The nurse is caring for an elderly patient with fever, joint stiffness, trismus, and opisthotonos. Which portion of their history is most concerning for this patient?
Patient was working in the garden last week
✓
Patient had vomiting after eating packaged salad yesterday
Patient just completed a nitrofurantoin prescription
Patient received a shingles vaccine 2 days ago
Correct Answer
Patient was working in the garden last week
A. Fever, joint stiffness, trismus (inability to open the jaw), and opisthotonos (severe arching of the back) are symptoms of tetanus. This systemic infection is caused by Clostridium tetani, which is found in soil, garden moss, and anywhere that human or animal excrement is found. People working in gardens often get cuts or puncture wounds and don’t think much of it. Older patients are more likely to be unimmunized for tetanus. Symptoms develop several days after exposure.
B. Vomiting after eating a packaged salad may be related to sensitivity to one of the ingredients or from Salmonella contamination of the produce. They would not demonstrate the symptoms of trismus or opisthotonos.
C. Side effects of the shingles vaccine include fever, nausea, headache, and shivering. Trismus and opisthotonos would not be seen as side effects. Guillain–Barré syndrome is a rare side effect of the vaccine, but the presentation is different from tetanus.
D. Nitrofurantoin is an antibiotic frequently used to treat urinary tract infections. Side effects can include fever, chills, and tingling or burning sensation of the hands or feet. Trismus and opisthotonos would not be seen as side effects of this medication.
Category: Musculoskeletal and Wound Emergencies, Wound, Wound infections
Question 2
A patient arrives and collapses in front of the triage desk. The patient does not have a pulse and is not breathing. Cardiopulmonary resuscitation is initiated, and the cardiac monitor displays ventricular tachycardia. What is the nurse’s priority action at this time?
Defibrillate using a biphasic defibrillator with 120–200 joules
✓
Administer sodium bicarbonate 1 mEq/kg
Administer amiodarone (Cordarone) 150 mg intravenously
Synchronize cardioversion with 200 joules
Correct Answer
Defibrillate using a biphasic defibrillator with 120–200 joules
A. Amiodarone is used for patients in pulseless ventricular tachycardia at a dose of 300 mg initially. The dose for amiodarone for a patient with ventricular tachycardia with a pulse is 150 mg.
B. Synchronized cardioversion is indicated for unstable patients (with a palpable pulse) in ventricular tachycardia or tachydysrhythmias. Defibrillation is indicated for patients with pulseless ventricular tachycardia.
C. Immediate defibrillation is the recommended treatment for a pulseless ventricular tachycardia, in conjunction with adequate cardiopulmonary resuscitation. Medications are added after the first defibrillation attempt. The defibrillation should be repeated every 2 minutes if a palpable pulse and palatable rhythm do not return. If using a monophasic defibrillator, 360 joules is recommended for defibrillation.
D. Sodium bicarbonate is used for correction of acidosis and may be indicated for a patient in cardiopulmonary arrest, but not in the initial treatment. Administration of sodium bicarbonate should be guided by blood gas analysis.
Category: Cardiovascular Emergencies, Cardiopulmonary arrest
Question 3
A child arrives with increasing dyspnea after running on the playground. The child has audible wheezes with visible chest retractions. Vital signs are BP 110/70 mm Hg, HR 120 beats/minute, RR 42 breaths/minute, SpO 91% room air, T 37.7°C 2 (99.9°F). What is the priority intervention anticipated by the nurse?
Racemic epinephrine nebulizer treatment
Albuterol nebulizer treatment
✓
Methylprednisolone intravenous push
Theophylline intravenous infusion
Correct Answer
Albuterol nebulizer treatment
A. Racemic epinephrine is not a first-line medication used in asthma control. The most effective evidence-based inhalants for asthma control include beta-2 adrenergic agonists such as albuterol.
B. Asthma is a chronic condition caused by airway inflammation and bronchospasm in response to a stimulus or irritant. The most effective treatment for airway inflammation is the inhaled administration of a beta-2 adrenergic agonist such as albuterol.
C. Theophylline is a bronchodilator administered orally or intravenously. However, the inhalation of bronchodilators is the preferred method of administration for immediate-acting asthma medications.
D. Systemic corticosteroids should be used in individuals who do not respond to short-acting beta-2 agonists; however, they are not a first-line medication used in asthma control.
Category: Respiratory Emergencies, Asthma
Question 4
The appropriate dose of albuterol is delivered by nebulizer to an asthmatic child. The nurse would expect which finding following this treatment?
An increased peak flow reading
✓
A decreased heart rate
A decreased respiratory rate
An absence of wheezing
Correct Answer
An increased peak flow reading
A. A decreased respiratory rate is not necessarily a sign of improvement and may signal impending respiratory failure.
B. Peak expiratory flow is measured by having the patient forcefully exhale into a peak flow meter. Bronchodilators (albuterol) are intended to reduce airway limitation, thereby increasing the volume of air the patient can exhale. Therefore, an increase in peak flow reading would be a sign the bronchodilator is improving the patient’s condition.
C. An absence of wheezing may indicate a severe obstruction with very little air exchange. This phenomenon may be termed silent chest, which is an ominous sign.
D. Albuterol may cause tremors, anxiety, tachycardia, palpitations, and nausea.
Category: Respiratory Emergencies, Asthma
Question 5
A patient with a history of chronic obstructive pulmonary disease (COPD) and hypertension arrives in moderate respiratory distress. The patient is alert and oriented. Vital signs are BP 192/110 mm Hg, HR 112 beats/minute, RR 36 breaths/minute, SpO 78% room air, T 37.2°C (99.0°F). What priority intervention 2 should the nurse anticipate?
Endotracheal intubation with PEEP
Chest radiograph
Intravenous hydralazine administration
Bilevel positive airway pressure (BiPAP)
✓
Correct Answer
Bilevel positive airway pressure (BiPAP)
A. Intravenous access is important for this patient, but it does not take priority over the patient’s breathing. Also, the hypertension may be a result of the patient’s effort to breathe. Breathing must be addressed first. Therefore, the hydralazine should be considered after an appropriate airway and breathing intervention has been facilitated.
B. Patients with COPD may be difficult to taper (or wean) off of mechanical ventilation. If possible, other airway support measures should be initiated first to improve their oxygenation.
C. Oxygen therapy for the COPD exacerbation should be attempted with noninvasive positive pressure ventilation before advancing to invasive methods (intubation with mechanical ventilation). The priority for this patient should be maintaining the airway, breathing, and circulation, followed by providing supplemental oxygen such as BiPAP. Based on the patient’s vital signs and presentation, BiPAP is the best option.
D. A chest radiograph is important to rule out a life-threatening pneumothorax, but this is not the initial priority. COPD is an underlying cause identified in 70% of patients who experience a spontaneous pneumothorax.
Category: Respiratory Emergencies, Chronic obstructive pulmonary disease
Question 6
What is the influenza vaccine recommendation from the Centers for Disease Control and Prevention (CDC) for 50-year-old patients with stage 1 chronic obstructive pulmonary disease (COPD)?
Patients who live alone are not required to receive the influenza vaccine each year.
Patients with COPD should receive an influenza vaccine every year.
✓
Patients under the age of 50 are not required to receive the influenza vaccine every year.
Patients with COPD should not receive influenza vaccines because of the high risk of severe side effects.
Correct Answer
Patients with COPD should receive an influenza vaccine every year.
A. The CDC recommends that any person with a chronic disease be immunized for influenza. Influenza, pneumonia, and other preventable diseases increase the risk of mortality in patients with chronic disease.
B. Severe side effects of the influenza vaccine are rare, and if they occur, they are usually mild and self-limiting. Patients with a chronic disease such as COPD should be immunized for influenza each year.
C. The CDC recommends that people under the age of 50 be immunized against influenza each year.
D. The CDC recommends that everyone 6 months and older receive an annual influenza vaccine, with the only exceptions being for those with life-threatening allergies to the vaccine or any ingredient in the vaccine.
Category: Respiratory Emergencies, Chronic obstructive pulmonary disease
Question 7
The presence of hypoxia in patients with chronic obstructive pulmonary disease is the result of which of the following?
The presence of a diminished pulmonary blood flow
An inability of the blood to carry oxygen
The inability of the body’s tissues to use the delivered oxygen
A ventilation/perfusion mismatch
✓
Correct Answer
A ventilation/perfusion mismatch
A. Anemia or high levels of carbon monoxide result in a reduced number of normal cells that can carry oxygen to tissues.
B. Ventilation/perfusion match occurs when the volume of air in the alveoli is equivalent to the volume of blood perfusing through the capillary space. In patients with chronic obstructive pulmonary disease, the adequate exchange of oxygen and carbon dioxide is impaired by the presence of damaged alveoli and an increase in secretions. Therefore, more blood is perfusing through the lungs than air is being inhaled.
C. Decreased blood flow is the result of the presence of hypovolemia, caused by either trauma or sepsis.
D. Poisonous substances such as cyanide can interfere with the ability of the body’s tissues to use oxygen that is being delivered.
Category: Respiratory Emergencies, Chronic obstructive pulmonary disease
Question 8
A patient presents with a complaint of severe left lower abdominal pain, nausea, and vomiting ×1, with no bowel movement or passing gas for 4 days. They note a history of diverticulitis. On exam, the abdomen is firm and rigid with rebound tenderness. Vital signs are BP 94/50 mm Hg, HR 112 beats/minute, RR 28 breaths/minute, T 38.7°C (101.6°F). The patient’s symptoms are most consistent with:
peptic ulcer disease.
appendicitis.
peritonitis.
✓
pancreatitis.
Correct Answer
peritonitis.
A. Presentation of appendicitis would include a mild fever, periumbilical pain shifting to the right lower quadrant, nausea, and anorexia.
B. Peritonitis can occur when abdominal organs perforate and release their contents into the peritoneal cavity. Given the patient’s history of diverticulitis, clinical symptoms, and vital signs, the presentation of hypovolemic shock is most likely due to the massive shift of fluid into the peritoneum from bowel perforation, secondary to diverticulitis.
C. Pain with pancreatitis is generally located in the left upper abdomen or epigastrium and may radiate through to the back. The cause of pancreatitis is usually excessive ethanol ingestion or blockage of the common bile duct secondary to the presence of gallstones.
D. Peptic ulcer is generally the result of a disruption of the protective mucosal barriers and increased acid secretion. Symptoms include episodic gnawing or burning pain accompanied by a feeling of fullness or bloating. Pain may be relieved or exacerbated by food.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 9
A patient presents to triage with a complaint of sharp right upper quadrant abdominal pain that began after eating dinner tonight. They also note some pain to the right shoulder blade but deny any recent trauma. Vital signs are BP 155/90 mm Hg, HR 110 beats/minute, RR 14 breaths/minute, T 38.1°C (100.6°F). You suspect that this patient is experiencing which of the following conditions?
Cholecystitis
✓
Infectious mononucleosis
Pancreatitis
Appendicitis
Correct Answer
Cholecystitis
A. Infectious mononucleosis is an acute viral illness. Symptoms include a sore throat and cervical lymphadenopathy. Abdominal tenderness resulting from splenomegaly or hepatomegaly may be present, but nausea and vomiting are not experienced.
B. Right upper quadrant pain that radiates to the right shoulder or scapula and is accompanied by nausea and vomiting is the characteristic presentation of cholecystitis.
C. The discomfort associated with pancreatitis is more likely to be described as dull, steady, and localized in the left upper abdomen or epigastrium.
D. The typical presentation of a patient with appendicitis includes periumbilical pain that localizes in the right lower quadrant and is associated with mild fever, anorexia, and nausea. The pain associated with appendicitis does not radiate to the right shoulder or scapula.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 10
A patient presents feeling “run down” for some time. The family accompanying the patient pulls you aside, telling you that the patient has recently become more confused and now has slurred speech. They also note that he is “yellow” and has swollen legs and bruises more easily. Management includes obtaining labs. You would expect to see which of these lab values?
Elevated albumin levels
Elevated prothrombin levels
✓
Normal alkaline phosphatase
Normal ammonia level
Correct Answer
Elevated prothrombin levels
A. Alkaline phosphatase levels associated with cirrhosis are usually out of proportion to other liver enzyme levels.
B. Albumin is a protein that will show decreased levels with cirrhosis because it is made by the liver.
C. Ammonia levels are usually elevated with hepatic encephalopathy but do not always correlate with the severity of the encephalopathy.
D. Abnormal coagulation values (PT, INR) with thrombocytopenia are usually associated with cirrhosis.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 11
A patient presents with a complaint of mild to severe crampy abdominal pain. They note their last bowel movement was 24 hours ago and was blood-streaked. You suspect that the patient may have:
appendicitis.
cholecystitis.
diverticulitis.
✓
pancreatitis.
Correct Answer
diverticulitis.
A. Acute pancreatitis can be caused by an obstruction from gallstones, injury, or infection. The pain associated with pancreatitis is described as a sharp, boring-type pain that is localized in the epigastric area, with radiation to the chest and back.
B. Diverticulitis is an inflammation of the diverticula of the colon, which can become obstructed with food or fecal matter. The pain associated with diverticulitis is typically described as cramping and is localized to the left lower abdominal quadrant. The patient may also experience constipation, fever, chills, nausea, and vomiting.
C. The pain associated with appendicitis usually begins in the periumbilical area and is diffuse in nature. Later, the pain localizes in the right lower abdominal quadrant. With acute appendicitis, the patient complains of colicky right lower quadrant pain with vomiting, constipation, and fever.
D. Cholecystitis is an inflammation of the gallbladder. The pain is sharp and constant and occurs in the right upper quadrant, with radiation to the right shoulder or scapula. Symptoms frequently occur after ingesting a meal high in fat content.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 12
Which of the following statements made by a patient diagnosed with hepatitis A indicates an accurate understanding of their disease?
“There must be some mistake; I had the hepatitis vaccine as a baby.”
“My partner is a recovering intravenous drug abuser. I may have gotten this after we had unprotected sex.”
“I will be very careful to remember to wash my hands after using the bathroom and when preparing food.”
✓
“I must be careful from now on so that I don’t get this disease again.”
Correct Answer
“I will be very careful to remember to wash my hands after using the bathroom and when preparing food.”
A. The hepatitis B vaccine is administered to the pediatric population. The hepatitis A vaccine is recommended for anyone who plans to travel to or reside for a long period in an area where the population is at risk for hepatitis infection or after exposure to the hepatitis A virus.
B. Intravenous drug abusers are more likely to be infected with hepatitis B and can transmit that infection through unprotected sexual contact. Hepatitis A is acquired through the fecal–oral route, most often through ingestion of contaminated food or water.
C. Hepatitis A is spread by fecal–oral contamination. Take enteric precautions, such as good hand hygiene, following food safety precautions, and being sure that patients receive the hepatitis A vaccine. Hepatitis A is a viral infection that usually doesn’t cause chronic illness or chronic complications.
D. Hepatitis A antibodies (IgG anti-HAV) appear early in the course of the disease and provide the patient with lifelong protection against the disease. There is no chronic form of hepatitis A. The patient will have no immunity to other forms of hepatitis, such as hepatitis B or hepatitis C.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 13
A patient presents to triage with a complaint of severe abdominal pain that has worsened over the past 48 hours. The patient notes a history of Crohn’s disease, but this is different: They have not had a bowel movement in 4 days, they are bloated, and their abdomen is tender to touch. Which of the following laboratory results would be expected with this patient?
Potassium level 5.5 mEq/dL
White blood cell count 5000
Amylase level 300 mg/dL
White blood cell count 15,000
✓
Correct Answer
White blood cell count 15,000
A. Advanced kidney disease is a common cause of hyperkalemia. A patient with peritonitis would have a normal or even low potassium level.
B. An elevated white blood cell count, not a low white blood count, may indicate an infection or inflammation.
C. A raised serum amylase level, at least 3 times the upper limit of normal, supports the diagnosis of acute pancreatitis, not peritonitis.
D. An elevated white blood cell count may indicate an infection or inflammation that is seen with peritonitis.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 14
Which of the following abnormal laboratory values would the nurse expect to find in a patient newly diagnosed with acute pancreatitis?
Decreased serum calcium
Decreased C-reactive protein
Elevated serum amylase
✓
Elevated serum glucose
Correct Answer
Elevated serum amylase
A. An elevated C-reactive protein, an inflammatory marker, is a late indicator of pancreatic disease and usually is indicative of pancreatic necrosis.
B. Elevations in both serum amylase and serum lipase are highly suggestive of pancreatitis. The serum amylase will return to baseline quickly, whereas the serum lipase level will remain elevated for several days following the onset of symptoms, making it the more specific and sensitive indicator of acute pancreatitis.
C. Insulin secretion may be altered when the pancreas is inflamed, causing the patient to be hyperglycemic, but this is not a diagnostic indicator.
D. Hypocalcemia can occur as a complication of acute pancreatitis, but it is not a diagnostic indicator of the presence of acute pancreatitis.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 15
Emergency medical services (EMS) transports a victim of a motor vehicle crash who has abdomen ecchymosis. On examination, the nurse notes tenderness to the epigastric region with decreased bowel sounds. Based on these assessment findings, the nurse suspects injury to which abdominal structure?
Duodenum
✓
Stomach
Bladder
Liver
Correct Answer
Duodenum
A. Liver injuries are more likely to occur as a result of a direct blow to the right upper quadrant. Injury to the liver will produce right upper quadrant pain, abdominal spasm, and rigidity. Based on the mechanism of injury in this patient, an intestinal injury is more likely.
B. Bladder injuries as a result of blunt trauma are unlikely unless the bladder was distended at the time of injury. Symptoms would include hematuria, the inability to void, abdominal distention, suprapubic pain, and tenderness and ecchymosis over the bladder and thighs.
C. Because both the small and large intestines are susceptible to injury with blunt abdominal trauma, the nurse should have a high index of suspicion for small bowel/large bowel injury when lap belt restraint marks are noted across the abdomen. Signs and symptoms of intestinal injury include vague generalized abdominal or epigastric pain with abdominal rigidity, spasm, or guarding. Bowel sounds are usually hypoactive or absent.
D. The stomach is not usually injured with blunt trauma because it is easily displaced; it is more often injured with penetrating trauma. Signs and symptoms would include left upper quadrant pain and tenderness, free air under the diaphragm on radiograph, and aspiration of blood drainage through a nasogastric tube.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 16
A patient presents with abdominal pain with mid-epigastric pain with abdominal distention. They note using an increased amount of ibuprofen (800 mg every 6 hours) for the last 4 days because of increasing arthritis pain. On exam, you note guarding and rigidity with tachycardia, tachypnea, and fever. You suspect that this patient has which of the following conditions?
Pancreatitis
Gastroenteritis
Bowel perforation
✓
Intussusception
Correct Answer
Bowel perforation
A. Pancreatitis is an inflammation of the pancreas, with tenderness to the epigastric region and abdominal distention. It is associated with alcohol intake, not use of nonsteroidal anti-inflammatory drugs.
B. Small bowel perforations can be associated with duodenal ulcers caused by the use of nonsteroidal anti-inflammatory drugs such as ibuprofen.
C. Intussusception occurs when a segment of the bowel telescopes within itself. Pain is colicky and spasmodic. The highest incidence of this condition is seen in infants aged 9–24 months.
D. Gastroenteritis is an inflammation of the lining of the stomach and intestine. Pain is usually crampy or colicky in nature and diffuse.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 17
A patient diagnosed with renal calculi will likely exhibit which signs and symptoms?
Unilateral scrotal pain
Sudden onset of colicky, ipsilateral flank pain radiating to the groin
✓
Urinary frequency and urgency with fever and chills
Sudden onset of severe back pain described as “ripping” or “tearing”
Correct Answer
Sudden onset of colicky, ipsilateral flank pain radiating to the groin
A. The pain associated with renal colic typically begins in the flank area of the lower back and radiates to the groin.
B. Patients with renal colic may have a low-grade fever. Fever and chills are more suggestive of an infectious process such as pyelonephritis.
C. The discomfort associated with renal calculi originates in the flank area and may radiate to the groin and scrotum. Pain that originates in the scrotum is more likely to be associated with the etiologies of conditions such as acute epididymitis or testicular torsion.
D. Symptoms associated with a dissecting aortic aneurysm, such as a sudden onset of a pain described as “ripping” or “tearing,” can mimic those of renal colic but are associated with greater hemodynamic instability and loss of distal pulses.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 18
A young male who was involved in a bicycle crash is brought to the emergency department by ambulance. He is found to have a nondisplaced pelvic fracture. He begins to complain of difficulty voiding, and when you attempt to straight catheterize him, you note blood at the urinary meatus. Which of the following interventions should the emergency nurse anticipate next?
Insertion of an indwelling urinary catheter
Performance of a retrograde urethrogram
✓
Obtaining a urine specimen for urinalysis
Application of a pelvic immobilization device
Correct Answer
Performance of a retrograde urethrogram
A. Urethral disruption can be associated with a pelvic fracture but can also be linked to other injuries, so application of a pelvic immobilization device would not be initially indicated for this patient.
B. In trauma patients, the presence of blood at the urinary meatus may indicate urethral disruption, and a urinary catheter should not be attempted until a retrograde urethrogram is performed.
C. The presence of urethral injuries is more common in males than in females. Blood at the urinary meatus may be an indication of urethral injury, and a retrograde urethrogram should be performed to rule out urethral injury.
D. A urine specimen will eventually be collected from this trauma patient, but the retrograde urethrogram to determine a partial or total urethral disruption is the priority intervention.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 19
An older man with a history of hypertension and high cholesterol presents with a complaint of having been unable to urinate for a few days, and he now has suprapubic pain and constipation. You anticipate that the cause of his urinary retention would be related to:
renal trauma and antihypertensive medications.
renal trauma and statin medications.
benign prostatic hypertrophy and antihypertensive medications.
✓
benign prostatic hypertrophy and statin medications.
Correct Answer
benign prostatic hypertrophy and antihypertensive medications.
A. A common cause of urinary retention is not related to renal trauma; it is related to urethral trauma and antihypertensives.
B. A common cause of urinary retention can be related to benign prostatic hypertrophy but not statins.
C. A common cause of urinary retention is not related to renal trauma or statins; it is related to urethral trauma and antihypertensives.
D. Common causes of urinary retention are benign prostatic hypertrophy and antihypertensives.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 20
Which of the following statements best describes critical incident stress?
A unique set of attributes or behaviors that buffer the effects of acute and/or chronic stress
A combination of complex cognitive, somatic, and behavioral effects caused by psychological trauma
A normal response to an abnormal event
✓
A combination of secondary traumatic stress and burnout from exposure to repeated suffering
Correct Answer
A normal response to an abnormal event
A. This is the definition of posttraumatic stress disorder (PTSD). People suffering from PTSD experience intrusive thoughts, nightmares, and flashbacks. Ultimately, if not treated, PTSD will lead to social, occupational, and interpersonal dysfunction.
B. Critical incident stress creates a struggle for those affected to regain control of their lives and a sense of normalcy.
C. This is the definition of resilience. Possession of these traits provides coping mechanisms in the face of stress and thus allows for a positive work experience.
D. This is the definition of compassion fatigue. Possession of these traits negatively impacts job satisfaction, productivity, and performance.
Category: Professional Issues, Nurse, Stress management (e.g., burnout,
Question 21
The family of an elderly patient who has sustained a cardiopulmonary arrest is being approached by the hospital organ procurement agency representative, asking them for consent for organ donation. Which statement, made by a member of the patient’s family, indicates an accurate understanding of the organ donation process?
“The organs of an elderly person are only suitable for research purposes and not for organ donation.”
“Our insurance will cover the additional costs related to the organ donation process.”
“We would not be able to have an open-casket funeral.”
“Our religion considers organ donation to be a noble gift.”
✓
Correct Answer
“Our religion considers organ donation to be a noble gift.”
A. There is no age limit that defines organ donation. The suitability of the organs for transplant is determined by the transplant team at the time of the donor’s death.
B. All costs associated with the organ donation process are assumed by the organ recipient. No costs are billed to the donor or donor family.
C. Organ and tissue donation does not alter the appearance of the body. An open-casket funeral is still possible.
D. Most major religions have published documents in support of organ donation.
Category: Professional Issues, Patient, End-of-life and palliative care (e.g., organ and
Question 22
A patient presents with a complaint of chest pain. The 12-lead electrocardiogram (ECG) reveals ST-segment elevation in leads I and aVL. The initial blood pressure is 112/69 mm Hg and decreases to a systolic 60 mm Hg following a dose of nitroglycerin 0.4 mg SL. The priority intervention is to:
complete a percutaneous coronary intervention (PCI) check sheet.
initiate a dopamine drip for blood pressure control.
obtain a right-sided 12-lead ECG.
administer a 0.9% sodium chloride bolus intravenously.
✓
Correct Answer
administer a 0.9% sodium chloride bolus intravenously.
A. Although the percutaneous coronary intervention check sheet needs to be completed in a timely manner in preparation for the patient to go to the cardiac cath lab, it is not the first priority of care in this scenario.
B. Blood pressure drop may be a transient response to the nitroglycerin; therefore, a vasopressor is not indicated unless the patient does not respond to fluid bolus resuscitation.
C. The patient’s 12-lead ECG reveals an injury pattern that is consistent with a lateral wall myocardial infarction, which is usually not associated with a right ventricular wall myocardial infarction.
D. Patients can be sensitive to the vasodilation effects of nitroglycerin. Initial intervention is the administration of a fluid bolus for the hypotension that occurs secondary to the nitroglycerin.
Category: Cardiovascular Emergencies, Acute coronary syndrome
Question 23
A patient with chest pain has a 12-lead electrocardiogram (ECG) that shows ST-segment elevation in leads V1–V6. This ST-segment pattern is consistent with an occlusion in which coronary artery?
Posterior descending artery
Circumflex artery
Right coronary artery
Left anterior descending artery
✓
Correct Answer
Left anterior descending artery
A. Occlusion of the LAD will show ST-segment elevation in the septal (V1–V2), anterior (V3–V4), and lateral (I, aVL, V5–V6) leads.
B. Circumflex artery occlusion would reflect changes as identified in the anterior and lateral leads (V5, V6, and III) of the ECG.
C. Posterior descending artery occlusion would reflect changes as identified in an inferior myocardial infarction ECG pattern.
D. Right coronary artery occlusion would reflect changes as identified in an inferior wall and right ventricular myocardial infarction ECG pattern.
Category: Cardiovascular Emergencies, Acute coronary syndrome
Question 24
A 68-year-old female presents with weakness, lightheadedness, and nausea. She denies the presence of chest pain or shortness of breath. What is the priority intervention?
Complete the triage process, including obtaining past medical history, current medications, and family history
Instruct the patient to chew 325 mg aspirin
Obtain vascular access and draw necessary laboratory studies specific to cardiac biomarkers
Perform a 12-lead electrocardiogram (ECG)
✓
Correct Answer
Perform a 12-lead electrocardiogram (ECG)
A. Having the patient chew aspirin is not the first priority. After obtaining a brief patient history and allergies, the aspirin can be administered.
B. Although this intervention would provide additional pertinent information, it would delay the acquisition of the necessary 12-lead ECG.
C. This needs to be completed, but it is not the first priority in the care of this patient.
D. The patient is describing an atypical acute coronary syndrome presentation. Women have a unique presentation of signs and symptoms, and their care is at risk of being delayed because of lack of early recognition. The 12-lead ECG should be completed within 10 minutes of arrival at the emergency department.
Category: Cardiovascular Emergencies, Acute coronary syndrome
Question 25
In a patient with acute respiratory distress syndrome, the goal of using a low tidal volume with mechanical ventilation is to:
prevent volutrauma.
✓
achieve normal blood gas values.
prevent ventilator–patient dyssynchrony.
wean the patient from the ventilator.
Correct Answer
prevent volutrauma.
A. The goal of low tidal ventilation is to prevent further lung injury so that the patient can be removed from the ventilator earlier than anticipated; weaning the patient from the ventilator is not the goal of low tidal ventilation.
B. The goal of treatment in caring for a patient with acute respiratory distress syndrome (ARDS) is to provide the best oxygenation possible without further injury to lung tissue. A patient with ARDS will not have normal blood gas values.
C. High tidal volumes can lead to ventilator-associated lung injury caused by overstretching of the lung tissue.
D. Ventilator–patient dyssynchrony is caused by spontaneous breathing during mechanical ventilation and can lead to lack of control of the tidal volumes being delivered.
Category: Respiratory Emergencies, Respiratory distress syndrome
Question 26
Which of the following demonstrates that effective cardiopulmonary resuscitation (CPR) is being delivered to a patient in cardiopulmonary arrest?
Waveform variation on the cardiac monitor
End-tidal CO of 20 mm Hg 2
✓
Decreased coronary perfusion pressure
Arterial pH of 6.9
Correct Answer
End-tidal CO of 20 mm Hg 2
A. Movement of the cardiac monitor cable can cause waveform movement on the cardiac monitor during CPR. This is not a reliable indicator of adequate CPR performance.
B. End-tidal CO levels greater than 10 mm Hg during CPR efforts 2 demonstrate adequate chest compression depth and good-quality CPR. The higher the end-tidal CO levels during resuscitation, the greater the likelihood 2 of return of spontaneous circulation.
C. An arterial pH of 6.9 demonstrates profound acidosis and would not be an indicator that effective CPR is being performed.
D. An increase in coronary perfusion pressure would be an indicator of good-quality CPR. Coronary perfusion pressures relate to myocardial blood flow and return of spontaneous circulation.
Category: Cardiovascular Emergencies, Cardiopulmonary arrest
Question 27
What is an appropriate intervention to reduce the risk for ventilator-associated pneumonia (VAP) in the emergency department?
Provide maximum sedation
Apply soft wrist restraints
Obtain serial CBC checking for leukocytosis
Elevate the head of the bed (HOB) 30–45 degrees
✓
Correct Answer
Elevate the head of the bed (HOB) 30–45 degrees
A. Maintaining the HOB at 30–45 degrees unless contraindicated is a component of the VAP strategies. Other strategies include strict handwashing and standard precautions, suction if needed, turning the patient every 2 hours, limiting sedation, and spontaneous breathing trials.
B. The patient with VAP may have elevated white blood cells. Obtaining lab specimens to check for this phenomenon would not reduce the risk. It would potentially identify its presence.
C. Increased sedation may be needed in the early phase of intubation; however, oversedation should be avoided.
D. Soft wrist restraints are useful in the prevention of accidental extubation, but they do not directly prevent VAP.
Category: Respiratory Emergencies, Infections
Question 28
Which symptom would prompt the nurse to suspect an abdominal aortic aneurysm (AAA)?
Hypertension
Distant heart sounds
Subcutaneous emphysema
Pulsatile mass
✓
Correct Answer
Pulsatile mass
A. Although the presence of a pulsatile mass in the abdomen may not always occur in a patient with an AAA, when present, the nurse should be highly suspicious of AAA and intervene immediately. Bedside ultrasonography can assist in a rapid diagnosis.
B. Distant heart sounds is an assessment finding in patients with cardiac tamponade.
C. Hypotension, not hypertension, is an indicator of an abdominal aortic aneurysm.
D. Subcutaneous emphysema is an assessment finding of tension pneumothorax but is not associated with an AAA.
Category: Cardiovascular Emergencies, Aneurysm and dissection
Question 29
Which patient would be an ideal candidate for targeted temperature management?
A patient remaining in ventricular fibrillation following a cardiopulmonary arrest
A responsive emergency patient who achieved return of spontaneous circulation (ROSC) following a successful resuscitation by emergency medical services personnel
A patient with an elevated temperature above 39.4°C (103°F) with a lactic acid level of 6.0 mmol/L
An unresponsive patient who arrives at the emergency department with ROSC following cardiopulmonary arrest
✓
Correct Answer
An unresponsive patient who arrives at the emergency department with ROSC following cardiopulmonary arrest
A. Targeted temperature management is not used for septic patients to control temperature. Cooling blankets can be used to lower extremely high temperatures but not to a certain target level for an extended period of time. The lactic acid level of 6.0 mmol/L could indicate sepsis.
B. The ideal candidate for targeted temperature management is the patient with ROSC following cardiopulmonary arrest who remains unresponsive. According to the American Heart Association 2020 guidelines for postresuscitation care, targeted temperature management should not be routinely initiated in the field using cold intravenous fluids or other invasive methods.
C. The ideal candidate for targeted temperature management is the patient with ROSC following cardiopulmonary arrest who remains unresponsive. According to the American Heart Association’s 2020 guidelines for postresuscitation care, the described patient should be considered for targeted temperature management immediately on arrival at the emergency department.
D. The ideal patient for targeted temperature management is a patient returning to spontaneous circulation who remains unresponsive. Ventricular fibrillation does not provide for circulating blood flow; therefore, this patient would not be a candidate for targeted temperature management.
Category: Cardiovascular Emergencies, Cardiopulmonary arrest
Question 30
The nurse is providing discharge education to a patient who has been diagnosed with pelvic inflammatory disease. You are discussing some of the potential long-term complications of untreated pelvic inflammatory disease and methods to prevent a recurrence. To be sure that the patient understands this information, you ask, “What are some of the things we covered?” Which patient response demonstrates understanding of pelvic inflammatory disease?
“I can douche as often as I like.”
“Now that I have been treated, I don’t have to worry about using condoms since I am on birth control pills.”
“I am more likely to have a tubal pregnancy because of the scarring.”
✓
“I need to take the medications, but I can stop once the pain goes away.”
Correct Answer
“I am more likely to have a tubal pregnancy because of the scarring.”
A. It must be stressed that the use of condoms will decrease the risk of getting a STI. Condoms should be used even if the patient uses other methods of birth control.
B. Sometimes the symptoms go away before the infection is cured. If they do, the patient should be told to take all of the medicine for as long as it is prescribed.
C. Scarring from PID also can prevent a fertilized egg from moving into the uterus. Instead, it can begin to grow in the fallopian tube, resulting in an ectopic pregnancy.
D. Women who douche may have a higher risk of getting PID than women who do not douche. This is because douching can cause harmful changes in the healthy bacteria that live in the vagina.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 31
A young female presents stating that she may have been sexually assaulted the night before. She states she was at a nightclub and awoke this morning in an unfamiliar place. She complains of vaginal soreness and bruising of her labia. Which statement made by the patient would further suggest to the nurse that a sexual assault may have been drug-facilitated?
“I woke up this morning and had nausea and vomiting.”
“I remember having a lot of drinks and then don’t remember much after that.”
“When I woke up this morning, I could not find my underwear.”
“I had one drink and then cannot recall the events of the evening.”
✓
Correct Answer
“I had one drink and then cannot recall the events of the evening.”
A. Nausea and vomiting may be a reaction to alcohol intake and do not independently suggest flunitrazepam (Rohypnol), ketamine, or gamma-hydroxybutyric acid (GHB).
B. Drug-facilitated sexual assault (DFSA) drugs such as flunitrazepam (Rohypnol), ketamine, and gamma-hydroxybutyric acid (GHB) can be added to drinks without changing the color, flavor, or odor of the beverage. Alcohol-induced amnesia is associated with excessive alcohol use, not one serving of alcohol.
C. Victims of a drug-facilitated sexual assault may find that their clothes are torn, or they are wearing their clothes improperly, such as inside-out or backward, but not being able to find them is not necessarily a sign of a drug-facilitated assault.
D. Loss of memory can be associated with heavy drinking and thus may not necessarily be a sign of a drug-facilitated assault.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 32
A 38-week-pregnant female presents with a sudden onset of severe abdominal cramping and some dark red blood noted on her underwear. She notes that the baby is not as active as usual. Vital signs are as follows: BP 80 mm Hg by palpation, HR 140 beats/minute, and RR 24 breaths/minute. The nurse suspects that the patient is experiencing:
amniotic fluid embolism.
active labor.
placenta previa.
abruptio placentae.
✓
Correct Answer
abruptio placentae.
A. Abruptio placenta is the premature separation of the placenta from its implantation site. Clinical presentation typically includes sudden onset of abdominal pain, an insignificant amount of dark red vaginal bleeding, and fetal distress. Depending on the extent of separation, fetal and maternal death can occur as a result of hemorrhage and hypovolemic shock. Placental abruption should be suspected in any pregnant female in the third trimester who presents with abdominal pain and vaginal bleeding.
B. Placenta previa refers to a placenta implanted over, or in close proximity to, the internal cervical os. The most characteristic clinical finding is painless, bright red bleeding.
C. During labor, the patient presents with contractions that may be mild to severe in nature. There is an increase in bloody show. The patient’s vital signs are normal, not hypotensive.
D. Amniotic fluid embolism is a catastrophic event in which amniotic fluid leaks into the mother’s circulation during labor or delivery, causing sudden respiratory distress and cardiopulmonary arrest. An amniotic fluid embolus can occur as a result of a placental abruption, but this patient’s symptoms of hypotension and tachycardia are consistent with hypovolemia as a result of bleeding.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 33
A 12-week-pregnant female presents with complaints of lower abdominal pain and light vaginal spotting. What information gathered from her history would place her at an increased risk for an ectopic pregnancy?
Pelvic inflammatory disease
✓
An incompetent cervix
Maternal age under 25 years
A previous pregnancy of twins or triplets
Correct Answer
Pelvic inflammatory disease
A. The incidence of an ectopic pregnancy is greater when the mother’s age is 35 years of age or older.
B. An incompetent cervix will increase the mother’s risk for a spontaneous abortion but does not increase the risk for an ectopic pregnancy.
C. A history of multiple-gestation pregnancy does not increase the mother’s risk for a subsequent ectopic pregnancy.
D. A history of pelvic inflammatory disease, previous ectopic pregnancy, endometriosis, and assisted reproductive technology such as in vitro fertilization (IVF) significantly raises the mother’s risk for having an ectopic pregnancy.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 34
Following the emergency home delivery of a full-term infant, a soft, boggy uterus is noted in the mother. For which of the following diagnoses is this patient at highest risk?
Postpartum infection
Postpartum hemorrhage
✓
Eclampsia
Placenta previa
Correct Answer
Postpartum hemorrhage
A. The symptoms associated with a postpartum infection are generally evident between 1 and 3 days following delivery; they include abdominal tenderness and a low-grade fever, and they may include a malodorous vaginal discharge.
B. Placenta previa is a situation in which the placenta is implanted low in the uterus and attempts to deliver before the fetus. This would be noted at the time of delivery and would manifest with painless vaginal bleeding, placing the mother at risk for hemorrhage.
C. Eclampsia in the postpartum patient is characterized by seizure activity.
D. A soft, boggy uterus is the assessment finding for uterine atony. Uterine atony is the most common cause of a significant postpartum hemorrhage. The nurse should perform manual massage of the uterus to help expel retained clots and restore uterine tone.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 35
During neonatal resuscitation, which of the following assessment parameters will provide the most accurate evaluation of the infant’s respiratory effectiveness?
Continuous cardiac monitoring
✓
Auscultation of the precordium
End-tidal CO measurement 2
Pulse oximetry monitoring
Correct Answer
Continuous cardiac monitoring
A. Changes in the heart rate of a newborn have been found to be the most sensitive indicator of the infant’s respiratory effectiveness. Measurement of the heart rate by pulse oximetry has not been found to be an accurate means to evaluate heart rate.
B. End-tidal CO monitoring and measurement is the most reliable method for 2 evaluating endotracheal tube placement and reflects alveolar gas exchange, but the heart rate more accurately assesses respiratory effectiveness.
C. An increase in the newborn’s heart rate is considered the most sensitive indicator of improvement in respiratory effectiveness. When compared with rate determination by either auscultation or pulse oximetry measurement, the three-lead electrocardiogram provides data with greater accuracy in a shorter period.
D. In previous treatment guidelines, auscultation of the precordium was recommended as the preferred method to evaluate heart rate. However, this method was determined to be unreliable and inaccurate because providers tended to underestimate the infant’s pulse rate, potentially leading to unnecessary interventions. In its 2020 Neonatal Resuscitation Guidelines, the American Heart Association recommends cardiac monitoring as the best method to evaluate changes in the infant’s heart rate.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 36
A patient in the 30th week of pregnancy presents with complaints of headache and swelling of the hands and face. Blood pressure is 154/92 mm Hg. Which of the following medications should be anticipated for this patient?
Acetaminophen (Tylenol)
Magnesium sulfate
✓
Furosemide (Lasix)
Labetalol (Normodyne)
Correct Answer
Magnesium sulfate
A. A blood pressure of 140/90 mm Hg is considered hypertension; however, lowering the diastolic pressure to less than 90–100 mm Hg may result in placental hypoperfusion and lead to fetal distress.
B. This patient is exhibiting signs and symptoms of preeclampsia. Edema associated with preeclampsia is a result of vasospasm, causing intravascular fluid to leak into the surrounding tissues; intravascular volume is therefore low. The administration of furosemide would cause further dehydration and potentially elevate the mother’s risk for seizures.
C. This patient is exhibiting signs and symptoms of preeclampsia. Preeclampsia is frequently associated with elevated liver enzymes. Administration of acetaminophen, a drug known to cause hepatotoxicity, therefore would be contraindicated for this patient.
D. This patient is exhibiting signs and symptoms of preeclampsia. Magnesium sulfate is given to decrease the seizure threshold in a patient who has preeclampsia.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 37
A 30-week-pregnant patient has onset of preterm labor after a motor vehicle crash. Which of the following medications would be administered to stimulate production of surfactant and reduce the potential for neonatal respiratory distress?
Betamethasone
✓
Magnesium sulfate
Oxytocin
Terbutaline
Correct Answer
Betamethasone
A. Oxytocin is indicated to stimulate labor contractions and would be contraindicated in this case.
B. When administered to a patient in preterm labor, magnesium sulfate may help reduce the risk of neurological injury that is associated with early birth. Magnesium sulfate is not indicated in the treatment of neonatal respiratory distress.
C. Terbutaline is a tocolytic medication that will delay preterm delivery from 2 to 7 days. It does not directly affect fetal lung development but will allow time for a full course of antenatal corticosteroids to be administered.
D. The use of betamethasone is indicated to hasten neonatal lung maturity for women greater than 24 weeks’ gestation who are at risk for delivery.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 38
A patient presents with pain and redness to the upper thigh, as well as abdominal rigidity, cramping, and pain after being at a campsite. Two small red marks are noted on the upper thigh. Which of the following would be the highest suspicion as the agent of injury for this patient?
Nonvenomous snake bite
Black widow spider bite
✓
Brown recluse spider bite
Scorpion sting
Correct Answer
Black widow spider bite
A. Nonvenomous snakes have rows of teeth and demonstrate scratch marks rather than a puncture wound. Although edema may be present, muscle cramps are not present.
B. A brown recluse spider bite is defined as necrotoxic, resulting in tissue destruction. Initially the bite will appear red and swollen, followed by a burning sensation at the site. The typical bite mark has a bluish discoloration, with tissue toxicity occurring over several hours.
C. The stings of most scorpions are considered harmless to humans and require no specific care or treatment. The sting causes immediate painful tingling at the site with local erythema and heightened sensitivity in the area.
D. A black widow spider bite is considered neurotoxic, causing initial stinging or severe sharp pain at the bite site, followed by redness or papules. Moderate edema is typically evident, along with a halo around the bite mark, which can appear as two small fang marks. Bites to the upper extremities may cause chest rigidity and spasms, and bites to the lower extremities can affect the abdominal area and back. Abdominal rigidity and pain can be present. The patient may also experience hypertension and diaphoresis. Black widow spiders are often found in outdoor latrines and are nocturnal in nature.
Category: Environment and Toxicology Emergencies, and Communicable
Question 39
Following a near drowning event, a patient’s reported arterial blood gas report is: pH 7.20 PaCO 35 mm Hg 2 PaO 75 mm Hg 2 HCO 18 mEq/L 3 Which of the following is the proper identification of these results?
Respiratory acidosis
Metabolic alkalosis
Metabolic acidosis
✓
Respiratory alkalosis
Correct Answer
Metabolic acidosis
A. The blood gas readings are indicative of metabolic acidosis, with an acidotic pH (normal pH = 7.35–7.45) and a decreased bicarbonate (HCO ) (normal = 22–28 3 mEq/L) level. The PaCO is normal (normal = 35–45 mm Hg). 2
B. The blood gas readings are indicative of metabolic acidosis, with an acidotic pH (normal pH = 7.35–7.45) and a decreased bicarbonate (HCO ) (normal = 22–28 3 mEq/L) level. The PaCO is normal (normal = 35–45 mm Hg). 2
C. Metabolic acidosis consists of a low pH, normal PaCO , and low HCO . 2 3 This blood gas result demonstrates metabolic acidosis, with a pH less than 7.35. The normal PaCO is 35–45 mm Hg, and the HCO is low, at 18 mEq/L, 2 3 with a normal value being 22–28 mEq/L.
D. The blood gas readings are indicative of metabolic acidosis, with an acidotic pH (normal pH = 7.35–7.45) and a decreased bicarbonate (HCO ) (normal = 22–28 3 mEq/L) level. The PaCO is normal (normal = 35–45 mm Hg). 3
Category: Environment and Toxicology Emergencies, and Communicable
Question 40
A school-age child is complaining of headache, muscle aches, and anorexia, with a low-grade fever and bilateral swollen salivary glands. The child has not received routine childhood immunizations. These assessment findings are most likely caused by which of the following disease processes?
Brucellosis
Rubella
Mumps
✓
Influenza
Correct Answer
Mumps
A. Fever, headache, muscle aches, and loss of appetite are all common signs and symptoms of influenza; however, swollen salivary glands are not a sign of influenza. Given the immunization status of this patient, the diagnosis of mumps is more probable.
B. The signs and symptoms exhibited in this case are classic findings in a child with mumps. In particular, the swollen salivary glands should alert the emergency nurse that this child may have mumps, especially with no vaccinations.
C. This child is at risk for rubella because of the immunization status and would likely experience many of these signs and symptoms. The first sign of rubella is generally a red rash that starts on the face and spreads, which this child does not have. Swollen salivary glands are not a manifestation of rubella.
D. Brucellosis is an infection caused by eating or drinking unpasteurized dairy products. Signs and symptoms include malaise, fever, lack of appetite, headache, and muscle pain, but not swollen salivary glands.
Category: Environment and Toxicology Emergencies, and Communicable
Question 41
Which of following findings would be expected in a patient diagnosed with diphtheria, indicating a severe complication of this disease?
ST-T wave changes
✓
Abdominal pain
Severe headache
High-grade fever
Correct Answer
ST-T wave changes
A. The presence of abdominal pain can be seen in many illnesses, but it is not a finding in patients with diphtheria.
B. In patients diagnosed with diphtheria, changes such as ST-T wave changes and dysrhythmias can indicate the presence of myocarditis and other possible cardiac involvement.
C. A fever does occur with diphtheria but is rarely greater than 103°F (39.4°C). It would not necessarily indicate a complication of this disease process.
D. A severe headache can be experienced by many patients and can be seen in diphtheria, but it is not an indication of a complication of this disease.
Category: Environment and Toxicology Emergencies, and Communicable
Question 42
An infant with a pulse rate of 30 is limp and not breathing normally despite a patent airway and adequate oxygenation and ventilation. What is the priority intervention?
Defibrillate with 2 joules/kg
Administer epinephrine (Adrenalin) 0.01 mg/kg
Continue rescue breathing at a rate of 20 breaths per minute
Initiate chest compressions at a rate of 100–120 per minute
✓
Correct Answer
Initiate chest compressions at a rate of 100–120 per minute
A. Rescue breathing would be indicated for an infant not breathing or not breathing normally, but chest compressions should be started immediately because of the presence of a pulse rate less than 60 with poor perfusion despite adequate oxygenation ventilation.
B. Chest compressions should be started immediately because of the pulse rate less than 60 beats per minute despite adequate oxygenation and ventilation.
C. Cardiopulmonary resuscitation with compressions and ventilations should be the immediate treatment. Defibrillation should be used in the presence of ventricular tachycardia without a pulse or if ventricular fibrillation rhythm is present. A pulse rate of 30 is described in this infant; therefore, the initiation of chest compressions at a rate of 100–120 is the priority.
D. Epinephrine would be indicated in this scenario if bradycardia persists despite correction of the underlying causes (i.e., hypoxia), but not before good-quality cardiopulmonary resuscitation has been initiated.
Category: Cardiovascular Emergencies, Cardiopulmonary arrest
Question 43
A patient presents with complaints of dizziness and palpitations. The electrocardiogram shows an accelerated junctional rhythm. What is the most likely cause?
Uncontrolled diabetes mellitus
Digoxin toxicity
✓
Chronic obstructive pulmonary disease
Marijuana use
Correct Answer
Digoxin toxicity
A. Marijuana use is associated with increases in heart rate that commonly originate in the sinus node, as seen in sinus tachycardia.
B. Chronic obstructive pulmonary disease is not commonly associated with an accelerated junctional rhythm.
C. Digitalis toxicity leads to the development of atrioventricular dysrhythmias and is a classic cause of an accelerated junctional rhythm.
D. Dysrhythmias that are associated with diabetes are frequently related to electrolyte imbalances and usually originate in the sinus node, not the atrioventricular node.
Category: Cardiovascular Emergencies, Dysrhythmias
Question 44
A patient is diagnosed with endocarditis. Which of the following statements indicates that the patient understands a possible cause of this disease?
“Endocarditis is a complication caused by my continued smoking.”
“Endocarditis may have been caused by my recent body piercings.”
✓
“I cannot believe I got this disease from a tick bite.”
“I never knew that this type of infection could originate from having the flu.”
Correct Answer
“Endocarditis may have been caused by my recent body piercings.”
A. Endocarditis has not been described as occurring as a complication of the flu (influenza).
B. Endocarditis is not considered a tickborne disease. Common tickborne diseases include Rocky Mountain spotted fever and Lyme disease.
C. Infective endocarditis has been shown to occur after recent body piercings or tattooing, in addition to recent cardiac surgery, prosthetic valve replacements, and cardiac pacemaker insertions. Poor dental hygiene, intravenous drug abuse, and rheumatic heart disease also have been noted to contribute to endocarditis.
D. Smoking causes significant pulmonary disease and vasoconstriction but is not generally related to endocarditis.
Category: Cardiovascular Emergencies, Endocarditis
Question 45
A female who is 26 weeks pregnant is sent to the emergency department by her OB/GYN physician because of elevated blood pressure. The nurse is aware that gestational hypertension is defined as:
diastolic BP greater than 90 mm Hg with a systolic BP above 110 mm Hg.
systolic BP 10 mm Hg above baseline and elevated pulse rate.
diastolic BP 20 mm Hg above baseline with a systolic BP 10 mm Hg above baseline.
systolic BP above 140 mm Hg or diastolic BP above 90 mm Hg.
✓
Correct Answer
systolic BP above 140 mm Hg or diastolic BP above 90 mm Hg.
A. Gestational hypertension is defined as a systolic BP above 140 mm Hg or diastolic BP above 90 mm Hg.
B. Gestational hypertension is defined as systolic BP above 140 mm Hg or diastolic BP above 90 mm Hg. The patient’s pulse rate is not defined in gestational hypertension.
C. Gestational hypertension is defined as systolic BP above 140 mm Hg or diastolic BP above 90 mm Hg. The systolic reading that is 10 mm Hg above baseline and diastolic reading that is 20 mm Hg above baseline are not variations used to define gestational hypertension.
D. Gestational hypertension is defined as systolic BP above 140 mm Hg or diastolic BP above 90 mm Hg. The diastolic value greater than 90 mm Hg and systolic value greater than 110 mm Hg are not correct for the definition for gestational hypertension.
Category: Cardiovascular Emergencies, Hypertension
Question 46
A patient is diagnosed with pericarditis. Based on this diagnosis, the nurse anticipates an order to administer which medication to this patient?
A. TPA is used to treat acute ischemic strokes and acute myocardial infarctions; it is not recommended in the treatment of pericarditis.
B. Nitroglycerine is used for the treatment of angina; it is not indicated for pericarditis.
C. Furosemide is used to treat heart failure; it is not indicated in the treatment of pericarditis.
D. Anti-inflammatory medications are the recommended treatment for pericarditis.
Category: Cardiovascular Emergencies, Pericarditis
Question 47
A patient presents with pain in their left lower leg. The assessment reveals the left lower leg to be pale and cool when compared with the right leg. Femoral pulses are equal, but the pulse behind the knee is significantly diminished on the left leg. The nurse suspects that the patient has which of the following?
Occlusion of the popliteal artery
✓
Occlusion of the femoral vein
Occlusion of the saphenous vein
Occlusion of the femoral artery
Correct Answer
Occlusion of the popliteal artery
A. Venous occlusion generally causes the limb to become engorged and ruddy in appearance, with little change in skin temperature.
B. The femoral artery is the main artery to the lower extremity. If the femoral artery were occluded, the patient would be exhibiting signs and symptoms affecting the entire leg.
C. Arterial occlusion causes diminished pulses, cooler temperature, and pain as a result of ischemia. The patient has equal femoral pulses, so the occlusion is distal and more likely to be the popliteal artery located in the soft space behind the knee.
D. Venous occlusion generally causes the limb to be engorged and ruddy, with little change in skin temperature.
Category: Cardiovascular Emergencies, Thromboembolic disease (e.g., deep vein
Question 48
Which assessment finding suggests that a patient is in compensated shock?
Marked hypotension
Weak, thready pulses
Narrowing pulse pressure
✓
Increased lactic acid level
Correct Answer
Narrowing pulse pressure
A. Marked hypotension that is unresponsive to vasopressors is a sign of irreversible shock.
B. Narrowing pulse pressure is an assessment finding associated with the presence of compensated shock. A bounding pulse is also an assessment finding that can indicate the presence of compensated shock.
C. Weak, thready pulses are associated with the presence of progressive or decompensated shock.
D. Increased lactic acid level is a symptom of progressive or decompensated shock.
Category: Cardiovascular Emergencies, Cardiogenic shock and obstructive shock
Question 49
Assessment findings of an unresponsive patient who hit a tree while snow skiing reveal hypotension, bradycardia, and warm, dry skin. What type of shock does the nurse suspect?
Distributive shock
✓
Hypovolemic shock
Obstructive shock
Progressive shock
Correct Answer
Distributive shock
A. The patient is at high risk for having sustained a spinal cord injury, resulting in the presence of neurogenic shock, a type of distributive shock. A disruption in the sympathetic regulation of vagal tone leads to venous and arterial vasodilation and loss of vascular resistance, resulting in hypotension, bradycardia, and warm, dry skin.
B. Obstructive shock occurs when there is an obstruction in either the vasculature or the heart, resulting in hypoperfusion of the tissues. The most common cause of obstructive shock is a pulmonary embolus.
C. Progressive shock is decompensated shock. The classic signs of progressive or decompensated shock are increased heart rate, decreased urinary output, decreased blood pressure, and altered mental status.
D. If the patient were exhibiting symptoms of hypovolemic shock, tachycardia and cool, clammy skin would have been present. This patient is exhibiting signs of neurogenic shock, a type of distributive shock characterized by hypotension, bradycardia, and warm, dry skin.
Category: Cardiovascular Emergencies, Cardiogenic shock and obstructive shock
Question 50
An infant with a history of cardiomyopathy presents lethargic, pale, and with weak peripheral pulses. After the infant is diagnosed with heart failure, the appropriate medication doses of an inotrope and a diuretic are administered. The emergency nurse can anticipate that the infant will demonstrate which of the following outcomes from the administration of these medications?
Warm extremities
✓
A bounding pulse
Capillary refill time of 3 seconds
Urine output of 0.5 mL/kg per hour
Correct Answer
Warm extremities
A. Normal urinary output for an infant is 2 mL/kg per hour. A urine output of 0.5 mL/kg per hour would indicate decreased renal and tissue perfusion.
B. A capillary refill time of less than 2 seconds would indicate clinical improvement of increased perfusion and a return to a normal hemodynamic state. A capillary refill time of 3 seconds indicates decreased perfusion.
C. A bounding pulse is a symptom of distributive shock, indicating inappropriate distribution of fluids. The peripheral pulse would be stronger, but not bounding, following administration of the inotrope and diuretic medications.
D. Warm extremities would indicate clinical improvement of increased perfusion and a return to a normal hemodynamic state. The infant’s weak peripheral pulses indicate decreased perfusion to the extremities, which results in skin that initially is cool to the touch.
Category: Cardiovascular Emergencies, Cardiogenic shock and obstructive shock
Question 51
A patient with a history of heart failure presents with shortness of breath, cough, and pleuritic chest pain. The nurse also notes crackles throughout the lung fields and 3+ edema to the bilateral lower extremities. A chest radiograph reveals small abnormal collections of fluid at the lateral lung bases. What is the most appropriate response by the nurse to the patient?
“There is no specific treatment for your symptoms at this time.”
“A thoracentesis will likely need to be performed to withdraw the fluid in your chest cavity.”
“Diuretic therapy may help relieve some of the fluid accumulated throughout your body.”
✓
“You will possibly need urgent dialysis to pull some of the fluid that is built up.”
Correct Answer
“Diuretic therapy may help relieve some of the fluid accumulated throughout your body.”
A. Clinical manifestations of a pleural effusion are dyspnea, cough, and pleuritic chest pain. The most common cause of pleural effusion is heart failure, and management is to treat the underlying cause with diuresis.
B. Dialysis may be needed, but less drastic attempts to remove the fluid should be made first.
C. A thoracentesis is performed to remove large collections of thoracic fluid; at this time, only small collections of fluid are noted, which should respond to diuretic therapy.
D. Diuretic therapy may help remove some of the fluid from the chest cavity and interstitial spaces.
Category: Respiratory Emergencies, Pleural effusion
Question 52
A hypoxic patient presents to the emergency department. The patient is immediately stabilized, and arterial blood gases are then drawn with the following results: pH 7.47; pCO 33 mm Hg; HCO 24 mEq/L. The nurse recognizes these 2 3 values indicate which of the following abnormalities?
Metabolic alkalosis
Metabolic acidosis
Respiratory acidosis
Respiratory alkalosis
✓
Correct Answer
Respiratory alkalosis
A. The pH is elevated, indicating alkalosis.
B. The low pCO with an elevated pH is an indication of respiratory alkalosis. 2
C. The pH is elevated, showing alkalosis, and HCO is normal, indicating that the 3 driving force is the respiratory system, not the metabolic system.
D. The HCO is normal, showing that the driving force of imbalance is related to the 3 respiratory system, not the metabolic system.
Category: Respiratory Emergencies, Noncardiac pulmonary edema
Question 53
The emergency nurse is caring for a patient with a pulmonary embolism. An order is expected for which of the following diagnostic tests?
Chest CT scan without intravenous contrast
Spiral computed tomography (CT) scan
✓
Chest radiograph
Ventilation/perfusion scan
Correct Answer
Spiral computed tomography (CT) scan
A. A CT scan is the recommended study for evaluating the perfusion of blood through the lungs to identify the presence of a pulmonary embolism. Using intravenous (IV) contrast, CT angiography has sensitivity and specificity comparable to that of contrast pulmonary angiography.
B. A chest radiograph (CXR) may be used for preliminary findings; however, it does not provide the detail needed for diagnosis of a pulmonary embolism. On rare occasions, the CXR may show a dilation of the pulmonary vessels proximal to an embolism, along with collapse of distal vessels, referred to as Westermark’s sign.
C. Although performing a ventilation/perfusion scan is an option for patients with allergies to IV contrast or when multidetector CT angiography is not available, it is not the recommended study for diagnosis of a pulmonary embolism.
D. Without timed contrast to evaluate blood flow through the lungs, a chest CT scan may be unable to detect the presence of a pulmonary embolism.
Category: Respiratory Emergencies, Pulmonary embolus
Question 54
A patient presents to the emergency department with severe dyspnea. The arterial blood gas results are pH 7.51, pCO 26 mm Hg, HCO 24 mEq/L. What acid–base 2 3 imbalance is present?
Metabolic acidosis
Metabolic alkalosis
Respiratory alkalosis
✓
Respiratory acidosis
Correct Answer
Respiratory alkalosis
A. The pH is high, indicating alkalosis; the pCO is low, indicating that the 2 cause is not metabolic, but the result of the patient’s respiratory status.
B. The pH is high, indicating alkalosis; the pCO is low, indicating that the cause is 2 respiratory; and the HCO remains within normal limits of 22–26 mEq/L. For the 3 arterial blood gas result to indicate metabolic alkalosis, the HCO would need to be 3 greater than 26 mEq/L.
C. The pH is high, indicating alkalosis. The pCO is low, indicating that the cause is 2 respiratory; the patient is retaining CO , and the cause is respiratory because the 2 result is less than 35. The HCO is within normal limits of 22–26 mEq/L, indicating 3 the cause of the patient’s abnormal values is not metabolic.
D. The pH is high, indicating alkalosis. The pCO is low, indicating that the cause is 2 respiratory. For acidosis to occur, the pH would need to be below 7.35. The patient is retaining CO , and the cause is respiratory. The HCO remains stable, indicating 2 3 that the blood is being adequately buffered by HCO from the kidneys. 3
Category: Respiratory Emergencies, Pulmonary embolus
Question 55
A patient who has been stabbed in the right chest arrives via emergency medical services. On assessment, the emergency nurse identifies the presence of a hissing sound with inspiration. What is the priority intervention?
Apply an occlusive dressing with firm pressure
Prepare for intubation and mechanical ventilation
Apply an occlusive dressing taped on three sides
✓
Prepare the patient for a computed tomography scan
Correct Answer
Apply an occlusive dressing taped on three sides
A. In the presence of a pneumothorax that has the potential to become a tension pneumothorax, an increase in the presence of breath sounds indicates a positive patient response to the intervention. A decrease in breath sounds is an indication of continued deterioration of the patient’s condition.
B. An improvement in the patient’s PaO level is an indication that the patient’s 2 oxygenation and gas exchange have improved.
C. The patient should experience a respiratory rate decrease in response to the intervention.
D. Continued retention of PaCO indicates that the patient is experiencing 2 hypercapnia and continued respiratory difficulty with inadequate gas exchange.
Category: Respiratory Emergencies, Respiratory trauma
Question 56
A patient diagnosed with Guillain–Barré syndrome presents complaining of progressive weakness and tingling of both upper and lower extremities over the past several weeks and difficulty breathing. Vital signs are BP 130/80 mm Hg, HR 92 beats/minute, RR 28 breaths/minute, SpO 90% on room air. Which of the 2 following interventions is most appropriate at this time?
Prepare for an electromyogram
Administer immune globulin
Prepare for plasmapheresis
Monitor the depth and adequacy of respirations
✓
Correct Answer
Monitor the depth and adequacy of respirations
A. There is potential for hypoventilation because of the patient’s respiratory muscle weakness, so careful monitoring of the patient’s respiratory pattern is important. Mechanical ventilation may be required until the patient’s respiratory muscle weakness spontaneously resolves, which is generally weeks after its onset.
B. Electromyograms are used to identify peripheral nerve demyelination to establish a diagnosis; however, they are not an emergent diagnostic study. In addition, performing a diagnostic study will not treat the patient’s current symptoms of increasing muscle weakness.
C. Intravenous immune globulin is frequently given to Guillain–Barré syndrome patients, but this will not immediately treat the patient’s symptoms of hypoventilation.
D. Plasmapheresis may be prescribed, but this will not immediately treat the patient’s symptoms of hypoventilation.
Category: Neurological Emergencies, Neurological disorders (e.g., multiple
Question 57
A patient presents complaining of a headache that feels like someone is squeezing their head in a grip. They say that this type of headache occurs every month. There are no associated signs and symptoms. The emergency nurse is aware that the patient is describing which type of headache?
Subcortical headache
Tension headache
✓
Cluster headache
Migraine headache
Correct Answer
Tension headache
A. A tension headache is associated with a report of tightening- or squeezing-type pain. It is frequently described as being a dull nonpulsating pain that begins in the occipital area and moves bilaterally to the frontal region.
B. A migraine headache is most often unilateral, has a pulsating quality, and rarely occurs without other associated symptoms such as nausea or photophobia.
C. Subcortical means below the cortex of the brain and is not a type of headache.
D. A cluster headache causes a severe sharp burning sensation. The associated pain is excruciating and results in tearing and nasal congestion with redness of the eye, diaphoresis, and pallor.
Category: Neurological Emergencies, Headache (e.g., temporal arteritis, migraine)
Question 58
The nurse is discharging a patient following treatment for a migraine headache. The patient’s discharge medications include sodium valproic acid (Depakote) to be used as a prophylaxis for the treatment of migraine headache. Which of the following statements by the patient indicates the need for further teaching?
“I should avoid medications with aspirin.”
“If I develop abdominal pain, I will call my doctor.”
“The doctor says my liver function tests are normal.”
“My boyfriend and I are not using birth control right now.”
✓
Correct Answer
“My boyfriend and I are not using birth control right now.”
A. Before valproic acid is prescribed, the provider screens the patient and checks liver function tests.
B. Aspirin increases the concentration of valproic acid.
C. Valproic acid is considered one of the most teratogenic drugs. It can result in neural tube, cardiac, and facial defects; therefore, birth control measures are indicated when taking this medication.
D. Patients who are taking valproic acid are at risk of developing abdominal pain secondary to the presence of pancreatitis.
Category: Neurological Emergencies, Headache (e.g., temporal arteritis, migraine)
Question 59
A young adult presents to the emergency department complaining of a headache, fever, petechial rash, and neck pain. What should be performed before any further contact with this patient?
Don personal protective equipment (PPE)
✓
Send a lab specimen to confirm diagnosis
Initiate intravenous access
Initiate administration of antibiotic and dexamethasone
Correct Answer
Don personal protective equipment (PPE)
A. Lab confirmation of the diagnosis is low on the list of priorities for this patient. The patient will require a lumbar puncture to confirm the diagnosis of meningococcemia. Meningitis can be fatal up to 56% of the time and has a high morbidity.
B. Intravenous access is priority; however, protection of the team is the first priority before proceeding with further patient care.
C. This patient raises a high degree of suspicion for meningococcemia, which is most commonly spread by respiratory droplets. The first priority is for the team to don PPE. To minimize the risk of exposure, the patient should be placed in respiratory isolation as indicated.
D. These are the drugs of choice for treatment of meningococcemia, but the first priority is protection of the team with PPE.
Category: Neurological Emergencies, Meningitis
Question 60
Which of the following instructions are included at discharge for a patient with mild traumatic brain injury?
The patient should avoid contact sports; all other activities are permitted.
If the patient is headache free, they can resume their normal activities.
The patient may need to refrain from engaging in activities such as computer work, texting, and watching TV for several days.
✓
The patient did not experience a loss of consciousness, so they may return to their usual activities.
Correct Answer
The patient may need to refrain from engaging in activities such as computer work, texting, and watching TV for several days.
A. Only 10% of patients with a mild traumatic brain injury experience a loss of consciousness; however, the patient still has a brain injury that occurred without a loss of consciousness.
B. A mild traumatic brain injury is a functional brain injury and requires both physical and cognitive rest to support recovery.
C. Mild traumatic brain injures may take 7–10 days or longer to resolve.
D. A patient with a mild traumatic brain injury needs both physical and cognitive rest to support recovery.
Category: Neurological Emergencies, Neurogenic shock
Question 61
Which lobe of the brain causes visual loss after head trauma?
The occipital lobe
✓
The frontal lobe
The temporal lobe
The parietal lobe
Correct Answer
The occipital lobe
A. The occipital lobe is responsible for vision and balance.
B. The frontal lobe is responsible for personality and motor function, not vision.
C. The temporal lobe is responsible for hearing, not vision.
D. The parietal lobe is responsible for sensory integration, not vision.
Category: Neurological Emergencies, Neurogenic shock
Question 62
An 18-month-old patient arrives with projectile vomiting for the past 12 hours. Vital signs are stable, and the patient is afebrile. The parent states that the child has a ventriculoperitoneal (VP) shunt but no other medical history. Which of the following is the most likely cause of the vomiting?
Viral syndrome
Shunt malfunction
✓
Gastroenteritis
Head injury
Correct Answer
Shunt malfunction
A. The patient is afebrile and vital signs are stable, so viral syndrome is unlikely.
B. Although gastroenteritis causes vomiting, it can also result in diarrhea, which this child does not have. The history of a VP shunt contributes to the likelihood that the patient’s projectile vomiting is related to increased intracranial pressure secondary to the shunt being clotted or dislodged.
C. VP shunts from brain to peritoneum can become occluded or displaced, requiring replacement as a child grows. The malfunctioning shunt results in hydrocephalus and the signs and symptoms of increased intracranial pressure, such as an altered level of consciousness, tense fontanelles (in children under 18 months), and projectile vomiting.
D. There is no history of a recent traumatic brain injury or assessment findings to indicate that this is the cause of the patient’s vomiting.
Category: Neurological Emergencies, Neurogenic shock
Question 63
Which of the following statements is true regarding interventions for frostbitten areas?
Immediately use ice or snow and gentle friction to massage the frozen area.
Rewarm the affected part in water temperatures of 103°F (39.4°C) to 106°F (41.1°C).
Protect and immobilize the affected extremity with loose dressings after thawing.
✓
Briskly rub the injured tissues in warm circulating water to increase blood flow.
Correct Answer
Protect and immobilize the affected extremity with loose dressings after thawing.
A. No friction or massaging should be used in the treatment of frostbite. This can further damage tissue. Ice or snow should not be used.
B. After rewarming, the affected area should be immobilized with bulky, loose sterile dressings. Cotton should be placed between digits, and blankets should not be used unless a bed cradle or similar device is used to keep pressure off the area. This intervention will help prevent further trauma.
C. Water temperature for the rewarming process should be between 99°F (37°C) and 102°F (39°C). The affected tissues should not touch the sides of the container.
D. Rubbing the injured tissue can lead to tissue destruction and additional trauma to the extremity. This is not recommended.
Category: Environment and Toxicology Emergencies, and Communicable
Question 64
Which of the following statements made by a patient diagnosed with Lyme disease indicates an understanding of discharge instructions?
“I should start to feel better after a few days of taking the antibiotics.”
“I may continue to experience fatigue for a month or longer.”
✓
“I will need to take antibiotics twice a day for 7 days.”
“I should avoid close contact with other people until I finish my antibiotics.”
Correct Answer
“I may continue to experience fatigue for a month or longer.”
A. It is common for patients with Lyme disease to experience fatigue for the 2–4 weeks of treatment and even longer. Some patients will experience fatigue for months following treatment.
B. According to the CDC, antibiotic treatment for Lyme disease is required for 10–14 days.
C. It is common for people with Lyme disease to experience lingering signs and symptoms after they have completed a full course of antibiotics.
D. There is no evidence that Lyme disease can be spread by direct person-to-person contact. It is transmitted by Ixodes ticks that carry the spirochete Borrelia burgdorferi.
Category: Environment and Toxicology Emergencies, and Communicable
Question 65
Which of the following sites is recommended in adults for the administration of intramuscular human diploid cell vaccine (HDCV) for rabies prophylaxis?
Dorsogluteal muscle
Gluteus maximus muscle
Vastus lateralis muscle
Deltoid muscle
✓
Correct Answer
Deltoid muscle
A. HDCV should never be administered in the gluteal area because it results in lower neutralizing antibody titers.
B. The deltoid muscle area is the only acceptable site of vaccination for adults and older children. For young children, the recommended site of HDCV administration is the anterolateral aspect of the thigh. HDCV is the vaccine that provides for active immunity and is provided on days 0, 3, 7, and 14. Immune globulin is a one-time dose, is administered for passive immunity, and is injected first around the bite area; the remainder is given at a site distant from that of the vaccine injection.
C. The deltoid muscle area is the only acceptable site of vaccination for adults and older children. For young children, the recommended site of HDCV administration is the anterolateral aspect of the thigh.
D. HDCV should never be administered in the gluteal area because it results in lower neutralizing antibody titers.
Category: Environment and Toxicology Emergencies, and Communicable
Question 66
When evaluating research data, which of the following statistical indicators best supports the validity of the data?
The number needed to treat is high.
The confidence interval is 90%.
The relative risk reduction is low.
The p-value (α) is reported as < 0.05.
✓
Correct Answer
The p-value (α) is reported as < 0.05.
A. The relative risk reduction is the mathematical difference in the outcomes of the experimental and control groups. This statistic can be misleading because a small difference in numbers, when translated into percentages, may appear larger and more significant.
B. The p-value indicates the probability that the findings are due simply to chance. A p-value of < 0.05 is generally accepted as being statistically significant and suggests that the findings are not due to chance alone.
C. This is a poor result in that there is a 10% chance that the findings are wrong. Most researchers consider a confidence interval between 95% and 99% to be acceptable.
D. The number needed to treat (NNT) indicates how many patients would need to be treated with a new therapy in order to achieve an outcome that is better than the current therapy. The ideal NNT = 1.
Category: Professional Issues, Nurse, Impaired nurse and drug diversion
Question 67
A young child arrives after a near drowning. Cardiopulmonary resuscitation (CPR) has continued for over 45 minutes, and the child remains in asystole. The child’s parents demand to be in the resuscitation room with their child. The nurse should do which of the following?
Ask the social worker or hospital chaplain to be with the parents in the private family waiting room.
Designate one person to provide the parents with updates on the condition of their child as indicated.
Explain to the parents that their child is critically ill, and staff will provide them with periodic updates on the condition of their child.
Offer the family presence at the bedside with a designated staff person to be with them.
✓
Correct Answer
Offer the family presence at the bedside with a designated staff person to be with them.
A. This may anger the parents further if staff do not permit them to see or be with their child during the actual resuscitation.
B. The social worker or chaplain should be notified to assist the family of a critically ill patient. The chaplain or social worker should be open and honest, and ensure that the family members are aware of what they will see; they can then decide if they wish to be at the bedside. If the family members request to be at the bedside, staff should attempt to honor their wishes.
C. Designation of one person as the patient advocate is important, but assisting the family to be at the bedside will often help them during the grieving process.
D. The Emergency Nurses Association has long advocated for family members to have the option to be at their loved one’s bedside. Emergency nurses have an obligation to provide the opportunity for the family to be in the treatment room. One designated healthcare team member should be assigned to be with the family members, explain in nonmedical terminology what is taking place, and provide the rationale as to why.
Category: Professional Issues, Patient, End-of-life and palliative care (e.g., organ and
Question 68
The nurse is participating on a committee that is developing guidelines for family presence during an emergency department resuscitation. This work includes which of the following considerations?
Situations in which family members should be offered the option of presence
Limitations to legally defined family members
The roles and responsibilities of each member of the resuscitation team
Education for resuscitation team members
✓
Correct Answer
Education for resuscitation team members
A. Education of all team members fosters support of inclusive family presence practices.
B. The roles and responsibilities of the physicians, nurses, and ancillary care personnel should not be affected by family presence in the resuscitation area.
C. All families should be offered the option of presence during a family member’s resuscitation.
D. The experience of each patient and family is unique, and no single model fits all. High-quality end-of-life care is multifaceted and requires an individual approach with acceptance of family diversity.
Category: Professional Issues, Patient, End-of-life and palliative care (e.g., organ and
Question 69
A patient who has been diagnosed with end-stage cardiac disease is receiving palliative care in the emergency department while awaiting placement in the hospice unit. Which of the following interventions is most appropriate for the nurse to implement in the care of this patient?
Restrict visitors to the patient’s immediate family
Provide oxygen to relieve the patient’s dyspnea
✓
Delegate hygiene care to family members
Obtain a 12-lead electrocardiogram
Correct Answer
Provide oxygen to relieve the patient’s dyspnea
A. In palliative care, the patient’s family should be encouraged and supported to participate in the care of the patient, but it cannot be assumed that the family is willing or able to assume the responsibility for any part of the patient’s care.
B. For the patient receiving palliative care, diagnostic testing should be cautiously considered. If the results obtained from the testing will not change the course of treatment or management, the diagnostic test may not be appropriate.
C. Palliative care is symptom management. Appropriate interventions that ease symptoms but do not attempt to treat the underlying disease process include providing oxygen, pain medications, or medications to relieve coughs or excessive fluids.
D. The emergency nurse should provide a private and quiet space within the emergency department in which care can be provided and where the patient, the patient’s family, and significant others can be together.
Category: Professional Issues, Patient, End-of-life and palliative care (e.g., organ and
Question 70
During a cardiac resuscitation, the provider orders amiodarone 600 mg intravenously to be given for ventricular fibrillation. The best action by the nurse is to:
ask for clarification of the dose before administering the medication.
✓
administer 300 mg of amiodarone as an intravenous bolus and the remaining 300 mg as an infusion drip.
mix the amiodarone in 300 mL of 0.9% sodium chloride and infuse over 30 minutes.
infuse the ordered dose of amiodarone over 1–2 minutes.
Correct Answer
ask for clarification of the dose before administering the medication.
A. The nurse should recognize that the dose ordered is not the recommended dose and should ask for clarification. The nurse should be prepared to state the correct recommended dose: amiodarone 300 mg as a rapid IV bolus initially, followed by a 150 mg rapid IV bolus. Safety measures should include closed-loop communication, readback protocols, and double-checking medication calculations before medication administration.
B. The dose ordered is not the recommended dose. Clarification must be obtained to prevent a medication error.
C. The dose ordered is not the recommended dose for amiodarone. In the presence of ventricular fibrillation, amiodarone is initially administered as an IV bolus.
D. This is not the advanced cardiac life support protocol for amiodarone in ventricular fibrillation. All members of the healthcare team must take responsibility to prevent medication errors by speaking up and asking for clarification. Patient safety and medication error prevention are a national initiative.
Category: Professional Issues, Patient, Patient safety
Question 71
Which of the following practices best contributes to patients’ reported satisfaction with their emergency department (ED) experience?
Providing pain management and accurate triage assessment
Maintaining actual wait times of less than 30 minutes
Using a combination of hourly rounding and bedside shift report
✓
Providing distractions such as television and food
Correct Answer
Using a combination of hourly rounding and bedside shift report
A. Recent literature has shown that patient satisfaction scores are similar for those who present with issues related to pain compared with those who do not.
B. Research has shown a correlation between EDs that use a combination of hourly rounding, bedside shift report, and AIDET (acknowledge, introduce, duration, explanation, and thank you), and increased satisfaction with the ED experience.
C. Data collected indicate that, although patients may appreciate distractions such as television and food, they do not contribute significantly to overall patient satisfaction.
D. Perceived, not actual, wait times are an important component of patient satisfaction with the ED experience.
Category: Professional Issues, Patient, Patient satisfaction
Question 72
Which of the following definitions best exemplifies the meaning of culture?
A group of people who share the same heritage or country of origin
A group of people who share the same attributes, such as social rank or socioeconomic status
The patterns of behavior and beliefs shared by persons living in a social group
✓
An organized or unorganized system of beliefs
Correct Answer
The patterns of behavior and beliefs shared by persons living in a social group
A. Culture is defined as the patterns of behavior and beliefs shared by persons living in a social group.
B. A group of people who share the same attributes, such as social rank or socioeconomic status, is the definition of a class.
C. The beliefs, values, and practices shared by a group of people based on heritage or the country of origin of one’s ancestors is the definition of ethnicity.
D. An organized or unorganized system of beliefs is the definition of religion.
Category: Professional Issues, Patient, Cultural considerations (e.g., interpretive
Question 73
A patient delivers a full-term baby in the emergency department of a facility that does not have OB/GYN or women’s services available. The ambulance transport crew has arrived to take the mother and baby to an appropriate accepting facility. Based on the Emergency Medical Treatment and Active Labor Act (EMTALA), the nurse identifies that this patient cannot be transported unless which of the following has occurred?
The baby is 1 hour old.
The placenta has been delivered.
✓
The nurse completes all necessary documentation.
The mother has voided urine.
Correct Answer
The placenta has been delivered.
A. The lack of voided urine by the mother following delivery would not be an indication for withholding transport if a patient is stable for transfer.
B. Nursing documentation is not affected by EMTALA. The nurse can finish any additional charting that was not complete after the patient is transported to another facility.
C. The age of the newborn infant is not a consideration under EMTALA. The patient and baby can leave after the delivery of the placenta and the mother and baby are both deemed to be in stable condition.
D. According to EMTALA, women who are in active labor are not considered stabilized until after the delivery of the placenta.
Category: Professional Issues, System, Federal regulations (e.g., HIPAA, EMTALA)
Question 74
Which type of consent for treatment is recognized when an alert and oriented patient presents for care in the emergency department?
Express consent
✓
Implied consent in law (emergency)
Implied consent
Involuntary consent
Correct Answer
Express consent
A. Express consent is the voluntary consent of an individual seeking medical treatment and is predicated on one’s mental competency.
B. Implied consent in law (emergency) for treatment occurs when an individual is in a life-threatening or a limb-threatening situation and unable to provide express consent. Implied consent for treatment is a legal consent and occurs even while all attempts are being made to contact the patient’s family members and obtain consent for treatment from them.
C. Involuntary consent is used when an incompetent individual refuses to consent to needed medical treatment. It is often used to ensure a that mentally incompetent individual receives necessary medical treatment.
D. Implied consent is implied by the patient’s actions, such as the act of a patient putting their arm out for bloodwork to be drawn.
Category: Professional Issues, System, Patient consent for treatment
Question 75
Following a mass casualty incident, a small child arrives via emergency medical services. The child is not breathing and has no palpable pulse. The child’s airway is repositioned, and, following 5 rescue breaths, the child begins breathing on their own. Based on the JumpSTART triage algorithm, which triage category should be assigned to this child?
Black (expectant)
Green (minor)
Yellow (delayed)
Red (immediate)
✓
Correct Answer
Red (immediate)
A. The black (expectant) category is designated for patients who are not expected to survive and for whom palliative care and/or pain medication should be given. The child who regains their ability to breathe after 5 rescue breaths and has a palpable pulse is to be placed in the red (immediate) JumpSTART triage category.
B. The yellow (delayed) category is indicated for patients whose transport can be delayed and who have either serious or potentially life-threatening injuries but are not expected to deteriorate within the next several hours. The child who regains their ability to breathe after 5 rescue breaths and has a palpable pulse is to be placed in the red (immediate) JumpSTART triage category.
C. If a child regains breathing ability and has a palpable pulse following rescue breaths, they are assigned the red JumpSTART (immediate) category.
D. The green (minor) category is for children who are able to walk when initially triaged. This patient had no spontaneous respirations or palpable pulse on initial assessment and would therefore be assigned a red (immediate) triage category.
Category: Professional Issues, System, Disaster management
Question 76
It is important to have effective communication among emergency department (ED) staff when completing a patient handoff between staff members as well as with other hospital departments. One form of communicating handoff is the SBAR technique. The S in the SBAR communication tool stands for:
situation.
✓
safety.
suggest alternatives.
support.
Correct Answer
situation.
A. Suggesting alternatives is used in the DESC tool for communication, which is applied in conflict management. In using SBAR, the S stands for describing the situation, which includes the chief complaint and reasons the patient has come to the ED, or why the patient is being admitted to the hospital.
B. Describing the situation includes the chief complaint and reasons the patient has come to the ED, or why the patient is being admitted to the hospital.
C. Safety is used in the CUS tool for communication when a team member recognizes an unsafe situation and “stops the line.” CUS stands for concern, uncomfortable, and safety. In using SBAR, the S stands for describing the situation, which includes the chief complaint and reasons the patient has come to the ED, or why the patient is being admitted to the hospital.
D. The S in the SBAR communication tool represents situation. Describing the situation includes the chief complaint and reasons the patient has come to the ED, or why the patient is being admitted to the hospital.
Category: Professional Issues, System, Performance and process improvement
Question 77
Before implementing a research study that involves patient outcomes, approval must be obtained from which of the following?
The medical staff involved with the patient population
The institutional legal consultant
The institutional review board
✓
The institutional ethics committee
Correct Answer
The institutional review board
A. The institutional review board is charged with overseeing the study and ensuring that it complies with all ethical standards.
B. The institutional review board is charged with overseeing the study and ensuring that it complies with all federal regulations regarding the use of human subjects.
C. All research studies that involve human subjects must be reviewed and approved by an institutional review board before the start of the study.
D. It is important that members of the medical staff be aware of any nursing research that is being conducted, and their cooperation may be beneficial. However, their approval is not required for nursing research to be conducted.
Category: Professional Issues, Nurse, Evidence-based practice
Question 78
Following the death of a patient in the emergency department who may have been the victim of crime, the proper collection of forensic evidence includes which of the following actions?
Use sterile metal forceps when handling bullets
Return jewelry and religious items to a family member because they are not admissible as evidence
Wrap wet clothing in plastic and then place it in a paper bag
Describe injuries as wounds
✓
Correct Answer
Describe injuries as wounds
A. Describe the injuries as “wounds” rather than potentially using the wrong term, such as laceration versus cut, or ecchymosis versus contusion.
B. Each article of clothing should be placed in its own separate paper bag to avoid possible cross-contamination. Wet articles should either be allowed to dry or placed while still wet into paper bags. Moisture collection on items wrapped in plastic could alter the evidence.
C. All items associated with the patient are considered evidence and should not be returned to the family or a significant other without the express permission of law enforcement.
D. Metal forceps may alter forensic markings on the outside of bullets. If necessary, place a plastic shield over the teeth of the forceps before touching the bullet.
Category: Professional Issues, Patient, Forensic evidence collection
Question 79
The registered nurse is caring for a patient who had a lumbar puncture performed one hour ago. Which of the following is an appropriate task to delegate to assistive personnel for this patient?
Obtaining a set of vital signs
✓
Evaluating for altered mental status
Monitoring the puncture site for drainage
Checking for extremity numbness
Correct Answer
Obtaining a set of vital signs
A. The registered nurse is accountable for the ongoing monitoring of the outcomes of nursing care. Elements of care may be delegated, but the nursing process itself may not be delegated. Reassessing vital signs postprocedure would be an appropriate element of care to delegate to the assistive personnel.
B. The registered nurse is accountable for the ongoing monitoring of the outcomes of nursing care. Elements of care may be delegated, but the nursing process itself may not be delegated. Evaluating for a change in mental status is part of the assessment and cannot be delegated.
C. The registered nurse is accountable for the ongoing monitoring of the outcomes of nursing care. Elements of care may be delegated, but the nursing process itself may not be delegated. Checking for numbness postprocedure is a part of the postprocedure neurological assessment and cannot be delegated.
D. The registered nurse is accountable for the ongoing monitoring of the outcomes of nursing care. Elements of care may be delegated, but the nursing process itself may not be delegated. Monitoring the puncture site for signs of bleeding or CSF leakage is part of the postprocedure assessment and cannot be delegated.
Category: Professional Issues, System, Delegation of tasks to assistive personnel
Question 80
A patient with history of posttraumatic stress disorder and schizophrenia is pacing and screaming repeatedly, “The voices are so loud. Make them stop!,” and then said they would like to take a gun to “blow your head off right now!” What is the appropriate Emergency Severity Index (ESI) triage classification for this patient?
ESI level 5
ESI level 3
ESI level 1
ESI level 2
✓
Correct Answer
ESI level 2
A. A patient who is actively aggressive, has homicidal thoughts, and does not have control of normal thought processes would fall into the category of high risk, which is the ESI level 2 category. The patient’s heart rate and respiratory pattern are most likely elevated, and they will require multiple resources for care.
B. ESI level 1 is designated for patients who require immediate lifesaving interventions. Suicidal and homicidal thoughts create an emergent situation, with the patient requiring care for their safety and the safety of others.
C. ESI level 5 is designated for patients who require no resources for care; their condition is considered minor in nature, and care could be delayed if necessary. Any patient who has active suicidal or homicidal thoughts is a safety risk and should be triaged at a higher level.
D. Patients who might fall into the ESI level 3 triage category may have suicidal or homicidal thoughts, but they are calm, cooperative, and seeking help for their current mental health.
Category: Mental Health Emergencies, Thought disorders (e.g., psychosis,
Question 81
A patient is brought in by several friends who report that the patient has alternating periods of extreme irritability and impulsivity, and periods of being very happy and sociable. The nurse recognizes this behavior as:
bipolar disorder.
✓
schizophrenia.
delirium.
anxiety.
Correct Answer
bipolar disorder.
A. Anxiety is often related to a perceived threat to self. The patient experiences the feeling of nervousness or increased apprehension. In severe cases of anxiety, the patient may have shortness of breath or chest pain.
B. Schizophrenia is a chronic psychotic disorder that manifests with hallucinations, delusions, flattened affect, and impaired social skills. The typical age of onset is adolescence or young adulthood.
C. This patient is exhibiting classic signs of bipolar disorder, which manifests with alternating bouts of depression and mania. Mania can include hyperactivity, exaggerated actions, including risky behaviors, and sometimes paranoia.
D. Delirium is characterized by a rapid change in mental status, including memory loss, and may include hallucinations and nightmares.
Category: Mental Health Emergencies, Mood disorders (e.g., bipolar, depression)
Question 82
An adolescent accompanied by their parents presents with a “desire to end my life” and cites increased school stressors as the reason for the suicidal thoughts. Which of the following statements by the parents exhibits their understanding of the discharge instructions?
“We will take our child out of school until his symptoms of suicidal ideation have resolved.”
“We will make an appointment for our child to see the therapist within 1 week.”
“We will ensure that our child sees the therapist tomorrow.”
✓
“We will take time off from work for the next 2 days to monitor our child at all times.”
Correct Answer
“We will ensure that our child sees the therapist tomorrow.”
A. If the adolescent has an effective support system that can ensure patient observation with appropriate follow-up within 24 hours, this is a good plan of action for the acutely depressed or possibly suicidal patient. Acknowledgment that the family will ensure the patient’s safety is also a sign of acceptance of the follow-up plan of care. Adolescents with a clear plan of possible suicide often require admission to an inpatient facility.
B. The best plan of action is to ensure that the patient has a confirmed appointment for adequate follow-up with a mental health provider as soon as possible. An adolescent who has written a potential suicide note is considered high risk and should be seen as soon as possible or admitted to an inpatient facility.
C. Although staying with the child to ensure their safety is important, the child should have an appointment with a mental health provider within the next 24–48 hours.
D. Taking the child out of school until the symptoms of suicidal ideation resolve does not ensure the proper prescribed follow-up and may delay an adequate mental health evaluation and care for the patient.
Category: Mental Health Emergencies, Mood disorders (e.g., bipolar, depression)
Question 83
A patient who is agitated, aggressive, and experiencing homicidal ideation is given an injection of haloperidol (Haldol). Within 30 minutes of the injection, the patient displays uncontrollable severe arching of the neck area and pulling of their head to one side. The patient’s eyes are moving in multiple directions. The patient states that they are unable to sit still, and it feels like their skin is crawling. The nurse anticipates the administration of benztropine (Cogentin) to treat which of the following symptoms this patient is exhibiting?
Hallucination
Tonic–clonic seizure
Petit mal seizure reaction
Torticollis
✓
Correct Answer
Torticollis
A. Hallucinations are altered sensory perceptions that are not actually present. Benztropine will not effectively treat hallucinations.
B. Benztropine will not be effective in eliminating the patient’s tonic–clonic seizure.
C. Benztropine may cause some drowsiness but would not be indicated in the activity associated with a petit mal seizure disorder.
D. Torticollis is a particular spasm of the neck muscles that causes the twisting of the neck that the patient cannot control. Opisthotonos is a hyperextension of the neck muscles caused by muscular spasm that places the patient in a hyperextended state that they cannot control. These behaviors are considered a dystonic reaction. Benztropine is used to treat dystonic reaction related to the administration of haloperidol.
Category: Mental Health Emergencies, Homicidal and suicidal ideation
Question 84
A school-age child presents with abdominal pain. The nurse notes that this is the third visit this month for a variety of complaints. The patient has followed up with the family physician as directed, but no official diagnosis has been made to account for the child’s numerous complaints. The parent reveals that the child does not like school and seldom wants to spend time with other children. The nurse suspects the child may have:
Tourette syndrome.
anorexia nervosa.
obsessive-compulsive disorder.
social anxiety disorder (SAD).
✓
Correct Answer
social anxiety disorder (SAD).
A. Children with obsessive-compulsive disorder form an obsession that becomes associated with a compulsive behavior; this presents as rituals needed to reduce the anxiety caused by the obsession.
B. A child with SAD may appear to be the typical “shy child,” but the disorder affects the child’s ability to function, possibly leading them to avoid other children and refuse to go to school. Further, children with SAD may present frequently to the emergency department with various complaints without organic cause. The more nonspecific the symptomology a child manifests, the more likely it is that anxiety plays a role in the presentation.
C. Tourette syndrome is associated with uncontrollable verbal and nonverbal tics.
D. Although eating disorders often appear comorbidly with anxiety disorders, neither the patient nor the parent reported symptoms consistent with anorexia nervosa, such as vomiting or excessive diarrhea.
Category: Mental Health Emergencies, Anxiety disorders (e.g., PTSD, anxiety, panic
Question 85
A patient with a history of situational depression and currently on a prescribed selective serotonin uptake inhibitor (SSRI) has asked the nurse about the effects of taking the herb St. John’s wort with it. Which of the following statements is the appropriate response by the nurse?
“Yes, you may combine them. Because St. John’s wort is a natural herb, it is safe for you to take.”
“If you combine the herb with the prescription, you should reduce the dose of your SSRI after 2 weeks.”
“It is not advised to take this herb with your current prescription without consulting with your provider.”
✓
“It might be a good idea. The herb will enhance the effectiveness of your prescription.”
Correct Answer
“It is not advised to take this herb with your current prescription without consulting with your provider.”
A. Patients should always be educated to discuss use of herbs and supplements with their provider. Reduction in the prescribed medication dose should be determined by the prescribing physician.
B. Although St. John’s wort may potentiate the effects of the SSRI, the combination might result in serious side effects.
C. This is a common but inaccurate belief. Many natural supplements interact with prescribed medications, resulting in untoward effects.
D. St. John’s wort, although often recommended to treat mild depression, can interact with SSRIs. Providers should be aware of any prescribed or over-the-counter herbs or supplements the patient may be taking.
Category: Mental Health Emergencies, Mood disorders (e.g., bipolar, depression)
Question 86
Which international normalized ratio (INR) laboratory value would indicate a therapeutic dosage range for a patient taking warfarin (Coumadin)?
1.2
5.0
2.3
✓
9.6
Correct Answer
2.3
A. A level of 1.2 is subtherapeutic and would not provide an adequate level of anticoagulation for the patient.
B. The recommended INR range is usually 2 to 3 for most patients. Levels lower than this are subtherapeutic and not effective for anticoagulation. Levels greater than the therapeutic range can cause the patient to experience bleeding episodes.
C. A level of 5.0 is above the therapeutic range and could result in the patient experiencing bleeding or prolonged clotting.
D. A level of 9.6 is well above the therapeutic range and can be life threatening. This value would require immediate intervention to reverse the effects of the warfarin.
Category: Medical Emergencies, Hematologic disorders
Question 87
A patient is transported from a restaurant by emergency medical services, who report that the patient had rapid-onset swelling to the tongue and lips, and dyspnea. On arrival, the patient is responding only to pain, and their face and tongue appear swollen. BP is 75/40 mm Hg. Their wife states that the patient is allergic to peanuts. What is the first medication the nurse should anticipate administering?
Fluid bolus of isotonic crystalloid solution
Famotidine (Pepcid)
Diphenhydramine (Benadryl)
Epinephrine (Adrenalin)
✓
Correct Answer
Epinephrine (Adrenalin)
A. Epinephrine is the first-line treatment for hemodynamically unstable anaphylaxis. Epinephrine will result in vasoconstriction and bronchodilation. Failure to promptly administer epinephrine is associated with mortality, hypoxic encephalopathy, and biphasic anaphylaxis.
B. The patient will require a fluid bolus to fill the intravascular space, but the administration of epinephrine is the first-line treatment for anaphylactic shock.
C. An antihistamine will need to be administered, but the first-line treatment for anaphylactic shock is epinephrine.
D. An H receptor antagonist is used to treat allergic reactions, but the 2 administration of epinephrine is the first-line treatment in patients with anaphylactic shock.
Category: Medical Emergencies, Allergic reactions and anaphylaxis
Question 88
A patient presents with itching, swelling around the lips and tongue, shortness of breath, and anxiety. The patient reports a history of a peanut allergy as a child but has not had a reaction in years, and denies eating any known products that contain peanuts. However, pancakes were eaten earlier in the day just before the symptoms began. What is the most likely cause of the patient’s symptoms?
Pneumonia
Anxiety attack
Peanut allergy
✓
Pulmonary embolism
Correct Answer
Peanut allergy
A. Although approximately 20% of children with peanut allergies eventually outgrow their allergy, the majority will not. Pancakes and other baked goods frequently contain peanut oil or peanut products. The patient should be advised to carry an epinephrine auto-injector (EpiPen) in case of future reactions.
B. The patient has a history of a peanut allergy, and the symptoms began suddenly after eating. Despite experiencing shortness of breath, the patient presentation is not consistent with pneumonia.
C. Despite experiencing shortness of breath and anxiety, the itching and swelling are not consistent with an anxiety attack.
D. Although the symptoms of shortness of breath and anxiety can be caused by a pulmonary embolism, this patient’s presentation, history, and onset of symptoms are more consistent with anaphylaxis, secondary to the documented peanut allergy.
Category: Medical Emergencies, Allergic reactions and anaphylaxis
Question 89
Which of the following interventions should be initiated for the treatment of a septic patient within 1 hour of arrival?
Blood cultures, antibiotics, and rapid administration of 30 mL/kg of crystalloids for a lactate level greater than or equal to 4 mmol/L
✓
Blood cultures, vasopressors, and central venous pressure monitoring if the mean arterial pressure is less than 65 mm Hg
Blood cultures, antibiotics, and 30 mL/kg intravenous fluids for a lactate level greater than 2 mmol/L
Antibiotics and vasopressors if mean arterial pressure is greater than 65 mm Hg and lactate level is greater than or equal to 4 mmol/L
Correct Answer
Blood cultures, antibiotics, and rapid administration of 30 mL/kg of crystalloids for a lactate level greater than or equal to 4 mmol/L
A. Begin rapid administration of crystalloids for hypotension or a lactate level greater than or equal to 4 mmol/L.
B. Central venous pressure monitoring may be initiated but is not included in the standard 1-hour goal for sepsis interventions.
C. Blood cultures, antibiotics, and rapid administration of 30 mL/kg of crystalloids are all the standard 1-hour goal for sepsis interventions.
D. Vasopressors are indicated if the patient is hypotensive during or after fluid resuscitation to maintain a mean arterial pressure of greater than or equal to 65 mm Hg.
Category: Medical Emergencies, Sepsis
Question 90
The nurse discusses health promotion with an immunocompromised patient and each of the patient’s frequent visitors. The nurse identifies that the teaching has been effective when the patient states:
“All my visitors should be screened for infections before entering my room.”
“I should limit the number of visitors permitted in the room to only one at a time.”
“All of my visitors should wash their hands when they enter my room.”
✓
“I need to remind all my visitors to wear a face mask when they are visiting me.”
Correct Answer
“All of my visitors should wash their hands when they enter my room.”
A. There is no minimum number of visitors attributed to a decrease in transmission of infection. As long as the patient is feeling well and desires visitors, there is no need for a strict limit to the number of visitors permitted in the patient’s room at one time unless otherwise directed by the health facility policy.
B. All visitors should perform hand hygiene before entering a patient room and immediately after leaving the room. Hand hygiene is a well-established means of reducing the microbial burden on hands and preventing pathogen transmission. In the healthcare setting, hand hygiene can prevent the spread of microorganisms between patients and visitors.
C. Face masks are required for patients with airborne and droplet precautions.
D. Screening all visitors for infection may not be feasible. Proper hand hygiene is one of the most effective infection control measures.
Category: Medical Emergencies, Immunocompromise (e.g., HIV/AIDS,
Question 91
A patient with which of the following disease processes would most likely benefit from prophylactic therapy for deep vein thrombosis?
Myxedema coma
Syndrome of inappropriate antidiuretic hormone
Hyperglycemic hyperosmolar syndrome (HHS)
✓
Diabetic ketoacidosis
Correct Answer
Hyperglycemic hyperosmolar syndrome (HHS)
A. Syndrome of inappropriate antidiuretic hormone does not create dehydration; rather, it increases the amount of fluid retained in the intravascular space, resulting in dilutional hyponatremia. In this situation, fluids would be restricted.
B. This malady rarely causes thrombotic events to occur. Individuals are usually younger, and though dehydration is part of the diabetic ketoacidosis process, it is not as pronounced as in HHS.
C. HHS creates extreme dehydration, a hyperosmolar state, and immobility. The patient is often bedfast or sedentary for either their age, comorbidities, or the critical nature of their illness. Therefore, prophylaxis for deep vein thrombosis that can lead to other thrombotic events is necessary.
D. Myxedema coma is a complication of hypothyroidism. This patient may progress to a phase of immobility and dehydration, but that is not the early manifestation.
Category: Medical Emergencies, Endocrine disorders
Question 92
Which of the following laboratory studies should the nurse expect in a patient who presents with diabetic ketoacidosis (DKA)?
Increased pCO 2
Elevated creatinine
✓
Decreased blood urea nitrogen (BUN)
Elevated pH
Correct Answer
Elevated creatinine
A. Decreased pCO occurs as a compensatory effect of acidosis. Kussmaul 2 respirations, defined as a deep, rapid respiratory pattern, result in the decreased pCO . 2
B. DKA results in severe dehydration secondary to osmotic diuresis. The patient will have an elevated creatinine and BUN level.
C. The pH level is expected to be decreased, consistent with the presence of metabolic acidosis. An elevated pH level reflects alkalosis.
D. The BUN level would be increased as a reflection of dehydration.
Category: Medical Emergencies, Endocrine disorders
Question 93
The nurse knows that which of the following hormones is altered in a patient in adrenal crisis?
Cortisol
✓
Thyroid-stimulating hormone
Follicle-stimulating hormone
Antidiuretic hormone
Correct Answer
Cortisol
A. Antidiuretic hormone is produced in the pituitary gland and is not involved in an adrenal crisis.
B. Adrenal crisis is an endocrine emergency caused by a lack of glucocorticoids (cortisol) and mineralocorticoids (aldosterone).
C. Follicle-stimulating hormone is a female reproductive hormone produced in the pituitary gland and is not involved in an adrenal crisis.
D. Thyroid-stimulating hormone is produced in the pituitary gland and is not involved in an adrenal crisis.
Category: Medical Emergencies, Endocrine disorders
Question 94
Which condition caused by excessive amounts of antidiuretic hormone (ADH) results in a patient developing dilutional hyponatremia?
Cushing’s syndrome
Syndrome of inappropriate antidiuretic hormone
✓
Adrenal crisis
Diabetes insipidus (DI)
Correct Answer
Syndrome of inappropriate antidiuretic hormone
A. High levels of ADH result in water intoxication and subsequent dilutional hyponatremia. The patient will also complain of headache, fatigue, and weight gain without edema, and may progress to seizures. Treatment depends on the severity of the patient’s hyponatremia. Fluid restriction should be initiated. Severe hyponatremia is treated with hypertonic saline and the administration of furosemide (Lasix).
B. Adrenal crisis, also known as acute adrenal insufficiency, is a life-threatening condition caused by a decrease in cortisol and aldosterone levels. The result is sodium and water loss from both the kidneys and gastrointestinal tract, causing the patient to become hypotensive and hypovolemic. As the body loses sodium, there is an increase in potassium, leading to hyperkalemia and the development of fatal dysrhythmias. Treatment includes fluid replacement, correction of hyperkalemia, and hydrocortisone administration.
C. DI is a life-threatening condition caused by insufficient ADH produced by the hypothalamus or released by the posterior pituitary gland. DI results in excretion of large amounts of diluted urine, and patients complain of fatigue and weight loss. Treatment for DI is fluid replacement and administration of synthetic ADH, desmopressin acetate.
D. Cushing’s syndrome results from prolonged intake of glucocorticoids (either endogenous or exogenous), causing the patient to develop a Cushingoid appearance: an increased amount of adipose tissue to the face, upper back, and base of the neck.
Category: Medical Emergencies, Endocrine disorders
Question 95
The priority goal of treatment for a patient with syndrome of inappropriate antidiuretic hormone (SIADH) is directed toward:
determining the severity of hypernatremia.
determining the severity of hyponatremia.
✓
slowly correcting the patient’s potassium level.
measuring the specific gravity of the patient’s urine.
Correct Answer
determining the severity of hyponatremia.
A. The patient’s serum potassium level is often normal and may not need to be corrected. The sodium level is the most important electrolyte to evaluate and treat.
B. A patient with SIADH will not have an elevated serum sodium level; instead, the patient will have a sodium level often as low as 125 mEq/L.
C. The specific gravity of the patient’s urine will be elevated because of the presence of severe hyponatremia. However, this is not the highest priority of care for the nurse.
D. SIADH results in severe dilutional hyponatremia (low serum sodium levels), often less than 125 mEq/L. Normal serum sodium level is 135 mEq/L–145 mEq/L. Symptomatic patients may require 3–5% hypertonic saline to be administered intravenously to correct the severe hyponatremia.
Category: Medical Emergencies, Endocrine disorders
Question 96
A patient has been prescribed spironolactone (Aldactone) for treatment of cirrhosis. The nurse acknowledges that the patient understands the discharge instructions when the patient states:
“I should not eat popcorn or rice cakes.”
“I should eat more dried fruit, like apricots.”
“I should eat an extra banana or avocado daily.”
“I should avoid eating bananas and avocados.”
✓
Correct Answer
“I should avoid eating bananas and avocados.”
A. Dried apricots are high in dietary potassium and therefore should be avoided by patients taking spironolactone.
B. Bananas and avocados are potassium rich and should be avoided with potassium-sparing diuretics.
C. Popcorn and rice cakes are not high-potassium food items, so they will not significantly alter the patient’s serum potassium levels.
D. Spironolactone is a potassium-sparing diuretic. Patients should receive education to avoid foods that are high in potassium. Both bananas and avocados provide high levels of nutritional potassium.
Category: Medical Emergencies, Electrolyte and fluid imbalance
Question 97
Which of the following complaints is most commonly associated with a patient experiencing a sickle cell crisis?
Priapism
✓
Hematochezia
Hematemesis
Anasarca
Correct Answer
Priapism
A. Anasarca is generalized edema and is not a common complaint associated with sickle cell disease. It is common in patients with a history of heart failure or kidney failure.
B. Hematemesis is vomiting bright red blood and is a sign of upper gastrointestinal bleeding.
C. Hematochezia is bright red blood in the stool and is not a common complaint associated with sickle cell disease. It is a common finding in lower gastrointestinal bleeding.
D. Priapism is a persistent painful erection and a genitourinary emergency. It is a common complication for male patients with sickle cell disease who experience a crisis. During a sickle cell crisis, red blood cells become sickle-shaped and lodge in the microvasculature, leading to entrapment of blood in the penis.
Category: Medical Emergencies, Hematologic disorders
Question 98
A patient who recently completed chemotherapy treatment for acute lymphocytic leukemia presents with complaints of fatigue and dyspnea. The primary survey includes these vital signs: HR 86 beats/minute; RR 18 breaths/minute; SpO 94% 2 on room air. Which of the following interventions would be the highest priority for this patient?
Preparing the patient for continuous positive airway pressure ventilation
Immediate triaging of the patient to the resuscitation room
Placing the patient in a private or isolation room
✓
Placing the patient in a negative-pressure isolation room
Correct Answer
Placing the patient in a private or isolation room
A. This patient is not in acute respiratory distress and does not require airway support.
B. A negative-pressure room circulates air from outside the room into the room and filters air in the room before moving it outside. Negative pressure is used to keep infectious organisms from entering the general air circulation. Negative-pressure rooms may be indicated for patients with infectious airborne pathogens.
C. The patient is stable and is not in need of emergent resuscitative interventions.
D. Immature white blood cells in leukemic patients result in increased vulnerability to infection. The patient must be isolated from other potentially infectious emergency department patients.
Category: Medical Emergencies, Hematologic disorders
Question 99
Which of the following is the most appropriate nursing intervention for a patient with disseminated intravascular coagulation (DIC)?
Secure all invasive lines
✓
Maintain the patient in a prone position
Avoid suctioning the patient
Administer all medications intramuscularly
Correct Answer
Secure all invasive lines
A. The patient’s airway must be kept patent. However, suctioning should be done only as necessary to minimize the risk of oral bleeding.
B. The patient should be turned and positioned for comfort to prevent skin injury and/or skin breakdown and minimize the risk of bleeding. Additional personnel should be used to move and position the patient as gently as possible.
C. Securing invasive lines minimizes the risk of bleeding as a result of unintentional or intentional dislodgement of the line.
D. Medications should primarily be administered intravenously to avoid the risk of bleeding.
Category: Medical Emergencies, Hematologic disorders
Question 100
A patient with hemophilia A presents with a laceration to the knee that requires suturing. Which of the following interventions by the nurse takes priority for this patient?
Prepare to administer factor IX
Prepare to suture the wound on the injured knee
Prepare to administer desmopressin acetate (DDAVP)
Prepare to administer factor VIII
✓
Correct Answer
Prepare to administer factor VIII
A. The highest priority of care for this patient is the replacement of factor VIII, the deficient factor in the patient with hemophilia A (classic hemophilia).
B. Factor IX is the deficient factor in patients with hemophilia B (Christmas disease).
C. DDAVP may be helpful in the presence of a mild bleeding episode; however, the administration of DDAVP is not the highest priority. DDAVP will stimulate the release of factor VIII and von Willebrand factor and is not a replacement for factor VIII. The patient should have factor VIII administered directly (not DDAVP, which will stimulate the release of factor VIII).
D. The patient will require sutures to further control bleeding, but the highest priority is to administer the deficient factor VIII. Continued pressure should be applied to any uncontrolled bleeding sites before suturing of the wound.
Category: Medical Emergencies, Hematologic disorders
Question 101
Which type of leukemia is the most commonly diagnosed in children?
Acute myelogenous leukemia
Chronic myelogenous leukemia
Acute lymphocytic leukemia (ALL)
✓
Chronic lymphocytic leukemia (CLL)
Correct Answer
Acute lymphocytic leukemia (ALL)
A. ALL is the most common type of leukemia diagnosed in children.
B. Acute myelogenous leukemia is not frequently diagnosed in the pediatric population.
C. CLL is the most common leukemia diagnosed in adults; it is very rare in the pediatric population.
D. Chronic myelogenous leukemia is very rare in children.
Category: Medical Emergencies, Hematologic disorders
Question 102
Which patient presenting to triage with a fever has the highest priority for bed placement?
The patient who is receiving chemotherapy
✓
The patient complaining of a rash
The patient who had surgery 2 weeks ago
The patient complaining of a productive cough
Correct Answer
The patient who is receiving chemotherapy
A. A postoperative patient is at increased risk of infection, but usually within a few days of the surgery. The febrile patient who underwent surgery 2 weeks earlier requires evaluation, but it does not need to be performed immediately. The cancer patient who has been receiving chemotherapy is at highest risk for decompensation secondary to sepsis.
B. The complaint of a fever and productive cough warrants assessment. However, the cancer patient who has been receiving chemotherapy is at highest risk for decompensation secondary to sepsis.
C. Though the presence of a rash and fever is concerning, it is common for some viral illnesses to cause a rash. The cancer patient who has been receiving chemotherapy is at highest risk for decompensation secondary to sepsis.
D. Cancer patients, especially those receiving chemotherapy, who present with a fever should be given priority, given the concern for neutropenia, their suppressed immune system, and the risk for rapid onset of sepsis.
Category: Medical Emergencies, Sepsis
Question 103
A patient with a fractured tibia and fibula presents with excessive pain on the splinted extremity, and the nurse is concerned about compartment syndrome. Which of the following priority interventions should the nurse perform?
Apply ice packs to the lower portion of the extremity
Elevate the extremity immediately above the heart level
Immediately transport the patient to radiology
Loosen or remove any restrictive devices on the extremity
✓
Correct Answer
Loosen or remove any restrictive devices on the extremity
A. Remove restrictive items, such as circumferential tape or elastic wraps, and ice bags in patients who are demonstrating possible signs and symptoms of compartment syndrome. These signs and symptoms are pain that is disproportional to the injury; pressure or tightness over the injury site; pale and cool skin; lack of or diminished pulses distal to the injury site; numbness/tingling (paresthesia) in the affected extremity; and paralysis.
B. The application of ice is contraindicated because this promotes further vasoconstriction in the presence of compartment syndrome.
C. Maintain the extremity in a neutral position, and elevate the limb only to the level of the heart to promote circulation. Further elevation above the level of the heart inhibits arterial perfusion to the affected tissue.
D. The patient may eventually require another x-ray of the extremity, but the highest priority is to remove any potential restriction that may be contributing to compartment syndrome.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Compartment
Question 104
An unrestrained driver involved in a motor vehicle collision presents with signs and symptoms of a possible femur fracture. Which of the following assessment findings would the nurse anticipate on a patient who presents with a suspected femur fracture?
Excessive hip flexion
Deformity of the ankle
Shortened length of the injured extremity
✓
Hyperextension of the knee
Correct Answer
Shortened length of the injured extremity
A. Excessive hip flexion indicates a possible hip injury in conjunction with the femur fracture.
B. Assessment findings of femur fractures include pain and the inability to bear weight; shortening of the affected leg; internal or external rotation; edema of the thigh; deformity of the thigh; and evidence of hypovolemic shock (this may or may not be present).
C. Hyperextension of the knee on the affected side would indicate a secondary injury in the knee joint, not a fractured femur.
D. Assessment findings of femur fractures do not include ankle deformity.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Fractures
Question 105
A child presents with pain to the ankle after jumping out of a tree. Assessment reveals inability to bear weight on the affected side, swelling, strong distal pulses, intact skin, and no gross deformity. Initial radiographs are negative for fracture. Which of the following types of fracture would the nurse suspects the child has?
Open
Displaced
Salter–Harris
✓
Comminuted
Correct Answer
Salter–Harris
A. Although swelling is observed, there is no bone displacement evident on radiographs.
B. Open fractures are graded 1–3 according to degree of soft tissue injury. The skin is intact on this patient, so the fracture is considered “closed.”
C. Comminuted fractures result in splintering of bone, with the presence of obvious fragments visible on radiograph.
D. The classification of Salter–Harris fractures (types I–V) involves the disruption of the epiphysis (growth plate). These fractures have implications for treatment, prognosis, and healing. A type V Salter–Harris fracture generally involves an axial load, and initial radiographs may be negative but can result in a poor functional outcome. Diagnosis is often made retrospectively after premature closure of the epiphysis.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Fractures
Question 106
A patient presents with continuous left knee pain and occasional swelling for the past month. Pain is described as worse on awakening in the morning but lessens after the patient is up and moving. The patient denies any trauma, previously trained for marathons, and continues to run at least 20 miles each week. Which musculoskeletal condition best describes the patient’s symptoms?
Septic arthritis
Rheumatoid arthritis
Osteoarthritis
✓
Bursitis
Correct Answer
Osteoarthritis
A. Rheumatoid arthritis is an autoimmune disorder associated with inflammation around the synovial joints. Rheumatoid arthritis often affects the small joints of the fingers and usually affects the joints bilaterally. The disorder should be managed by a rheumatologist because it will require long-term management to prevent permanent disability.
B. Osteoarthritis is associated with pain in one or more joints. The pain is not always bilateral but can be, and swelling may or may not be present. Osteoarthritis is marked by stiffness that improves when the patient is active. Osteoarthritis can be associated with sports such as running, which can cause a lot of wear and tear on weight-bearing joints, including knees and hips.
C. Bursitis is an inflammation of a bursa. It usually occurs over bony prominences such as the elbow but can also occur in the knees or hips. Bursitis can be caused by trauma, repetitive use or pressure (such as always resting elbows on a hard surface), or infection in the bursa.
D. Septic arthritis occurs when a joint becomes infected with bacteria. It is commonly seen in the presence of trauma to the joint space or surrounding area, such as a puncture wound where bacteria are able to enter into the joint space. The joint will be red, swollen, and warm to touch, and it will be painful for the patient to move.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Inflammatory
Question 107
A patient is being discharged after treatment for an ankle injury sustained while playing soccer. The patient “rolled” their ankle on an uneven area on the field. The ankle is swollen and tender to touch, and there is difficulty with weight-bearing. The nurse acknowledges the need for further instructions when the patient states:
“I need to rest my ankle, keep it elevated, ice it, and use an ACE bandage.”
“It is okay to go back to playing soccer once the swelling is gone.”
✓
“I should start physical therapy and stretching exercises in about a week.”
“It is okay for me to take acetaminophen (Tylenol) or ibuprofen (NSAID) for the pain in my ankle.”
Correct Answer
“It is okay to go back to playing soccer once the swelling is gone.”
A. This statement shows understanding of correct discharge instructions. RICE (Rest, Ice, Compress, Elevate) principles are used to decrease swelling/inflammation and decrease pain.
B. This injury is consistent with an ankle sprain. There are different grades of ankle sprains, and the ankle may still be unstable even if the swelling goes down. It will be important for the patient to have the ankle reevaluated with their primary care provider once the swelling is gone to determine ankle stability and the need for possible further treatment, especially if the patient continues having difficulty bearing weight.
C. This statement shows understanding of correct discharge instructions for ankle sprains. Physical therapy or a sports provider can recommend stretching and strengthening exercises that will increase the strength and stability of the joint.
D. This statement shows understanding of correct discharge instructions for ankle sprains. Anti-inflammatories such as ibuprofen and analgesics such as acetaminophen may help decrease inflammation and pain.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Ligament
Question 108
The best way for the nurse to evaluate the effectiveness of teaching a patient with an injured ankle to crutch-walk is to have the patient:
teach back the procedure to the nurse.
teach the skill to a friend in the presence of the nurse.
demonstrate crutch-walking.
✓
restate the crutch walking instructions.
Correct Answer
demonstrate crutch-walking.
A. Teach-back has been proved as an effective technique for cognitive learning, but demonstration of the skill is superior in psychomotor situations.
B. Verbalization of the steps may indicate a cognitive understanding; however, it does not indicate the ability to perform the procedure.
C. Teach-back has been proved as an effective technique for cognitive learning, but demonstration of the skill is superior in psychomotor situations.
D. With a psychomotor skill such as crutch-walking, return demonstration of the proper techniques offers the best ability to evaluate learning.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Ligament
Question 109
A patient complains of severe pain to the back of their foot above the heel and states they heard a popping noise while running. There is tenderness, swelling, and difficulty pointing their toes. The patient’s past medical history is significant for traveler’s diarrhea, treated with a fluoroquinolone over the past month. The nurse suspects the patient has sustained a(n):
Achilles tendon rupture.
✓
ankle dislocation.
calcaneal fracture.
ankle sprain.
Correct Answer
Achilles tendon rupture.
A. Symptoms of dislocation include joint deformity and swelling over the affected area. Ambulation would be unlikely with an ankle dislocation. The history of fluoroquinolone use is a known risk factor for tendinitis and tendon rupture.
B. Symptoms of Achilles tendon rupture include pain along the back of the foot and above the heel, especially when stretching the ankle or standing on toes; tenderness; swelling; stiffness; a popping noise during injury; and difficulty flexing the foot or pointing the toes. The administration of fluoroquinolones is a known risk factor for tendinitis and tendon rupture.
C. Sprain symptoms include swelling and pain over the lateral and/or medial malleolus.
D. Symptoms include pain in the heel, but the mechanism of running is unlikely to cause a fracture calcaneus; the history of fluoroquinolone use places this patient at risk for tendinitis and tendon rupture.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Ligament
Question 110
A patient has undergone an incision and drainage of a large abscess under the axilla. The nurse anticipates which type of further wound treatment for the area?
Suturing of the abscess cavity
Using a wet-to-dry dressing
Packing with iodoform gauze
✓
Using adhesive wound glue to close the abscess cavity
Correct Answer
Packing with iodoform gauze
A. Application of a wet-to-dry dressing would not be appropriate for this type of wound.
B. Abscesses are typically not sutured to allow for continued drainage from the abscess cavity.
C. Adhesive wound glue is not indicated for the closure of an abscess cavity following incision and drainage.
D. Following incision and drainage, an abscess is packed with iodoform gauze to prevent the premature closure of the skin and to facilitate further drainage from the area.
Category: Musculoskeletal and Wound Emergencies, Wound, Wound infections
Question 111
The nurse is aware that the priority assessment of a patient who has sustained a traumatic laceration with deep tissue injury to the upper arm is to assess which of the following?
Skin color and temperature
Range of motion of the fingers of the affected extremity
Capillary refill in the affected extremity
Distal pulses in the extremity
✓
Correct Answer
Distal pulses in the extremity
A. Decreased capillary refill can indicate impaired perfusion to the extremity but is not as reliable an indicator of tissue perfusion as the presence of a radial pulse and ulnar pulse.
B. Limited range of motion in the affected extremity may indicate that a tendon has been compromised by the injury, but assessing circulation is a higher-priority assessment.
C. Lack of a distal pulse may indicate vascular compromise to the arm and requires an immediate intervention because perfusion to the extremity has been compromised.
D. Altered skin color and temperature can indicate decreased perfusion to the arm but is not as reliable an indicator as the presence of a radial pulse and ulnar pulse.
Category: Musculoskeletal and Wound Emergencies, Wound, Lacerations
Question 112
In providing discharge instructions to the mother of a toddler who had a forehead laceration closed with tissue adhesive, the nurse identifies the mother’s proper understanding of the instructions when she states which of the following?
“It is important for me to keep the wound covered every day.”
“I should keep the wound area clean and dry.”
✓
“I should wash the wound area daily with soap and water.”
“I must apply antibiotic ointment to the area every day.”
Correct Answer
“I should keep the wound area clean and dry.”
A. Wounds closed with tissue glue should be kept clean and dry; if wetness develops during bathing, the area should be gently patted dry.
B. Wounds closed with tissue glue should be kept clean and dry.
C. The wound should be kept open to the air and observed for signs of possible infection.
D. Application of an ointment will weaken the integrity of the tissue glue and should be avoided.
Category: Musculoskeletal and Wound Emergencies, Wound, Lacerations
Question 113
The nurse is providing discharge instructions to a patient with gout. Which of the following statements by the patient indicates understanding of the discharge instructions?
“I’ll be sure to only take acetaminophen for pain control during my gout flare-up.”
“I need to limit my water intake because too much fluid can cause a gout flare-up.”
“I should eat more seafood to help prevent future gout flare-ups.”
“My hydrochlorothiazide could have contributed to this flare-up of gout.”
✓
Correct Answer
“My hydrochlorothiazide could have contributed to this flare-up of gout.”
A. Staying hydrated will help decrease the incidence of the patient experiencing a gout flare-up. Not staying well hydrated will increase the incidence of gout flare-up.
B. Thiazide diuretics can contribute to gout flare-ups because they cause loss of fluid in the body. This causes the remaining body fluids to become more concentrated, which increases the likelihood that urate crystals will then deposit in joint spaces.
C. Though recent research has shown little difference in the use of nonsteroidal anti-inflammatory drugs such as colchicine, they are still recommended for pain during a gout attack. However, aspirin should be avoided because it can alter uric acid levels and possibly make the attacks worse.
D. Patients should eat foods low in purine; therefore, patients with gout should avoid organ meats, red meats, and seafood. In addition, patients need to limit their intake of alcohol and drink plenty of water to reduce the occurrence of flare-ups.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Inflammatory
Question 114
A patient presents to triage with a handwritten note indicating that they are experiencing severe throat pain. When attempting to speak, the patient’s voice sounds as though they are speaking with a hot potato in their mouth. The nurse immediately recognizes this as a symptom of which of the following?
Exudative pharyngitis
Peritonsillar abscess
✓
Epiglottitis
Laryngeal foreign body
Correct Answer
Peritonsillar abscess
A. Laryngeal foreign body typically occurs in children under the age of 6 years. The most common foreign bodies include peanuts, hot dogs, grapes, and other small objects that can obstruct the main stem bronchi or distal trachea, leading to airway obstruction. The patient will present with stridor.
B. Epiglottitis occurs most commonly in children under the age of 7 years. Hallmark signs of epiglottitis are sudden onset with fever and severe sore throat; speech is muffled, and drooling is present because of the increased difficulty swallowing.
C. Peritonsillar abscess results from an infection affecting the tonsils and surrounding tissue. Patients experience a severe sore throat, have difficulty speaking and swallowing, and classically sound like they are speaking with hot potato in their mouth. The tonsils may become so enlarged that the uvula can be displaced, and the patient is unable to swallow.
D. Microorganisms that result in pharyngitis can also affect the tonsils. Patients will experience enlarged tonsils, sore throat, difficulty swallowing, and cervical lymphadenopathy.
Category: Maxillofacial and Ocular Emergencies, Maxillofacial, Abscess (i.e.,
Question 115
A patient presents with complaints of tinnitus and dizziness. Which of the following is the most likely cause of the patient’s symptoms, leading the nurse to suspect this patient has labyrinthitis?
Blurred vision
Viral illness
✓
Unilateral sensorineural hearing loss
Episodic vertigo
Correct Answer
Viral illness
A. Visual disturbance is frequently associated with Ménière’s disease, not labyrinthitis.
B. Labyrinthitis is an inflammatory response of the inner ear and can result from a recent viral or bacterial infection. The inflammation affects the cochlea, resulting in tinnitus and dizziness.
C. Unilateral sensorineural hearing loss is a hallmark symptom of Ménière’s disease, along with episodic vertigo and tinnitus. Labyrinthitis may result in decreased hearing.
D. Episodic vertigo is a hallmark symptom of Ménière’s disease, along with unilateral hearing loss and tinnitus.
Category: Maxillofacial and Ocular Emergencies, Maxillofacial, Acute vestibular
Question 116
A patient presents with a complaint of sudden onset of severe sharp pain in the left ear after a recent airline flight. They experienced a sudden onset of sharp pain in the ear that has not decreased, and they had no previous difficulty with ear pain when flying. Which of the following assessment findings would indicate the presence of a traumatic ruptured tympanic membrane?
Pain in the ear when opening the lower jaw
Blood in the ear canal with no purulent discharge
✓
Redness of the pinna
Presence of purulent material within the ear canal
Correct Answer
Blood in the ear canal with no purulent discharge
A. In the presence of a traumatic ruptured tympanic membrane, normal ear canal landmarks are lost and cannot be visualized; blood will be visualized within the ear canal.
B. Purulent material visualized in the ear canal is consistent with ruptured tympanic membranes from serous otitis media, not traumatic ruptured tympanic membrane.
C. Redness of the pinna is associated with otitis externa, also referred to as “swimmer’s ear,” and is the result of water that accumulates within the ear canal. The patient will experience intense pain when the tragus of the ear is pulled or moved. The ear canal is narrowed because of the presence of purulent material that is lining the canal.
D. The temporomandibular joint (TMJ) lies just under the ear canal. Pain that is localized to the TMJ is the result of arthritis or unusual stress that is placed on the TMJ. The pain can occur from crunching hard food, such as ice cubes or carrots, or result from a direct blow to the mandible on the affected side.
Category: Maxillofacial and Ocular Emergencies, Maxillofacial, Maxillofacial trauma
Question 117
A patient presents to triage after tripping over a rug and falling directly onto their face. There is noticeable periorbital and facial edema, and ecchymosis is noted around the left eye, with the presence of infraorbital hypoesthesia. The patient complains of “seeing double” and is having trouble opening their mouth. There is blood around the nares. The nurse anticipates this patient has sustained which type of facial fracture?
Orbital rim fracture
Le Fort II fracture
Zygomatic fracture
✓
Nasal fracture
Correct Answer
Zygomatic fracture
A. Orbital rim fracture is associated with visible or palpable deformity around the orbit, ocular entrapment, diplopia, enophthalmos, infraorbital paresthesia, and subconjunctival hemorrhage.
B. Symptoms of a zygomatic fracture are trismus, infraorbital hypoesthesia, diplopia, epistaxis, symmetrical abnormality, and the presence of facial edema and ecchymosis. The mechanism of injury for this patient was a direct blow to the face, which is indicative in the presence of a zygomatic fracture.
C. Nasal fracture can involve nasal deformity, crepitus, ecchymosis, and edema, as well as anterior or posterior epistaxis.
D. Le Fort II fracture extends above the nose in a pyramidal manner. The nose and upper palate are separated from the rest of the face. If the upper teeth are manipulated, the nose and upper palate will remain mobile, while the orbits remain fixed. The patient will complain of midfacial pain and flattened nares. The patient may also exhibit subconjunctival hemorrhage.
Category: Maxillofacial and Ocular Emergencies, Maxillofacial, Maxillofacial trauma
Question 118
A patient with a history of acute closed-angle glaucoma presents with a complaint of severe unilateral eye pain, nausea, and blurred vision. What is the priority action for this patient?
Place the patient in a darkened room
Immediately notify the emergency provider of the patient’s arrival
✓
Treat the patient’s accompanying symptoms of nausea and headache
Dilate the eye to determine if the cornea has become edematous
Correct Answer
Immediately notify the emergency provider of the patient’s arrival
A. The emergency department provider can complete tonometry and, if elevated pressures are present, provide prompt definitive treatment to preserve vision. The patient will most likely also require an examination by an ophthalmologist. The condition must be recognized within hours of symptom onset to prevent blindness due to optic nerve damage from the increased pressure.
B. Eye dilation may further exacerbate the increased intraocular pressure.
C. A darkened room may cause pupillary dilation and exacerbate the presence of increased intraocular pressure.
D. The presence of nausea and a headache can be treated with the appropriate medication; however, definitive treatment should be initiated immediately to minimize risk of blindness. In addition, these symptoms usually resolve without treatment once the increased intraocular pressure has decreased.
Category: Maxillofacial and Ocular Emergencies, Ocular, Increased intraocular
Question 119
A friend accompanies a young adult patient and states the patient was at a party and suddenly became dizzy, confused, and lethargic. The friend is concerned that the patient may have possibly ingested a “date rape” drug. Which of the following medications should the nurse anticipate administering for acute flunitrazepam (Rohypnol) ingestion?
Diazepam (Valium)
Alprazolam (Xanax)
Flumazenil (Romazicon)
✓
Naloxone (Narcan)
Correct Answer
Flumazenil (Romazicon)
A. Diazepam is a benzodiazepine, like flunitrazepam, so it would not be an appropriate choice to treat this patient.
B. Flumazenil is used for benzodiazepine reversal because it acts to antagonize the actions of benzodiazepines on the central nervous system (flunitrazepam is a benzodiazepine). Use flumazenil carefully, because it causes seizures if other medications are also ingested.
C. Naloxone is used for opiate reversal.
D. Alprazolam is a benzodiazepine, like flunitrazepam, so it would not be an appropriate choice to treat this patient.
Category: Medical Emergencies, Substance use and abuse (e.g., alcohol and drug
Question 120
A patient experiencing alcohol withdrawal has received intravenous haloperidol (Haldol) for delirium, delusions, and hallucinations. Which electrocardiogram abnormality might occur from haloperidol administration?
QT interval prolongation
✓
Osborne waves
Peaked T-waves
Delta waves
Correct Answer
QT interval prolongation
A. Peaked T-waves occur in hyperkalemia but are not associated with the administration of haloperidol.
B. QT interval prolongation in the cardiac cycle may occur in critically ill patients receiving haloperidol. QT prolongation places the patient at risk for ventricular dysrhythmias. Continuous electrocardiogram monitoring should be maintained with intravenous haloperidol use.
C. Delta waves are present in Wolff–Parkinson–White syndrome but are not associated with the administration of haloperidol.
D. Osborne waves occur in the presence of hypothermia but are not associated with the administration of haloperidol.
Category: Medical Emergencies, Withdrawal syndrome
Question 121
An elderly female is brought in by her daughter, who reports that her mother has been unable to sleep for the past 3 days. The daughter states that her mother has been talking to her deceased husband and has been found wandering outside her home. Which of the following is most likely the cause of this change in the patient’s behavior?
Insomnia
Delirium
✓
Suicidal ideation
Depression
Correct Answer
Delirium
A. Suicidal ideation would involve the patient voicing the desire to injure herself. The patient may have a plan, as well as access to things that could harm her, including a weapon.
B. Depression is manifested by several symptoms, such as an altered mood, to include anxiety, sleep disturbances, and lack of interest in activities. It has a slow onset of symptoms.
C. Delirium is a potentially reversible neuropsychiatric emergency in which the patient is acutely disturbed. It involves changes in attention, awareness, and cognition. The symptoms may occur acutely or develop over days. Causes of delirium include illnesses, such as a urinary tract infection or pneumonia; metabolic disturbances, such as hyponatremia; medications, especially in patients who take multiple medications; and sleep deprivation.
D. Insomnia is a sleep disorder that involves problems with falling and staying asleep. The patient may manifest some abnormal behaviors and problems with cognition, especially if they have not been able to sleep for long periods. It would be important to evaluate if the patient has a history of insomnia, but it generally does not cause acute behavioral changes by itself.
Category: Neurological Emergencies, Neurological disorders (e.g., multiple
Question 122
A patient presents following a motorcycle collision. Multiple abrasions are noted on the patient’s left leg, hip, trunk, and arm. While preparing to provide treatment, the nurse explains the goals of wound care to the patient. Which of the following is a goal of wound care?
Restore thermoregulation
Obtain homeostasis
Manage pain
Maintain function
✓
Correct Answer
Maintain function
A. Maintaining and/or preserving function is a goal or desired outcome of wound care and management of the trauma patient. Additional goals are prevention of complications such as infection, and promotion of wound healing.
B. Thermoregulation, an essential integumentary function, is restored through the process of wound healing but is not a goal of wound healing.
C. Pain management is an overall goal of managing the trauma patient. Interventions to manage pain are beneficial before performing wound care.
D. A phase of wound healing, homeostasis occurs with the formation of a clot through platelet aggregation, the clotting cascade, and vasoconstriction. Interventions to control bleeding, such as direct pressure or tourniquets, are used to obtain and maintain homeostasis, which is a goal of treating surface trauma.
Category: Musculoskeletal and Wound Emergencies, Wound, Avulsions and
Question 123
The nurse is caring for a patient who was recently intubated. The ventilator sounds a low-pressure alarm. The nurse has difficulty immediately identifying the cause of the alarm. What is the priority action at this time?
Replace all ventilator circuits
Call the radiology department and request a stat chest x-ray
Replace the ventilator unit
Provide manual breaths with a bag-mask device
✓
Correct Answer
Provide manual breaths with a bag-mask device
A. A low-pressure alarm frequently is associated with an accidental disconnection. The most appropriate action, if the cause cannot be quickly determined, is to disconnect the ventilator and provide breaths via a bag-mask device until the cause of the alarm can be found.
B. Replacing the ventilator unit is time consuming and does not address the cause of the alarm. The patient may not be receiving ventilation during this time. The priority is to maintain the airway and provide breathing for the patient.
C. Replacing the ventilator circuits is time consuming. While it may help fix the cause by reconnecting a loose connection, it is not the priority intervention.
D. A chest x-ray may identify a pneumothorax, which can be associated with mechanical ventilation. However, the alarm associated with a pneumothorax is high pressure. In addition, this intervention is time consuming and does not take priority over performing breaths for the patient.
Category: Respiratory Emergencies, Obstruction
Question 124
A patient arrives in the emergency department following blunt-force trauma to the chest. Assessment reveals hypotension, tachycardia, dyspnea, muffled heart sounds, and pulsus paradoxus. The nurse anticipates which intervention to be performed?
Chest tube insertion
Pericardiocentesis
✓
Intubation
Needle decompression
Correct Answer
Pericardiocentesis
A. The patient is experiencing signs and symptoms of cardiac tamponade. Pericardiocentesis is the initial intervention to relieve the pressure on the heart. Needle decompression would be used for a tension pneumothorax.
B. The patient is experiencing signs and symptoms of cardiac tamponade. Pericardiocentesis is the initial intervention to relieve the pressure on the heart. Intubation is not needed at this time but is usually used with a flail chest.
C. The patient is experiencing signs and symptoms of cardiac tamponade. Pericardiocentesis is the initial intervention to relieve the pressure on the heart. Chest tube insertion would be used for a pneumothorax.
D. The patient is experiencing signs and symptoms of cardiac tamponade. Pericardiocentesis is the initial intervention to relieve the pressure on the heart. Assessment findings can include Beck’s triad (hypotension, distended neck veins, and muffled heart sounds), chest pain, tachycardia, and pulsus paradoxus. If the patient is hypotensive, distended neck veins may not be appreciated.
Category: Cardiovascular Emergencies, Pericardial tamponade
Question 125
What assessment findings may cause the nurse to suspect pericardial tamponade?
Distant heart sounds and hypotension
✓
Subcutaneous emphysema and air in the mediastinum
Poor cardiovascular response and electrocardiogram abnormalities
Distended neck veins and tracheal deviation
Correct Answer
Distant heart sounds and hypotension
A. Decreased stroke volume and cardiac output are findings associated with pericardial tamponade. These findings are the result of blood collecting in the pericardium, compressing the heart, and decreasing the ability of the ventricles to fill.
B. Distended neck veins and tracheal deviation are findings associated with the presence of a tension pneumothorax. Air enters the pleural space, resulting in lung collapse. The pressure continues to increase, and the mediastinum shifts to the opposite side, resulting in tracheal deviation. Distended neck veins are a sign of impaired venous return, which may be seen in both tension pneumothorax and pericardial tamponade.
C. Subcutaneous emphysema and air in the mediastinum are findings associated with the presence of blunt esophageal injury. Blunt esophageal rupture can be associated with fractures of the first and second ribs, and cervical spine fracture.
D. Poor cardiovascular response and electrocardiogram abnormalities are findings of blunt cardiac injury, which can occur following acceleration–deceleration injuries as well as any significant fall.
Category: Cardiovascular Emergencies, Pericardial tamponade
Question 126
A patient is diagnosed with pneumonia and meets the sepsis criteria. How soon should antibiotics be started after recognition of sepsis?
Within 4 hours
Within 2 hours
✓
Within 6 hours
Within 8 hours
Correct Answer
Within 2 hours
A. According to the Surviving Sepsis guidelines, the suggested time to start antibiotics is within 1 hour if the patient has septic shock and less than 3 hours if the patient has sepsis without shock. However, administering the antibiotics sooner will act to potentially improve patient outcomes.
B. According to the Surviving Sepsis guidelines, the suggested time is within 1 hour if the patient has septic shock and less than 3 hours if the patient has sepsis without shock. However, administering the antibiotics sooner will act to potentially improve patient outcomes.
C. According to the Surviving Sepsis guidelines, the suggested time is within 1 hour if the patient has septic shock and less than 3 hours if the patient has sepsis without shock. However, administering the antibiotics sooner will act to potentially improve patient outcomes.
D. According to the Surviving Sepsis guidelines, the suggested time is within 1 hour if the patient has septic shock and less than 3 hours if the patient has sepsis without shock. However, administering the antibiotics sooner will act to potentially improve patient outcomes.
Category: Respiratory Emergencies, Infections
Question 127
A patient with a brain tumor arrives with signs of increased intracranial pressure. The nurse is educating the family members on the patient’s condition. Which statement made by the family indicates the need for further education?
“Keeping the head of the bed flat is important.”
✓
“Speaking may be slow or difficult.”
“Talking quietly and holding hands is helpful.”
“Shaking and stiffness is an emergency.”
Correct Answer
“Keeping the head of the bed flat is important.”
A. Intracranial pressure may increase because of noxious stimuli such as suctioning, rectal temperatures, pain, or agitation. Reassurance and closeness of family provides a soothing, calming presence.
B. Maintaining a 30-degree or higher elevation of the head promotes drainage of cerebrospinal fluid and/or blood, resulting in decreasing intracranial pressure. The family requires education on proper positioning, which also includes keeping the head and neck aligned to further promote drainage.
C. Seizures are a complication of increased intracranial pressure and may indicate declining neurological status. Families participate in care by learning to recognize situations that require intervention.
D. Varying centers of the brain may be affected by increased pressure or tumor location. Families should be aware that personality, behavior, or speech may be different.
Category: Neurological Emergencies, Increased intracranial pressure (ICP)
Question 128
A 5-year-old child dove head-first into a shallow pool and is unable to move their arms or legs. The radiologic studies are negative for any acute vertebral injury. Which of the following is most likely?
Spinal cord injury without radiographic abnormality
✓
Brown–Séquard syndrome
Psychological reaction to trauma
Posterior cord syndrome
Correct Answer
Spinal cord injury without radiographic abnormality
A. Posterior cord syndrome results from hyperextension but causes impairment to light touch and proprioception, not to motor movement.
B. Brown–Séquard syndrome includes same-side motor loss and opposite-side sensory loss.
C. Neurologic deficits without evidence of vertebral fracture or radiographic abnormality constitute the condition described. This can be seen in the pediatric patient due to the patient’s weak neck muscles and flexibility of the vertebral ligaments.
D. Children do not “fake” injuries, and the mechanism of injury is probable for spinal cord injury.
Category: Neurological Emergencies, Head and spinal cord trauma
Question 129
A 2-year-old child is diagnosed with gastroenteritis. The child has been rehydrated in the emergency department and is currently taking fluids by mouth. Initial discharge dietary instructions should direct the child’s parents to administer which of the following?
Provide a clear liquid diet of ice pops and apple juice
Provide small amounts of a glucose and electrolyte solution
✓
Keep the child NPO for the next 24 hours
Resume normal eating habits
Correct Answer
Provide small amounts of a glucose and electrolyte solution
A. Oral rehydration solutions contain balanced osmolality, glucose, and sodium. This solution will help to replace needed electrolytes and minimize additional stomach irritation.
B. Patients who have been rehydrated and are able to take fluids by mouth are generally discharged with instructions to maintain a clear liquid diet.
C. This patient should be discharged with instructions for a clear liquid diet. Ice pops would be appropriate, but apple juice is hyperosmolar and would worsen the diarrhea.
D. The early resumption of a regular diet may cause additional stomach stimulation and can worsen symptoms of vomiting and diarrhea.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 130
Following completion of a joint aspiration of the knee by the provider, which of the following is the priority intervention?
Elevate the extremity above the level of the heart
Place an ice pack on the aspiration site
Apply pressure to the aspiration site
✓
Place a heat pack on the aspiration site
Correct Answer
Apply pressure to the aspiration site
A. Applying direct pressure for at least 2 minutes is the first thing that should be performed following the procedure to stop further bleeding at the site. Other interventions, like applying ice or a pressure dressing, can be delayed until active bleeding at the insertion site has stopped.
B. Application of an ice pack is an appropriate intervention after the dressing has been applied, but applying pressure to the aspiration site is the priority intervention.
C. Placing heat on an aspiration site following the procedure is not recommended because this can increase blood flow to the area, increasing swelling and the risk of further bleeding.
D. Elevation is a recommended intervention and is thought to reduce swelling, but applying direct pressure to the site for 2 minutes, followed by the application of a pressure dressing, is the priority intervention.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Inflammatory
Question 131
A patient is brought in holding their tooth in their hand, stating that the tooth was knocked out while playing soccer. Which of the following is the best intervention to protect the tooth for reimplantation?
Place the tooth in milk or saline
Place the tooth under the patient’s tongue
Wrap the tooth in moist, saline-soaked gauze
Rinse the tooth and place it back in the socket
✓
Correct Answer
Rinse the tooth and place it back in the socket
A. The longer the tooth is out of the socket, the greater the risk for tissue hypoxia and necrosis of the pulp. If the patient is able, rinsing the tooth and replacing it in the socket increases the chances of successful reimplantation.
B. Wrapping the tooth may damage the periodontal ligament fragments and endanger the success of reimplantation. Moist saline gauze may be applied to the avulsion site to relieve pain or control bleeding.
C. It is appropriate to transport an avulsed tooth in the patient’s mouth, under the tongue or between the cheek and gum, but it also places the patient at risk for aspiration. If the patient is able, rinsing the tooth and replacing it in the socket increases the chances of successful reimplantation.
D. It is appropriate to transport an avulsed tooth in milk or saline; however, successful reimplantation is best accomplished within 30 minutes after the tooth has been avulsed.
Category: Maxillofacial and Ocular Emergencies, Maxillofacial, Abscess (i.e.,
Question 132
A patient presents with increased tearing, salivation, urination, and diarrhea after spraying his fields with insecticide. Which of the following tests would provide the best information in the diagnostic workup for this patient?
Urine drug screen
Pseudocholinesterase level
✓
Platelet count
Serum lactate level
Correct Answer
Pseudocholinesterase level
A. Blood platelets are not altered by exposure to organophosphates, so a platelet count is not indicated.
B. Serum lactate levels are not indicated to confirm organophosphate exposure; they are indicated in the presence of suspected sepsis.
C. A urine drug screen will not confirm a patient’s exposure to organophosphates.
D. Organophosphate poisoning may be confirmed by measuring the patient’s plasma pseudocholinesterase level. Organophosphate molecules attach to cholinesterase in the body, making it unable to perform its function to break down acetylcholine. This poisoning allows acetylcholine to become overactive, thereby leading to the symptoms associated with it.
Category: Environment and Toxicology Emergencies, and Communicable
Question 133
An unresponsive patient with an electrical shock injury from a live wire arrives in the emergency department. Which of the following treatment options would be anticipated for this patient?
Defibrillation
✓
External pacing
Chest tube placement
Synchronized cardioversion
Correct Answer
Defibrillation
A. The most common dysrhythmia associated with alternating-current shocks is ventricular fibrillation, not bradycardic rhythms, which would require external pacing.
B. Synchronized cardioversion would be necessary for a patient in ventricular tachycardia. Ventricular fibrillation is the most common dysrhythmia associated with alternating-current shocks.
C. The most common dysrhythmia associated with alternating-current shocks is ventricular fibrillation, which requires immediate defibrillation and resuscitation.
D. Chest tube placement might be useful in the care of a patient with asystole, because a potential cause is tension pneumothorax. Asystole would not be the rhythm most commonly associated with alternating-current shocks. Ventricular fibrillation is the anticipated dysrhythmia with alternating-current shocks.
Category: Environment and Toxicology Emergencies, and Communicable
Question 134
A child presents with a fever and generalized rash in various stages of eruptions, with some macular and others crusted vesicles. Areas of scratching are noted around the rash. The child is unvaccinated. Which of the following disease processes is the highest suspicion for this child?
Varicella
✓
Pertussis
Rubella
Herpes zoster
Correct Answer
Varicella
A. The rash associated with rubella (measles) is maculopapular that begins on the face and progresses to a generalized rash. It appears as a reddish and blotchy type of rash.
B. Varicella (chickenpox) presents with a generalized itching rash in various stages of eruption and healing. A fever is usually present with this disease. That the child’s rash is in various stages is a hallmark sign of this process.
C. Herpes zoster (shingles) produces a rash that follows a dermatome and is therefore unilateral. It does not cross the midline of the body. It appears vesicular and is painful.
D. A rash is not a part of the manifestations of pertussis (whooping cough).
Category: Environment and Toxicology Emergencies, and Communicable
Question 135
A patient presents with severe abdominal cramping, fever, bloody diarrhea, a petechial type rash on the neck and upper chest, and copious vomiting after returning home from mission work in Africa. The patient is hypotensive, tachycardic, and febrile, with a pulse oximetry reading of 95%. Which of the following is the priority intervention?
Initiate intravenous hydration with crystalloid solution
Place the patient in droplet and contact isolation
✓
Obtain a complete blood count, electrolyte panel, and stool for analysis
Provide oxygen at 2 L/minute via nasal cannula
Correct Answer
Place the patient in droplet and contact isolation
A. This patient has traveled from a potentially endemic area for hemorrhagic fevers and now presents with possible symptomatology of Ebola virus disease. It is imperative that isolation procedures are instituted immediately for the safety of the staff and other patients.
B. Laboratory testing would be ordered for this patient but is not considered a priority intervention. It is important to protect everyone caring for this patient, so isolation procedures should be instituted immediately.
C. This patient does need to have intravenous therapy with administration of crystalloids; however, all staff must be protected, so this patient should be officially placed on isolation—droplet and contact—immediately.
D. The patient’s respiratory rate is within normal parameters, and oxygen saturation level is 95%; therefore, supplemental oxygen would not be indicated.
Category: Environment and Toxicology Emergencies, and Communicable
Question 136
Which of the following laboratory test results, trending in a decreasing fashion, would indicate an improvement in a patient being treated for suspected cyanide poisoning after a house fire?
White blood cell count
Potassium level
Platelet count
Lactate level
✓
Correct Answer
Lactate level
A. Platelets are not impacted by the presence of cyanide.
B. The potassium level is not implicated in the symptoms or treatment of cyanide poisoning.
C. The white blood cell count does not change in the presence of cyanide.
D. Cyanide poisoning impacts lactate levels. Cyanide prevents aerobic metabolism, which causes a deficit of energy production that leads to cellular hypoxia. The ensuing anaerobic metabolism causes high lactate levels. Therefore, a reduction in lactate levels would indicate the restoration of aerobic metabolism and improvement in a patient being treated for cyanide poisoning.
Category: Environment and Toxicology Emergencies, and Communicable
Question 137
A patient arrives from a skilled nursing facility with a 3-day history of watery diarrhea, low-grade fever, and decreased fluid intake. The patient is presently taking levofloxacin (Levaquin) for pneumonia. The physician has ordered a stool specimen for Clostridioides (formerly Clostridium) difficile. Which of the following specimens is appropriate to send?
Stool collected over 12 hours ago
Formed stool
Watery stool
✓
Unrefrigerated stool over 2 hours old
Correct Answer
Watery stool
A. Testing for C. difficile is usually appropriate on diarrheal stools—stools that are loose enough to take the shape of the container. They should be fresh (no more than 12 hours) and should be refrigerated if not sent within 1–2 hours of collection. The C. difficile toxin is unstable and degrades at room temperature, usually within 2 hours.
B. Testing for C. difficile is usually appropriate on diarrheal stools—stools that are loose enough to take the shape of the container. Most labs will reject a formed stool for testing of C. difficile. Stools should be fresh (no more than 12 hours) and should be refrigerated if not sent within 1–2 hours of collection.
C. Testing for C. difficile is usually appropriate on diarrheal stools—stools that are loose enough to take the shape of the container. They should be fresh and should be refrigerated if not sent within 1–2 hours of collection.
D. Testing for C. difficile is usually appropriate on diarrheal stools—stools that are loose enough to take the shape of the container. They should be fresh, preferably collected within 1 hour, but no more than 12 hours, and refrigerated if not sent within 1–2 hours of collection.
Category: Environment and Toxicology Emergencies, and Communicable
Question 138
A patient presents following a syncopal episode. The cardiac monitor displays a cyclic irregular rhythm with an inconsistent PR segment, which becomes progressively longer until dropping a QRS complex. The cyclic pattern repeats every 4 complexes. What is the cardiac rhythm?
First-degree heart block
Second-degree Mobitz I block
✓
Second-degree Mobitz II block
Third-degree heart block
Correct Answer
Second-degree Mobitz I block
A. Second-degree Mobitz I block, or Wenckebach rhythm, is described as the progressive lengthening of the PR segment, ending in a dropped QRS complex usually occurring after 3–5 beats. One of the P-waves fails to be conducted to the ventricles, resulting in a “dropped beat,” and then repeating. This is a second-degree Mobitz I block, or Wenckebach rhythm.
B. A second-degree Mobitz II heart block represents a cardiac rhythm in which the sinus node impulses occur at regular intervals, but conduction to the ventricles is intermittently absent. The P-waves will have a consistent configuration, and the PR interval with the complex that is conducted to the ventricles will remain constant. The P-waves that are not conducted below the atria result in failure of the ventricles to contract, and the absence of the QRS complex. Typically, a second-degree Mobitz II block rhythm occurs in conjunction with bradycardia and will require treatment considerations to maintain adequate cardiac output.
C. Third-degree heart block is characterized by the complete absence of conduction between the atria and the ventricles. The sinus node continues to release an impulse, but it is not conducted to the ventricles. As a result, the ventricles release their own impulse to maintain ventricular contraction, resulting in a lower cardiac output. A third-degree heart block rhythm has P-waves that occur independent of the QRS complexes. This cardiac rhythm requires immediate lifesaving interventions to improve cardiac output and hemodynamic instability.
D. A first-degree heart block is characterized by a consistent PR interval that is greater than 0.20 second.
Category: Cardiovascular Emergencies, Dysrhythmias
Question 139
Shortly after drug-assisted intubation and initiation of mechanical ventilation, the following changes are noted: a decrease in the patient’s blood pressure and oxygen saturation, restlessness, and cyanosis. What is the most likely cause for the sudden change in the patient’s condition?
Development of a tension pneumothorax
✓
Inadequate mechanical ventilation
Adverse reaction to sedation medication
Dislodged endotracheal tube
Correct Answer
Development of a tension pneumothorax
A. Sedation medications may cause a decrease in blood pressure but would not have the effect of oxygen saturation of a mechanically ventilated patient.
B. Dislodgement of an endotracheal tube would result in decreased oxygen saturation caused by inadequate ventilation, and a subsequent decrease in cardiac output resulting from depleting oxygen reserves. Decreased blood pressure will not be evident immediately. In contrast, the building intrathoracic pressure that occurs with a tension pneumothorax results in decreased cardiac output, which will manifest quickly as hypotension and poor tissue perfusion.
C. Because barotrauma is a complication of mechanical ventilation, patients requiring ventilation must be frequently assessed for development of a pneumothorax. The decline in hemodynamics indicates that a life-threatening emergency known as a tension pneumothorax may be the cause. Increasing intrathoracic pressure compresses the lungs, heart, and great vessels, resulting in markedly decreased cardiac output, ventilation, and tissue perfusion.
D. Inadequate ventilation would result in decreased oxygen saturation and a subsequent decrease in cardiac output that is due to depleting oxygen reserves. Decreased blood pressure will not be evident immediately. In contrast, the building intrathoracic pressure that occurs with a tension pneumothorax results in decreased cardiac output, which will manifest quickly as hypotension and poor tissue perfusion.
Category: Respiratory Emergencies, Pneumothorax
Question 140
In a patient with prolonged immobility, which of the following is a contributing factor to thrombus formation that can cause a pulmonary embolus?
Pulmonary vascular pressure
Venous stasis
✓
Hypercoagulable state
Endothelial injury
Correct Answer
Venous stasis
A. Endothelial injury is a major risk factor for thromboemboli formation. It is caused by damage to the innermost layer of a vein or artery from trauma, burns, surgery, or infection, not from immobilization.
B. Increased pulmonary vascular pressure results in pulmonary edema and does not contribute to thromboemboli formation.
C. Hypercoagulable states are a major risk factor for thromboemboli formation. Contributing factors include postpartum period, contraceptive use, malignancy, major surgery, and disease processes.
D. Venous stasis is a major risk factor for thromboemboli formation. Heart failure, limb immobilization, prolonged lying or sitting, obesity, pregnancy, and venous insufficiency can result in venous stasis. Venous stasis, epithelial damage, and alterations in coagulation are known as Virchow’s triad and can lead to venous thrombi.
Category: Respiratory Emergencies, Pulmonary embolus
Question 141
An emergency department patient with complaints of pain and decreased movement of the lower extremities has just been diagnosed with Guillain–Barré syndrome. Which of the following is the priority intervention for this patient?
Prepare for prophylactic intubation
Control pain with intravenous medications
✓
Prepare for lumbar puncture to confirm the diagnosis
Allow the patient to take daily oral medications
Correct Answer
Control pain with intravenous medications
A. Patients with Guillain–Barré syndrome have a motor impairment, but sensation is still present. Pain from nerve root inflammation still requires treatment. Oral medications should be held until a swallow study can be performed because of the risk of aspiration, so control pain with IV or IM medications initially.
B. Guillain–Barré syndrome is a clinical diagnosis. Many tests, including lumbar puncture, are used to rule out other possible causes of the symptoms, but none are diagnostic for Guillain–Barré syndrome.
C. Patients with suspected or actual Guillain–Barré syndrome should be kept NPO (nothing by mouth) until a swallow study has been completed because of the risk for aspiration.
D. Intubation may be needed, but only 20–30% of Guillain–Barré syndrome patients ever require intubation. Frequent assessment of respiratory function and effort should continue.
Category: Neurological Emergencies, Neurological disorders (e.g., multiple
Question 142
A child is carried to the emergency department after waking up with pain to the neck. The child is lying on the cart with their head rotated to the left and the neck tilted laterally. The child complains of pain on the right side of the neck. What is the priority intervention for this patient?
Maintain the cervical spine in the current position
✓
Apply heat or ice to the neck
Apply a rigid cervical collar
Medicate with a nonsteroidal anti-inflammatory drug
Correct Answer
Maintain the cervical spine in the current position
A. Based on the symptoms, this patient may have an atlantoaxial rotary subluxation. This is more common in children, thought to be due to anatomical differences in the neck. It can occur spontaneously or following injury or an infection. It presents with the head rotated to one side, with the head tilted; pain is on the long side of the neck, whereas torticollis is usually on the short side of the neck. Until other conditions are ruled out, allow the patient to maintain a position of comfort.
B. Based on the symptoms, this patient may have an atlantoaxial rotary subluxation. This is more common in children, probably due to anatomical differences in the neck. A rigid collar is not needed for this patient, though a soft collar will probably be ordered for comfort.
C. Based on the symptoms, this patient may have an atlantoaxial rotary subluxation. This is more common in children, probably due to anatomical differences in the neck. Application of heat or ice may help with the pain/spasm, but maintaining the current cervical spine position is the priority.
D. Based on the symptoms, this patient may have an atlantoaxial rotary subluxation. This is more common in children, probably due to anatomical differences in the neck. An anti-inflammatory drug should be given, but it is not the priority.
Category: Neurological Emergencies, Head and spinal cord trauma
Question 143
A patient arrives via emergency medical services with a generalized motor seizure that has lasted for 25 minutes. Which of the following laboratory results would the nurse expect to see?
Hyperglycemia
Elevated urine myoglobin
✓
Metabolic alkalosis
Decreased creatinine phosphokinase
Correct Answer
Elevated urine myoglobin
A. Continual seizures over 5 minutes in duration are considered status epilepticus and can cause muscle damage from prolonged contraction. Myoglobin, seen in rhabdomyolysis, is released from damaged muscles and rapidly excreted in the urine, producing a reddish-brown urine.
B. Continual seizures over 5 minutes in duration are considered status epilepticus and can cause muscle damage from prolonged contraction. Metabolic acidosis is seen with prolonged seizures because of muscle hypoxia during the seizure.
C. Continual seizures over 5 minutes in duration are considered status epilepticus and can cause muscle damage from prolonged contraction. The prolonged seizure activity will use up glucose stores, so the patient will be hypoglycemic.
D. Continual seizures over 5 minutes in duration are considered status epilepticus and can cause muscle damage from prolonged contraction. Creatinine phosphokinase is released along with myoglobin from damaged muscle, so its levels will be increased.
Category: Neurological Emergencies, Seizure disorders
Question 144
A patient involved in a rollover motor vehicle collision was treated with mannitol for increased intracranial pressure. The most recent vital signs show a temperature of 102.3°F (39°C). What is the priority intervention for this patient?
Draw a complete blood count
Administer an antipyretic
✓
Apply a cooling blanket
Obtain a set of blood cultures
Correct Answer
Administer an antipyretic
A. Fever and other metabolic demands such as pain, seizures, and shivering can increase intracranial pressure. The goal is to reduce any extra metabolic demands to avoid further increasing intracranial pressure.
B. Fever and other metabolic demands such as pain, seizures, and shivering can increase intracranial pressure. Drawing a set of blood cultures will be important for identification of a possible source of the fever, but is not the priority.
C. Fever and other metabolic demands such as pain, seizures, and shivering can increase intracranial pressure. A cooling blanket may bring the fever down but may also cause hypothermia and worsen shivering. Hypothermia has been studied with conflicting results in isolated brain injury but contributes to the trauma triad of death in multi-system injuries.
D. Fever and other metabolic demands such as pain, seizures, and shivering can increase intracranial pressure. Drawing a complete blood count will be important to see if there is an elevated white blood cell count, but it is not the priority.
Category: Neurological Emergencies, Increased intracranial pressure (ICP)
Question 145
A patient is being seen in the emergency department for fatigue. The discharge diagnosis is “fatigue related to multiple sclerosis exacerbation.” Which of the following discharge instructions is important for targeting the fatigue?
Stay out of the heat to keep your body temperature down.
✓
Limit your fluid intake throughout the day to prevent frequent voiding.
Start your corticosteroid injections after the fatigue passes.
Stop exercising until you follow up with your physician next week.
Correct Answer
Stay out of the heat to keep your body temperature down.
A. Exacerbations produce sustained effects on disability, so the goal is to decrease the duration. Heat aggravates the fatigue and weakness that occur during these periods. Keeping the body temperature down by avoiding the heat, staying in an air-conditioned environment, and drinking ice water all help.
B. Exacerbations produce sustained effects on disability, so the goal is to decrease the duration. Elevated body temperatures can cause an exacerbation. Staying well hydrated will help keep the body temperature down. Decreasing fluid intake at bedtime is, however, recommended for urinary frequency issues.
C. Exacerbations produce sustained effects on disability, so the goal is to decrease the duration. For multiple sclerosis, corticosteroids are used in the management of acute exacerbations. They reduce inflammation in the central nervous system.
D. Exacerbations produce sustained effects on disability, so the goal is to decrease the duration. Exercise is important to prevent deconditioning, but during an exacerbation, it should involve short intervals with rest periods in between. Physical therapy can help develop a program that is patient-specific.
Category: Neurological Emergencies, Neurological disorders (e.g., multiple
Question 146
A patient with a spinal cord injury at the level of T5 has been diagnosed with neurogenic shock. Which rhythm would the nurse expect to see on the electrocardiogram?
Sinus bradycardia
✓
Third-degree heart block
Sinus tachycardia
Supraventricular tachycardia
Correct Answer
Sinus bradycardia
A. In a patient with neurogenic shock, the body loses sympathetic vasomotor regulation and can no longer oppose the parasympathetic responses. Unopposed parasympathetic stimulation results in bradycardia and hypotension from vasodilation.
B. In a patient with neurogenic shock, the body loses sympathetic vasomotor regulation and can no longer oppose the parasympathetic responses. This will result in sinus bradycardia, not tachycardia.
C. In a patient with neurogenic shock, the body loses sympathetic vasomotor regulation and can no longer oppose the parasympathetic responses. This will result in sinus bradycardia, not a conduction blockage in the heart.
D. In a patient with neurogenic shock, the body loses sympathetic vasomotor regulation and can no longer oppose the parasympathetic responses. This will result in sinus bradycardia, not supraventricular tachycardia.
Category: Neurological Emergencies, Neurogenic shock
Question 147
A patient arrives with right-sided hemiparesis and expressive aphasia. The most important information for the nurse to obtain is:
history of recent surgery.
history of recent trauma.
symptom onset.
✓
patient allergies.
Correct Answer
symptom onset.
A. Although recent trauma may be considered an exclusion to the administration of tissue plasminogen activator, it must first be determined whether the patient is within the treatment window of 3 to 4.5 hours for certain eligible patients to receive this drug.
B. Although allergies are important, the ability to administer tissue plasminogen activator safely requires knowing the last time the patient was seen in their usual state of health.
C. The time of symptom onset or the last time seen in their usual state of health will help to determine if this patient is a candidate to receive tissue plasminogen activator. The patient is considered within the treatment window if “last seen well” is 3 to 4.5 hours in eligible patients.
D. Although recent surgery may be considered an exclusion to tissue plasminogen activator, providers must first determine if the patient is within the treatment window of 3 to 4.5 hours for certain eligible patients to receive this drug.
Category: Neurological Emergencies, Stroke
Question 148
A patient presents with a left ventricular assistive device (LVAD). Which statement made by the patient demonstrates understanding of the LVAD function?
“I can’t have a heart attack since I have an LVAD.”
“You will only be able to hear one number for my blood pressure.”
✓
“I know my LVAD is working if I do not hear it humming continuously.”
“My LVAD clicks every time it opens and closes.”
Correct Answer
“You will only be able to hear one number for my blood pressure.”
A. LVADs produce a continuous blood flow. A manual BP cuff should be used, with the mean arterial pressure being the first sound heard. The mean arterial pressure generally fluctuates between 70 and 90 mm Hg. Automatic blood pressure devices should not be used with an LVAD patient.
B. A clicking sound is consistent with a mechanical heart valve, not an LVAD. The LVAD typically has a continuous humming sound.
C. Though rare, patients with an LVAD can have a myocardial infarction. Suspect embolization from an aortic root thrombus.
D. A functioning LVAD will have a continuous humming sound. The provider should listen for the humming as part of the patient assessment.
Category: Cardiovascular Emergencies, Heart failure
Question 149
A young woman states that she has been sexually assaulted. Based on the Emergency Severity Index (ESI) 5-level triage system, the nurse assigns the patient an ESI level 2. Which of the following statements is true regarding the triage nurse’s decision?
Assessment for life-threatening injury and evidence collection are time-sensitive interventions.
✓
The patient should be placed in a secluded area of the emergency department.
The patient will require at least two resources and a 1:1 mental health consult.
The patient is in custody of the law enforcement officer.
Correct Answer
Assessment for life-threatening injury and evidence collection are time-sensitive interventions.
A. Identification of life-threatening injuries is a priority. Collection of evidence may be done before full patient assessment or treatment of non-life-threatening injuries. The patient is potentially high risk for deterioration, and there is a time-sensitive element to assessment and interventions.
B. Although the patient may be with the police to ensure that the forensic chain of evidence is followed, the patient may not be under arrest or in police custody.
C. Placing the patient in a safe, private environment is a priority. The patient does not need to be secluded from the general emergency department patient population. Patient placement within the department does not determine the ESI level.
D. Resource utilization alone is not the main reason the patient receives a high acuity level. Assessment and evidence collection are time-sensitive, high-priority interventions, indicating that this patient should be assigned an ESI level 2.
Category: Mental Health Emergencies, Aggressive and violent behavior
Question 150
A patient presents with complaints of chest pain and shortness of breath, and appears apprehensive and restless. The patient had been discharged the previous day following repair of a fractured femur. Vital signs are BP 132/84 mm Hg, HR 98 beats/minute, RR 22 breaths/minute, T 37.7°C (100°F). The nurse anticipates the most likely explanation for the patient’s symptoms is the presence of:
a pulmonary embolism.
✓
myocardial infarction.
deep vein thrombosis (DVT).
hemorrhage.
Correct Answer
a pulmonary embolism.
A. The patient’s vital signs do not reflect signs of excessive bleeding.
B. Patients who have sustained recent trauma with long bone injuries that require surgery and immobility are at a high risk for the development of a pulmonary fat embolism. Patients with a pulmonary embolism often appear anxious and restless, and are tachycardic and tachypneic. The patient with a fat embolus may have petechiae.
C. The patient does not indicate signs consistent with DVT, such as calf tenderness, redness, or swelling. A DVT can lead to a pulmonary embolus.
D. The patient’s history of trauma with long bone fracture and recent surgery is more likely the cause of the pulmonary embolism. More information and diagnostic studies are needed to rule out the presence of a myocardial infarction.
Category: Respiratory Emergencies, Pulmonary embolus