms of pneumonia are fever, chills, malaise, productive cough, shortness of breath, chest pain, and crackles.
C. Pneumothorax can be a complication from COPD, but the symptoms are chest pain, shortness of breath, and decreased or absent breath sounds on the affected side.
D. Symptoms of blood clots are pain at the site of thrombus, with localized swelling. Some risk factors are obesity, hormone therapy, surgery, trauma, and atrial fibrillation.
Category: Respiratory Emergencies, Chronic obstructive pulmonary disease
Question 52
A patient diagnosed with myocardial contusion from blunt chest trauma during a motor vehicle collision has decreased cardiac contractility and decreased cardiac output without volume loss. Goal-directed therapy includes fluid boluses and inotropic support. Which of the following will the nurse monitor for in this patient?
Fluid overload
✓
Tension pneumothorax
Urinary output
Hemorrhage
Correct Answer
Fluid overload
A. Hemodynamic measurements indicate possible cardiogenic shock as a result of the myocardial contusion, causing impaired contractility of the heart muscle. Successful emergent stabilization includes administering judicious fluid boluses to ensure adequate preload and inotropic support to improve contractility and to help the heart move blood forward. An excess of volume administration or an increase in afterload can result in pulmonary edema and increased myocardial ischemia. Therefore, it is important to monitor for signs of fluid overload.
B. Monitoring urinary output is important when the patient has volume loss associated with hypovolemic shock. However, this patient is in cardiogenic shock, so the priority is to evaluate for the presence of fluid overload.
C. Mediastinal shift with obstruction to atrial filling is the pathology underlying a tension pneumothorax and is associated with the presence of obstructive shock, not cardiogenic shock.
D. Hemorrhage is associated with volume loss and hypovolemic shock, not cardiogenic shock.
Category: Cardiovascular Emergencies, Cardiogenic shock and obstructive shock
Question 53
Which of the following interventions will decrease preload?
Successful cardioversion of new-onset atrial fibrillation to sinus rhythm
Administration of morphine sulfate 2–4 mg intravenous
✓
Placing the patient in a supine position with legs elevated
Administration of a beta blocker
Correct Answer
Administration of morphine sulfate 2–4 mg intravenous
A. Beta blockade will increase preload by slowing the heart rate, therefore allowing for an increased ventricular filling time.
B. Successful cardioversion and returning the patient to sinus rhythm will improve ventricular filling time and will increase, not decrease, preload.
C. Passive leg raise by placing the patient in a supine position with legs elevated will act to increase the patient’s preload through an increase in venous return from the lower extremities.
D. Morphine sulfate will act as a venodilator and will decrease venous return to the heart, resulting in a decrease in preload.
Category: Cardiovascular Emergencies, Cardiogenic shock and obstructive shock
Question 54
A nurse is assessing breath sounds in a patient with asthma and knows that to auscultate vesicular breath sounds, it is best to listen over the:
major bronchi.
peripheral lung fields.
✓
scapular region.
trachea/thorax region.
Correct Answer
peripheral lung fields.
A. Bronchial breath sounds are auscultated over the trachea and thorax and are noted for their high pitch, loud amplitude, and short duration on inspiration and long duration on expiration.
B. Bronchovesicular breath sounds are auscultated over the major bronchi, between the scapulae, and around the sternum in the first and second intercostal spaces. Bronchovesicular sounds are noted to have a moderate pitch, moderate amplitude, and the same duration on inspiration and expiration.
C. The three types of normal breath sounds are bronchial, bronchovesicular, and vesicular. Vesicular breath sounds are auscultated over the peripheral lung fields and are noted for their low pitch, soft amplitude, and long duration on inspiration and short duration on expiration.
D. It is very difficult to auscultate breath sounds directly over the scapula. Vesicular breath sounds are auscultated over the peripheral lung fields and are noted for their low pitch, soft amplitude, and long duration on inspiration and short duration on expiration.
Category: Respiratory Emergencies, Asthma
Question 55
A patient with exacerbation of chronic obstructive pulmonary disease (COPD) presents in respiratory acidosis. Which of the following is the priority medication that should be administered to improve oxygenation and ventilation?
Diuretic
Bronchodilator
✓
Antibiotic
Corticosteroid
Correct Answer
Bronchodilator
A. Respiratory acidosis is an indication of retained carbon dioxide in the lungs. Bronchodilators, given by nebulizer or single-metered-dose inhaler, work through direct action on the smooth muscle cells of the airway, thereby dilating airway passages and increasing oxygen and carbon dioxide exchange in the lungs. Bronchodilator use is an important therapy in the initial treatment of an acute exacerbation of COPD.
B. Corticosteroids work to decrease inflammation and to enhance the action of the bronchodilator during an acute exacerbation of COPD, but they do not have the same immediate effects that bronchodilators exert on lung tissue.
C. Diuretics are prescribed for heart failure and are not indicated in the immediate treatment of an exacerbation of COPD.
D. Antibiotics have been shown to improve outcomes from COPD exacerbations, especially if the patient has recent changes in sputum production and/or sputum consistency or is currently febrile. However, the immediate treatment for a COPD patient in respiratory acidosis is to administer a bronchodilator.
Category: Respiratory Emergencies, Chronic obstructive pulmonary disease
Question 56
A patient complains of a headache that feels as though someone is squeezing their head in a vise. The patient experiences these headaches monthly and complains of no other signs or symptoms. Which of the following types of headaches is suspected?
Migraine headache
Hydronephrosis headache
Tension headache
✓
Subcortical headache
Correct Answer
Tension headache
A. A migraine headache can occur with or without an aura. Migraine headache without aura is usually unilateral in nature, can have a pulsating quality, and is aggravated by physical activity. Migraine headache with aura is commonly localized to the cerebral cortex or brain stem. It commonly develops over 20 minutes and can last up to 72 hours, with the patient experiencing photophobia and nausea.
B. Subcortical refers to the area below the cortex of the brain and is not a type of headache.
C. A tension headache is associated with a report of tightening- or squeezing-type pain. A tension headache usually starts at the occipital area and moves around to the front area as if a band is squeezing the head. This type of headache can last up to 7 days.
D. Hydronephrosis refers to alterations within the kidney that are related to ischemic tissue changes. Hydronephrosis is not a type of headache.
Category: Neurological Emergencies, Headache (e.g., temporal arteritis, migraine)
Question 57
Of the following patients presenting with a chief complaint of headache, which would most likely require intracranial imaging?
A 25-year-old patient who presents with a new-onset tension-type headache
A patient diagnosed with small cell lung cancer who complains of a new-onset headache
✓
A patient with a history of migraines who presents with their typical symptom complex
A patient with a headache accompanied by a fever, elevated erythrocyte sedimentation rate, and no leukocytosis
Correct Answer
A patient diagnosed with small cell lung cancer who complains of a new-onset headache
A. A patient who presents with new onset of headache and who has secondary headache risk factors should be imaged regardless of other neurological findings or deficits. Secondary headache is caused by an underlying disorder. Examples of secondary headache risk factors are (1) human immunodeficiency virus, (2) uncontrolled hypertension, (3) malignancy, and (4) recent head injury. A secondary type of headache must be ruled out in these circumstances.
B. A patient with a chronic primary headache diagnosis and a presentation that is typical based on their history does not require intracranial imaging. Any change in the onset and/or characteristics of the headache or accompanying neurological deficits would require intracranial imaging.
C. Any patient younger than 5 and older than 50 who presents with a headache has a higher risk of secondary headaches and would require intracranial imaging to rule out potential risk factors.
D. A headache accompanied by fever and elevated erythrocyte sedimentation rate but without the presence of leukocytosis is most likely temporal arteritis. In addition, physical examination findings may include an increase in pain with palpation of the temporal artery. This diagnosis would require a temporal artery biopsy and would not have a strong indication for intracranial imaging.
Category: Neurological Emergencies, Headache (e.g., temporal arteritis, migraine)
Question 58
A patient is found unresponsive at home. A family member states that the patient regularly abuses alcohol. Bruising is noted to the patient’s face and head. On assessment, the patient has a fixed and dilated left pupil, has increased deep respirations with periods of apnea, is bradycardic, and is experiencing a continual rise in only the systolic blood pressure. Based on these findings, which should be suspected?
Ischemic stroke
Subdural hematoma
✓
Absence seizure
Narcotic overdose
Correct Answer
Subdural hematoma
A. The patient is known to abuse alcohol and has signs of a possible traumatic brain injury, which increases the patient’s risk for a subdural hematoma. A subdural hematoma is a slow-growing intracranial venous bleed that, left untreated, can result in coma and death from brain herniation. Signs of brain herniation include Cushing’s triad: (1) bradycardia, (2) abnormal or apneic respirations, and (3) a widening pulse pressure secondary to a rising systolic blood pressure. In this case, the patient has Cheyne–Stokes respirations (increased deep respirations with periods of apnea), bradycardia, and a rising systolic blood pressure.
B. An absence seizure causes a short period of “blanking out” or staring into space but does not cause unconsciousness; there should be no changes in breathing pattern, heart rate, or systolic blood pressure.
C. Classic pupillary changes that result from stroke reveal sluggishness of pupils. A fixed dilated pupil is most likely associated with an intracranial hemorrhage.
D. A narcotic overdose may cause bradycardia and irregular or apneic respirations but does not present with a widening pulse pressure. There is also no information to suggest a possible overdose or narcotic use. Pupils would be pinpoint bilaterally with a narcotic overdose.
Category: Neurological Emergencies, Increased intracranial pressure (ICP)
Question 59
A patient previously diagnosed with a brain tumor arrives unresponsive. An osmotic diuretic is administered. Which of the following indicates an effective response to this medication?
Absence of pulsus paradoxus
Urinary output of 30 mL/hour
Widening pulse pressures
Glasgow Coma Scale score of 13
✓
Correct Answer
Glasgow Coma Scale score of 13
A. Osmotic diuresis decreases intracranial pressure by pulling fluid from the brain and excreting it in the urine. Although this output is a desirable effect of therapy, its presence is not indicative of improvement.
B. Widening pulse pressures occur as systolic blood pressures rise and diastolic pressures decrease. This is an indication of increasing intracranial pressure. In combination with bradycardia and irregular respirations, it is also known as Cushing’s response as the body attempts to compensate for rising intracranial pressure.
C. Pulsus paradoxus is a symptom of cardiac tamponade. As the heart is compressed by fluid in the pericardial sac, the left and right sides compete for filling volume, resulting in a drop in blood pressure.
D. An unresponsive patient receives a score of 1 on the eye-opening portion of the Glasgow Coma Scale score. The maximum score is 5 for verbal response and 6 for motor response. The maximum score on initial presentation cannot exceed 12. An improving score indicates improvement in neurological status.
Category: Neurological Emergencies, Increased intracranial pressure (ICP)
Question 60
The most common symptom of bacterial meningitis is:
high fever.
✓
seizure.
stiff neck.
blanching rash.
Correct Answer
high fever.
A. Seizure may result from a high fever, but it is a nonspecific symptom of bacterial meningitis. The most common symptoms are headache and high fever.
B. Stiff neck, or nuchal rigidity, is a common symptom associated with bacterial meningitis, but it is not always present.
C. The most common symptoms associated with bacterial meningitis are headache and high fever.
D. A nonblanching rash is associated with the presence of meningococcemia.
Category: Neurological Emergencies, Meningitis
Question 61
On assessing a patient with a complaint of severe headache and fever, the nurse observes that when the patient’s head is flexed forward, their knees and hips also flex. Based on this assessment finding, which diagnosis is anticipated?
Meningitis
✓
Spinal cord injury
Cervical spine fracture
Trapezius muscle injury
Correct Answer
Meningitis
A. Spinal cord injury typically results in loss of movement and/or sensation.
B. Fractures typically present with pain and may have an associated spinal cord injury.
C. The pain would typically be limited to the shoulder area and not involve the leg.
D. The patient is experiencing signs of possible meningitis. The involuntary flexion of the hips and/or the knees when the neck is flexed, also known as Brudzinski’s sign, is an indication of meningeal irritation.
Category: Neurological Emergencies, Meningitis
Question 62
Which of the following parameters is most consistent with neurogenic shock?
Decreased SvO 2
Increased central venous pressure
Hypertension
Bradycardia
✓
Correct Answer
Bradycardia
A. Hypertension is not an assessment finding in the presence of neurogenic shock.
B. Increased intracranial pressure is not an assessment finding in the presence of neurogenic shock.
C. Neurogenic shock is a type of distributive shock related to spinal trauma and results in a complete loss of vasomotor tone. As a result of a loss of sympathetic and vasomotor tone, the hemodynamic findings include hypotension, bradycardia, decreased pulmonary occlusion pressure, decreased cardiac index, decreased systemic vascular resistance, decreased central venous pressure, and decreased SvO . 2
D. An increased SvO is not an assessment finding in the presence of neurogenic 2 shock.
Category: Neurological Emergencies, Head and spinal cord trauma
Question 63
The patient with a subarachnoid hemorrhage (SAH) has a blood pressure of 180/115 (MAP 137). The nurse anticipates which medication to be ordered for this patient?
Intropin (Dopamine)
Hypertonic saline
Propofol (Diprivan)
Labetalol (Trandate)
✓
Correct Answer
Labetalol (Trandate)
A. Hypertonic saline is indicated for the management of increased intracranial pressure but is not indicated in the management of blood pressure.
B. Dopamine will increase the patient’s blood pressure, not reduce their blood pressure. The patient’s blood pressure in a SAH should be kept below 160 mm Hg systolic, but hypotension must be avoided.
C. The patient with a SAH should have their MAP kept less than 110 mm Hg to avoid further risk of hemorrhage, but hypotension must be avoided. Nicardipine may also be used to lower the patient’s systolic blood pressure.
D. Propofol may be ordered for sedation, but it is not for blood pressure management. Propofol has a hypotensive effect but is not used to lower a patient’s blood pressure.
Category: Neurological Emergencies, Stroke
Question 64
A patient with right facial droop is being discharged with home care instructions related to Bell’s palsy. The patient asks if their facial paralysis is permanent. The most appropriate response from the emergency nurse is:
“All of your facial weakness will resolve, just be patient with the recovery.”
“This is difficult to predict, but most patients have a complete recovery within 3 to 6 months following the onset of their symptoms.”
✓
“Your facial weakness will come and go.”
“The damage from the virus will not resolve but over time, but you will become accustomed to the facial droop.”
Correct Answer
“This is difficult to predict, but most patients have a complete recovery within 3 to 6 months following the onset of their symptoms.”
A. A majority of patients with Bell’s palsy recover totally without treatment. If symptoms have not resolved within 6 months, a referral to neurologist may be required.
B. A majority of patients with Bell’s palsy recover totally without treatment. If symptoms have not resolved within 6 months, a referral to neurologist may be required.
C. A majority of patients with Bell’s palsy recover totally without treatment. If symptoms have not resolved within 6 months, a referral to neurologist may be required.
D. Weakness and paralysis associated with Bell’s palsy are the result of decreased lower motor neuron function from viral pathogens. Patients with Bell’s palsy are not expected to have recurrent episodes of remission and relapse of their symptoms.
Category: Neurological Emergencies, Neurological disorders (e.g., multiple
Question 65
A mother presents to triage with a 2½-year-old toddler who sustained a lip laceration related to a fall while playing in the yard. The child has numerous bruises in various stages of healing on bilateral knees and a healing abrasion on one elbow, but no other apparent injuries. Which of the following statements about assessment for potential child maltreatment is most accurate?
Multiple areas of injury are indicative of potential abuse, especially in the toddler population.
The bruises in various stages of healing are a clear sign of potential abuse and should be evaluated.
Intentional injuries are easily spotted because they are generally inflicted in patterns.
Unintentional injuries tend to occur on bony prominences, which may be normal for a toddler.
✓
Correct Answer
Unintentional injuries tend to occur on bony prominences, which may be normal for a toddler.
A. As toddlers are learning to walk and run, it is not uncommon to see bruises on bony prominences such as knees and elbows.
B. Although bruises in various stages of healing may be signs of abuse and should be evaluated, they are not necessarily clear signs.
C. Multiple areas of injury may be signs of abuse; however, the nurse must consider the developmental age of the patient.
D. Intentional injuries are not necessarily easily spotted. Abusers may cover intentional injures with clothing. Pattern injuries could be associated with intentional injury and should be evaluated.
Category: Professional Issues, Patient, Abuse and neglect
Question 66
Which of the following actions would work best to propose a solution to the problem of emergency department (ED) overcrowding?
Serve on a hospital-wide committee to discuss patient flow.
✓
Petition the nursing administration to hire additional transporters to assist with patient flow.
Contribute to the development of ED protocols to divert overflow patients to neighboring hospitals.
Participate in a strategic planning session to expand the number of telemetry beds.
Correct Answer
Serve on a hospital-wide committee to discuss patient flow.
A. Hiring additional ancillary staff will not address the root of the problem, which is an ineffective hospital-wide patient flow system.
B. ED crowding is recognized as a product of ineffective patient flow that results in increased costs and compromised care. There is agreement that it is a hospital-wide and community problem, not an isolated ED issue.
C. Providing additional telemetry beds may ease the holding of cardiac patients in the ED, but the issue affects patients with noncardiac diagnoses as well. Patient boarding in the ED is a hospital-wide patient flow problem, and the solution requires an interdisciplinary team approach.
D. ED crowding is recognized as a hospital- and community-wide issue that affects quality of care and access to care. Diverting patients to neighboring hospitals does little to address the root of the problem, which is an ineffective patient flow system.
Category: Professional Issues, Patient, Transitions of care
Question 67
A patient diagnosed with gastroesophageal reflux disease is being discharged and prescribed a proton pump inhibitor (PPI). The instructions provided by the emergency nurse should instruct the patient to take the medication at which time?
2 hours before or after bismuth subsalicylate
At the first indication of stomach pain
20–30 minutes before a meal
✓
At bedtime
Correct Answer
20–30 minutes before a meal
A. PPIs are activated by an alkaline environment. The stomach environment overnight is typically acid, so the PPI would be ineffective.
B. PPIs are activated by an alkaline stomach environment, so they should be taken 20–30 minutes before a meal.
C. It may take several days of continuous PPI therapy for the patient to obtain relief, and up to 12 weeks of therapy may be needed to reduce the symptoms of gastroesophageal reflux disease.
D. Bismuth subsalicylate is concurrently administered with PPI therapy to eradicate the H. pylori bacterium. The two medications can be taken together.
Category: Professional Issues, Patient, Discharge planning
Question 68
Which of the following is most important to consider when developing evidence-based practice guidelines for the emergency department?
The availability of published clinical practice guidelines to direct the change in practice
The availability of advanced practice nurses or nursing researchers to identify an appropriate clinical research question
Findings from relevant research, combined with practitioner expertise and patient preferences
✓
Findings obtained from the results of well-conducted randomized controlled trial research studies alone
Correct Answer
Findings from relevant research, combined with practitioner expertise and patient preferences
A. Evidence-based practice consists of the synthesis of the findings from the most relevant research, the experience and expertise of the practitioner, and patient preferences and values.
B. Randomized controlled trial research studies are considered the strongest level of evidence and produce new knowledge. However, the findings, although valid and rigorous, do not always translate into clinical practice. Evidence-based practice is the blending of this new knowledge with practitioner expertise and patient preferences. These blended components guide the decision making, leading to higher-quality care and improved patient outcomes.
C. The ability to apply a published clinical practice guideline to a specific emergency department may not be possible because of institutional differences, such as financial resources, physical setting, patient population, or staffing mix.
D. The first step in the development of evidence-based practice guidelines is the support of a culture in which all clinicians, regardless of profession or educational preparation, are encouraged to question their current practices and explore opportunities to improve patient outcomes.
Category: Professional Issues, Nurse, Evidence-based practice
Question 69
A patient who has sustained a self-inflicted gunshot wound is brought to the emergency department. Which of the following interventions describes the appropriate collection and handling of forensic evidence?
Projectiles such as bullets or BBs should be secured in a sterile plastic container using a metal instrument.
Local authorities must be present during evidence collection.
Document any personal items that have been returned to the family.
Place each piece of the patient’s clothing in a separate paper bag.
✓
Correct Answer
Place each piece of the patient’s clothing in a separate paper bag.
A. Projectiles should be wrapped in gauze or gripped with rubber-tipped instruments. Handling projectiles with a bare metal instrument may alter trace evidence or ballistic markings that are used to link the projectile to a weapon.
B. Each piece of the patient’s clothing should be placed in a separate paper bag. Placing the clothing in a paper bag rather than a plastic bag will allow air to circulate and prevent moisture from accumulating on the clothing, which can alter the evidence.
C. It is an expectation that nurses will collect and preserve evidence according to local protocols.
D. Personal items should not be removed and given to family members or significant others without the approval of law enforcement.
Category: Professional Issues, Patient, Forensic evidence collection
Question 70
Providing adequate information, prompt response to patients’ needs, and caring behaviors are all attributes that lead to:
emergency overcrowding.
long wait times.
patient satisfaction.
✓
staff retention.
Correct Answer
patient satisfaction.
A. Factors associated with staff turnover are more individual, such as workload, role ambiguity, management support, and work environment. All of these factors impact quality of care but are not directly related to patient satisfaction in the hospital.
B. Prolonged ED boarding times decrease system-level satisfaction scores.
C. Patient satisfaction is influenced by nurses’ caring behavior when providing adequate information, and prompt response to patients’ needs with technical and professional expertise.
D. Many factors contribute to crowding, including variable patient volume and acuity, along with contributing hospital factors, such as inadequate nursing support and insufficient inpatient beds.
Category: Professional Issues, System, Performance and process improvement
Question 71
An employee from the hospital’s nuclear medicine department arrives at the emergency department stating that they may have been exposed to radioactive material. The patient is pale and diaphoretic and is complaining of a sudden onset of midsternal chest pain that radiates to the jaw. The priority action for the emergency nurse is to:
don personal protective equipment.
prepare the patient to obtain a 12-lead electrocardiogram.
✓
accompany the patient to the decontamination shower.
secure intravenous (IV) access and administer atropine 1 mg IV STAT.
Correct Answer
prepare the patient to obtain a 12-lead electrocardiogram.
A. External irradiation exposure does not render a victim radioactive and does not pose a threat to caregivers; therefore, personal protective equipment for the caregiver is not required.
B. The patient presents with symptoms suggestive of a myocardial infarction. The radiation exposure of this patient does not pose a threat to the caregivers. The priority is to medically stabilize the patient, appropriately decontaminate, and then refer for further treatment.
C. Securing IV access is a priority; however, atropine sulfate would not be the initial drug of choice for a patient who is suspected of having a myocardial infarction.
D. An individual who has been exposed to radiation may require decontamination, but lifesaving measures should not be delayed.
Category: Professional Issues, Patient, Patient safety
Question 72
Handoff communication between providers is most effective when patient information is shared using which type of communication tool?
Focused solely on the patient and the plan of care
Suitable for use by a care provider with a lower level of knowledge or skill
Standardized approach and communication
✓
Adaptable to a format for an audiotaped report
Correct Answer
Standardized approach and communication
A. It is the position of the Emergency Nurses Association that the handoff/transfer of care should only occur between caregivers of equal or higher levels of knowledge, skills, and clinical judgment.
B. The most effective handoff/transfer processes provide an opportunity for the receiving caregiver to ask questions and clarify and confirm information. An audiotaped report would not meet this requirement.
C. The Joint Commission estimates that 80% of serious medical errors occur because of miscommunication during patient handoff/transfer and requires accredited organizations to use a standardized approach for handoff communications.
D. When possible and appropriate, patients and families should be involved in the information sharing that occurs in handoff communication.
Category: Professional Issues, Patient, Transitions of care
Question 73
Which of the following is most likely to be related to inadequate communication?
Blood transfusion hypersensitivity reaction
Improper delegation of nursing tasks
Medication errors
✓
Emergency department (ED) overcrowding
Correct Answer
Medication errors
A. More than 80% of medical errors can be attributed to inadequate communication between caregivers. Medication errors are among the more serious consequences of poor handoff communication.
B. Hypersensitivity reactions occur during a blood transfusion when antibodies in the recipient’s blood react with substances in the donor’s blood.
C. ED overcrowding is recognized as a systemwide issue. An ineffective handoff may contribute to a delay in treatment or diagnosis and lead to a prolonged length of ED stay, but it is not the single determining factor in ED overcrowding.
D. Emergency nurses should follow the five rights of delegation when assigning tasks to other nurses or ancillary personnel. These rights include delegating the right task to the right personnel.
Category: Professional Issues, Patient, Transitions of care
Question 74
The JumpSTART (Simple Triage and Rapid Treatment) pediatric triage for mass casualty events uses the same criteria for triage as the adult START triage, with respiratory rate, capillary refill, and mental status; however, JumpSTART triage includes which additional intervention?
Intravenous fluids
Glucose
Warming
Rescue breaths
✓
Correct Answer
Rescue breaths
A. Emergency management procedures have a few variations in caring for the pediatric population, including the recognition that children have physiological differences as compared with an adult patient. The pediatric triage system for mass casualty events is called JumpSTART triage. Adult patients typically have circulatory failure before respiratory failure. In the child, respiratory failure tends to affect the child before circulatory failure. For this reason, offering rescue breaths can provide a child with the respiratory support that they need to survive.
B. Remembering to keep the child warm is important because of the availability of less fat stores to maintain body heat in the child. However, remembering to keep the child warm is not included as a component of the JumpSTART triage algorithm.
C. Children have less circulatory volume than adults; therefore, loss of fluids leading to dehydration affects children more quickly than adults. A child will need intravenous fluids to maintain their circulatory volume, but it is not a part of the JumpSTART triage algorithm.
D. Infants and children have less glucose reserves than adults. The administration of glucose should be considered when treating the child, but it is not part of the JumpSTART triage algorithm.
Category: Professional Issues, System, Disaster management
Question 75
A patient presents to the emergency department with chest pain, but the hospital does not accept their medical insurance plan. To be compliant with the Emergency Medical Treatment and Active Labor Act (EMTALA), what must be a component of the medical screening exam for a patient complaining of chest pain?
Assessment by a physician
Comprehensive triage
Chemistry panel
Electrocardiogram (ECG)
✓
Correct Answer
Electrocardiogram (ECG)
A. To establish if a life-threatening condition such as an ST-elevation myocardial infarction or fatal dysrhythmia is present, an ECG should be a part of the medical screening exam of a patient complaining of chest pain.
B. Although laboratory diagnostic testing would be typical for a patient with chest pain, a basic chemistry panel is not necessary to determine that a life-threatening cardiac condition exists. However, cardiac enzymes might need to be drawn.
C. Comprehensive triage is not necessary to be compliant with EMTALA and is not considered a medical screening exam, though some of the components, such as vital signs, would be a part of the medical screening exam.
D. Whoever the hospital designates to perform a medical screening exam can complete the assessment. In addition to a physician, an advanced practice provider or possibly an obstetrics nurse can complete the exam.
Category: Professional Issues, System, Federal regulations (e.g., HIPAA, EMTALA)
Question 76
An unaccompanied 16-year-old patient arrives at triage seeking treatment for a sexually transmitted disease. The patient’s request for treatment is:
granted only if parents provide consent.
not permitted.
granted only if the patient can provide documentation of emancipation.
permitted.
✓
Correct Answer
permitted.
A. Minors can consent to treatment in specific areas, such as birth control counseling, sexually transmitted disease treatment, substance abuse or alcohol rehabilitation, and pregnancy-related issues. Because the patient is seeking care for treatment of a sexually transmitted disease, they can consent on their own and receive care in the emergency department without a parent’s consent.
B. Minors can consent to treatment in specific areas, such as birth control counseling, sexually transmitted disease treatment, and substance abuse or alcohol rehabilitation, and female patients can seek care for pregnancy-related issues. Because the patient is seeking care for treatment of a sexually transmitted disease, they can consent on their own and receive care in the emergency department without a parent’s consent.
C. The patient can seek treatment alone because minors are able to consent to treatment in specific areas, such as birth control counseling, sexually transmitted disease treatment, and substance abuse or alcohol rehabilitation, and female patients can seek care for pregnancy-related issues. Because the patient is seeking care for treatment of a sexually transmitted disease, they can consent on their own and receive care in the emergency department without a parent’s consent.
D. The patient would not need to be emancipated in this situation because minors are able to consent to treatment in specific areas, such as birth control counseling, sexually transmitted disease treatment, and substance abuse or alcohol rehabilitation, and female patients can seek care for pregnancy-related issues. Because the patient is seeking care for treatment of a sexually transmitted disease, they can consent on their own and receive care in the emergency department without a parent’s consent.
Category: Professional Issues, System, Patient consent for treatment
Question 77
A 4-year-old was found locked in a car on a hot day. The patient is agitated and confused, skin is hot to touch, and lips are parched. Which of the following would be the priority intervention for this patient?
Infuse Ringer’s lactate solution
Administer acetaminophen (Tylenol)
Immerse the patient in an ice water bath
Initiate core temperature monitoring
✓
Correct Answer
Initiate core temperature monitoring
A. Ringer’s lactate solution is not a recommended intervention because the liver may not be able to metabolize lactate. Liver injury is often a sequela of heat stroke. Normal saline is recommended in this situation.
B. Although ice water immersion is an accepted treatment for heat stroke, it is difficult to monitor the patient and can also cause increased agitation and discomfort, along with shivering that creates heat in the body. It is not recommended for children.
C. This patient is experiencing signs and symptoms of heat stroke. Continuous core temperature monitoring is essential during the cooling phase to prevent hypothermia. This is the priority for this patient because it is crucial to monitor this vital sign.
D. Antipyretics will not treat the problem with heat stroke because it is not an issue with a pyrogen, but rather a thermoregulation problem from an overwhelmed heat-regulating mechanism. Acetaminophen (Tylenol) can also cause increased problems if the liver is damaged from the initial insult of heat stroke.
Category: Environment and Toxicology Emergencies, and Communicable
Question 78
Which form of radiation exposure injury is considered to have an expectant or fatal outcome?
Central nervous system (CNS) syndrome
✓
Hematopoietic (bone marrow) syndrome
Gastrointestinal syndrome
Cutaneous radiation injury
Correct Answer
Central nervous system (CNS) syndrome
A. CNS syndrome is equated with expectant or fatal outcomes. CNS syndrome includes symptoms such as extreme nervousness, confusion, altered level of consciousness, convulsions, and death. Onset of symptoms occurs within 5–6 hours of exposure, with death occurring within 5 days.
B. Hematopoietic syndrome results in lymphopenia, pancytopenia, sepsis, and hemorrhage but is not associated with a fatal or expectant outcome. Patients can have a full recovery within a few weeks and up to 2 years following exposure.
C. Gastrointestinal syndrome is associated with nausea, vomiting, and abdominal pain but is not commonly associated with death.
D. Radiation injury to the skin and tissues can occur with doses of radiation as low as 200 rads. This form of radiation exposure produces symptoms of itching, tingling, and edema and does not result in death.
Category: Environment and Toxicology Emergencies, and Communicable
Question 79
Which of the following statements made by a parent indicates understanding of heat advisory instructions after a class on heat injury prevention?
“I can maintain my child’s soccer and sports activity schedule between 11:00 a.m. and 2:00 p.m.”
“I can briefly leave my child inside my automobile while I run in to the market.”
“I will provide frequent drink breaks that include electrolytes during the day.”
✓
“I will dress my child in dark-colored clothing with long sleeves to protect him from the sun.”
Correct Answer
“I will provide frequent drink breaks that include electrolytes during the day.”
A. Children should never be left unattended, even briefly, inside a hot automobile. Temperatures rise rapidly, and children’s bodies are not able to adequately compensate for the rapid rise in temperature.
B. Taking frequent breaks to drink fluids will help prevent the child from becoming overheated. Restoring electrolytes is also important, along with fluid intake.
C. The sun is at its maximum intensity between 11 a.m. and 2 p.m. Vigorous activity should be scheduled for cooler parts of the day, such as in the early morning or late evening.
D. Light-colored clothing with short sleeves should be worn so that the sun’s rays are not easily absorbed by the clothing itself.
Category: Environment and Toxicology Emergencies, and Communicable
Question 80
Which of the following patients must receive the series of rabies prophylaxis?
The patient with a bite from a pet cat
The patient who may or may not have been bitten by a guinea pig
The patient with a bite from a pet dog
The patient who may or may not have been bitten by a bat
✓
Correct Answer
The patient who may or may not have been bitten by a bat
A. Rodent transmission of rabies is unusual. Bites from any animal that can be observed for 2 weeks usually do not require rabies prophylaxis.
B. Bites from any animal that can be observed for 2 weeks usually do not require rabies prophylaxis. Domestic cats have usually been vaccinated against rabies.
C. Bites from any animal that can be observed for 2 weeks usually do not require rabies prophylaxis. Domestic dogs have usually been vaccinated against rabies.
D. Bats are a common carrier of rabies. Prophylaxis is recommended following any exposure to a bat.
Category: Environment and Toxicology Emergencies, and Communicable
Question 81
A non-English-speaking patient presents to emergency department triage. To best communicate with the patient, the triage nurse should use which of the following methods?
A member of the patient’s family who speaks English
A certified translator employed by the hospital
✓
A hospital employee who speaks the patient’s native language
A picture-based communication board
Correct Answer
A certified translator employed by the hospital
A. The use of nonprofessional interpreters increases the risk of miscommunication and misunderstanding because the provider may not know if the message has been communicated correctly. Nonprofessional interpreters may have difficulty conveying a message to the patient because of a limitation of knowledge or embarrassment.
B. Family members may have difficulty conveying a message to the patient because of a limitation of knowledge or embarrassment. Children should never be used as interpreters because of their limited ability to understand adult situations.
C. Culturally competent communication has been identified as a patient right and an essential component of the provision of safe and effective health care. Mechanisms to provide effective communication include the use of certified translators, either in person or through a video or telephone interpretation service. The use of professional interpreters (in person or via telephone) has been found to increase patient satisfaction, improve adherence and outcomes, and reduce adverse events. Failure to provide such services may be interpreted as an act of discrimination under Title VI of the Civil Rights Act.
D. Picture-based communication tools are an effective means for some aspects of communication, but the use of in-person certified translators or video or telephone interpretation services is preferred as the primary means of communication.
Category: Professional Issues, Patient, Cultural considerations (e.g., interpretive
Question 82
While awaiting the determination of brain death for a patient who has sustained multiple traumatic injuries and is a potential organ donor, the nurse should anticipate which of the following interventions to maintain organ perfusion?
Administer norepinephrine to avoid hypotension
Administer atropine to treat bradydysrhythmias
Administer vasoactive agents
Administer intravenous fluids
✓
Correct Answer
Administer intravenous fluids
A. Hypotension will occur in most donors secondary to relative hypovolemia exacerbated by reduced systemic vascular resistance. Crystalloid or colloid infusions should be titrated to achieve euvolemia. For refractory hypotension, vasopressin is the drug of choice to maintain adequate pressure and organ perfusion.
B. Brain death may result in cerebral herniation and hypertension, but this is usually self-limiting. If the MAP remains persistently high, vasoactive infusions should be stopped, and short-acting agents should be used (i.e., esmolol or sodium nitroprusside).
C. Vasopressin is often used rather than norepinephrine. Norepinephrine may be used, but research has shown that it has a negative effect on capillary perfusion and oxygen consumption in the case of heart transplantation.
D. A patient who has lost autoregulation no longer has vagal tone, and anticholinergic drugs such as atropine are ineffective in increasing heart rates. If strong chronotropic agents like isoproterenol are unsuccessful, electrical pacing is indicated to prevent circulatory compromise.
Category: Professional Issues, Patient, End-of-life and palliative care (e.g., organ and
Question 83
Which of the following medications should the nurse anticipate administering to prevent the onset of Wernicke–Korsakoff syndrome in a patient with suspected alcohol intoxication?
Dextrose 50%
Thiamine (vitamin B ) 1
✓
Magnesium
Lorazepam (Ativan)
Correct Answer
Thiamine (vitamin B ) 1
A. Thiamine is given to prevent Wernicke–Korsakoff syndrome, a degenerative brain condition that results from vitamin B deficiency. The syndrome manifests with 1 gait ataxia, mental confusion, confabulation, nystagmus, or ophthalmoplegia.
B. Dextrose 50% is given for hypoglycemia and is not indicated for the prevention of Wernicke–Korsakoff syndrome.
C. Lorazepam (Ativan) is given to prevent the onset or progression of signs and symptoms associated with alcohol withdrawal.
D. Hypomagnesaemia may occur in chronic alcoholism; therefore, magnesium can be given to supplement the patient. Magnesium is also the drug of choice in the presence of torsades de pointes.
Category: Medical Emergencies, Withdrawal syndrome
Question 84
A patient who presents with emergency medical services personnel is unresponsive to stimuli; has pale, cool, dry skin; and has bilateral pupil constriction. No signs of injury are observed. Vital signs are BP 84/58 mm Hg, HR 52 beats/minute, RR 6 breaths/minute, SpO 88%, and T 35.4°C (95.7°F). Which of 2 the following is the highest-priority intervention for this patient?
Administer 0.4 to 2 mg of naloxone (Narcan) intravenously
Obtain a serum glucose level
Open the airway and provide bag-mask device respirations
✓
Initiate intravenous access and begin an infusion of normal saline
Correct Answer
Open the airway and provide bag-mask device respirations
A. The patient has classic signs of opioid overdose. The highest priority for this patient is to address respiratory depression. The patient’s vital signs display bradypnea with a decreased oxygen saturation and bradycardia.
B. This is an appropriate intervention for this patient but would not take priority over airway management and resuscitation.
C. It is likely that this patient is experiencing a drug overdose, and naloxone would be an appropriate early intervention. However, resuscitation (with a bag-mask ventilation) takes priority over the administration of naloxone.
D. Inserting an IV line to administer normal saline is an appropriate intervention, but securing a patent airway and assisting with ventilation is the priority intervention for this patient.
Category: Medical Emergencies, Substance use and abuse (e.g., alcohol and drug
Question 85
Which of the following signs and symptoms is associated with an overdose of oxycodone (Oxycontin)?
Dilated pupils
Hypertension
Bradycardia
✓
Tachypnea
Correct Answer
Bradycardia
A. Patients with opioid overdoses can present with pinpoint pupils, not dilated pupils.
B. Bradycardia can be seen in opioid overdoses, along with hypotension, bradypnea, and a decrease in temperature or hypothermia.
C. Hypotension is an expected sign of opioid overdoses.
D. Slow respirations, or bradypnea, and apnea can occur in the presence of opioid overdoses.
Category: Mental Health Emergencies, Intentional overdose and ingestions
Question 86
A child arrives by emergency medical services, who report that the patient was tackled while playing football and is now complaining of difficulty breathing. Patient assessment reveals swelling and ecchymosis of the neck, subcutaneous emphysema, inspiratory stridor, and a hoarse voice. The nurse anticipates this patient has sustained a:
fractured larynx.
✓
pulmonary contusion.
cardiac tamponade.
tension pneumothorax.
Correct Answer
fractured larynx.
A. Cardiac tamponade is characterized by hypotension, muffled heart sounds, and distended neck veins, also referred to as Beck’s triad. This patient’s assessment findings are not specific to the presence of cardiac tamponade.
B. Common symptoms associated with a tension pneumothorax are anxiety, respiratory distress, distended neck veins, and very diminished or absent breath sounds on the affected side. The patient’s assessment findings are not consistent with tension pneumothorax.
C. Blunt-force trauma to the neck may cause the larynx to fracture. Presenting symptoms such as hoarseness, stridor, and subcutaneous emphysema may progress to the inability of the patient to maintain an adequate airway. This patient’s assessment findings are consistent with blunt-force neck trauma.
D. Although a pulmonary contusion may result in dyspnea and may require airway intervention, the patient’s assessment findings are more consistent with the presence of blunt-force neck trauma.
Category: Maxillofacial and Ocular Emergencies, Maxillofacial, Maxillofacial trauma
Question 87
A patient arrives with cervical spine precautions following an all-terrain vehicle collision. Initial assessment reveals the presence of rhinorrhea and otorrhea, which tests positive for the presence of glucose. The nurse anticipates that the patient has sustained which type of fracture?
Depressed skull fracture
Le Fort I fracture
Mandibular fracture
Cribriform plate fracture
✓
Correct Answer
Cribriform plate fracture
A. A depressed skull fracture extends through the skull, with pieces of bone depressed toward the brain. Leakage of cerebral spinal fluid is found in basilar skull fractures or fractures of the ethmoid bone, which includes the cribriform plate.
B. A Le Fort I fracture is a transverse maxillary fracture characterized by independent movement of the maxilla from the face. Swelling and malocclusion are also common findings. Leakage of cerebral spinal fluid is not a common finding with a Le Fort I fracture.
C. The mandible is the lower portion of the jaw. A fracture of the mandible is identified by the inability of the patient to open their mouth, also referred to as trismus, and malocclusion of the teeth. Leakage of cerebral spinal fluid does not occur with a mandible fracture.
D. Fracture of the cribriform plate, part of the ethmoid bone, results in leakage of cerebral spinal fluid (CSF) from the nose and/or ears. CSF will test positive for glucose and produce a halo effect, described as an appearance of rings when the CSF is placed on white paper.
Category: Maxillofacial and Ocular Emergencies, Maxillofacial, Maxillofacial trauma
Question 88
A patient presents to triage with epistaxis (nosebleed). The patient is coughing and spitting blood into a towel. The patient informs the nurse that they are currently taking warfarin (Coumadin). The priority intervention for this patient is to:
perform oropharyngeal suction.
✓
apply direct pressure to the patient’s nostrils.
administer vitamin K (phytonadione).
provide supplemental oxygen.
Correct Answer
perform oropharyngeal suction.
A. Coughing and spitting out blood can compromise the airway; immediate intervention with suctioning is required to prevent aspiration.
B. It is unknown if the patient has an elevated international normalized ratio or even if the patient’s warfarin level is within therapeutic range. Although the administration of vitamin K may be needed, it is not the priority intervention.
C. There is no report of breathing difficulty or abnormalities. Maintaining a patent airway is the initial priority, followed by performing the patient’s breathing assessment.
D. Applying direct pressure to the patient’s nostrils is indicated and should be applied to the bridge of the nose; however, clearing the patient’s airway is the priority intervention.
Category: Maxillofacial and Ocular Emergencies, Maxillofacial, Epistaxis
Question 89
A patient presents to triage with a tooth in their hand after an altercation approximately 4 hours ago. Which action by the nurse indicates the need for reeducation?
Inspect and irrigate the dental socket with normal saline
Assess for further facial and cervical spine injury
Attempt to reimplant the tooth into the dental socket
✓
Place the tooth in milk or Save-A-Tooth solution
Correct Answer
Attempt to reimplant the tooth into the dental socket
A. Implantation of the tooth into the socket within 30 minutes of it being removed from the dental socket will increase the likelihood of healing and successful reimplantation. However, after 60 minutes, the dental tissue and ligaments that hold the tooth in the dental socket begin to die, limiting the chance of a successful implantation.
B. Irrigation with normal saline will clean the socket.
C. An avulsed tooth should be handled by the crown to avoid any damage to the periodontal ligaments and can be placed in milk or Save-A-Tooth solution. Neither action will improve the chances of successful implanting of the tooth but may act to reassure the patient.
D. The patient should be examined for potential further injury from the altercation.
Category: Maxillofacial and Ocular Emergencies, Maxillofacial, Abscess (i.e.,
Question 90
The nurse is discharging a patient who had a facial laceration sutured. The patient’s accurate understanding of the discharge instructions is indicated when they state:
“I will return in 3–5 days to have the sutures removed.”
✓
“I will return in 10–14 days to have the sutures removed.”
“I will return in 6–7 days to have the sutures removed.”
“I will return in 7–10 days to have the sutures removed.”
Correct Answer
“I will return in 3–5 days to have the sutures removed.”
A. Facial sutures should be removed 3–5 days after they are first placed.
B. Sutures that are placed in the scalp should be removed 6–7 days after they are first placed.
C. Sutures that have been placed over an articulating joint should be removed 10–14 days after they are first placed.
D. Sutures that are not placed on the face, on the scalp, or over an articulating joint should be removed in 7–10 days.
Category: Musculoskeletal and Wound Emergencies, Wound, Lacerations
Question 91
During the alcohol screening of a patient, the nurse determines that the patient drinks 6–8 alcoholic drinks every day. How long after the last drink of alcohol would the nurse expect the patient to begin demonstrating early signs and symptoms of acute alcohol withdrawal?
12–72 hours
2–3 hours
4–5 hours
6–8 hours
✓
Correct Answer
6–8 hours
A. Signs and symptoms of alcohol withdrawal do not usually present until 6 hours after the last drink was consumed.
B. Signs and symptoms of alcohol withdrawal do not usually present until 6 hours after the last drink was consumed.
C. Early signs and symptoms of alcohol withdrawal often present in the first 6–8 hours after the last drink was consumed.
D. The most serious signs and symptoms of alcohol withdrawal often occur 12–72 hours after the last intake of alcohol; however, early signs and symptoms may be present at 6–8 hours following consumption of the last drink.
Category: Medical Emergencies, Withdrawal syndrome
Question 92
Which of the following interventions would the nurse anticipate in the care of a patient with an avulsion wound to the scalp?
Trim wound edges that are gray or dusky in appearance
Application of a wet-to-dry dressing
Cleaning and debridement of the devitalized tissue
✓
Prepare for suturing by local injection of lidocaine with epinephrine
Correct Answer
Cleaning and debridement of the devitalized tissue
A. Skin edges of the avulsed segment should be approximated and should not be trimmed.
B. Lidocaine with epinephrine is contraindicated in the care of avulsed skin because of the vasoconstriction action of epinephrine, which would result in decreased blood supply to the avulsed fragment.
C. Avulsion injuries are at risk for wound infection, so cleansing, irrigation, and debridement are appropriate treatments.
D. A sterile saline-soaked dressing may be applied after hemostasis and infection control are initiated.
Category: Musculoskeletal and Wound Emergencies, Wound, Avulsions and
Question 93
Which of the following most accurately describes a grade II ankle sprain?
Partial tear of the ligament with stability of the ankle joint
✓
Rupture of the muscle or tendon with an unstable joint
Remarkable tear of the ligament with an unstable joint
Partial tear of the tendon or muscle with stability of the ankle joint
Correct Answer
Partial tear of the ligament with stability of the ankle joint
A. Sprains involve injury to a ligament, not a tendon or muscle. A strain involves injury to a tendon or muscle and, like a sprain, has three grades. A grade I strain involves stretching of muscle fibers, a grade II strain involves partial tearing of the tendon or muscle, and a grade III strain is notable for rupture of the tendon or muscle.
B. A sprain involves injury to the ligaments. A grade I sprain has minimal damage to the ligament and a stable joint. A grade II sprain has partial tearing of the ligament and a stable joint. A grade III sprain has remarkable tearing to the ligament and an unstable joint.
C. A grade III sprain involves remarkable tearing of the ligament and an unstable joint.
D. Sprains involve injury to a ligament, not a tendon or muscle. A grade III strain is notable for rupture of the tendon or muscle.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Ligament
Question 94
Complete blood count (CBC) and erythrocyte sedimentation rate (ESR) are ordered for a patient with swelling, tenderness, redness, and pain in the small joints of fingers on both hands. Which rationale validates the order for ESR?
Definitive diagnosis of the presence of rheumatoid arthritis
Predictor for the severity of sepsis
Indicator of tissue damage within the body
Indicator of a nonspecific inflammatory process
✓
Correct Answer
Indicator of a nonspecific inflammatory process
A. ESR is not used as a measurement of severity of any disease. More appropriate laboratory tests, such as a serum lactate level, should be used when sepsis is suspected.
B. ESR is not diagnostic of any diseases but may be used to support a diagnosis. If the ESR results are elevated (positive for inflammation, infection, neoplasm, or necrosis), other tests will need to be run to determine if this patient has rheumatoid arthritis.
C. ESR is a nonspecific test that detects inflammation, infection, neoplasms, or necrosis. It can be used if the patient is complaining of vague symptoms or to support a suspected diagnosis; however, it is not diagnostic for a specific disease process or disorder.
D. ESR does not indicate the degree of tissue damage that has occurred within the body. ESR is used as a nonspecific marker to determine whether inflammation, infection, neoplasm, or necrosis is present.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Inflammatory
Question 95
An elderly patient presents with complaints of stiff knees every morning, joint pain with movement, and swelling for the past several months. Which condition best reflects the symptoms?
Osteoporosis
Osteomalacia
Osteoarthritis
✓
Osteomyelitis
Correct Answer
Osteoarthritis
A. Osteoporosis results from inadequate production of bone, excessive removal of bone, or a combination of both, resulting in thin bones. Populations at risk include postmenopausal women, persons who take steroids, and persons who use alcohol.
B. Also known as degenerative joint disease, osteoarthritis is the most common joint disease and results in the degeneration of the articular cartilage in joints. Patients will experience joint stiffness, pain with movement, and occasional swelling of the joint. Osteoarthritis occurs more commonly in men before age 45 and more commonly in women after age 45.
C. Osteomyelitis is an inflammatory disorder of bone caused by the presence of an infection. It can lead to necrosis and destruction of the bone, often resulting in amputation.
D. Osteomalacia is characterized by softening of the bone caused by poor mineral content, leading to a marked deformity of weight-bearing bones, distortion of the bone structure, and possible pathologic fractures. Osteomalacia, which is caused by inadequate intake of vitamin D, is often referred to as adult rickets.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Inflammatory
Question 96
A patient is referred for care from an urgent care center for possible costochondritis. On patient assessment, the nurse anticipates which of the findings for a patient being evaluated for costochondritis?
Tenderness of the midsternal area
✓
Muffled heart sounds
Atelectasis on chest radiograph film
The presence of ectopy on electrocardiogram
Correct Answer
Tenderness of the midsternal area
A. Ectopy on electrocardiogram is not an assessment finding that is associated with the presence of costochondritis.
B. Atelectasis is the complete or partial collapse of a lung. The patient may experience pain with deep inspiration, yet palpation over the area of lung collapse will not result in reproducing pain.
C. Muffled heart sounds are an assessment finding in patients who are experiencing pericardial tamponade, not costochondritis.
D. Costochondritis is an acute, self-limiting inflammation of the costal cartilage of the rib and sternal junctions. Inflammation may result from physical exertion or repetitive movements. Palpation to the area, deep inspiration, cough, and some movements result in reproducible pain (point tenderness to palpation of chest wall).
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Inflammatory
Question 97
Which Emergency Severity Index classification level will be designated for a patient with an isolated complaint of suicidal ideation and no medical health problems?
Level 5: no resources
Level 3: many resources
Level 2: high risk
✓
Level 1: immediate lifesaving interventions
Correct Answer
Level 2: high risk
A. The level 1 designation is reserved for those who are unstable and need immediate lifesaving interventions. The patient is high risk and should be evaluated immediately but does not require lifesaving interventions at this time.
B. The patient is high risk and should be evaluated immediately. The patient will require resources such as a psychiatric consult and diagnostic testing (serum blood test, urine test, etc.).
C. The patient with suicidal ideation is considered high risk and should be evaluated immediately. Designating this patient as a level 3 is a common example of undertriage and not considering the possible patient safety risk.
D. Resources such as a psychiatric consult and diagnostic testing (serum blood test, urine test) will be required.
Category: Mental Health Emergencies, Homicidal and suicidal ideation
Question 98
Which of the following instructions does the nurse provide to the patient being discharged after treatment for muscle spasms from acute lumbosacral strain?
Twist gently from side to side to maintain range of motion in the spine
Lying flat, place a small pillow under the upper back to flex the lumbar spine gently
Keep the head elevated slightly and flex the knees when resting in bed
✓
Avoid the use of ice because it will exacerbate the muscle spasms
Correct Answer
Keep the head elevated slightly and flex the knees when resting in bed
A. Twisting from side to side will increase tension and pain in the lumbar–sacral area. Rest alternating with moderate activity will help to alleviate muscle spasms.
B. Resting with the head elevated and knees flexed will reduce the strain on the back and decrease muscle spasms. The knees should be flexed to prevent pressure on the muscles of the lower back and support structures of the spine.
C. A pillow placed under the upper back will cause strain and pain in the lumbar spine. The prone position places more strain on the back and therefore should be avoided. Pelvic tilt from knee flexion will help to alleviate tension on the lower back.
D. Alternate application of cold and heat should be used to decrease low back pain and muscle spasms.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Inflammatory
Question 99
Which disease process is most commonly associated with a patient developing disseminated intravascular coagulation (DIC)?
Sepsis
✓
Intracerebral hemorrhage
Cardiac tamponade
Renal failure
Correct Answer
Sepsis
A. Cardiac tamponade may result from the clotting problems that DIC causes, but cardiac tamponade is not a cause of DIC.
B. Renal failure may result from a patient having DIC but is generally not a cause of DIC.
C. Intracerebral hematoma leading to hemorrhage may result from the clotting problems that DIC causes, but intracerebral hematoma is not a cause of DIC.
D. Patients who develop sepsis have a 30–50% chance of developing DIC.
Category: Medical Emergencies, Hematologic disorders
Question 100
What is the highest-priority intervention for a patient with a flat affect and despondency following the recent loss of their job and significant other?
Inform the patient about possible grief counseling groups
Refer the patient to a psychiatrist
Assess whether the patient plans to harm themself
✓
Assist the patient with resources to find a new job
Correct Answer
Assess whether the patient plans to harm themself
A. Grief counseling may assist the patient with their loss-related depression, but securing their immediate safety and security is the most important intervention.
B. Ensuring the patient’s safety and security is the highest priority and the most important aspect in the initial phases of care of the acutely depressed patient. Ensure that the patient’s immediate environment is safe from objects that they could potentially harm themself with and that the patient feels safe and secure in the emergency department setting.
C. This patient will require evaluation by a mental health provider after their immediate safety care needs have been met.
D. Referral to a social worker may be indicated to assist with the patient’s immediate social care needs, but this is not the highest priority during this phase of care.
Category: Mental Health Emergencies, Situational crisis (e.g., terminal diagnosis,
Question 101
The patient is asked to demonstrate crutch walking after receiving instructions for discharge. Which of the following actions by the patient would indicate understanding of the proper use of the crutches?
The crutches are placed approximately 3 inches from either side of the patient.
The patient’s elbows remain at a 90-degree angle when using the handgrips.
The patient’s elbows are slightly bent when using the handgrips.
✓
The crutches are placed close to the body on either side of the patient.
Correct Answer
The patient’s elbows are slightly bent when using the handgrips.
A. Handles that cause the patient to have elbows at 90 degrees are not measured properly. Elbows bent to a 90-degree angle place the handles too close to the axilla and cause the patient to lean forward, resulting in unequal weight distribution.
B. The crutches should be about 1.5 inches below the patient’s axilla on either side, which allows for a slight bending of the elbow when using the handgrips. The hand grips are used only to absorb the patient’s weight.
C. Crutches should be placed at approximately 6 inches to the front and side of the patient, which allows for proper body mechanics and weight distribution.
D. Crutches should be placed at approximately 6 inches to the front and side of the patient, which allows for proper body mechanics and weight distribution. Crutches placed too close to the body result in difficulty distributing weight across the devices.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Fractures
Question 102
A child presents with a suspected “nursemaid’s elbow.” Which terminology accurately describes the symptoms of this type of injury?
Radial head subluxation
✓
Olecranon fracture
Radial head fracture
Olecranon dislocation
Correct Answer
Radial head subluxation
A. A subluxation is a partial or incomplete dislocation. Nursemaid’s elbow is defined as the subluxation of the radial head. This injury results from a pulling action that places traction while the child’s arm is in full extension. Children between the ages of 2 and 3 years are the most susceptible to this type of injury.
B. Radial head fracture is not associated with this type of injury.
C. An olecranon fracture occurs in the bony prominence of the elbow.
D. Olecranon dislocation is a complete dislocation of the elbow.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Fractures
Question 103
Which assessment finding would the nurse anticipate with a patient who sustained a hip fracture after falling out of a wheelchair?
Ligamentous instability in the lower leg
Misalignment of the extremity
✓
Cool extremity
Absence of pedal pulses
Correct Answer
Misalignment of the extremity
A. Absence of pedal pulses is a very late sign of vascular compromise, as seen in late-stage compartment syndrome.
B. Ligamentous instability (which requires disruption of structures), inability to straighten the leg, and peroneal nerve and popliteal artery injury are the most common in injuries of the knee.
C. Clinical findings of a fractured hip include hip flexed, adducted, internally rotated, and shortened. These findings result in a misalignment of the extremity. The patient may also have an associated fracture of the femoral head and the presence of a sciatic nerve injury.
D. An extremity that is cool to touch is a late sign of a decreased perfusion. If perfusion is not restored, permanent dysfunction of the extremity can occur.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Fractures
Question 104
A patient presents with severe pain in the left forearm after being found unresponsive lying on the floor for an unknown period. Assessment findings reveal swelling, taut skin that is cool to touch, inability to rotate the left upper extremity, and left radial pulse that is weaker than the right. Which of the following conditions would describe the signs and symptoms of the patient?
Ecchymosis
Upper extremity fracture
Compartment syndrome
✓
Rhabdomyolysis
Correct Answer
Compartment syndrome
A. Ecchymosis is a discoloration of skin caused by blood vessel rupture leading to bleeding into the subcutaneous tissue.
B. Fracture occurs from excessive force placed against a bone from an outside source or from a repetitive motion injury. Signs and symptoms of a fracture include pain and swelling over the affected area. Compartment syndrome can occur as a complication of a fracture.
C. Rhabdomyolysis results when significant muscle damage has occurred, and myoglobin has been released into the bloodstream. The patient is at risk for renal failure due to myoglobin clogging the renal tubules, leading to acute renal injury. Compartment syndrome may lead to rhabdomyolysis as a result of excessive force or pressure being exercised against the compartment; muscle damage and the release of myoglobin into the bloodstream follow.
D. Increased pressure within the fascial compartment can be caused by an internal hemorrhage or external event (i.e., crush injury). Lying on the limb for an extended period can result in compartment syndrome, and this has been associated with a drug overdose. Classic signs and symptoms of compartment syndrome include pallor, paresthesia, pulselessness, paralysis, pain, and pressure. Additionally, the extremity can be cool to touch.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Compartment
Question 105
Which of the following outcomes does the nurse expect from the administration of intravenous immunoglobulin to a child recently diagnosed with idiopathic thrombocytopenic purpura (ITP)?
Increase in the prothrombin time and partial prothrombin time levels
Rapid increase in platelet count
✓
Resolution of the infection that caused ITP
Increase in white blood cell count
Correct Answer
Rapid increase in platelet count
A. IVIG is not given to treat the infection but has been found to increase platelet count in the patient with ITP.
B. Prothrombin time and partial prothrombin time levels usually remain constant in the presence of thrombocytopenia. IVIG administration for ITP is given to increase the patient’s platelet count.
C. ITP is a decrease in platelet count (< 150,000) that may occur as a result of a recent viral illness, or it can be associated with vaccinations. ITP results in petechial rash and ecchymosis. ITP is usually self-limiting, but some patients have a more severe response requiring immunoglobulin, corticosteroids, and possibly splenectomy.
D. White blood cell count may be elevated because of the presence of an infection; however, IVIG for ITP is given to increase the patient’s platelet count.
Category: Medical Emergencies, Hematologic disorders
Question 106
Which of the following hemophiliac patients would have the highest priority for care?
Patient with a headache following a fall
✓
Patient with severe swelling into the knee joint following a fall
Patient who presents with epistaxis (nosebleed)
Patient with bleeding gums following a tooth extraction
Correct Answer
Patient with a headache following a fall
A. A patient with hemophilia may have prolonged bleeding following a tooth extraction, but this may not be life-threatening. The patient should be instructed to bite down on gauze to minimize and control the bleeding.
B. The presence of a prolonged nosebleed may be serious in a patient with hemophilia. The prolonged bleeding is related to decreased factor VIII. Direct pressure to the area of bleeding via nose-packing may be required to stop the bleeding.
C. Severe swelling into joints with decreased movement of the joint can be common after an injury to the joint space. Elevation of the extremity, immobilization, application of ice, and compression dressing will assist in decreasing swelling and bleeding into the joint.
D. A headache or a change in mental status following a fall would have the highest priority for care because of the risk for the presence of an intracranial bleed. This patient would require an emergent computed tomography scan. The presence of an intracranial bleed is often the cause of death in patients with hemophilia.
Category: Medical Emergencies, Hematologic disorders
Question 107
A patient with a history of leukemia presents with multiple bruises on the extremities and increasing dyspnea over the past several days. Which of the following is the most likely cause of the patient’s bruising?
Malignant cells within the dermis
Generalized lymphadenopathy
Thrombocytopenia
✓
Immaturity of white blood cells
Correct Answer
Thrombocytopenia
A. Lymphadenopathy in leukemia is caused by infiltration of cancerous blood cells. It is not directly related to the appearance of bruising.
B. Proliferation of immature white blood cells is the pathophysiology of leukemia and results in increased vulnerability to infection.
C. Decreased number of thrombocytes, or platelets, is a result of bone marrow depression. Without adequate platelets to activate the clotting cascade, petechiae, ecchymoses, and gingival bleeding may be present.
D. Leukemia is a malignant neoplasm arising from hematopoietic stem cells. Typically, malignant cells do not deposit within the dermis.
Category: Medical Emergencies, Hematologic disorders
Question 108
Which of the following discharge instructions is most appropriate for the patient treated with sickle cell vaso-occlusive crisis?
“Apply ice to the painful, swollen areas to reduce swelling and discomfort.”
“Apply moist heat to the sore areas to reduce swelling and pain.”
✓
“Decrease your fluid intake until you are feeling better.”
“Be sure to exercise vigorously.”
Correct Answer
“Apply moist heat to the sore areas to reduce swelling and pain.”
A. Strenuous exercise could trigger a sickle cell vaso-occlusive crisis.
B. The application of ice to an area of pain in treatment for sickle cell disease can worsen the patient’s pain. In sickle cell disease, red blood cells (RBCs) contain abnormal hemoglobin (HbS) that precipitates into long crystals, causing RBCs to assume a sickle shape when exposed to cold temperatures, low oxygen levels, dehydration, infection, or strenuous exercise.
C. The application of heat to areas of soreness assists in reducing swelling and pain, symptoms associated with sickle cell disease and vaso-occlusive crisis. Heat promotes vasodilation, decreasing the painful vascular occlusion caused by clumps of sickled cells.
D. Patients should be encouraged to maintain adequate hydration to avoid dehydration, which may trigger a sickle cell vaso-occlusive crisis.
Category: Medical Emergencies, Hematologic disorders
Question 109
After application of topical lidocaine, epinephrine, and tetracaine (LET) gel, the nurse is aware that the patient is ready for wound closure when:
the patient is drowsy.
blanching is observed around the wound.
✓
10 minutes has passed.
redness is observed around the wound.
Correct Answer
blanching is observed around the wound.
A. LET gel has vasoconstrictive properties and results in a blanching effect of the skin, not redness.
B. LET gel should be applied for at least 15–20 minutes before wound closure to allow for adequate anesthesia of the area.
C. LET gel has vasoconstrictive properties that result in a blanching effect of the skin, usually within 20 minutes of application. The absence of blanching indicates that there is incomplete anesthesia of the area.
D. Topical LET gel will not cause a patient to become sleepy.
Category: Musculoskeletal and Wound Emergencies, Wound, Lacerations
Question 110
A patient who has repeatedly been placed on BiPAP develops a deep open wound across the bridge of the nose from the mask. The nurse documents this wound as a(n):
stage 1 pressure injury.
unstageable pressure injury.
stage 2 pressure injury.
stage 4 pressure injury.
✓
Correct Answer
stage 4 pressure injury.
A. A stage 1 pressure ulcer is defined as intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from that of the surrounding area.
B. A stage 2 pressure ulcer is defined as partial-thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough; it may also present as an intact or open/ruptured serum-filled blister.
C. Stage 4 pressure injury is defined as full-thickness tissue loss with exposed bone, tendon, or muscle. The bridge of the nose lacks subcutaneous tissue.
D. An unstageable pressure injury is defined as the loss of full-thickness skin and tissue, and the extent of the tissue damage cannot be determined because the area is obscured by the presence of eschar or sloughing tissue.
Category: Musculoskeletal and Wound Emergencies, Wound, Wound bleeding (e.g.,
Question 111
A geriatric patient was found lying on the floor at home for the past 6 hours after a fall. The nurse suspects the patient has rhabdomyolysis based on which classic finding?
Pain out of proportion to the injury
A petechial chest rash
Shortness of breath at rest
Tea- or cola-colored urine
✓
Correct Answer
Tea- or cola-colored urine
A. Pain out of proportion to the injury is indicative of compartment syndrome.
B. Petechial rash found over the chest, axillae, and conjunctiva is an assessment finding of fat emboli syndrome.
C. Significant muscle damage and cellular destruction release myoglobin, a muscle protein, into the bloodstream. Because myoglobin is excreted in the kidneys, the risk of acute renal failure is high. Classic assessment findings include dark red or brown urine, muscle pain, and weakness. Other symptoms include numbness or changes in sensation.
D. Shortness of breath at rest is not an assessment finding consistent with rhabdomyolysis.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Ligament
Question 112
A patient presents with a mammal bite to the hand. What is the nurse’s priority assessment?
Source of the bite
Presence of active bleeding or exudate
✓
Time the bite occurred
Size and depth of the wound
Correct Answer
Presence of active bleeding or exudate
A. Determining the source of the bite is important because certain animals carry rabies and prophylaxis may be needed, but it is not the priority.
B. Active bleeding must be controlled before moving on to other assessments and intervention. The presence of exudate may indicate a wound infection.
C. The timing of an injury is important to determine wound closure options. Canine bites are rarely closed because of the risk of infection.
D. Identifying the size and depth of the wound is important for further management, but identifying and then controlling active bleeding takes priority.
Category: Environment and Toxicology Emergencies, and Communicable
Question 113
Which of the following pathophysiologic responses is associated with the catecholamine release that occurs during a hypoglycemic episode?
Pupillary constriction
Diaphoresis
✓
Dry skin
Abdominal cramping
Correct Answer
Diaphoresis
A. The release of epinephrine during an episode of hypoglycemia can cause diaphoresis, anxiety, dry mouth, mydriasis (papillary dilation), and tremors. The release of epinephrine can also interfere with how the body uses the glucose that is present for the duration of these episodes.
B. The release of epinephrine is part of the “fight or flight” response, which is part of the sympathetic nervous system. Mydriasis, or pupillary dilation, is part of the sympathetic response. Pupillary constriction is a parasympathetic response.
C. Although dry mouth can be part of the process of hypoglycemia, patients tend to experience diaphoresis, not dry skin, during a hypoglycemic event.
D. Hunger can be one of the autonomic responses when patients become hypoglycemic; however, abdominal cramping would most likely be associated with the parasympathetic response in an individual.
Category: Medical Emergencies, Endocrine disorders
Question 114
A patient in diabetic ketoacidosis (DKA) has the following laboratory values: blood glucose 525 mg/dL; arterial pH 7.30; serum potassium 4.8 mEq/L; elevated blood urea nitrogen (BUN), creatinine (Cr), and hematocrit (HCT). The nurse recognizes that which of the following is the most appropriate order?
A. The BUN and Cr levels are elevated, which is consistent with dehydration that occurs in DKA as a result of osmotic diuresis. Administering a diuretic would further facilitate diuresis and is therefore contraindicated.
B. The routine use of sodium bicarbonate bolus is discouraged because it can cause a rapid alkalosis to occur. As the serum glucose is lowered with treatment, the pH will return to normal.
C. The potassium level is at the high end of normal. Providing a dose of intravenous IV potassium at this time could be dangerous. The potassium level will decrease as serum glucose levels return to normal with the administration of fluids and insulin. Potassium replacements may be indicated at that time via maintenance dosing, as opposed to bolus infusion.
D. For patients in DKA, an IV bolus followed by an insulin drip at 0.1 unit/kg/hour will be administered. Only regular insulin should be used for IV infusion.
Category: Medical Emergencies, Endocrine disorders
Question 115
A patient presents with palpitations, agitation, high fever, hot, dry skin, and exophthalmos. Vital signs are BP 172/48 mm Hg, HR 174 beats/minute, RR 24 breaths/minute, T 40.1°C (104.3°F). The nurse recognizes that the patient is experiencing:
thyroid storm/hyperthyroid crisis.
✓
acute adrenal insufficiency.
hypothyroid coma or myxedema coma.
syndrome of inappropriate antidiuretic hormone secretion.
Correct Answer
thyroid storm/hyperthyroid crisis.
A. Signs and symptoms of syndrome of inappropriate antidiuretic hormone secretion include headache, fatigue, confusion with decreased level of consciousness, nausea, vomiting, and weight gain without peripheral edema.
B. Hypothyroid coma, or myxedema coma, is characterized by signs of decreased metabolism that include bradycardia, bradypnea, hypothermia, cool pale skin, and altered level of consciousness.
C. Acute adrenal insufficiency, or adrenal crisis, is a rare, life-threatening condition characterized by depletion of adrenal glucocorticoids. It occurs as a complication of Addison’s disease or when there is an abrupt cessation of corticosteroids. Patients may present with tachycardia at rest, orthostatic hypotension, and signs of severe dehydration. The classic presentation involves peaked T-waves secondary to severe hyperkalemia as a result of aldosterone deficiency.
D. Thyroid storm, or hyperthyroid crisis, is a life-threatening complication of hyperthyroidism and is due to a rapid rise in thyroid hormone. The result is severe tachycardia and tachypnea, hypertension with wide pulse pressure, extreme agitation, and short attention span.
Category: Medical Emergencies, Endocrine disorders
Question 116
Which of the following life-threatening conditions is caused by a decrease in both cortisol and aldosterone levels?
Myxedema coma
Diabetes insipidus
Cushing’s syndrome
Adrenal crisis
✓
Correct Answer
Adrenal crisis
A. Cushing’s syndrome is the result of a prolonged exposure to glucocorticoids (either endogenous or exogenous), causing the patient to develop a Cushingoid appearance. There is an increased amount of adipose tissue to the face, upper back, and base of the neck.
B. Diabetes insipidus is a life-threatening condition resulting from insufficient antidiuretic hormone (ADH) release from the posterior pituitary gland. The patient will excrete large amounts of dilute urine and complain of fatigue and weight loss. Treatment is fluid replacement and ADH replacement with medications such as desmopressin acetate (DDAVP).
C. Myxedema coma is a rare, life-threatening complication of hypothyroidism that affects older patients with pulmonary or vascular disease. Patients complain of fatigue, shortness of breath, and weight gain and may experience tongue swelling. Treatment includes support of the patient’s airway, breathing, and circulation (ABCs), as well as thyroid hormone replacement.
D. Adrenal crisis, also known as acute adrenal insufficiency, is a life-threatening condition caused by a decrease in cortisol and aldosterone levels. This results in sodium and water loss from the kidneys and gastrointestinal tract, leading to hypovolemia and hypotension. Hyperkalemia results from hyponatremia and can lead to fatal dysrhythmias. Treatment includes fluid replacement, correction of hyperkalemia, and hydrocortisone administration.
Category: Medical Emergencies, Endocrine disorders
Question 117
A patient who sustained multiple bee stings complains of chest pains, lightheadedness, and difficulty breathing. Prior medical history includes hypertension and “heart problems.” Vital signs are BP 70/40 mm Hg, HR 122 beats/minute, RR 24 breaths/minute, SpO 88%, and T 37.7°C (100.0°F). Which 2 intervention is the highest priority for the nurse to initiate?
Obtain intravenous access
Obtain a 12-lead electrocardiogram
Administer epinephrine
Apply high-flow oxygen via nonrebreather face mask
✓
Correct Answer
Apply high-flow oxygen via nonrebreather face mask
A. Obtaining an electrocardiogram is indicated to rule acute myocardial infarction secondary to the bee sting, also known as Kounis syndrome, but the first priority is oxygenation. Kounis syndrome is characterized by the concurrence of acute coronary syndrome and a mast cell degranulation induced by allergic or hypersensitivity reactions.
B. Epinephrine administration is a high-priority intervention in treatment of anaphylaxis. However, airway and breathing should be the first priority of care.
C. The patient is experiencing an anaphylactic reaction to a bee sting. Initial management includes securing and maintaining airway patency and adequate oxygenation. The patient’s SpO should be kept greater than 90%. 2
D. Obtaining intravenous access for medication administration is important; however, securing and maintaining airway patency and adequate oxygenation is the highest priority.
Category: Medical Emergencies, Allergic reactions and anaphylaxis
Question 118
A patient who recently started treatment for an ear infection presents with a red rash to the face, chest, and back. The nurse suspects that the cause of the rash is:
shingles (herpes zoster).
an allergic reaction.
✓
impetigo.
scabies.
Correct Answer
an allergic reaction.
A. A rash may occur as a side effect or as an allergic reaction to antibiotics used for the treatment of the ear infection. The rash usually starts within the first week of taking a new medication. It often starts as red spots that spread and merge, eventually covering large areas of the body. If the drug is stopped, the rash will typically clear within a few days or weeks.
B. Impetigo is a bacterial infection caused by either a Streptococcus or a Staphylococcus infection. It manifests as discrete pustules that crust into honey-colored lesions. Impetigo is highly contagious and requires either topical or systemic antibiotic treatment.
C. Scabies is due to infestation of mites under the surface of the skin and results in pruritic erythematous papules, vesicles, and crusted pinpoint lesions. The rash is often located in the creases of the skin.
D. Shingles is a viral infection that manifests with erythematous vesicles along the sensory nerve ganglia, most commonly along the ribs. The vesicles will rupture and then crust. The patient will complain of severe itching, burning, tingling, or pain until the lesions have healed completely.
Category: Medical Emergencies, Allergic reactions and anaphylaxis
Question 119
A patient with a history of depression and bipolar disorder presents with suicidal ideation and auditory hallucinations. The patient becomes increasingly agitated, is pacing, and threatens staff members. The nurse actively listens and speaks in clear, concise language while ensuring the patient’s safety. Which of the following demonstrates a desired response to the interventions?
The patient states that they do not need to be in restraints any longer.
The patient is able to verbalize their feelings.
✓
The patient’s suicidal ideation has ceased.
The patient accepts their medication.
Correct Answer
The patient is able to verbalize their feelings.
A. Restraints indicate that the patient did not respond to the verbal interventions attempted by the nurse initially.
B. An appropriate response to establishing rapport by active listening and speaking in clear and concise sentences is the patient being able to verbalize their feelings.
C. Medication may have had to be administered, but an initial appropriate response to therapeutic communication is that the patient can communicate back to the nurse.
D. Resolution of suicidal ideation is a desired response to treatment, but an initial response to therapeutic communication is that the patient is able to communicate back to the nurse. Restraint may be appropriate for a physically assaultive patient, but it is not the most therapeutic action while the patient is escalating.
Category: Mental Health Emergencies, Mood disorders (e.g., bipolar, depression)
Question 120
A patient with renal failure presents with abdominal cramping, diarrhea, and a potassium level of 6.8 mEq/L. Tall, peaked T-waves are noted on the electrocardiogram. Priority interventions, in addition to cardiac monitoring, include the administration of:
0.9% sodium chloride IV bolus.
intravenous (IV) dextrose solution followed by regular insulin.
✓
sodium polystyrene (Kayexalate) via nasogastric tube.
a potassium-sparing diuretic, such as spironolactone.
Correct Answer
intravenous (IV) dextrose solution followed by regular insulin.
A. This therapy is a temporary measure to correct hyperkalemia. Insulin facilitates the transport of glucose and potassium back into cells. Other measures may be implemented, such as administration of sodium polystyrene or hemodialysis to lower the patient’s potassium level.
B. Although sodium polystyrene might be part of the treatment regimen in the presence of hyperkalemia, it would not be a priority intervention. The administration of IV dextrose solution followed by regular insulin is the priority intervention.
C. This would not be a treatment option because potassium-sparing diuretics cause the retention of potassium.
D. The patient’s elevated potassium level will not be quickly corrected with 0.9% sodium chloride alone. The patient is in renal failure, so a fluid bolus may not be an option. This patient needs to have their potassium levels quickly lowered to avoid cardiac arrest.
Category: Medical Emergencies, Electrolyte and fluid imbalance
Question 121
A patient presents dressed in a robe and carrying a staff, stating that they are “Jesus Christ” and are “going to save the world.” Which of the following interventions should be considered for this patient?
Speaking calmly to the patient
✓
Telling the patient they are not “Jesus Christ”
Administering intravenous haloperidol
Restraining the patient
Correct Answer
Speaking calmly to the patient
A. When a patient is experiencing a possible psychotic episode, behavioral approaches should be used initially. De-escalation techniques should be employed, including establishing a rapport with the patient; speaking calmly; and recognizing patient needs, such as for food, water, and safety. At times, the patient may be in physical pain and in need of pain management.
B. Attempting to restrain the patient could result in further agitation and could escalate to violence, resulting in injury to the patient and staff.
C. Challenging or arguing with the patient may agitate them further and cause them to escalate to violent behavior.
D. Medication may be indicated, but de-escalation techniques should be attempted first, especially if the patient is cooperative with the staff. Development of a trusting relationship between the patient and staff is an important intervention.
Category: Mental Health Emergencies, Thought disorders (e.g., psychosis,
Question 122
A combat veteran is brought in by their social worker. The patient has a history of depression, increasing angry outbursts, and nightmares since returning from combat. The patient appears anxious, is tearful, and tells the nurse, “I can’t take this anymore. Please help me.” The nurse escorts the patient to a quiet room and suspects that their symptoms are suggestive of which condition?
Acute psychosis
Alcohol withdrawal syndrome
Panic attack
Posttraumatic stress disorder
✓
Correct Answer
Posttraumatic stress disorder
A. Alcohol withdrawal syndrome is a potentially life-threatening emergency characterized by shaking, fever, and elevated heart rate. The patient is not trembling, and vital signs are within normal limits. There is no information indicating the patient’s alcohol intake.
B. Posttraumatic stress disorder is defined as an anxiety disorder in response to an extremely traumatic event. Given the patient’s history of being a combat veteran, coupled with a history of depression, the patient is most likely exhibiting signs of posttraumatic stress disorder, including nightmares, flashbacks, feeling emotionally numb, and loss of interest in previously enjoyed activities.
C. Signs and symptoms of acute psychosis present quickly and are short lived. The patient may experience hallucinations, delusions, and disorganized speech.
D. Although the patient could be experiencing a panic attack, the signs and symptoms presented gradually. A panic attack typically has an acute onset, characterized by a pounding heart rate, hyperventilation, diaphoresis, and intense anxiety.
Category: Mental Health Emergencies, Anxiety disorders (e.g., PTSD, anxiety, panic
Question 123
Law enforcement arrives with a patient who was found wandering around a local neighborhood. The patient is alert, oriented, and cooperative but appears agitated. They are pacing in circles and mumbling to themself. The patient has a psychiatric and seizure history and is well known to local law enforcement. The patient complains of headache, nausea, and vertigo and states that they’ve been having nightmares. The most likely cause of the patient’s current condition is which of the following?
Withdrawal from benzodiazepine medication
✓
Overdose on tricyclic antidepressant medication
Abrupt discontinuation from phenytoin
Overdose on selective serotonin inhibitor medication
Correct Answer
Withdrawal from benzodiazepine medication
A. Sudden cessation of phenytoin may result in increased seizure activity or frequency of seizures, not the symptoms being exhibited by this patient.
B. Benzodiazepines, which are often used to treat anxiety, alcohol withdrawal, and seizures, may cause physical dependence. Sudden withdrawal from benzodiazepines is likely to cause the symptoms being exhibited by this patient: agitation, anxiety, and hallucinations.
C. Signs and symptoms of selective serotonin inhibitor overdose include altered level of consciousness, respiratory depression, and hyperthermia. This patient’s vital signs are within normal limits, and they are oriented.
D. Signs and symptoms of tricyclic antidepressant overdose include altered level of consciousness, dysrhythmias, and hypotension.
Category: Mental Health Emergencies, Situational crisis (e.g., terminal diagnosis,
Question 124
Which of the following medications would the nurse prepare to administer to a patient experiencing an acute dystonic reaction?
Flumazenil (Romazicon)
Diazepam (Valium)
Diphenhydramine (Benadryl)
✓
Naloxone (Narcan)
Correct Answer
Diphenhydramine (Benadryl)
A. Benzodiazepines, such as diazepam, are often used concurrently with antipsychotics to manage acute mania. Benzodiazepines have no benefit in treating acute dystonia.
B. Naloxone is the reversal agent for opioid overdoses and has no benefit in treating acute dystonia.
C. Flumazenil is the reversal agent for benzodiazepine overdoses and has no benefit in treating acute dystonia.
D. Diphenhydramine, an anticholinergic and antihistamine, is the drug of choice for treating acute dystonia, which is a known side effect of antipsychotics.
Category: Mental Health Emergencies, Mood disorders (e.g., bipolar, depression)
Question 125
A patient reports experiencing short episodes of intense fear accompanied by chest pain, shortness of breath, lightheadedness, and numbness. Which of the following statements made by the patient indicates an understanding of the treatment options for this experience?
“I will first try to determine what made me feel anxious.”
“Breathing in and out into a paper bag may help the symptoms initially subside.”
✓
“I should take some over-the-counter pain medication when I experience these symptoms.”
“I should call for an ambulance as soon as the symptoms start.”
Correct Answer
“Breathing in and out into a paper bag may help the symptoms initially subside.”
A. The patient should try to alleviate symptoms temporarily and, if unable to do so, proceed to seeking care from a medical provider.
B. Determining the cause of the onset of the panic attack is a realistic expectation, but initially the patient should try to get symptoms to subside. Focusing on the cause may not alleviate the symptoms.
C. Panic attacks are short-lived episodes of anxiety or intense fear accompanied by a range of somatic symptoms (commonly cardiac, gastrointestinal, or neurologic). These symptoms often mimic symptoms of life-threatening conditions. Having the patient rebreathe their own carbon dioxide using a paper bag may result in temporary subsiding of symptoms.
D. The physical signs and symptoms originated because of an intense fear or anxiety reaction. A decrease in carbon dioxide (CO ) results in the continuation and 2 progression of symptoms. Rebreathing CO may help decrease or eliminate the 2 somatic symptoms, and analgesics are not necessary.
Category: Mental Health Emergencies, Anxiety disorders (e.g., PTSD, anxiety, panic
Question 126
A patient presents with a productive cough, fever of 40°C (104°F), and respiration rate (RR) of 22 breaths/minute. The patient’s chest radiograph reveals a right lower lobe pneumonia. Antibiotics are being administered. The patient’s RR increases to 30 breaths/minute, and they become agitated and confused. The nurse identifies that these signs indicate the patient is now experiencing:
the presence of a pulmonary embolus.
an allergic reaction to the intravenous antibiotic.
a response to the elevated temperature.
life-threatening organ dysfunction.
✓
Correct Answer
life-threatening organ dysfunction.
A. A patient with an elevated temperature may have an altered mental status and increased respiratory rate, but in the presence of a known infection, the patient is at increased risk of life-threatening organ dysfunction from sepsis.
B. The Sequential (sepsis-related) Organ Failure Assessment (SOFA) tool was developed to assess for signs of life-threatening organ dysfunction in a patient who has a diagnosed infection and is at risk for septic shock. This tool has been adapted to qSOFA, or the quick SOFA. The qSOFA can identify a patient at risk of life-threatening organ dysfunction based on the following: RR of 22 breaths/minute or greater, an altered mental status (GSC < 15), and a systolic blood pressure of 100 mm Hg or less. If two of these criteria are present in a patient with an infection, the risk of organ dysfunction is increased, and appropriate interventions should be rapidly initiated.
C. Allergic reaction to an antibiotic may result in a rash, oral swelling, wheezing, and an increase in the patient’s respiratory rate.
D. Symptoms of a pulmonary embolus include chest pain and shortness of breath. Fever is not consistent with pulmonary embolus.
Category: Medical Emergencies, Sepsis
Question 127
A patient presents with pain around their Achilles tendon after walking several miles and denies recent injury to the ankle or foot. Which medication puts the patient at risk for the presentation?
Losartan (Cozaar)
Lisinopril (Zestril)
Levothyroxine (Synthroid)
Levofloxacin (Levaquin)
✓
Correct Answer
Levofloxacin (Levaquin)
A. Angiotensin receptor blocker medications such as losartan are not associated with tendon rupture.
B. Levothyroxine (Synthroid), a thyroid medication, is not associated with tendon rupture.
C. Fluoroquinolones, such as ciprofloxacin (Cipro) and levofloxacin (Levaquin), are associated with tendon rupture.
D. Angiotensin-converting enzyme inhibitors such as lisinopril are not associated with tendon rupture.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Ligament
Question 128
A wound was irrigated with saline via a syringe with an attached 18-gauge catheter. The nurse identifies that the wound has been appropriately irrigated when they observe which of the following?
The wound is no longer actively bleeding.
There is the presence of white tissue around the wound without debris.
There is no obvious presence of debris.
✓
There is no redness surrounding the wound.
Correct Answer
There is no obvious presence of debris.
A. A normal wound has signs of inflammation; white tissue may indicate deeper tissue injury.
B. The irrigation solution is meant to remove cellular debris and surface pathogens contained in wound exudates. Contaminated wounds should be irrigated until all visible debris is removed.
C. A syringe with an attached 18-gauge needle typically delivers an output pressure range of 11–31 psi, which may cause wound irritation and redness; however, the removal of bacteria outweighs the tissue trauma.
D. Low-pressure wound irrigation may result in oozing as attached bacteria and debris are removed.
Category: Musculoskeletal and Wound Emergencies, Wound, Penetrating injuries
Question 129
Which of the following questions asked by the nurse would provide the most important information regarding possible causes of a febrile illness in a child?
“Is your child up to date on immunizations?”
✓
“Has your child been in contact with anyone who is ill?”
“Does your child attend daycare?”
“When did your child start having a fever?”
Correct Answer
“Is your child up to date on immunizations?”
A. Asking about sick contacts is a valid question, but this knowledge is not as helpful in identifying possible causes of the fever. Questions regarding immunization status should always be asked when assessing a febrile patient.
B. Children in daycare do have an increased risk for contracting infections because of close contact, but this knowledge is not as helpful in identifying possible causes of the fever. Questions regarding immunization status should always be asked when assessing a febrile patient.
C. Unimmunized and underimmunized children are at an increased risk for contracting serious infections. Their immunization status should be assessed during any visit to the emergency department. Children who are up to date on their immunizations have a reduced incidence of contracting a preventable disease.
D. Knowing the onset of the fever may be helpful in identifying certain causes, but questions regarding immunization status will assist with evaluating for specific etiologies and should always be asked when assessing a febrile patient.
Category: Medical Emergencies, Sepsis
Question 130
A caregiver presents to triage with a 6-month-old child, stating, “My baby hasn’t been breathing right since last night and won’t take a bottle.” The infant is pale with a respiratory rate of 72 breaths/minute and a heart rate of 147 beats/minute. The emergency nurse is aware that this presentation indicates that the infant:
is experiencing a decline in their cardiopulmonary status.
✓
ranks as “sicker” on the Pediatric Assessment Triangle.
is experiencing gastrointestinal distress.
has a respiratory rate that is within normal parameters.
Correct Answer
is experiencing a decline in their cardiopulmonary status.
A. Children with sustained respiratory rates of greater than 60 breaths/minute are at risk for respiratory failure because of compensatory mechanisms that fail faster than those of an adult.
B. A respiratory rate of 72 breaths/minute is not within the parameters of respiratory rates for infants. Respiratory rates greater than 60 breaths/minute in an infant require immediate interventions.
C. Infants with gastroenteritis may not take their normal nutrition and can have elevated heart rates as a result of dehydration, but breathing issues are not usually associated with it.
D. The patient’s elevated respiratory rate heart rate and pale color indicate disruption in two elements of the Pediatric Assessment Triangle—work of breathing and circulation; therefore, the patient falls into the “sickest” category.
Category: Respiratory Emergencies, Respiratory distress syndrome
Question 131
Which medication is a rapid-acting, first-line drug that is administered quickly and used emergently to treat status epilepticus in an adult with a normal glucose?
Levetiracetam (Keppra)
Phenytoin (Dilantin)
Phenobarbital (Luminal)
Lorazepam (Ativan)
✓
Correct Answer
Lorazepam (Ativan)
A. Phenytoin is not a first-line drug to treat active seizures because a therapeutic drug level must be obtained.
B. Phenobarbital is considered a second- or third-line drug for the treatment of active seizures.
C. Benzodiazepines, such as lorazepam (Ativan), are considered first-line drugs in the treatment of active seizures.
D. Although levetiracetam (Keppra) may be administered among the first-line drugs, it typically takes 15 minutes to administer.
Category: Neurological Emergencies, Seizure disorders
Question 132
A patient has sustained a subdural hematoma. Which of the following is a contraindication to placing the patient in semi-Fowler’s position?
Systolic blood pressure of 120 mm Hg
PaO of 80 mm Hg 2
PaCO of 50 mm Hg 2
Mean arterial pressure of 45 mm Hg
✓
Correct Answer
Mean arterial pressure of 45 mm Hg
A. This value is not a contraindication to placing the patient in semi-Fowler’s position. Semi-Fowler’s position can enhance oxygenation and ventilation for certain patients.
B. A mean arterial pressure below normal indicates hypotension, and raising the head of the bed from the supine position may further worsen blood pressure and impair blood flow.
C. This blood pressure is within normal parameters and is not a contraindication to placing the patient in semi-Fowler’s position.
D. This value is higher than normal, and if hypercapnia is related to impaired ventilation, semi-Fowler’s position may help reduce this number to within normal values.
Category: Neurological Emergencies, Increased intracranial pressure (ICP)
Question 133
When the nurse is performing the Glasgow Coma Scale (GCS) assessment, the patient is awake and does not follow commands, but the right arm crosses midline to get to the source of the applied pressure to their arm. Based on this observation, what score will the nurse document for motor?
2: extension
4: withdrawal
3: abnormal flexion
5: localizes pain
✓
Correct Answer
5: localizes pain
A. The motor scale scoring for the GCS is: 6: follows commands; 5: localizes (crosses midline); 4: withdraws; 3: abnormal flexion; 2: abnormal extension; and 1: no response to pain.
B. A score of 2 indicates extension or decorticate posturing, a sign of severe brain damage. The motor scale scoring for the GCS is: 6: follows commands; 5: localizes (crosses midline); 4: withdraws; 3: abnormal flexion; 2: abnormal extension; and 1: no response to pain.
C. Withdrawal does not involve the purposeful attempt to remove a pain source. The motor scale scoring for the GCS is: 6: follows commands; 5: localizes (crosses midline); 4: withdraws; 3: abnormal flexion; 2: abnormal extension; and 1: no response to pain.
D. A score of 5 represents localization, an effort to remove the source of a painful stimuli. The motor scale scoring for the GCS is: 6: follows commands; 5: localizes (crosses midline); 4: withdraws; 3: abnormal flexion; 2: abnormal extension; and 1: no response to pain.
Category: Neurological Emergencies, Neurogenic shock
Question 134
A 26-week-pregnant female presents with bright red vaginal bleeding, using one pad every hour for the past 3 hours. The uterus is painful and tender to palpation. Fetal heart tones are 152 beats/minute. The patient has slight tachycardia, but otherwise vital signs are within normal limits. Which of the following interventions should be anticipated for this patient?
Discharged home on bedrest with physician follow-up
Immediate blood transfusion
Emergent caesarean section
Admission for fetal monitoring
✓
Correct Answer
Admission for fetal monitoring
A. This patient is most likely experiencing placental abruption. Because her vital signs are stable and fetal heart tones are within normal limits, she would most likely be admitted for a trial of fetal monitoring and modified bedrest before determining her disposition.
B. Although emergent caesarean section may be indicated in placental abruption, the patient’s vital signs and the fetal heart tones are stable at this time. Because she is not near term in her pregnancy (< 36 weeks), monitoring would be the first choice in the stable patient.
C. With stable vital signs and fetal heart tones, immediate blood transfusion is not indicated at this time, although laboratory tests ordered would probably include blood and Rh typing.
D. Although the patient appears stable at this time, fetal monitoring is indicated to ensure maintained stability of both the patient and the fetus. Discharge to home would not be anticipated for the diagnosis of placental abruption.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 135
Which of the following laboratory results would be suggestive of the development of HELLP syndrome?
Elevated potassium level
Decreased platelet count
✓
Decreased liver enzymes
Increased magnesium level
Correct Answer
Decreased platelet count
A. HELLP is a life-threatening complication of pregnancy whose defining characteristics are hemolysis (H), elevated liver enzymes (EL), and low platelet count (LP). The development of hemolysis leads to activation of the coagulation cascade, causing consumption of the patient’s platelets.
B. HELLP causes a rise in liver enzymes that is due to hypoxia of the liver.
C. HELLP does not cause a rise in serum potassium or affect other serum electrolyte values.
D. HELLP does not affect serum electrolyte levels.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 136
An adult patient weighing 80 kg presents with full-thickness thermal burns to the head, chest, and bilateral arms. Using the rule of nines to determine total body surface area burned, how much fluid replacement should be administered in the first 8 hours based on the Parkland formula at its upper limit?
3600 mL
7200 mL
✓
4800 mL
14,400 mL
Correct Answer
7200 mL
A. The Parkland formula for replacement of fluids is 2–4 mL × weight in kg × TBSA, though the upper limit is now recommended for adults. The patient’s total body surface area burned is 45% (9% right arm, 9% left arm, 18% chest, and 9% head). Calculation for this patient: 80 (kg) × 4 (mL) × 45 (%) = 14,400 mL. Half of the fluid (7200 mL) should be administered in the first 8 hours, and the other half is administered over the next 16 hours.
B. Using the upper limit of the Parkland formula, this is only half of what the patient should receive in the first 8 hours.
C. Using the upper limit of the Parkland formula, this is one-third of the total dose needed in 24 hours. Half of the total amount should be infused in the first 8 hours.
D. Using the upper limit of the Parkland formula, this is the total amount to be infused in 24 hours. Half of this should be infused in the first 8 hours.
Category: Environment and Toxicology Emergencies, and Communicable
Question 137
A patient with a hydrofluoric acid burn should be monitored for which of the following imbalances?
Hypokalemia
Hypocalcemia
✓
Hypernatremia
Hyperglycemia
Correct Answer
Hypocalcemia
A. Glucose levels are not impacted with hydrofluoric acid burns. The element at high risk is calcium.
B. Sodium levels are not a part of the problem with hydrofluoric acid burns. Available calcium will bind with the fluoride ions, creating hypocalcemia.
C. Hyperkalemia and hypocalcemia are risks with a burn with hydrofluoric acid.
D. Hydrofluoric acid exposure causes a depletion of serum calcium due to the fluoride ions combining with available calcium. The presence of hypocalcemia can result in the patient developing cardiac dysrhythmias.
Category: Environment and Toxicology Emergencies, and Communicable
Question 138
Which of the following symptomatologies would be expected in a patient who was contaminated with insect spray?
Tachycardia
Salivation
✓
Mydriasis
Oliguria
Correct Answer
Salivation
A. Urinary output is increased, not decreased, with organophosphate poisoning, which causes a cholinergic crisis.
B. Bradycardia, not tachycardia, is the common dysrhythmia seen with organophosphate poisoning.
C. Miosis (pinpoint pupils) rather than mydriasis would accompany a cholinergic crisis situation that occurs with organophosphate poisoning.
D. Insect sprays are organophosphates and can cause cholinergic manifestations. This causes an overdrive of all bodily secretions, including salivation, lacrimation, urination, and defecation. Miosis (pinpoint pupils) and bradycardia are included in the cholinergic response.
Category: Environment and Toxicology Emergencies, and Communicable
Question 139
A patient presents to the emergency department with malaise, headache, and fatigue after a weekend camping trip. A red bull’s-eye-shaped rash is noted on the leg. Which of the following diagnoses should be suspected with this patient?
Rocky Mountain spotted fever
Tularemia
Lyme disease
✓
Cellulitis
Correct Answer
Lyme disease
A. Fever, headache, and rash are common signs and symptoms of Rocky Mountain spotted fever. The rash with this disorder is pink and macular, starting on the palms and soles of the feet and then spreading to other parts of the body.
B. The patient is presenting with classic signs and symptoms of Lyme disease. The bull’s-eye rash is a hallmark sign of this disease process. Having returned from a camping trip should be a red flag for a tick-related disorder.
C. Cellulitis generally presents with fever and a red, swollen area on the skin.
D. Tularemia is caused by contact with the bacterium Francisella tularensis from rabbits, squirrels, or rodents. It is transferred by ingestion, contact, or aerosol. It will cause flulike symptoms, which can progress to deadly complications.
Category: Environment and Toxicology Emergencies, and Communicable
Question 140
Which of the following statements made by a family member of a patient being treated for Ebola virus indicates an understanding of this disease process?
“I will only need to wear gloves when I am around my father.”
“I will tell everyone at the reunion next week about my father’s illness.”
“I will return for treatment for myself if I develop a fever or any bleeding.”
✓
“I am sure that these antibiotics will work well to heal my father.”
Correct Answer
“I will return for treatment for myself if I develop a fever or any bleeding.”
A. Individuals around patients with Ebola must adhere to strict isolation techniques, including wearing personal protective equipment appropriate for droplet, contact, and standard precautions. This would include gown, gloves, and mask. Only those who are actively caring for the patient should be in contact with them.
B. Ebola is a viral illness. Antibiotics are used only until the viral illness is diagnosed. Supportive care is the treatment of choice in these patients.
C. Ebola is a febrile hemorrhagic disease process. If symptoms of fever or bleeding from any location occurs, the individual must seek care early.
D. Family members or other acquaintances of patients with active Ebola should not attend large gatherings. As a general rule, these outbreaks are usually limited to smaller geographic areas, and it would be important to maintain this low threshold for transfer of the virus.
Category: Environment and Toxicology Emergencies, and Communicable
Question 141
According to the principles of a Just Culture, which of the following management options would take place after a nurse error in which a patient was transferred to an intensive care bed as a result of the inadvertent administration of a wrong medication?
Changes in process design
✓
Creation of rewards for good behaviors
Firing of the nurse
Increasing awareness of situations
Correct Answer
Changes in process design
A. At-risk behavior is involved in those mistakes that are a choice. The nurse does not recognize or believe that the risk involved is justified. For these types of mistakes, the Just Culture recommends increasing the awareness of the situation as one of its guiding principles.
B. When mistakes are made that are inadvertent and caused by a slip or lapse in judgment, the management protocols may call for a change in processes or procedures so that future mistakes are not made again. The nurse must take responsibility, but the mistake may have occurred because of a process problem.
C. When the nurse is aware that the mistake is being made or has conscious disregard for the principle, then punitive measures, such as firing, must take place.
D. Awarding good behaviors and taking away any incentives for behaviors that create an at-risk environment are management options for mistakes made when the nurse made a conscious choice or decision that impacted the patient outcome.
Category: Professional Issues, Nurse, Stress management (e.g., burnout,
Question 142
A patient presents with a history of near syncope. Upon arrival to the room, the patient develops a tonic–clonic seizure. The airway is being properly maintained. What is the next assessment that should be completed?
Obtain blood glucose level
Auscultate a blood pressure
Evaluate extraocular movements
Check for a pulse
✓
Correct Answer
Check for a pulse
A. Circulation assessment is a priority. Assessing for the presence of a pulse, along with the quality, amplitude, and rhythm of the pulse, is a priority for this patient. The presence of ventricular rhythms can lead to syncope and seizures because of decreased cardiac output and tissue perfusion.
B. Obtaining the patient’s blood pressure is not a priority at this time. Assessing for the presence of a pulse is the priority for this patient.
C. Obtaining blood glucose level is important because low blood glucose can present with seizure-like activity, but airway, breathing, and circulation take priority.
D. Extraocular movements may not be evaluated at this time. The presence of active seizures precludes this assessment because the patient is unable to respond to verbal direction.
Category: Neurological Emergencies, Seizure disorders
Question 143
A patient presents with sudden onset of pain and swelling in their left leg. The patient denies any recent trauma. Which of the following elements of the patient’s history is most concerning?
Stent placement 4 years ago
Smokes two packs of cigarettes a day
✓
Non-insulin-dependent diabetic
Poorly controlled hypertension
Correct Answer
Smokes two packs of cigarettes a day
A. The patient’s complaint of leg pain may be caused by a deep vein thrombosis (DVT). Although diabetes does cause damage to the blood vessels, this risk factor is not the most concerning for DVT.
B. The patient’s complaint of leg pain may be caused by a DVT. The patient had a stent 4 years ago and should be on daily aspirin, so this risk factor is not the most concerning for DVT.
C. Smoking and a sedentary lifestyle are the two risk factors for DVT. These two factors put this patient at a very high risk for developing a DVT—in this case, in their left leg.
D. Hypertension is a risk factor for DVT but is not the most concerning of this patient’s risk factors.
Category: Cardiovascular Emergencies, Thromboembolic disease (e.g., deep vein
Question 144
A patient presents with fatigue, night sweats, prolonged fevers, increasing shortness of breath, and numerous purplish dark nodules on the skin and hard palate of the mouth. Based on the patient’s history and presentation, what is the most likely cause of these symptoms?
Tuberculosis
Acute hepatitis B virus infection
Acquired immunodeficiency syndrome
✓
Ebola virus disease
Correct Answer
Acquired immunodeficiency syndrome
A. Tuberculosis symptoms include fatigue, productive cough (sputum or blood) lasting for weeks, fever, and night sweats. The purplish spots are consistent with Kaposi’s sarcoma, not this infection.
B. Hepatitis B virus would usually present with fatigue, anorexia, nausea, vomiting, diarrhea, and jaundice. The purplish spots are consistent with Kaposi’s sarcoma, not this infection.
C. This patient is showing signs of an advanced stage of human immunodeficiency virus infection known as acquired immunodeficiency syndrome (AIDS). The purplish spots/nodules are Kaposi’s sarcoma, a rare form of skin cancer that occurs in immunosuppressed individuals and may be found on the skin, mouth, and internally. These patients will usually be extremely fatigued and have fevers lasting 10 or more days.
D. Ebola virus disease is a hemorrhagic fever that can present with high fever, myalgias, shortness of breath, copious vomiting and diarrhea, and bleeding gums. The purplish spots are consistent with Kaposi’s sarcoma, not this infection.
Category: Medical Emergencies, Immunocompromise (e.g., HIV/AIDS,
Question 145
The nurse is helping the disaster management team develop a hazard map for their hospital system. Which phase of disaster management is this?
Response
Mitigation
✓
Recovery
Preparedness
Correct Answer
Mitigation
A. Preparedness includes planning, training, and educational activities for events that cannot be mitigated.
B. Mitigation is the phase that includes actions taken to prevent or reduce the cause, impact, and consequences of disasters. A hazard map is included in the mitigation phase.
C. Recovery is when restoration efforts occur concurrently with regular operations and activities.
D. The response phase occurs in the immediate aftermath of a disaster.
Category: Professional Issues, System, Disaster management
Question 146
A patient arrives with complaints of headache, dry mouth, and facial flushing. Medication history includes metformin and metoprolol. What is the priority intervention for this patient?
Administer subcutaneous insulin
Obtain an electrocardiogram (ECG)
Check blood glucose level
✓
Obtain a manual blood pressure
Correct Answer
Check blood glucose level
A. This patient is most likely experiencing diabetic ketoacidosis, and the priority is to confirm the suspected diagnosis with a blood glucose level. Insulin would be administered intravenously, not subcutaneously, for this patient.
B. This patient is most likely experiencing diabetic ketoacidosis, and the priority is to confirm the suspected diagnosis with a blood glucose level. The need for insulin would come after a glucose level is obtained. This patient will also need measurement of vital signs and an ECG, but they are not the priority.
C. This patient is most likely experiencing diabetic ketoacidosis, and the priority is to confirm the suspected diagnosis with a blood glucose level. This patient may need an ECG, but symptoms are more suggestive of an elevated blood glucose.
D. This patient is most likely experiencing diabetic ketoacidosis, and the priority is to confirm the suspected diagnosis with a blood glucose level. Blood pressure measurement will eventually be needed but is not the priority.
Category: Medical Emergencies, Endocrine disorders
Question 147
Emergency medical services arrives with a patient who was involved in an all-terrain vehicle crash. Paramedics report that the patient was thrown and landed on their head. The patient responds to pain and has the following vital signs: BP 82/40 mm Hg, HR 45 beats/minute, RR 28 breaths/minute. Skin is warm and dry. Based on these findings, what should the nurse suspect?
Neurogenic shock
✓
Cardiogenic shock
Obstructive shock
Spinal shock
Correct Answer
Neurogenic shock
A. Spinal shock is the neuromuscular response to a spinal cord injury that results in muscle flaccidity and areflexia below the level of the lesion.
B. Cardiogenic shock and obstructive shock result from injury to the heart. Both would result in hypotension but not bradycardia or warm, dry skin.
C. Neurogenic shock, a form of distributive shock, is the cardiovascular response to a cervical or upper thoracic spinal cord injury, in which sympathetic innervation is impaired. The resulting unopposed parasympathetic innervation results in vasodilation, causing hypotension, bradycardia, and warm, dry skin.
D. Obstructive shock and cardiogenic shock result from injury to the heart. Both would result in hypotension but not bradycardia or warm, dry skin.
Category: Neurological Emergencies, Neurogenic shock
Question 148
The use of succinylcholine in patients with Guillain–Barré syndrome is contraindicated because of which of the following potentially fatal electrolyte abnormalities?
Hyperkalemia
✓
Hypernatremia
Hypercalcemia
Hypermagnesemia
Correct Answer
Hyperkalemia
A. Patients with Guillain–Barré syndrome have an increased potential for elevated levels of potassium because of the cellular up-regulation of this electrolyte. When it is combined with the effects of succinylcholine, which can cause a transient hyperkalemia, an extreme amount of potassium can be affected. This hyperkalemia can cause severe dysrhythmias and death. Sodium, calcium, and magnesium are not affected by Guillain–Barré syndrome or succinylcholine.
B. Patients with Guillain–Barré syndrome have an increased potential for elevated levels of potassium because of the cellular up-regulation of this electrolyte. When it is combined with the effects of succinylcholine, which can cause a transient hyperkalemia, an extreme amount of potassium can be affected. This hyperkalemia can cause severe dysrhythmias and death. Sodium, calcium, and magnesium are not affected by Guillain–Barré syndrome or succinylcholine.
C. Patients with Guillain–Barré syndrome have an increased potential for elevated levels of potassium because of the cellular up-regulation of this electrolyte. When it is combined with the effects of succinylcholine, which can cause a transient hyperkalemia, an extreme amount of potassium can be affected. This hyperkalemia can cause severe dysrhythmias and death. Sodium, calcium, and magnesium are minimally affected by Guillain–Barré syndrome and succinylcholine.
D. Patients with Guillain–Barré syndrome have an increased potential for elevated levels of potassium because of the cellular up-regulation of this electrolyte. When it is combined with the effects of succinylcholine, which can cause a transient hyperkalemia, an extreme amount of potassium can be affected. This hyperkalemia can cause severe dysrhythmias and death. Sodium, calcium, and magnesium are not affected by Guillain–Barré syndrome or succinylcholine.
Category: Neurological Emergencies, Neurological disorders (e.g., multiple
Question 149
A patient in the emergency department has a history of physiologic anisocoria. When performing a neurological exam, the nurse would expect which abnormal eye assessment?
Clouding of the lens
Unequal round pupils
✓
Right visual field loss
Blood in the anterior chamber
Correct Answer
Unequal round pupils
A. Unequal pupils is an abnormal finding, but for some patients, it might be normal. Anisocoria is characterized by approximately a 1-mm difference between the pupils. In about 30% of the population, this is not related to any underlying condition and is considered “physiologic.”
B. Glaucoma symptoms include seeing halos around lights, an eye that may look hazy or cloudy, eye pain, and redness. The pupils should not be different sizes unless the patient had surgery.
C. Loss of half the visual field (right or left) is a condition called homonymous hemianopia (or hemianopsia). It is caused by lesions of the visual pathways. It does not affect the size of the pupil.
D. Blood in the anterior chamber is a classic sign of a hyphema. It is usually secondary to a blunt injury to the eye.
Category: Maxillofacial and Ocular Emergencies, Ocular, Ocular trauma (e.g.,
Question 150
A patient presents with acute exacerbation of chronic systolic congestive heart failure. Blood pressure is 150/70 mm Hg. The patient complains of dyspnea, and crackles are heard bilaterally. The patient is not hypoxic, nor does the electrocardiogram demonstrate evidence of an acute myocardial ischemia or infarction. Which of the following medications could be harmful to administer to the patient at this time?
Vasopressor agents
✓
Opiates
Diuretics
Positive inotropic agents
Correct Answer
Vasopressor agents
A. Positive inotropic agents increase contractility and cardiac output, decrease myocardial workload, and improve oxygen delivery to the tissues.
B. Vasopressors increase systemic resistance and blood pressure. The patient is not currently hypotensive and does not need treatment with vasopressor agents.
C. Guidelines recommend diuretic therapy as the cornerstone of therapy for acute heart failure.
D. Intravenous opiates should be considered in patients with heart failure who exhibit anxiousness or restlessness.
Category: Cardiovascular Emergencies, Heart failure