The nurse is preparing to discharge a child who has been diagnosed with a febrile seizure. Which response by the child’s caregivers indicates that they understand what to do if their child has another seizure at home?
“We will not put anything in our child’s mouth.”
✓
“We will drive our child to the hospital if the seizure lasts more than 5 minutes.”
“We will use a cold-water bath to bring the fever down.”
“We will place our child on their back on a safe surface.”
Correct Answer
“We will not put anything in our child’s mouth.”
A. If the patient’s seizure lasts longer than 5 minutes or they have more than one seizure without being fully awake in between, the caregivers should call 911.
B. Cold-water baths should not be used to bring down most fevers, especially in children. It will cause shivering and drive up the child’s temperature.
C. The patient should be placed on their side, not on their back, to prevent aspiration or airway compromise.
D. During any seizure, no one should attempt to open the patient’s mouth and place something in it. The patient should be turned on their side to help prevent the tongue from blocking the airway.
Category: Neurological Emergencies, Seizure disorders
Question 2
Aspirin has been ordered for a patient suspected of having an acute myocardial infarction. The patient has reported an allergy to aspirin. What is the nurse’s best response?
“I will administer your aspirin with diphenhydramine.”
“I will administer an aspirin suppository instead.”
“I will document your aspirin as not given.”
“I will request an order for clopidogrel instead.”
✓
Correct Answer
“I will request an order for clopidogrel instead.”
A. For patients with allergies to aspirin, the medications ticagrelor, clopidogrel, or prasugrel can be considered.
B. There is an alternative to aspirin for this patient. Administering aspirin with diphenhydramine would not be advised without first obtaining information about the patient’s reaction to aspirin.
C. Aspirin is important to prevent platelet aggregation. Alternatives should be considered in this scenario.
D. Suppository aspirin may be preferred for some patients, but the patient with an allergy to aspirin should not receive it via any route unless the benefits outweigh the risks.
Category: Cardiovascular Emergencies, Acute coronary syndrome
Question 3
A patient has been diagnosed with Raynaud’s disease. Which of the following statements made by the patient would reflect an understanding of this disease?
“I am fearful that I may require a liver transplant if the disease does not improve.”
“I am more likely to have this disease because I am female and live in a cold climate.”
✓
“I noticed the onset of the symptoms when I started coughing, usually at night.”
“If I take an antibiotic for a while, the disease should go away.”
Correct Answer
“I am more likely to have this disease because I am female and live in a cold climate.”
A. Raynaud’s disease is a disorder of blood vessels that supply blood to the skin. Characteristics include intense vasospasms of the fingertips, pallor, and cool skin temperature. Women are affected more than men, and the fingers are the most common site. Cool environments and smoking are noted to enhance the disease.
B. Raynaud’s disease is a circulatory disease that affects blood vessels of the skin. It generally causes throbbing pain to the fingers, along with pallor and coolness to touch. Raynaud’s disease does not affect liver function.
C. Treatment for Raynaud’s disease generally does not require antibiotic therapy unless an infectious process is also present. Chronic exacerbations may lead to skin thickening and possible development of gangrene in the affected fingers.
D. Nighttime coughs may indicate respiratory disease but are not associated with Raynaud’s disease.
Category: Cardiovascular Emergencies, Peripheral vascular disease
Question 4
A patient presents with a complaint of bright red blood with clots in their stool for the past 2 weeks. The patient is in no apparent distress and has normal vital signs, and laboratory values are within normal limits. You suspect that the source of the bleeding is:
ulcerative colitis.
Mallory–Weiss syndrome.
hemorrhoids.
✓
esophageal varices.
Correct Answer
hemorrhoids.
A. The symptoms of ulcerative colitis include bloody diarrhea with cramping abdominal pain, fever, and tachycardia. The patient’s current vital signs are not abnormal, so an inflammatory bowel etiology such as ulcerative colitis is not likely.
B. Bleeding from esophageal varices results in vomiting of bright red blood. Blood that travels through the gastrointestinal tract will become darker and result in the passage of dark red or black tarry stools.
C. The patient’s symptoms suggest bleeding that originates from the lower gastrointestinal area. The most common cause of bright red rectal bleeding is hemorrhoids. Bleeding from hemorrhoids, located closer to the rectum, is more likely to be bright red and contain clots.
D. Mallory–Weiss syndrome occurs as the result of mucosal tears in the gastroesophageal junction because of violent retching or vomiting. The patient is in no distress, and vital signs do not suggest fluid loss from vomiting.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 5
A patient presents with a complaint of recurrent abdominal pain with radiation to the right shoulder. They note that the pain often occurs after a meal out or after eating burgers at a fast-food chain. Pain is primarily in the right upper quadrant and resolves after an hour. The nurse suspects this abdominal pain is due to which of the following?
Pancreatitis
Cholecystitis
✓
Pyelonephritis
Appendicitis
Correct Answer
Cholecystitis
A. The pain associated with pyelonephritis usually is experienced in the flank area over the costovertebral angle. The pain does not radiate into the abdomen or to the shoulder area.
B. The presence of gallstones can result in the development of pancreatitis; however, pancreatitis would cause the patient to experience epigastric pain that radiates through to the back.
C. The pain associated with an inflamed appendix typically begins in the periumbilical area and then localizes to the right lower quadrant.
D. Patients with symptomatic cholelithiasis experience biliary colic due to intermittent obstruction of the gallbladder neck by gallstones. Fatty meals exacerbate these painful episodes, secondary to the secretion of hormones that cause gallbladder contraction and bile release into the digestive tract to aid in the breakdown of fats in the intestines. These episodes typically last < 6 hours and resolve spontaneously.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 6
A patient with a history of cirrhosis presents with a complaint of spitting up bright red blood that was provoked by sneezing. On exam, the nurse notes ascites, tachycardia, and hypotension. Which of the following is the most likely source of the patient’s bleeding?
Ulcerative gingivitis
Peptic ulcer disease
Tuberculosis
Esophageal varices
✓
Correct Answer
Esophageal varices
A. Hemoptysis is a symptom associated with tuberculosis; however, the patient’s history of cirrhosis, distended abdomen, and bruises are more suggestive of ascites and portal hypertension due to hepatic disease.
B. Necrotizing ulcerative gingivitis is an intraoral bacterial infection associated with a debilitating illness, immunosuppression, and nutritional deficiencies. The patient may develop intraoral ulcerations and bleeding gums but would also exhibit intraoral pain, fever > 38.3°C (101°F), cervical adenopathy, and cervical lymph node enlargement.
C. Esophageal varices often develop because of portal hypertension secondary to liver cirrhosis. Bleeding esophageal varices are a frequent cause of death in patients with hepatic disease.
D. Peptic ulcers can cause upper gastrointestinal bleeding, and the nurse should consider this etiology as a source of the patient’s symptoms; however, the patient’s history of cirrhosis, distended abdomen, and evidence of bruising suggest a coagulopathy along with portal hypertension. Esophageal varices are the most likely source of the patient’s symptoms.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 7
A patient with a history of alcoholic cirrhosis presents with a complaint of coffee-ground emesis. They had been drinking for the past few days and report not eating properly. A fecal occult test is positive. The nurse anticipates administration of which of the following?
Intravenous vitamin C
Analgesics such as a nonsteroidal anti-inflammatory drug
A somatostatin analog such as octreotide
✓
Calcium channel blocker such as diltiazem
Correct Answer
A somatostatin analog such as octreotide
A. Administration of a beta blocker, not a calcium channel blocker, is indicated after an acute episode of variceal hemorrhage and reduces the rebleeding rate and mortality.
B. Administration of analgesics is appropriate, but not a nonsteroidal anti-inflammatory drug, which is a risk factor for esophageal bleeding and varices.
C. A somatostatin analog such as octreotide is administered to lower portal venous pressure and as an adjuvant to endoscopic management.
D. Administration of vitamin C is not indicated in this situation. Vitamin D, along with fresh frozen plasma, is indicated to assist with the treatment of coagulopathies.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 8
A patient complains of a burning, gnawing-type pain in the left upper quadrant and epigastrium that is associated with numerous episodes of nausea and vomiting. The patient is diagnosed with acute gastritis. Based on the patient’s symptoms, the nurse expects which diagnostic test to yield abnormal results?
Serum electrolytes
✓
Liver enzymes
Serum lipase
Serum creatinine
Correct Answer
Serum electrolytes
A. Serum creatinine is a measurement of renal function and will be increased in renal failure. Prolonged dehydration as a result of vomiting may lead to acute renal injury, but the patient has no evidence of this at this time.
B. Liver enzymes should remain normal in a patient with gastritis.
C. Potassium is found in gastric juices and can be lost through vomiting; therefore, the patient may have a decreased potassium level or hypokalemia.
D. The patient’s serum amylase and serum lipase would be elevated in the case of acute pancreatitis. This diagnostic test would not be abnormal in the presence of gastritis.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 9
A patient presents with a complaint of fatigue, joint pain, and anorexia for the past 3 months. On assessment, the patient has an elevated temperature, yellowed sclera, and tenderness in the right upper quadrant. The patient admits to intravenous (IV) drug use. The nurse would anticipate a positive result for which diagnostic test?
Hepatitis A antigen
Hepatitis B antigen
✓
Enzyme-linked immunosorbent assay (ELISA) test
Human immunodeficiency virus immunoassay
Correct Answer
Hepatitis B antigen
A. The patient’s symptoms of right upper quadrant tenderness, anorexia, and jaundice are consistent with hepatic disease, and the patient’s history of IV drug use suggests hepatitis B as the source. Presence of the hepatitis B antigen indicates that the patient has an acute hepatitis B infection.
B. The patient’s symptoms are consistent with hepatic disease, and the patient’s admission of previous IV drug use suggests an infection with the hepatitis B virus. Hepatitis A is spread through contact with contaminated food or water.
C. A patient with a history of IV drug abuse is at risk for contracting human immunodeficiency virus; however, this patient’s clinical presentation is consistent with hepatic disease, most likely hepatitis B contracted through IV drug use.
D. The ELISA identifies antibodies in the blood and is used in the diagnosis of diseases such as Lyme disease, Rocky Mountain spotted fever, and varicella zoster. ELISA is not a test used to diagnose hepatitis B.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 10
A patient presents complaining of the feeling that something is caught in their throat. It began after the patient swallowed a piece of meat. After assessing that the patient’s airway is not compromised, the nurse would anticipate the intravenous administration of what medication?
Metoclopramide
Omeprazole
Glucagon
✓
Nitroglycerin
Correct Answer
Glucagon
A. Omeprazole is a proton pump inhibitor, which decreases gastric acid secretion. It has no effect on facilitating the movement of a food bolus through the esophagus.
B. Glucagon relaxes esophageal smooth muscle and the lower esophageal sphincter, which helps to move the impacted food bolus through the esophagus to the stomach. Glucagon also acts to increase blood glucose in patients who are hypoglycemic.
C. Metoclopramide is indicated as a treatment for gastric paresis. It stimulates gastric motility and increases the tone of the lower esophageal sphincter, which would make passage of an impacted esophageal food bolus more difficult.
D. Nitrates may relax the gastrointestinal muscles; however, there is a substantial risk of producing hypotension in the patient, so its use is not recommended.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 11
A patient presents with acute-onset epigastric pain, nausea, and two episodes of nonbloody, nonbilious vomiting. Past medical history includes hyperlipidemia, hypertriglyceridemia, diabetes, and alcohol abuse. The patient states that their last drink was this morning, and denies any fevers or chills. Physical exam is notable for tenderness to palpation of the epigastrium. The nurse suspects that which of the following is causing these symptoms?
Appendicitis
Peritonitis
Gastritis
Pancreatitis
✓
Correct Answer
Pancreatitis
A. Between 50% and 75% of cases of acute pancreatitis are attributable to alcoholism or the presence of gallstones in the common bile duct.
B. Peritonitis is an inflammation of the peritoneum. Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss. It can be caused by pancreatitis and can involve fever, chills, and abdominal pain.
C. Appendicitis is an inflammation of the appendix pain that begins around the navel and often shifts to the lower right abdomen.
D. Gastritis is an inflammation of the lining of the stomach; the most common symptom is upper abdominal pain.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 12
A patient presents with a complaint of recurrent “stomach pain” that occurs before meals and is relieved by eating. The patient tells the nurse that they take 800 mg ibuprofen 6 times daily for chronic shoulder pain. Based on this information, the nurse suspects that the patient’s symptoms are most likely the result of:
Mallory–Weiss syndrome.
gastric ulcer.
duodenal ulcer.
✓
gastroesophageal reflux disease.
Correct Answer
duodenal ulcer.
A. The pain associated with gastroesophageal reflux disease is typically described as a burning or squeezing in the upper chest, which may mimic cardiac-related chest pain. Symptom onset usually occurs after the ingestion of irritating foods or medications.
B. The pain associated with a gastric ulcer is typically experienced after eating. This is an important assessment finding that assists in differentiating between a duodenal ulcer and a gastric ulcer.
C. The pain associated with duodenal ulcers is typically worse when the stomach is empty and is relieved when food is in the stomach. Duodenal ulcers occur most commonly in people between 30 and 55 years of age. A patient’s risk of developing a duodenal ulcer is elevated with chronic ingestion of irritants such as nonsteroidal anti-inflammatory drugs.
D. Mallory–Weiss syndrome is the development of tears in the gastroesophageal mucosa as a result of violent retching. Upper gastrointestinal bleeding may result from a Mallory–Weiss tear. Persistent vomiting, not pain, is the presenting symptom of this syndrome.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 13
A patient with a kidney stone explains that the pain they have is intense, sharp, and wavelike, with radiation to the scrotum. The patient states that it feels like they have to void, but only a small amount of urine is passed. Based on the patient’s signs and symptoms, where may the kidney stone be located?
Urethra
Renal calyx
Renal medulla
Ureter
✓
Correct Answer
Ureter
A. A kidney stone usually will not cause symptoms until it moves around within the kidney (wavelike pain) or passes into the ureters.
B. A kidney stone in the urethra can cause pain in the side, decreased or increased urine flow, and urinating at night. Symptoms are more common if the blockage is sudden and complete.
C. A kidney stone usually will not cause symptoms until it moves around within the kidney (wavelike pain) or passes into the ureters.
D. The pain associated with renal calculi may continue as the calculus passes through the ureter. The pressure on the kidney caused by the backflow of urine, combined with spasms in the ureter as the body tries to clear the stone, can cause intense pressure and pain to the lower back, side, and/or groin.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 14
A sexually active male complains of one-sided testicular pain and urinary frequency. He also reports pain with urination. Physical exam reveals a swollen right testicle with substantial induration. Urinalysis reveals positive leukocyte esterase and 20 WBC/hpf. The patient will receive antibiotics for which disease process?
Priapism
Testicular torsion
Prostatitis
Epididymitis
✓
Correct Answer
Epididymitis
A. Priapism is a painful and sustained erection not associated with sexual arousal.
B. Epididymitis is frequently caused by inflammation of the epididymis and is the result of a sexually transmitted infection commonly caused by C. trachomatis or N. gonorrhoeae.
C. Prostatitis is an inflammation of the prostate that is commonly the result of an E. coli infection and is frequently related to the presence of a urinary tract infection.
D. Testicular torsion occurs because of a sudden twisting of the spermatic cord, resulting in vascular compromise to the male testis. If left untreated, testicular torsion will result in male sterility.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 15
A patient is being discharged with a diagnosis of vaginitis. The discharge plan would include a discussion of methods to prevent recurrence and a prescription for:
antimicrobial medications.
✓
probiotic medications.
antiviral medications.
immune-response modifier medications.
Correct Answer
antimicrobial medications.
A. The most common causes of vaginitis include bacterial vaginosis, Candida albicans, and Trichomonas vaginalis. Antibiotics or antifungal agents are required to eradicate these organisms.
B. Although there is evidence to support the benefit of probiotics in the prevention and treatment of bacterial vaginosis, probiotics are not effective in the treatment of Candida albicans or Trichomonas vaginalis infection.
C. Antiviral medications are effective in the management of gynecological viral infections such as the herpes simplex virus; they are not indicated for the treatment of infections caused by bacterial or fungal organisms.
D. Immune-response modifiers are an effective treatment for genital condylomas (warts) that do not respond to other treatments. They are not indicated for the treatment of vaginitis.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 16
A patient with a history of ovarian cysts presents with a complaint of sudden, sharp lower abdominal pain. Which of the following diagnostic tests is most appropriate to assist in making the definitive diagnosis of a ruptured ovarian cyst?
CT scan of the pelvis
Pelvic ultrasound
✓
Pelvic examination
Clean-catch urine specimen
Correct Answer
Pelvic ultrasound
A. CT scan of the pelvis is not indicated in this process. The definitive diagnosis of an ovarian cyst is best made through a pelvic ultrasound.
B. A pelvic examination would identify tenderness of the uterus, fallopian tubes, or cervix but would not be the definitive test to rule out the presence of an ovarian cyst.
C. The definitive diagnosis of an ovarian cyst is best made through a pelvic ultrasound. A serum beta hCG to rule out a pregnancy should be completed first.
D. A clean-catch urine specimen would be helpful to identify a urinary cause for the abdominal pain but would not identify the presence of, or verify the absence of, an ovarian cyst.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 17
An adolescent male presents with a sudden onset of severe scrotal pain radiating to the abdomen. He notes that his symptoms started about 45 minutes earlier while he was playing basketball. The pain has been constant without relieving factors, such as rest and ice. He denies penile discharge, dysuria, or abdominal pain but complains of persistent nausea and two episodes of vomiting. Ultrasound is ordered to assist in what diagnosis?
Penile fracture
Epididymitis
Testicular torsion
✓
Urinary calculi
Correct Answer
Testicular torsion
A. Epididymitis can cause severe scrotal pain with radiation to the abdomen but may have urethral discharge.
B. Penile injuries result in pain, swelling, and ecchymosis and most often occur during sexual intercourse.
C. Urinary calculi involve intermittent back pain that radiates to the lower abdomen or groin with an urge to void.
D. Testicular torsion is a true emergency. If surgery is not performed within 6–8 hours from the onset of the torsion, the affected testicle’s blood supply is compromised, and the testicle may become necrotic.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 18
If left untreated, a male who experiences a penile fracture resulting from the rupture of the tunica albuginea may develop which complication?
Penile ischemia
Erectile difficulties
✓
Impaired urinary function
Infertility
Correct Answer
Erectile difficulties
A. The tunica albuginea stretches when the penis is erect, making it thin and inflexible, and thus more prone to rupture with lateral bending. Patients with penile fracture experience immediate pain with rapid detumescence and a resultant penile hematoma with swelling. An audible popping sound is often heard as well. Penile fractures require prompt urological consultation and surgery. If treatment is delayed for rupture of the tunica albuginea or if it is left untreated, erectile difficulties may develop.
B. A penile fracture resulting from a rupture of the tunica albuginea will not impair urinary function; that effect is usually seen with straddle injuries causing injury to the urethra.
C. Penile ecchymosis, which may be significant enough to distort the penile shaft, can occur but will eventually resolve and will not result in penile ischemia.
D. A fractured penis as the result of a rupture of the tunica albuginea does not affect the production of sperm.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 19
A patient with bacterial vaginosis is prescribed clindamycin vaginal cream. Which of the following statements made by the patient indicates a clear understanding of the discharge instructions?
“I should continue to use this medication until my symptoms are gone.”
“I should use this immediately as soon as I get up in the morning.”
“This is the only medication that can be used to treat this infection.”
“We should not use a condom for contraception and find another method of prevention while I am on this medication.”
✓
Correct Answer
“We should not use a condom for contraception and find another method of prevention while I am on this medication.”
A. Clindamycin cream should be applied at bedtime.
B. Clindamycin cream can weaken latex condoms, so an alternative form of birth control should be used for 72 hours following the use of clindamycin vaginal cream.
C. Metronidazole (Flagyl) is another medication that can be administered to treat bacterial vaginosis.
D. The patient should continue to take the medication as directed until the prescription is completed. This is especially important because a patient with bacterial vaginosis may be asymptomatic.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 20
A 40-year-old female in the first trimester of pregnancy presents complaining of severe right lower quadrant pain and tenderness with vaginal bleeding. The patient is lethargic, pale, hypotensive, and tachycardic. Which of the following would be the priority intervention for this patient?
Administer methotrexate injection
Prepare for emergency surgery
✓
Draw a serum beta human chorionic gonadotropin level
Obtain a transvaginal ultrasound
Correct Answer
Prepare for emergency surgery
A. Transvaginal ultrasound can accurately identify the intrauterine gestational sac and is effective for diagnosis, particularly before a tubal rupture. However, the clinical presentation of this patient suggests a ruptured ectopic pregnancy, and because she is hemodynamically unstable, surgical intervention—not additional diagnostic testing—is the priority.
B. Methotrexate is a cytotoxic agent that interferes with cell multiplication. It is indicated for use in patients with an unruptured tubal ectopic pregnancy who are hemodynamically stable and have minimal symptoms.
C. Ectopic pregnancy is a considerable cause of maternal morbidity, causing pelvic/abdominal pain and vaginal bleeding. A ruptured ectopic pregnancy should be strongly suspected in a patient in the first trimester presenting with syncope and signs of shock, including tachycardia, pallor, and collapse. Decompensation with shock is suggestive of tubal rupture with intraperitoneal bleeding. Immediate surgical intervention is indicated.
D. An elevated beta human chorionic gonadotropin (β-hCG) concentration will indicate that the patient is pregnant but will not identify the pregnancy as being ectopic (not implanted within the uterus). An initial β-hCG level may be beneficial for baseline determination, but resuscitation and surgical intervention take priority.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 21
Which of the following assessment parameters indicates a need for immediate intervention in a neonate within 1 minute after birth?
Respiratory rate of 54 breaths per minute
Pulse oximeter heart rate reading of 60 beats per minute
Heel-stick glucose of 35 mg/dL
✓
APGAR scoring of 7 at 1 minute
Correct Answer
Heel-stick glucose of 35 mg/dL
A. Blood glucose levels below 40 mg/dL, acquired by heel stick, should be treated in a neonate with a 10% solution of dextrose.
B. Pulse oximeter readings at 1–2 minutes after birth are often inaccurate. This avenue of obtaining the heart rate of a neonate should not be used. Cardiac monitoring is the recommended manner of counting the heart rate.
C. APGAR scoring of 7 or above is considered normal for a neonate at 1 minute.
D. Normal respiratory rates for a neonate are 40–60 breaths per minute.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 22
Following the delivery of a full-term neonate, intravenous pitocin (Oxytocin) is administered to the mother. Which of the following is the expected action of this medication?
Reduce postpartum bleeding
✓
Stimulate breast milk production
Facilitate delivery of the placenta
Prevent Rh incompatibility
Correct Answer
Reduce postpartum bleeding
A. Placental delivery occurs naturally up to 30 minutes after delivery. Fundal massage and administration of oxytocin should occur after delivery of the placenta.
B. The most common cause of postpartum hemorrhage is uterine atony. Administration of intravenous oxytocin will promote and maintain uterine contractility.
C. Oxytocin has no effect on the mother’s production of breast milk. It can function in milk ejection, but not production.
D. Rh immune globulin, not oxytocin, is the drug indicated for the prevention of Rh incompatibility.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 23
A 36-week-pregnant female presents with sudden onset of painless, bright red vaginal bleeding. Which of the following is the priority intervention for this patient?
Manual pelvic examination
Immediate cesarean delivery
Assessment of fetal heart tones
Obtain pelvic ultrasound
✓
Correct Answer
Obtain pelvic ultrasound
A. If the placenta is covering the cervical os, the insertion of the provider’s hand or a speculum can result in an unintentional placental perforation, resulting in hemorrhage. Pelvic examination with third trimester bleeding is contraindicated.
B. Assessment of fetal heart tones is an important component of the nursing assessment; however, a change in fetal heart tones can only verify fetal distress. It does not identify the cause. Determining the origin of the vaginal bleeding is critical to ensure the hemodynamic stability of the mother and baby.
C. An immediate cesarean delivery may be indicated, depending on the gestational age of the fetus, the extent and cause of the bleeding, and the hemodynamic status of the mother. The ultrasound will provide needed information to determine next steps in the care of the patient with suspected placenta previa.
D. Painless vaginal bleeding in the third trimester is suspicious for placenta previa. Placental abruption is associated with painful bleeding in the third trimester. Ultrasonography is indicated as the initial procedural test to diagnose placenta previa and identify the specific location of the placenta.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 24
An adult patient presents with thermal burns to the face, chest, and bilateral arms. Primary assessment reveals an alert, agitated patient who has difficulty speaking. The patient has blisters around the mouth and decreased breath sounds. The patient is hypertensive, tachycardic, and normothermic, with an SpO of 85% on 2 oxygen 6 L/minute via mask. Pain level is 10/10. Which of the following is the priority intervention for this patient?
Maintain a patent airway
✓
Provide universal precautions to prevent infection
Establish intravenous access
Administer pain medication
Correct Answer
Maintain a patent airway
A. Pain management is an important part of the immediate plan of care for this patient; however, the priority intervention is managing the patient’s airway.
B. This patient is at risk for fluid volume deficit and requires intervention; however, securing a patent airway would take priority.
C. This patient has signs of respiratory distress and of burn injury to the airway. The management of this patient’s airway is the priority for care, and early intubation should be considered.
D. The potential for infection is an important consideration in the patient’s plan of care; however, securing a patent airway would take priority.
Category: Environment and Toxicology Emergencies, and Communicable
Question 25
A combative, confused patient arrives after participating in 8 hours of intense outdoor physical training. Vital signs are blood pressure 80/48 mm Hg, heart rate 66 beats/minute, respiratory rate 30 breaths/minute and shallow, temperature 41°C (105.8°F), SpO 90% without supplemental oxygen. Which of the following is the 2 priority intervention?
Place the patient on the cardiac monitor
Initiate 1–2 L of 0.9% sodium chloride
Administer supplemental oxygen
✓
Apply cooling blankets
Correct Answer
Administer supplemental oxygen
A. The patient’s SpO is 90% without supplemental oxygen. Respirations are 2 shallow and increased, and the patient is displaying signs of hypoxia through the confusion and combativeness. Support of breathing is the priority intervention for this patient. Circulation is also part of the ABCs for the primary survey, but airway and breathing take precedence and are crucial for patient recovery.
B. Although fluid volume is depleted in most victims of hyperthermia, the priority of care is airway support.
C. Cooling blankets are a recommended treatment for heat stroke; however, the initial priority of care is airway support.
D. Cardiac monitoring is necessary for heat stroke, but the initial priority of care for this patient is airway support.
Category: Environment and Toxicology Emergencies, and Communicable
Question 26
A patient with open wounds to the right buttock and right forearm agrees to postexposure rabies prophylaxis after being bitten by a wild fox. This is their first exposure to the rabies immunizations. Which of the following sites would be appropriate for the administration of the rabies vaccine?
Right ventrogluteal
Right deltoid
Left deltoid
✓
Left ventrogluteal
Correct Answer
Left deltoid
A. The administration of the vaccine near sites where the rabies immune globulin has been administered may cause suppression of antibody production. For adults, the deltoid is considered the only acceptable injection site for the rabies vaccine.
B. A patient who has never been vaccinated for rabies requires both rabies immune globulin and the rabies vaccine for the first rabies postexposure prophylaxis. The rabies immune globulin is administered once into and around the wounds when anatomically feasible. The rest is given in a large muscle. The vaccine should be administered to a site as far away as possible from where the rabies immune globulin was administered because rabies immune globulin may partially suppress antibody production from the vaccine. For adults, the deltoid is considered the only acceptable injection site for the rabies vaccine. Since the immune globulin would have been injected into the wound on the right arm, the vaccine needs to be given in the left deltoid.
C. The right ventrogluteal would be proximal to where the immune globulin is administered, running the risk of suppression of antibody production; therefore, this site should not be used. It is recommended that the deltoid be used for rabies vaccine.
D. The right deltoid is more proximal to the site where rabies immune globulin is administered, running the risk of antibody suppression; therefore, this site should not be used. The left deltoid would be the site of choice for this patient to receive the rabies vaccine.
Category: Environment and Toxicology Emergencies, and Communicable
Question 27
A patient presents complaining of fever, muscle pain, and headache, and has a small, flat, pink rash on the palms, wrists, forearms, soles, and ankles after returning home from a camping trip. Which of the following diagnoses does this patient most accurately depict?
Lyme disease
Colorado tick fever
Tularemia
Rocky Mountain spotted fever
✓
Correct Answer
Rocky Mountain spotted fever
A. This patient is presenting with early signs and symptoms of Rocky Mountain spotted fever. Patients will often develop a fever, headache, and a macular rash in the areas described within the first 10 days following the tick bite.
B. The rash associated with Lyme disease is a “bull’s-eye” rash. Other symptomatology for Lyme disease includes headache and muscle pain, much like Rocky Mountain spotted fever.
C. Tularemia usually presents with a single lesion that is necrotic looking. Other symptoms include fever, chills, muscular aching, cough, headache, and pleuritic chest pain.
D. Tick paralysis does not include a rash as part of its manifestations. Symmetrical, ascending paralysis is the hallmark of this disease, which can involve the respiratory system and require mechanical ventilation.
Category: Environment and Toxicology Emergencies, and Communicable
Question 28
A toddler presents with general malaise, fever, and a pruritic rash on the face and trunk that has progressed from macules to vesicles over the past several days. Which of the following types of isolation would be appropriate for this patient?
Protective
Airborne
✓
Enteric
Droplet
Correct Answer
Airborne
A. This patient is most likely presenting with varicella (chickenpox), which would require airborne and contact precautions. Droplet precautions are not sufficient to prevent the spread of this infection.
B. The rash described is most likely varicella (chickenpox), requiring both contact and airborne precautions. Enteric isolation would not be required for varicella. This is a form of contact isolation for fecal vectors.
C. This patient is most likely presenting with varicella (chickenpox), which would require airborne and contact precautions. Protective isolation is used for patients who are at risk of contracting viral or bacterial infections.
D. This patient is most likely presenting with varicella (chickenpox), which would require airborne precautions. Contact isolation would also be required for these patients, as well as universal or standard precautions that would be used on all patients.
Category: Environment and Toxicology Emergencies, and Communicable
Question 29
A firefighter presents with seizures, hypotension, and hypoxia after fighting a house fire. Which of the following substances is the probable cause of these symptoms?
Methamphetamine
Pesticides
Petroleum distillates
Cyanide
✓
Correct Answer
Cyanide
A. Methamphetamine fires can be dangerous for first responders. The manifestations would involve respiratory problems and eye and skin irritations.
B. Patients with pesticide toxicity present with cholinergic symptomatology, including pinpoint pupils and increased secretion of body fluids such as urine, diaphoresis, tears, and saliva. Uncontrollable defecation can also occur along with seizure activity.
C. Exposure to petroleum distillates can produce signs and symptoms of respiratory difficulty, infiltrates on chest radiographs, abnormal arterial blood gases, or dysrhythmias.
D. This patient presents with signs and symptoms of cyanide toxicity, secondary to exposure to smoke from the fire. Exposure to cyanide can occur from the combustion of polyurethane, wood, cotton, and nylon. Even minute amounts of cyanide exposure can lead to severe lactic acidosis from hypoxia, seizure activity, and hypotension. Respiratory arrest occurs with this poisoning.
Category: Environment and Toxicology Emergencies, and Communicable
Question 30
A first responder presents with bradypnea, confusion, agitation, and seizures, status post house fire. Which of the following medications would be the priority intervention for this patient?
Atropine
Narcan (Naloxone)
N-acetylcysteine (Mucomyst)
Hydroxocobalamin (vitamin B ) 12
✓
Correct Answer
Hydroxocobalamin (vitamin B ) 12
A. Fires can release cyanide from the burning of plastics in homes and other buildings. The symptoms from this exposure are confusion, seizure activity, bradycardia, and hypertension; followed by hypotension and bradypnea; and, finally, respiratory arrest. Treatment can involve a cyanide kit that induces methemoglobinemia through amyl nitrite, sodium nitrite, and sodium thiosulfate, which then helps to excrete the product. Hydroxocobalamin (vitamin B ) is now being used for this poisoning to combat the 12 manifestations.
B. Atropine would be used to counteract the effects of nerve agents such as sarin gas. The symptoms associated with this poisoning would be increased salivation, defecation, lacrimation, and urination, along with pinpoint pupils.
C. N-acetylcysteine (Mucomyst) is used in the treatment of acetaminophen (Tylenol) overdose. Manifestations of this poisoning are weakness, malaise, vomiting, elevated liver enzymes, jaundice, hypoglycemia, disseminated intravascular coagulation, and sepsis.
D. Narcan (Naloxone) is used to treat opioid overdose. Manifestations expected with this poisoning are decreased level of consciousness, seizures, apnea, and pinpoint pupils. Fighting a fire would not expose an individual to an opiate overdose.
Category: Environment and Toxicology Emergencies, and Communicable
Question 31
A patient presents via emergency medical services in cardiopulmonary arrest. Chest compressions and bag-mask ventilation are being performed. The cardiac monitor shows ventricular tachycardia. While the defibrillator is charging for defibrillation, the nurse should ensure that:
no one is touching the patient.
high-quality cardiopulmonary resuscitation (CPR) is continued.
✓
oxygen delivery via nasal cannula continues at 6 L/minute.
the defibrillator pads have been placed on the patient.
Correct Answer
high-quality cardiopulmonary resuscitation (CPR) is continued.
A. High-quality CPR should continue up to the moment just before the actual defibrillation. It is important that no one touch the patient when the actual defibrillation occurs because the current can travel through a rescuer and possibly induce a lethal dysrhythmia.
B. The 2020 American Heart Association guidelines include the continuation of high-quality CPR with optimal oxygen delivery to the patient while the defibrillator is charging. This results in a reduction of the time between stopping compression and defibrillation, thereby increasing the success of the defibrillation.
C. Because of the risk of sparking or ignition during defibrillation, all oxygen administration should be discontinued.
D. Defibrillation pads (no touch pads) should be placed on the patient’s chest during the initial rhythm assessment.
Category: Cardiovascular Emergencies, Cardiopulmonary arrest
Question 32
A 3-month-old infant weighing 11 pounds (5 kg) arrives at the emergency department in full cardiopulmonary arrest. The monitor shows ventricular fibrillation. Good-quality cardiopulmonary resuscitation is being performed, and the infant has been defibrillated once. Which medication should be administered via intravenous/intraosseous route next?
Sodium bicarbonate 5 mEq
Amiodarone 25 mg
Atropine 0.1 mg
Epinephrine 0.05 mg
✓
Correct Answer
Epinephrine 0.05 mg
A. Epinephrine is the first-line drug for an infant in cardiopulmonary arrest because of ventricular fibrillation. The correct dose is 0.01 mg/kg. The correct IV/IO dose for this infant would be 0.01 mg × 5 kg, or 0.05 mg.
B. Atropine is not indicated in the treatment of ventricular fibrillation.
C. Amiodarone is not considered the first drug for ventricular fibrillation; it would be administered after epinephrine. The dose of amiodarone is 5 mg/kg, or 25 mg.
D. Although sodium bicarbonate may be indicated during cardiopulmonary arrest for correction of acidosis, it is not considered a first-line treatment. The correct dose for sodium bicarbonate is 1 mEq/kg, or 5 mEq IV.
Category: Cardiovascular Emergencies, Cardiopulmonary arrest
Question 33
An obese patient presents to the emergency department complaining of leg pain. The patient reports no history of trauma. The lower leg appears swollen, slightly reddened, and painful to touch. When asked to dorsiflex the foot, the patient complains of increasing pain in the calf area of the leg. Based on this assessment, the nurse would suspect which of the following?
Chronic arterial occlusion
Arthritis
Deep vein thrombosis
✓
Raynaud’s syndrome
Correct Answer
Deep vein thrombosis
A. Although acute arthritis may cause painful joints and swelling, the pain is usually unchanged with dorsiflexion of the foot.
B. Patients at risk for developing a deep vein thrombosis include obese patients, those with limited use of the affected extremity, smokers, patients who have sustained extremity trauma (long-bone fractures), and those with long sedentary periods and limited mobility. Symptoms include a swollen, painful extremity that is warm to touch, and pain with dorsiflexion of the foot (Homan’s sign) if the deep vein thrombosis is located in the lower extremity. Stasis of blood, damage to the vessel epithelium, and potential alterations in coagulation put a patient at risk for developing a deep vein thrombosis.
C. A chronic arterial occlusion would present with a painful extremity, usually swollen and discolored, from a pale whitish to a bluish color. An arterial occlusion would also demonstrate decreased pulses distal to the occlusion.
D. Raynaud’s syndrome affects the ears, nose, and fingertips, causing pale to bluish discoloration. Raynaud’s syndrome is a peripheral vascular disease affecting blood vessels to the skin.
Category: Cardiovascular Emergencies, Thromboembolic disease (e.g., deep vein
Question 34
A patient is being discharged from the emergency department following an asthma exacerbation. When providing discharge education, what should the nurse teach the patient about their montelukast prescription?
“This medication should be taken subcutaneously every 2 to 4 weeks.”
“This medication should be used as soon as symptoms of asthma are noted.”
“This medication is taken daily for prevention of symptoms, not acute attacks.”
✓
“This medication should be shaken vigorously prior to administration.”
Correct Answer
“This medication is taken daily for prevention of symptoms, not acute attacks.”
A. Montelukast is an oral leukotriene modifier that is used to block the release of substances from mast cells and eosinophils to produce a bronchodilator and anti-inflammatory effect; however, they are not used for acute asthma attacks.
B. This medication is not intended for acute attacks; it is for daily prevention.
C. Omalizumab is a monoclonal antibody that decreases circulating free IgE levels. It should be administered subcutaneously every 2 to 4 weeks in the healthcare provider’s office because of the risk of anaphylaxis.
D. Many metered-dose inhalers should be shaken before use. Montelukast is administered orally.
Category: Respiratory Emergencies, Asthma
Question 35
What clinical manifestation would be expected in a patient diagnosed with bronchitis?
Infiltrates on their chest radiograph
Dry cough initially that develops into a productive cough
✓
Course crackles on physical exam
Wheezing on physical exam
Correct Answer
Dry cough initially that develops into a productive cough
A. The presence of infiltrates on a chest radiograph is more indicative of pneumonia.
B. Acute bronchitis is usually brought on by a virus that results in airway irritation and inflammation. Patient presentation includes dyspnea, fever, pain, malaise, and an environmental history that involves either occupational exposures or smoking.
C. The presence of wheezing on physical exam is more indicative of asthma. Breath sounds on auscultation with a patient with acute bronchitis include the presence of rhonchi that may clear when the patient coughs.
D. Course crackles and bronchial sounds over the affected area are more indicative of the presence of pneumonia.
Category: Respiratory Emergencies, Infections
Question 36
A patient arrives via emergency medical services after sustaining burns to the face, neck, and chest from a fire. The patient is alert and has a productive cough of carbonaceous sputum. What is the priority intervention to perform?
Prepare for intubation
✓
Monitor continuous pulse oximetry
Remove all clothing and jewelry
Obtain a full set of vital signs
Correct Answer
Prepare for intubation
A. Carbonaceous sputum is a sign of possible inhalation injury, and the patient will likely need emergent intubation because of progressive airway edema caused by thermal burns.
B. Although obtaining the patient’s vital signs is an important assessment for the patient’s respiratory status, this is not the priority. Carbonaceous sputum is a sign of possible inhalation injury, and the patient will likely need intubation because of progressive airway edema caused by thermal burns.
C. Although obtaining the patient’s pulse oximetry is an important assessment for the patient’s respiratory status, it is not the priority. Carbonaceous sputum is a sign of possible inhalation injury, and the patient will likely need intubation because of progressive airway edema caused by thermal burns.
D. It is important to assess the entire patient for additional thermal burns and to stop the burning process from clothing and jewelry that are in contact with the skin. However, the priority is always to assess the airway first, especially when early intubation is a consideration.
Category: Respiratory Emergencies, Inhalation injuries
Question 37
A patient arrives complaining of mild pleuritic chest pain and a productive cough. The nurse notes the presence of a pleural friction rub on auscultation. What plan of care would be most appropriate for this patient?
Prepare for hospital admission
Provide comfort measures
Treat the underlying disease process
✓
Obtain blood cultures and administer antibiotics
Correct Answer
Treat the underlying disease process
A. Chest pain, productive cough, and pleural friction rub are indicative of both pleural effusion and pneumonia. Identification of the underlying disease process is necessary to determine the plan of care.
B. Identification of the underlying disease process is necessary before determining proper management of symptoms.
C. Chest pain, productive cough, and pleural friction rub are indicative of both pleural effusion and pneumonia. Identification of the underlying disease process is initially the priority because multiple disease processes may cause pleural effusions that could mimic the symptoms of pneumonia.
D. Chest pain, productive cough, and pleural friction rub are indicative of both pleural effusion and pneumonia. However, pleural effusions are a clinical manifestation of an underlying problem and can be caused by multiple disease processes, including pneumonia. Treatment of the underlying disease process is necessary to determine proper disease management.
Category: Respiratory Emergencies, Pleural effusion
Question 38
While transferring a patient with a chest tube, the drainage system falls and breaks. What is the priority intervention at this time?
Insert the end of the chest tube into sterile water
✓
Clamp the chest tube 3 cm from the insertion point
Remove the chest tube and cover with an occlusive dressing
Elevate the end of the chest tube and cover with a gloved finger
Correct Answer
Insert the end of the chest tube into sterile water
A. In the event a chest tube system breaks, the chest tube should be inserted into sterile water at a 2 cm level to act as an emergency water seal.
B. Clamping a chest tube is no longer recommended. Know your agency’s policies and procedures concerning clamping of chest tubes by nursing.
C. Chest tube removal is performed by physicians and qualified advanced practice providers, and a disconnected chest tube is not an indication for removing a chest tube.
D. In the case of a disconnected chest tube, the priority intervention is to reestablish a water seal. Covering the end of the chest tube could result in a tension pneumothorax by not allowing air to escape.
Category: Respiratory Emergencies, Pneumothorax
Question 39
An unresponsive patient arrives via emergency medical services following a motor vehicle collision. Initial assessment reveals absent breath sounds and bruising on the left side of the chest, a deviated trachea, and the appearance of cyanosis. What should the nurse suspect?
Rupture of the diaphragm
Flail chest
Tension pneumothorax
✓
Right mainstem bronchial intubation
Correct Answer
Tension pneumothorax
A. A tension pneumothorax is a life-threatening emergency that occurs when air enters the pleural space during inspiration and is unable to escape during exhalation. The increasing intrathoracic pressure compresses the lungs, heart, and great vessels, resulting in markedly decreased cardiac output. Noted signs and symptoms include severe respiratory distress, decreased or absent breath sounds to the affected side, tachycardia, hypotension, poor tissue perfusion, and cyanosis. As intrathoracic pressure increases, chest cavity contents are compressed and shift to the unaffected side, and tracheal deviation will occur.
B. Rupture of the diaphragm occurs when blunt or penetrating trauma causes a tear in the diaphragm, allowing abdominal contents to herniate into the chest cavity. Signs and symptoms include dyspnea, dysphagia, decreased breath sounds on the affected side (most commonly the left), and bowel sounds in the thoracic cavity.
C. Flail chest occurs when two or more adjacent ribs are fractured in two or more places or when the sternum is detached, causing the flail segment to respond to changes in intrathoracic pressure in a paradoxical manner. Flail chest may lead to respiratory distress and respiratory failure as pulmonary mechanics are disrupted. A pneumothorax or hemothorax may accompany a flail chest.
D. Advancement of the endotracheal tube too far during intubation will most often cause a malposition of the tube into the right mainstem, leading to atelectasis of the left lung. Breath sounds will be absent on the left, and inadequate ventilation will occur; however, a right mainstem bronchial intubation will not cause tracheal deviation.
Category: Respiratory Emergencies, Pneumothorax
Question 40
A patient arrives complaining of dyspnea and mild right-sided chest pain that began last evening and now increases with exertion. The patient states that 3 days ago, they sustained an injury to their right lower leg. The patient has a previous history of deep vein thrombosis that occurred 15 years ago. Which test should the nurse anticipate as being the most beneficial in finding the diagnosis for this patient?
Comprehensive metabolic panel
B-type natriuretic peptide
Complete blood count
d-dimer
✓
Correct Answer
d-dimer
A. This test is useful in ruling out pneumonia and an infection process but does not directly indicate the presence of a pulmonary embolism.
B. Based on the patient’s chief complaint and history, the nurse should be concerned about a deep vein thrombosis and a pulmonary embolism on this patient. The specific test for fibrin split products is a d-dimer test; results elevated above 500 indicate the presence of a pulmonary embolism.
C. This test is useful in providing information about electrolyte imbalances but does not directly indicate a pulmonary embolism.
D. This test is useful in evaluating and identifying the presence of congestive heart failure but does not indicate the presence of a pulmonary embolism.
Category: Respiratory Emergencies, Pulmonary embolus
Question 41
A patient with a recent positive purified protein derivative (PPD) test is started on isoniazid (INH) and presents with abdominal pain, nausea, and generalized weakness. Which of the following laboratory tests would provide the best information, given the patient’s history?
Creatinine
Hemoglobin
Liver function tests
✓
Blood urea nitrogen
Correct Answer
Liver function tests
A. INH can cause hepatotoxicity. It is important to have knowledge of baseline liver function and to monitor these values throughout the medication regimen. Presenting with abdominal pain, weakness, and nausea could have hepatic origins—thus the need for these laboratory tests.
B. INH does not cause renal problems. Creatinine, which details renal function, would not have added value in the assessment of this patient.
C. INH can cause hepatotoxicity, not renal issues. Blood urea nitrogen provides information on kidney function and would not assist in the care of this patient related to the INH regimen.
D. Hemoglobin is not impacted by the administration of INH. Hepatotoxic issues are the concern with this medication.
Category: Environment and Toxicology Emergencies, and Communicable
Question 42
In which of the following individuals would a positive tuberculin PPD skin test be considered positive with 5 mm induration?
An individual with intravenous substance abuse
An individual with a recent liver transplant
✓
An individual who works within the prison system
An individual who migrated from an endemic area
Correct Answer
An individual with a recent liver transplant
A. Individuals working within the prison system or with homeless populations would have positive reactions with the normal reading of 10 mm induration.
B. Immunosuppressed individuals would be read as positive with the PPD skin test with 5 mm induration instead of the normal positive reading of 10 mm induration. Patients who have transplanted organs are on immunosuppressant medication to negate rejection. Any immunosuppressed individual should be read as positive with 5 mm induration. Individuals with a past chest radiograph consistent with tuberculosis, such as imaging showing fibrotic changes, would also be considered positive with a 5 mm induration reading.
C. Patients who are intravenous substance abusers would fall into the category of the normal positive reading of 10 mm induration.
D. Immigrants from endemic areas would be considered positive with a reading of the normal positive reaction of 10 mm induration.
Category: Environment and Toxicology Emergencies, and Communicable
Question 43
What is the primary purpose of extracorporeal membrane oxygenation (ECMO) in a patient with acute respiratory distress syndrome (ARDS)?
To prevent respiratory failure
To circumvent the damaging effects of mechanical ventilation
To maintain oxygen levels while allowing the lungs to rest
✓
To provide hemodynamic support
Correct Answer
To maintain oxygen levels while allowing the lungs to rest
A. Preventing further lung damage is a benefit of ECMO, but it is not a reason to use it for a particular patient (or not).
B. ECMO can be used in patients with severe refractory hypoxemia in conjunction with lung-protective mechanical ventilation to provide gas exchange while decreasing stress on the lungs. ECMO is often a last-resort treatment because of its complexity and cost, and the specialized knowledge needed to care for the patient.
C. ECMO may be used for hemodynamic support in some circumstances. However, in the treatment of ARDS, ECMO is used for respiratory support of the patient. Using ECMO will ease stress on the lungs caused by ARDS and may assist the patient in achieving improved hemodynamic stability.
D. A patient with ARDS is already experiencing the signs and symptoms of respiratory failure.
Category: Respiratory Emergencies, Respiratory distress syndrome
Question 44
The hospital is notified that two victims of radiation exposure are en route from the nearby nuclear power plant. What is the priority of care for these patients on arrival to the hospital?
Consulting the hospital radiation safety officer
Decontamination
Medical stabilization
✓
Notifying law enforcement
Correct Answer
Medical stabilization
A. Notification of law enforcement is not a priority for these patients.
B. Decontamination is appropriate following medical stabilization. Avoiding contamination must be considered during resuscitation efforts.
C. Stabilization of the patent is the top priority. The patient must have a patent airway, with breathing and adequate circulation assessed immediately. Once life-threatening priorities are corrected, decontamination can occur.
D. Consultation with the hospital radiation officer is appropriate but not the priority of care for these patients.
Category: Professional Issues, System, Symptom surveillance
Question 45
Along with identifying the best available research and their clinical expertise, nurses incorporate which other component to make evidence-based practice decisions in the clinical area?
Traditional practices
Promoting better patient outcomes
✓
Administrative support
Education level of nursing staff
Correct Answer
Promoting better patient outcomes
A. The education level of nursing staff is not a component of the evidence-based practice decision-making process.
B. Administrative support is important to the development and implementation of evidence-based practice changes, but it is not a component of the individual patient care decision-making process.
C. Traditional practices frequently provide the basis for evidence-based practice change, but these practices are not incorporated into the individual patient care decision-making process.
D. Evidence-based practice incorporates the best available research with knowledge gained through clinical experience and promoting better patient outcomes.
Category: Professional Issues, Nurse, Evidence-based practice
Question 46
The nurse is aware that a patient with which of the following preexisting medical conditions is not eligible to donate organs or tissues for transplantation?
Human immunodeficiency virus
✓
Diabetes mellitus
Coronary artery disease
Primary brain tumor
Correct Answer
Human immunodeficiency virus
A. A patient with diabetes is eligible to donate organs and tissues for transplantation.
B. A patient with a primary brain tumor that has not spread past the brain stem is usually eligible for organ donation.
C. Although a medical evaluation is conducted to determine organ viability on a case-by-case basis, patients with human immunodeficiency virus do not normally meet the criteria for organ donation.
D. A patient with coronary artery disease may donate organs and tissues for transplantation.
Category: Professional Issues, Patient, End-of-life and palliative care (e.g., organ and
Question 47
A victim with multiple gunshot wounds arrives. The nurse is aware that a key principle of preserving clothing evidence of the victim of a violent crime is to perform which of the following actions?
Place each piece of clothing in an individual paper bag; label each bag with patient identification, and seal with tape.
✓
Place all the clothing in a large paper bag; label the bag, seal with tape, and include appropriate patient identification.
Place the clothing directly into plastic bags because of saturation of blood on the clothing.
Cut the clothing off immediately to expose the patient regardless of bullet holes, tears, rips, or holes.
Correct Answer
Place each piece of clothing in an individual paper bag; label each bag with patient identification, and seal with tape.
A. Using separate paper bags for each piece of clothing is the best way to preserve evidence and prevent cross-contamination that might occur if clothing is placed together in the same bag.
B. Moisture can collect within the plastic bag and alter the clothing evidence.
C. In the primary assessment of the trauma patient, exposure is important, but to preserve evidence, care should be taken to not cut through any bullet holes, tears, rips, or stains on the clothing if possible. It is important to preserve the integrity of the evidence as much as possible.
D. Placing all the clothes together in one large paper bag may lead to possible cross-contamination of evidence from one piece of clothing to the other.
Category: Professional Issues, Patient, Forensic evidence collection
Question 48
The provider directs the nurse who is caring for a patient to suture the patient’s forearm laceration. The nurse should do which of the following on receiving this order?
Perform the procedure
Perform the procedure with a physician assistant present
Delegate the task to assistive personnel
Do not perform the procedure
✓
Correct Answer
Do not perform the procedure
A. Suturing would be outside the scope of practice for a registered nurse. Emergency nurses are accountable to, and expected to practice within, the Nurse Practice Act guidelines in their state and follow the policies and procedures developed within their place of employment.
B. Suturing would be outside the scope of practice for a registered nurse. Emergency nurses are accountable to, and expected to practice within, the Nurse Practice Act guidelines in their state and follow the policies and procedures developed within their place of employment.
C. Suturing would be outside the scope of practice for a registered nurse. Emergency nurses are accountable to, and expected to practice within, the Nurse Practice Act guidelines in their state and follow the policies and procedures developed within their place of employment. It would, however, be within the scope of practice for a physician assistant to suture the patient’s laceration.
D. Emergency nurses are accountable to, and expected to practice within, the Nurse Practice Act guidelines in their state and follow the policies and procedures developed within their place of employment. Suturing would be outside the scope of practice for a registered nurse and could not be delegated to unlicensed assistive personnel.
Category: Professional Issues, System, Risk management
Question 49
A patient with a history of chronic obstructive pulmonary disease arrives, complaining of increasing respiratory difficulty over the past several days. On assessment, the patient has diminished breath sounds bilaterally and is extremely anxious. The emergency provider orders an albuterol and ipratropium bromide nebulized treatment for this patient. The nurse anticipates which of the following responses to this intervention?
Decreased heart rate
Auscultation of bilateral wheezing
✓
Increase in PaCO level 2
Increased respiratory rate
Correct Answer
Auscultation of bilateral wheezing
A. Following a nebulized treatment with albuterol and ipratropium bromide (Atrovent), airway passages should be relaxed and open, allowing for improved gas exchange and a decreased respiratory rate.
B. Following a nebulized treatment with albuterol and ipratropium bromide (Atrovent), airway passages should be relaxed and open, allowing for improved auscultation of breath sounds and the identification of bilateral wheezing in a patient with chronic obstructive pulmonary disease.
C. Following a nebulized treatment with albuterol and ipratropium bromide (Atrovent), heart rate will increase in response to the inhaled albuterol. A decrease in the patient’s heart rate would indicate a deterioration in their condition.
D. Following the nebulized treatment, the patient would be expected to experience an opening of airway passages, allowing for improved gas exchange and resulting in a decrease in the patient’s PaCO level. 2
Category: Respiratory Emergencies, Chronic obstructive pulmonary disease
Question 50
A patient presents to triage stating, “I feel like my heart is jumping out of my chest.” The patient denies routine drug use and states that they have been studying for end-of-the-semester final exams for the past 3 days and took a pill to help them study. You palpate a radial pulse that is 170 beats/minute and regular. Which of the following dysrhythmias would be suspected?
Atrial fibrillation
Ventricular tachycardia
Sinus rhythm with premature atrial complexes
Supraventricular tachycardia (SVT)
✓
Correct Answer
Supraventricular tachycardia (SVT)
A. SVT is common in young people with no history of organic heart disease and is frequently associated with the use of stimulants.
B. Ventricular tachycardia is associated with an underlying myocardial conduction disturbance or structural deficits. Sustained ventricular tachycardia that does not deteriorate into ventricular fibrillation is very rare in this age group.
C. Atrial fibrillation is characterized by an irregular heartbeat and is commonly associated with the presence of heart failure, atrial enlargement, hypertension, thyrotoxicosis, coronary artery disease, or rheumatic heart disease. The patient does not have any of these comorbidities, nor is their heart rate described as irregular, making it highly unlikely that the patient is experiencing atrial fibrillation. The presence of SVT is more commonly associated with young people who have no history of organic heart disease.
D. Premature atrial complexes are frequently associated with use of stimulants but would present with an irregular rhythm; this patient has a regular rhythm.
Category: Cardiovascular Emergencies, Dysrhythmias
Question 51
An echocardiogram determines that a patient has infective endocarditis with bacterial or fungal growth isolated to the tricuspid valve. In addition to a heart murmur, what other pertinent signs or symptoms might the nurse identify in the assessment related to this finding?
Jugular vein distention
✓
Blood-tinged frothy sputum
Sharp, piercing chest pain that decreases when leaning forward
Severe chest pain radiating to the back and 20 mm Hg difference in blood pressure between arms
Correct Answer
Jugular vein distention
A. Blood-tinged frothy sputum is a sign of left-sided heart failure. If the mitral valve were damaged because of infective endocarditis, the patient may exhibit these signs and symptoms.
B. The tricuspid valve is on the right side of the heart and is most often the first to be damaged with infective endocarditis. Damage to this valve can lead to right-sided heart failure. Signs and symptoms of right-sided heart failure include shortness of breath, pedal edema, and jugular vein distention.
C. In addition to a friction rub, these are pertinent signs and symptoms for pericarditis.
D. These signs and symptoms are pertinent for the diagnosis of acute aortic dissection.
Category: Cardiovascular Emergencies, Endocarditis
Question 52
A patient presents complaining of sudden-onset chest pain that is worse with inspiration, and a fever. The patient reports having had a coronary artery bypass graft 2 weeks ago. The nurse auscultates a leathery grating sound when auscultating the heart. The patient describes relief from the pain when leaning forward. The patient is describing symptoms associated with:
wound infection.
pericarditis.
✓
coronary artery occlusion.
acute aortic dissection.
Correct Answer
pericarditis.
A. A patient with an aortic dissection typically presents with severe tearing-like pain in the chest or across the back; this type of pain is associated with hypotension and tachycardia.
B. If a coronary artery were to occlude, chest pain would be more severe, and associated symptoms of a myocardial infarction would be present. A pericardial friction rub is not normally heard in the presence of a coronary artery occlusion.
C. The patient does not display signs and symptoms of a typical wound infection; the surgical site is described without redness or drainage present.
D. Inflammation of the pericardium, or pericarditis, can occur following open-heart surgery, acute myocardial infarction, or a viral illness. Symptoms include chest pain, low-grade fever, and a pericardial friction rub or leathery grating sound on auscultation. The pain or discomfort may be relieved by sitting up or leaning forward. Treatment options may include the administration of anti-inflammatory medications.
Category: Cardiovascular Emergencies, Pericarditis
Question 53
A young child presents with difficulty swallowing, drooling, inspiratory stridor, and an elevated temperature of 39.2°C (102.6°F). The physician suspects the patient may have acute epiglottitis. What is the priority intervention that the nurse should anticipate for this patient?
Establish intravenous access
Visualize the oropharynx using a tongue blade
Administer high-flow humidified oxygen
Prepare for endotracheal intubation
✓
Correct Answer
Prepare for endotracheal intubation
A. In a patient with acute epiglottitis, you want to provide the patient with as much supplemental oxygen as they will tolerate; however, the priority is to stabilize the airway and prepare for endotracheal intubation.
B. In a patient with acute epiglottitis, it is important to establish intravenous access; however, the priority is to maintain airway patency.
C. Hallmark signs of epiglottitis are an abrupt onset of symptoms, muffled voice, inspiratory stridor, and sore throat. Epiglottitis, or inflammation of the epiglottitis, places a patient at severe risk for airway obstruction. Endotracheal intubation is performed to protect the patient’s airway patency.
D. Stimulation to the oropharynx can cause laryngospasm, leading to complete airway obstruction. Therefore, it is important to avoid any unnecessary stimulation of the patient’s airway that could lead to airway obstruction.
Category: Respiratory Emergencies, Obstruction
Question 54
A patient presents to triage with chest wall pain and worsening cough after cliff-diving 90 feet into the water below. The patient complains of pink, frothy sputum when coughing. Based on the patient’s history, the nurse is concerned this patient may have which of the following?
Pulmonary embolism
Pulmonary edema
✓
Asthma
Pleural effusion
Correct Answer
Pulmonary edema
A. The presence of pink, frothy sputum when coughing is a sign of pulmonary edema, not a pulmonary embolus. The signs and symptoms of a pulmonary embolism include dyspnea, hypoxia, feelings of anxiety, and chest pain. Risk factors for a pulmonary embolism include venous stasis, recent trauma, obesity, pregnancy, use of oral contraceptives, and a history of thrombosis.
B. The presence of frothy, pink sputum is indicative of pulmonary edema. A patient with a history of diving 90 feet into water is at risk for possible drowning injuries related to impact. When a human is submerged, there is initial panic, followed by breath holding and hyperventilation; this results in aspiration and swallowing of fluid, which leads to hypoxia and pulmonary injury.
C. The presence of pink, frothy sputum when coughing is a sign of pulmonary edema, not asthma. The signs and symptoms of asthma include tachypnea, wheezing, anxiety, and dyspnea.
D. The presence of pink, frothy sputum when coughing is a sign of pulmonary edema, not pleural effusion. The signs and symptoms of a pleural effusion include chest pain, dyspnea, and a dry, nonproductive cough.
Category: Respiratory Emergencies, Noncardiac pulmonary edema
Question 55
A patient has a computed tomography (CT) angiogram of the chest ordered for a suspected pulmonary embolism. The nurse would use which of the following anatomical areas to initiate an intravenous (IV) line prior to the scan?
Median cubital vein
✓
Dorsal metacarpal veins
Cephalic vein
Exterior jugular vein
Correct Answer
Median cubital vein
A. Although this site can be used, it is not the preferred site because of the risk for infiltration of CT IV contrast from the pressurized syringe and rapid infusion of the delivery system.
B. The IV must be within 1 inch of the median cubital vein because of the pressure used to infuse the IV contrast; CT personnel will not infuse the contrast required through an IV inserted into the cephalic vein.
C. IV insertion must be within 1 inch of the median cubital vein because of the pressure used to infuse the IV contrast; CT personnel will not infuse the contrast required through an IV inserted into a dorsal metacarpal vein.
D. This is the ideal IV site for a CT angiogram because the vein is large enough to handle the pressure of the contrast infusion that will be needed to evaluate the lungs for the presence of a pulmonary embolism.
Category: Respiratory Emergencies, Pulmonary embolus
Question 56
Following the administration of intravenous (IV) crystalloids, the nurse initiates IV dobutamine to a patient who has been diagnosed with a right ventricular infarction (RVI). The emergency nurse identifies that this medication has been effective when the patient demonstrates which of the following?
Decrease in heart rate
Presence of distended neck veins
Onset of atrial fibrillation
Increase in blood pressure
✓
Correct Answer
Increase in blood pressure
A. Typically, dobutamine will cause an increase in heart rate. A decrease in heart rate would be a concern in this patient. A patient who has experienced an RVI may have bradycardia that is an indication of impaired cardiac function and contractility.
B. Patients who experience an RVI are preload dependent and require additional fluids to increase their blood pressure. If the patient’s blood pressure does not respond to the additional fluid administration, the administration of dobutamine is indicated to increase the patient’s cardiac output, thereby increasing the blood pressure.
C. The presence of distended neck veins indicates an increase in central venous pressure, thereby indicating right ventricular failure and impaired ventricular contraction and emptying. Dobutamine is indicated in the presence of decreased contractility to enhance cardiac output and increase the patient’s heart rate, in addition to increasing the patient’s blood pressure.
D. New-onset atrial fibrillation following an RVI indicates the presence of atrial infarction and/or atrial dilation, and, therefore, impaired atrial contraction and ventricular filling.
Category: Cardiovascular Emergencies, Acute coronary syndrome
Question 57
A patient who became unconscious during ascent while scuba diving arrives via emergency medical services. The patient is unconscious and hypotensive. What is the most appropriate position in which to place this patient during their examination by the physician?
Right lateral decubitus, head down
Left lateral decubitus, head down
✓
Left lateral decubitus, head up
Supine
Correct Answer
Left lateral decubitus, head down
A. Positioning the patient in a left lateral decubitus, head down position prevents air from traveling through the right side of the heart into the pulmonary arteries, leading to a possible right ventricular outflow obstruction.
B. Placing the patient on their right side would potentiate the obstruction of the pulmonary arteries by the presence of an air embolism.
C. Placing the patient with their head up would act to increase the passage of air through the vasculature, increasing the possibility of an air embolism. Placing the patient head down limits the passage of air through the right side of the heart.
D. Placing the patient in a supine position will not limit the possibility of an air embolism entering the right side of the heart and leading to a possible right ventricular outflow obstruction. The best position is for the patient to be placed in a left lateral decubitus position with head down.
Category: Cardiovascular Emergencies, Cardiogenic shock and obstructive shock
Question 58
Which of the following findings would be expected in a patient with an aortic dissection?
Petechial lesions on the patient’s palms or soles
Chest pain radiating to the left shoulder
Orthopnea and jugular venous distention
Bilateral blood pressure differences
✓
Correct Answer
Bilateral blood pressure differences
A. Bilateral systolic BP differences > 20 mm Hg are suggestive of aortic dissection.
B. Chest pain radiating to the left shoulder is a symptom of pericarditis. Patients with a dissecting aortic aneurysm may complain of excruciating “ripping” substernal chest pain with radiation to the back.
C. Orthopnea and jugular venous distention are symptoms of congestive heart failure.
D. Petechial lesions of the palms or soles (Janeway lesions) are indicative of infective endocarditis.
Category: Cardiovascular Emergencies, Aneurysm and dissection
Question 59
A patient in cardiac arrest shows an organized rhythm on the monitor, but no palpable pulse is detected, and the patient is determined to be in pulseless electrical activity (PEA). While performing high-quality chest compressions, the resuscitation team is evaluating the “Hs and Ts” to determine potential reversible causes of PEA. What is a potential reversible cause of PEA?
Hypoxia
✓
Thrombocytopenia
Hypervolemia
Hyperthermia
Correct Answer
Hypoxia
A. Hypovolemia, not hypervolemia, is a potential reversible cause of PEA.
B. Hypoxia is a potential reversible cause of PEA.
C. Hypothermia, not hyperthermia, is a potential reversible cause of PEA.
D. “Ts” include cardiac tamponade, thrombus (coronary), toxin, tension pneumothorax, and thromboembolism (pulmonary). Thrombocytopenia is not a reversible cause of cardiac arrest per Advanced Cardiovascular Life Support.
Category: Cardiovascular Emergencies, Dysrhythmias
Question 60
A patient in cardiopulmonary arrest remains in ventricular fibrillation despite having been defibrillated 6 times, receiving good-quality cardiopulmonary resuscitation, and the administration of epinephrine and amiodarone. Arterial blood gases reveal a pH of 7.02, PO 96 mm Hg, and pCO 40 mm Hg. What medication order should 2 2 the emergency nurse anticipate next for this patient?
Adenosine 6 mg
Calcium chloride 1 g
Vasopressin 40 units
Sodium bicarbonate 1 mEq/kg
✓
Correct Answer
Sodium bicarbonate 1 mEq/kg
A. Adenosine is an antidysrhythmic used to slow conduction at the AV node. Ventricular fibrillation is a dysrhythmia of the ventricles. Adenosine is typically used for supraventricular tachycardia.
B. Calcium chloride would be indicated for hypocalcemia or other electrolyte abnormalities such as hyperkalemia, hypermagnesemia, or hyperphosphatemia.
C. Vasopressin is currently not recommended for administration for ventricular fibrillation, according to the 2020 guidelines of the American Heart Association.
D. Sodium bicarbonate is indicated for documented acidosis during prolonged cardiopulmonary arrest. Arterial gases indicate a pH of 7.0, or acidosis. Sodium bicarbonate will raise the pH to a value closer to a normal range of 7.35–7.45. This arterial blood gas does not reflect a respiratory cause for the acidosis in the presence of a normal pCO value. The latest 2 recommendation from the American Heart Association is to administer sodium bicarbonate at 1 mEq/kg.
Category: Cardiovascular Emergencies, Cardiopulmonary arrest
Question 61
A patient in acute heart failure is complaining of chest pain and shortness of breath. A 12-lead ECG shows ischemia in the anterior leads. The patient’s heart rate is 110 beats/minute, and the blood pressure is 88/52 mm Hg. An invasive hemodynamic monitoring device is placed, and readings indicate that central venous pressure and systemic vascular resistance (SVR) are elevated. Based on these findings, what type of shock is this patient experiencing?
Obstructive shock
Hypovolemic shock
Cardiogenic shock
✓
Distributive shock
Correct Answer
Cardiogenic shock
A. In cardiogenic shock, the heart has a decreased pumping ability (contractility), which decreases perfusion to the tissues. Underperfused tissues become ischemic, as evidenced by the changes seen on the 12-lead ECG. Compensatory mechanisms include elevated heart rate and an increased SVR to temporarily increase the cardiac output.
B. Hypovolemic shock results from significant fluid loss that causes a decrease in preload. Causes of hypovolemic shock include blood loss from trauma, vomiting, diarrhea, and dehydration.
C. Obstructive shock is caused by compression of the great vessels that results in decreased preload, impaired contractility, inadequate circulating volume, and decreased perfusion to the tissues. Conditions that can lead to obstructive shock include pulmonary embolus, tension pneumothorax, and cardiac tamponade.
D. Distributive shock results from maldistribution of circulating volume that is due to either vasodilation or loss of autonomic sympathetic functions. SVR will be decreased in distributive shock because of the vasodilatory state.
Category: Cardiovascular Emergencies, Cardiogenic shock and obstructive shock
Question 62
A patient with end-stage lung cancer is brought in with progressive dyspnea. The patient is diagnosed with a pleural effusion secondary to the lung malignancy. Which of the following interventions is appropriate and consistent with the patient’s palliative care management at home?
Prepare the patient for a thoracentesis
✓
Prepare the patient for a paracentesis
Perform chest physiotherapy
Administer intravenous antibiotics
Correct Answer
Prepare the patient for a thoracentesis
A. Infections such as tuberculosis and pneumonia can cause a pleural effusion; however, the etiology of this patient’s effusion is the malignancy, so antibiotics would not be initially indicated.
B. Chest physiotherapy is indicated when the patient is dyspneic because of an inability to mobilize secretions. The patient’s symptoms are related to a pleural effusion, and a thoracentesis is the indicated medical intervention.
C. A paracentesis may be indicated if the patient’s dyspnea is related to ascites. This patient’s symptoms are related to excess fluid in the pleural cavity, not the abdominal cavity.
D. The intent of palliative care in end-stage disease is to relieve symptoms. This patient’s breathing difficulty is due to an increase of fluid in the pleural space, which limits lung expansion. A thoracentesis will remove the excess fluid, allowing the lung to expand and relieving the patient’s dyspnea.
Category: Professional Issues, Patient, End-of-life and palliative care (e.g., organ and
Question 63
The development of secondary traumatic stress (STS) can occur as the result of caring for those who are exposed to suffering or traumatic events. Symptoms of STS include which of the following?
Emotional exhaustion
Repeated reliving of disturbing events
✓
Reduced empathy toward patients or their families
Difficulty making decisions
Correct Answer
Repeated reliving of disturbing events
A. Emotional exhaustion is an example of a symptom associated with burnout, not with STS.
B. The repeated reliving of disturbing events is a symptom of intrusion. Intrusion is one of the three categories associated with STS; the other categories are avoidance and arousal.
C. Repeated difficulty in making decisions is an associated symptom of a response to a traumatic event.
D. A symptom of compassion fatigue is lack of empathy toward patients or families; it is not associated with STS.
Category: Professional Issues, Nurse, Stress management (e.g., burnout,
Question 64
Which agent administered intravenously before procedural sedation has the shortest duration of action?
Propofol
✓
Ketamine
Fentanyl
Midazolam
Correct Answer
Propofol
A. Intravenous ketamine has a rapid onset and peak, with a duration of action of 5–10 minutes.
B. Intravenous midazolam has a rapid onset and peak, with a duration of action of 30 minutes to 2 hours.
C. Intravenous propofol has a rapid onset and peak, with a duration of action of 3–8 minutes.
D. Intravenous fentanyl has a rapid onset and peak, with a duration of action of 30 minutes to 1 hour.
Category: Professional Issues, Patient, Pain management and procedural sedation
Question 65
Studies have shown that patients report increased satisfaction with the care they received during their emergency department (ED) visit when they are provided with which of the following?
Frequent interactions and timely updates with the registered nurse
✓
Additional blankets and pillows
Distraction devices such as televisions or laptop computers
The ability to fill the prescription provided at discharge in the hospital pharmacy
Correct Answer
Frequent interactions and timely updates with the registered nurse
A. Drivers of increased patient satisfaction in the ED include shorter wait times, receiving accurate information regarding care, and clear discharge instructions. Patients do not report being inconvenienced by having to fill prescriptions at an outside pharmacy.
B. Patients appreciate distractions such as magazines, television, and Wi-Fi Internet access to reduce their idle time and make the wait seem shorter, but timely access to care and information has been shown to increase patient satisfaction.
C. Hourly interactions with and timely updates from the ED registered nurse lead to increased patient satisfaction and increased patient safety.
D. Patients appreciate comfort measures, but receiving accurate information regarding their care and clear discharge instructions provide more patient satisfaction with their visit.
Category: Professional Issues, Patient, Patient satisfaction
Question 66
A patient with terminal cancer arrives at the emergency department in septic shock. The patient refuses to have any life-sustaining interventions initiated. The nurse states they cannot morally care for this patient because it is against their beliefs. What document supports transferring the care of this patient to another nurse?
Emergency Nurses Association position statement: Patient handoff/transfer
The patient’s bill of rights
American Nurses Association code of ethics
✓
The Patient Self-Determination Act
Correct Answer
American Nurses Association code of ethics
A. The Emergency Nurses Association position statement: Patient handoff/transfer supports the development and use of standardized tools to improve handoff communication between caregivers. It does not address circumstances under which a transfer of care would or should occur.
B. The patient’s bill of rights was developed by the American Hospital Association. It outlines the services that should be offered to the patient and directs the hospital and practitioners to provide fair and ethical treatment. Transferring the care of this patient to another nurse preserves the patient’s rights.
C. This act requires all facilities that receive Medicare and Medicaid funds to provide all patients with written information and counseling on advance directives and the institution’s policy governing them.
D. The American Nurses Association code of ethics states that a nurse is justified in refusing to participate in the care of a patient based on moral (but not prejudiced or biased) grounds. The nurse may not abandon the patient and can only cease to provide care when nursing care to the individual is ensured.
Category: Professional Issues, Nurse, Ethical dilemmas
Question 67
A terminally ill patient is admitted to the emergency department (ED). The patient informs the nurse that they have a living will (advance directive) with a Do Not Resuscitate (DNR) order. The emergency nurse would:
ask the patient’s family members what lifesaving interventions they would like performed in the event of a cardiopulmonary arrest.
make the patient a full code because nothing will likely happen while in the ED.
take no action, because the advance directive and the DNR only apply once the patient is admitted to the hospital.
document in the chart that the patient is a DNR and ask the patient for a copy of their living will and DNR to place in their medical record.
✓
Correct Answer
document in the chart that the patient is a DNR and ask the patient for a copy of their living will and DNR to place in their medical record.
A. A living will is a legal document that states a person’s wishes regarding medical care should they become terminally ill and incompetent or unable to communicate. It should be honored and noted despite the patient’s current condition or expected outcome of the admission.
B. A living will is an advance care document that states a person’s wishes regarding medical care should they become terminally ill and incompetent or unable to communicate. Because of the Patient Self-Determination Act, all patients must be asked during the admission phase whether they have an advance directive (living will) in place. If so, copies must be placed in the medical record. Interactions about advance directives must be documented in the medical record.
C. If the patient already has a living will and DNR, the patient’s wishes regarding medical care should be honored. The family members’ opinions may vary; following the advance directive will honor the patient’s wishes.
D. Because of the Patient Self-Determination Act, all patients must be asked during the admission phase whether they have an advance directive in place. If so, copies must be placed in the medical record. Interactions about advance directives must be documented in the medical record. Asking about advance directives is a part of the ED nurse’s admission responsibilities. Also noting that the patient is a DNR while they remain in the ED is important in the event that the patient’s condition deteriorates before they are admitted.
Category: Professional Issues, System, Patient consent for treatment
Question 68
A child is transported to the emergency department following a mass casualty incident. The child is unable to ambulate, has spontaneous respirations of 32 breaths/minute, has a palpable pulse, and is alert. Which JumpSTART triage category should be assigned to this child?
Green (minor)
Black (expectant)
Red (immediate)
Yellow (delayed)
✓
Correct Answer
Yellow (delayed)
A. A child who is not able to ambulate but has spontaneous respirations at a rate greater than 15 and less than 45 breaths per minute with a palpable pulse and who is alert or responsive to verbal stimuli falls in the yellow (delayed) JumpSTART triage category.
B. An adult patient would meet criteria to be placed in the red (immediate) category because of the respiratory rate of 32. Children are physiologically different from adults, and the respiratory parameters are greater than 15 and less than 30. This child does not ambulate but meets all other JumpSTART triage criteria and therefore would be placed into the yellow (delayed) category.
C. Although this patient is not able to ambulate, the child does have spontaneous respirations and a palpable pulse. This would move the patient into a higher level within the JumpSTART categories than the black (expectant) category.
D. The green (minor) category is assigned to those patients who are able to walk. This child is not ambulatory and would need to be further triaged to determine the triage level. Because this child meets all other triage criteria—respiratory rate greater than 15 and less than 45, a palpable pulse, and alert or responding to verbal stimuli—the triage category would be yellow (delayed).
Category: Professional Issues, System, Disaster management
Question 69
A nurse leaves a patient’s chart open on a portable workstation. A patient’s family member is observed looking at the open chart on the workstation. This action by the nurse is considered a violation of the:
Emergency Medical Treatment and Active Labor Act (EMTALA).
Patient Self-Determination Act.
Health Insurance Portability and Accountability Act (HIPAA).
✓
patient’s bill of rights.
Correct Answer
Health Insurance Portability and Accountability Act (HIPAA).
A. Typically a patient’s bill of rights includes autonomy over medical decisions, fair treatment, and other guarantees while receiving medical care.
B. EMTALA requires the medical screening of individuals seeking emergency care to determine whether an emergency condition exists and, if so, stabilizing the patient to the best of the hospital’s capabilities before discharge or transfer. EMTALA does not address issues of unprotected health information.
C. Leaving health information unprotected is considered a violation of HIPAA. HIPAA states that a patient’s protected health information cannot be used or shared without the consent of the patient unless it is for treatment, payment, and other healthcare operation activities.
D. The Patient Self-Determination Act is a federal law that provides hospitalized patients with information regarding advance directives; it does not address the issues of unprotected health information.
Category: Professional Issues, System, Federal regulations (e.g., HIPAA, EMTALA)
Question 70
A pediatric traumatic cardiopulmonary arrest is in progress when the charge nurse comes to assist the primary nurse with the resuscitation. The patient looks similar to the son the charge nurse recently lost because of a terminal illness. The charge nurse is unable to stay focused on the necessary resuscitation tasks for this patient. Upon debriefing, the code team discusses the charge nurse’s challenges. The best response to encourage resiliency is which of the following?
“Don’t forget, we are a team, and you are part of our team. We can help you find resources to work through this.”
✓
“We need more situation awareness from this team. If one of us is not able to step up, we need to speak up and get someone else in who can do the job. We cannot risk patient safety.”
“This experience should help you get you back to the bedside. You are a ‘super nurse.’ You can take care of anyone who rolls through those doors.”
“This is a tough place to work. Management didn’t give you enough time off to grieve, staff members don’t take initiative to help, and you are tired and overworked. Have you considered looking to work somewhere else that will support you in a better way?”
Correct Answer
“Don’t forget, we are a team, and you are part of our team. We can help you find resources to work through this.”
A. Hospital cultures that implicitly or explicitly encourage staff members to be emotionally tough and convey the opinion that they should be able to handle anything may exacerbate the stressors already present and further predispose staff to or accelerate secondary traumatic stress (STS) and compassion fatigue.
B. Trauma nurses with higher levels of burnout have a significantly higher variability in STS. Identifying factors that support the nurse’s burnout will exacerbate the STS.
C. Secondary traumatic stress, burnout, and compassion satisfaction have a high correlation with such coping strategies as coworker support, a sense of personal accomplishment in one’s work, meditation and exercise, and decreasing hours of exposure to traumatic events. These strategies lead to the development of compassion satisfaction and resiliency.
D. Although it is necessary to recognize when the dynamics of a code response are subpar, the delivery of the message should be worded with consideration for the charge nurse’s STS experience. Perhaps a different forum could be considered for process improvement.
Category: Professional Issues, Nurse, Stress management (e.g., burnout,
Question 71
When using a certified interpreter to communicate with a non-English-speaking patient, the nurse should direct questions to which participant in the conversation?
Patient
✓
Oldest male family member
Designated family spokesperson
Certified interpreter
Correct Answer
Patient
A. When using a certified interpreter, the nurse should speak directly to the patient, phrasing questions in the first and second person (“I” and “you” questions) and avoiding the use of the third person (“tell her” or “ask him”).
B. Questions and statements should be directed to the patient. The certified interpreter should serve only as a facilitator of the conversation that takes place between the nurse and the patient.
C. In some cultures, the oldest male family member may be the decision maker; however, for reasons of accuracy and privacy, the conversation must occur between the patient and the nurse, with the certified interpreter serving as the facilitator of the conversation.
D. For reasons of accuracy and privacy, the conversation should occur between the patient and the nurse, with the certified interpreter serving as the facilitator of the conversation.
Category: Professional Issues, Patient, Cultural considerations (e.g., interpretive
Question 72
A patient presents from a long-term care facility where the staff reports an altered mental status. On assessment, the nurse notes crackles, cough, and the presence of a gastrostomy tube. Based on the information present, what should the nurse anticipate as the diagnosis?
Pleural effusion
Urinary tract infection (UTI)
Aspiration pneumonia
✓
Bronchitis
Correct Answer
Aspiration pneumonia
A. UTIs are likely in the older population. However, the information does not suggest a UTI. Clinical manifestations frequently associated with UTI are frequency, dysuria, urgency, suprapubic discomfort, and cloudy urine.
B. Patients with pneumonia often present with fever, chills, malaise, and changes in respiratory sounds. In the older population, there may be a change in mental status. The presence of the gastrostomy tube should make the nurse consider aspiration pneumonia because there is a risk of aspiration if feedings are not delivered correctly, with the head of the patient’s bed at a 45-degree angle.
C. A pleural effusion may accompany the pneumonia, but that is not the most correct response. Pleural effusions are typically a result of another disorder. Once the primary disorder is treated, the pleural effusion should resolve.
D. Patients with bronchitis would present with sore throat, stuffy nose, and a cough that changes over time.
Category: Respiratory Emergencies, Infections
Question 73
Chronic obstructive pulmonary disease (COPD) is diagnosed by:
arterial blood gas.
chest radiograph.
pulmonary function tests.
✓
6-minute walk test.
Correct Answer
pulmonary function tests.
A. Arterial blood gas may show mild hypoxemia in early stages of COPD but would most likely only be obtained during an acute exacerbation of the disease.
B. A chest radiograph is necessary to rule out other conditions such as lung cancer or pneumonia, but signs of COPD are generally not identified on chest radiograph until the advanced stages of the disease are present.
C. Pulmonary function tests include forced expiratory volume (FEV ), a 1 measurement used to see how much air a person can exhale during a forced breath. The FEV test is completed with multiple attempts at forced exhalation. Forced vital capacity is the total amount of air exhaled during the FEV test. In a patient with symptoms of COPD, the presence of a FEV less than 70% 1 following administration of a bronchodilator confirms the diagnosis of COPD.
D. The walk test measures exercise capacity and is used to help determine the stage of COPD that the patient is experiencing.
Category: Respiratory Emergencies, Chronic obstructive pulmonary disease
Question 74
The nurse is caring for a 6-week-old infant with a fever. During the initial assessment, the nurse notices that the infant is rapidly moving their right leg in a bicycling fashion. Based on this assessment finding, what should the nurse suspect?
Focal seizure
✓
Temper tantrum
Vagal nerve palsy
Moro reflex
Correct Answer
Focal seizure
A. The vagus nerve, cranial nerve X, can affect swallowing, gag reflex, and the abdominal viscera. It does not affect limb movement.
B. This is not developmentally appropriate for a 6-week-old infant.
C. Meningitis causes signs and symptoms of seizures and of increased intracranial pressure. Any infant younger than 60 days of age with a fever or a subnormal temperature must be evaluated for the presence of meningitis. Meningitis is a syndrome involving inflammation and infection of the brain.
D. The Moro reflex, also known as the startle reflex, is a normal response to a loud sound or movement. The infant will throw back their head and extend their extremities, then pull them back in. This can be mistaken for a seizure.
Category: Neurological Emergencies, Meningitis
Question 75
A patient presents to triage complaining of increasing difficulty walking. The patient has an uneven gait and feels “unsteady” when standing. Speech is clear, and vital signs are stable. Which assessment criteria would the emergency nurse use to evaluate the patient for the presence of cerebellar dysfunction?
Extraocular eye movements
Appropriate decision making
Visual acuity assessment
Finger-to-nose coordination
✓
Correct Answer
Finger-to-nose coordination
A. Extraocular eye movements are used to evaluate the function of cranial nerve III, cranial nerve IV, and cranial nerve VI.
B. Decision making is a complex function that uses the frontal lobe of the brain, not the cerebellum.
C. Finger-to-nose coordination is assessed by having the patient place their finger to the examiner’s finger, and then returning their finger to their nose; these movements are repeated quickly, over and over. The cerebellum is responsible for coordinated movement and balance. The function of the cerebellum is assessed via finger-to-nose coordinated movement or by the heel-to-shin coordinated movement.
D. Visual acuity assesses cranial nerve II or the optic nerve, which is essential for vision.
Category: Neurological Emergencies, Neurological disorders (e.g., multiple
Question 76
The nurse is preparing to discharge a patient who has been treated for a migraine headache. The patient asks how similar headaches in the future can be prevented. The most appropriate response by the nurse would be:
“Maintain a headache diary to identify what triggers your headache.”
✓
“Avoid foods that contain tyramine, such as aged cheeses, pickled food, and red wine.”
“Herbal products such as butterbur or feverfew are helpful.”
“Eliminating stress will reduce the incidence of migraine headaches.”
Correct Answer
“Maintain a headache diary to identify what triggers your headache.”
A. Maintaining a headache diary can help patients track and identify migraine triggers. The information can then be shared with the healthcare provider.
B. Eliminating stress levels is impossible, but reducing stress levels aids some patients in reducing the incidence of their migraine headaches.
C. These foods have been identified as triggers in some patients who experience migraine headaches. Keeping a headache diary will help the patient identify if these foods are a potential headache trigger.
D. These products should only be used under the direction of a healthcare provider. These products may be helpful for some patients in controlling the frequency and/or intensity of their migraine headaches. They should also be checked for any interactions with current medications.
Category: Neurological Emergencies, Headache (e.g., temporal arteritis, migraine)
Question 77
A patient presents via emergency medical services following an altercation in a nearby pub. The patient was struck in the head, torso, and pelvic region numerous times with a bar stool. The patient is able to move all extremities but has no recollection of the event and is oriented to person only. The presence of right otorrhea is also observed. The patient is in full spinal immobilization with a rigid cervical collar. Vital signs are BP 110/60 mm Hg, HR 106 beats/minute, RR 20 breaths/minute, SpO 98% on 4 L nasal cannula. What is the most appropriate 2 initial intervention to be performed for this patient?
Application of a long spine board
Removal of the cervical collar
Obtain blood alcohol level
Computed tomography (CT) scan of the neck
✓
Correct Answer
Computed tomography (CT) scan of the neck
A. The National Emergency X-radiography Utilization Study (NEXUS) low-risk criteria include (1) no midline cervical tenderness, (2) no focal neurologic deficit, (3) normal alertness and level of consciousness, (4) absence of intoxication, and (5) no painful, distracting injury. This patient does not meet these criteria and therefore warrants CT scanning of the neck. The cervical collar should remain in place until the CT scan has been completed and reviewed by the provider.
B. The National Emergency X-radiography Utilization Study (NEXUS) low-risk criteria include (1) no midline cervical tenderness, (2) no focal neurologic deficit, (3) normal alertness and level of consciousness, (4) absence of intoxication, and (5) no painful, distracting injury. This patient does not meet the NEXUS low-risk criteria and therefore warrants CT scanning of the neck. Based on the patient’s assessment, the patient will also require a CT scan of the head.
C. Use of a long spine board facilitates transport of the patient. Maintaining the patient in alignment in a supine position is adequate and will reduce complications associated with long board use, such as pressure sore development.
D. The patient already meets other National Emergency X-radiography Utilization Study (NEXUS) exclusion criteria. Assessing the blood alcohol level (BAL) may be appropriate, but assessing intoxication solely on a BAL is not necessary.
Category: Neurological Emergencies, Head and spinal cord trauma
Question 78
A patient presents to the emergency department with sudden onset of confusion, restlessness, visual hallucinations, and memory gaps. The family reports that the patient has a history of an ischemic stroke but had been functioning independently at home. The nurse recognizes these symptoms are an indication of which of the following conditions?
Delirium
✓
Schizophrenia
Dementia
Mania
Correct Answer
Delirium
A. Delirium is defined as an acute and sudden onset of a change in behavior, resulting in a potentially reversible state of confusion, lack of attention, and change in cognition and perception that can be precipitated by a medical condition. It is more common in patients who are elderly or suffer comorbid conditions.
B. Dementia represents a chronic progressive loss of independent functioning and memory. Dementia onset is slow; the patient’s attention is initially normal with clear consciousness, whereas the patient’s orientation is often impaired.
C. Patients with mania can exhibit an exaggerated sense of well-being, rapidly changing emotions and moods, auditory hallucinations, rapid and fluent speech, and anger. Sexual content of speech or thought is often present.
D. Schizophrenia onset is gradual, with symptoms occurring for at least one month prior to diagnosis, but usually longer. Behaviors are characterized as bizarre and disorganized, and the person has decreased ability to care for themself or function in work or social situations.
Category: Neurological Emergencies, Stroke
Question 79
A patient who is 26 weeks pregnant arrives exhibiting left-sided weakness and slurred speech that began 20 minutes before arrival. The computed tomography scan comes back negative for cerebral hemorrhage. Which intervention should the emergency team prepare for next?
Transfer to a labor and delivery unit
Administration of fibrinolytics
✓
Induction of labor
Emergency cesarean section
Correct Answer
Administration of fibrinolytics
A. The induction of labor delays treatment of the patient with a stroke. At 26 weeks’ gestation, the goal is to keep the fetus in utero and maintain placenta perfusion for as long as possible.
B. The priority intervention for stroke is the administration of fibrinolytics. Fibrinolytics do not cross the placenta, thereby minimizing risk to the fetus. Risks associated with the administration of fibrinolytics to the pregnant patient are similar to those for any other patient.
C. An emergency cesarean section increases risk of bleeding and delays proper intervention for the mother.
D. Transferring the patient to labor and delivery will further delay the administration of fibrinolytics for the mother, which is the priority for a patient with an ischemic stroke.
Category: Neurological Emergencies, Stroke
Question 80
The Five Rights of Delegation are right task, right circumstances, right person, right direction and communication, and which of the following?
Right assessment and reassessment
Right equipment and supplies
Right supervision and evaluation
✓
Right documentation
Correct Answer
Right supervision and evaluation
A. The registered nurse, under right supervision and evaluation, would be assessing whether the assistive personnel are using the right equipment and supplies.
B. The registered nurse would be assessing that the proper direction and communication have taken place; however, right documentation completed is not a component of the five rights of delegation. Proper documentation is the responsibility of the registered nurse.
C. Right supervision and evaluation is the fifth right of delegation.
D. The registered nurse is accountable for the ongoing monitoring of the outcomes of nursing care.
Category: Professional Issues, System, Delegation of tasks to assistive personnel
Question 81
The nurse is caring for a patient on a ventilator with an endotracheal tube (ETT). Which of the following interventions will help prevent the patient from developing ventilator-associated pneumonia (VAP)?
Provide frequent oral care to decontaminate the mouth
✓
Frequent use of saline when suctioning the ETT
Keep the head of the bed (HOB) flat to prevent aspiration
Refrain from suctioning the mouth to avoid introducing new pathogens
Correct Answer
Provide frequent oral care to decontaminate the mouth
A. One of the biggest risks for VAP is colonization of the oral cavity. Secretions adhere to the ETT and migrate into the lower airways. Even though it takes about 48 hours for pneumonia to develop, prevention starts in the ED. Chlorhexidine oral care is recommended to help decontaminate the mouth.
B. Keeping the HOB flat actually increases the risk of aspiration. The HOB should be elevated to 30–45 degrees as soon as possible, or try reverse Trendelenburg position if tolerated.
C. Routine use of saline lavage should be avoided because it can increase the risk of VAP.
D. Suctioning of the oral cavity is important to remove oral secretions that pool in the mouth and can adhere to the ETT and migrate. Inline (closed) suctioning of the ETT is important to prevent opening it to contamination.
Category: Respiratory Emergencies, Infections
Question 82
The nurse anticipates administration of which antidote to a patient being treated for acetaminophen overdose?
N-acetylcysteine
✓
Flumazenil
Octreotide
Diphenhydramine
Correct Answer
N-acetylcysteine
A. Glutathione is a substance in the liver that promotes acetaminophen metabolism. Liver damage occurs in acetaminophen overdose because of the depletion of hepatic glutathione stores. N-acetylcysteine restores hepatic glutathione levels so the additional acetaminophen can be metabolized. N-acetylcysteine should be administered within 8 hours of acetaminophen ingestion.
B. Flumazenil is the antidote for benzodiazepine overdose.
C. Octreotide is the antidote for sulfonylurea overdose.
D. Diphenhydramine as an antihistamine has many indications and is given to patients who have overdosed by taking phenothiazines.
Category: Mental Health Emergencies, Intentional overdose and ingestions
Question 83
A patient with a history of alcohol abuse is being admitted with an unrelated diagnosis. Which early sign of alcohol withdrawal should the nurse observe for in this patient?
Hallucinations
Tremulousness
✓
Delirium
Low-grade fever
Correct Answer
Tremulousness
A. Hallucinations, referred to as alcoholic hallucinosis, can occur 12–48 hours after the last drink was consumed.
B. Tremulousness can occur within 6–8 hours after the last drink was consumed. The patient may also exhibit anxiety and restlessness.
C. Delirium tremens is a late sign of alcohol withdrawal, and it can occur 48–96 hours after the last drink was consumed. The risk of delirium tremens increases in patients over the age of 30 and in those with a prolonged drinking history.
D. A low-grade fever is a late sign of alcohol withdrawal and can occur in the presence of delirium tremens.
Category: Medical Emergencies, Withdrawal syndrome
Question 84
Which change in the patient’s assessment would indicate to the nurse that the treatment for acute digoxin toxicity has had its intended effect?
Hypoglycemia
Potassium level of 4.2 mEq/L
✓
Signs and symptoms of hypovolemia
Bradycardia
Correct Answer
Potassium level of 4.2 mEq/L
A. Patients with digoxin toxicity may present with hypoglycemia, so a treatment goal would be to increase the patent’s serum glucose level to normal values.
B. Bradycardia can occur because of digoxin toxicity, so an increase in the patient’s heart rate is indicative of a positive treatment goal.
C. Patients with digoxin toxicity may present with hyperkalemia, so a normal potassium level will indicate that the treatment is having the intended effect.
D. Hypovolemia may result from digoxin toxicity, so the provider would want to correct hypovolemia by increasing circulating fluid volume to maintain adequate blood pressure.
Category: Mental Health Emergencies, Intentional overdose and ingestions
Question 85
The patient presents with a complaint of a persistent toothache for over 1 week. The tooth is loose, and there is marked inflammation of the surrounding gum. The nurse anticipates that the patient will require which of the following initially?
Antibiotic
✓
Referral to a dentist
Acetaminophen for the pain
Tooth extraction
Correct Answer
Antibiotic
A. Dental pain does not usually resolve with the administration of acetaminophen; however, it is indicated for the treatment of any associated fever. Nonsteroidal anti-inflammatory medications such as ibuprofen are preferred for the treatment of dental pain.
B. Tooth extraction is not indicated for a dental abscess unless it is unresponsive to therapy. All efforts should be made to salvage the tooth once the infection has resolved.
C. The patient most likely has a dental abscess. A dental abscess results in swelling and inflammation in the tissue surrounding the affected tooth, resulting in the tooth being loose within the dental socket. The administration of an antibiotic will help to relieve the swelling and inflammation associated with the infection.
D. Follow-up with a dentist within 24–48 hours is necessary for definitive care.
Category: Maxillofacial and Ocular Emergencies, Maxillofacial, Abscess (i.e.,
Question 86
The nurse is conducting discharge teaching for a patient with a forehead laceration that has been closed with adhesive wound glue. The patient acknowledges understanding of discharge instructions when they state the following:
“I will apply a thin layer of antibiotic ointment to the laceration every day after showering.”
“I need to avoid showering for 24 hours.”
“I must return to the emergency department for removal of adhesive glue in 3 days.”
“I will be sure to wear sunscreen over the area once the glue is gone.”
✓
Correct Answer
“I will be sure to wear sunscreen over the area once the glue is gone.”
A. Patients may shower without risk of removing the adhesive wound glue.
B. Using ointments with a petroleum jelly base will result in the adhesive wound glue coming away from the newly closed wound.
C. Abraded skin is sensitized, and hyperpigmentation can occur after sun exposure. Patients should be instructed to use sunscreen once the glue is gone.
D. Adhesive wound glue will gradually slough off in 5–10 days from the area of application.
Category: Musculoskeletal and Wound Emergencies, Wound, Lacerations
Question 87
A patient presents with a human bite to the hand as a result of an assault. What is the nurse’s priority in the care of this patient?
Identify any treatment of the bite before arrival
Assess the wound for the presence of exudate
✓
Determine the source of the bite
Ask the patient when the bite occurred
Correct Answer
Assess the wound for the presence of exudate
A. Human bite injuries pose a high risk for infection, and the presence of exudate may indicate a possible wound infection. Antibiotics would need to be started as soon as possible.
B. Determining the source of the bite is important but is not the priority in the care of the patient.
C. Finding out when the injury occurred is important in determining when and if wound closure should take place, but it is not the priority in the care of the patient.
D. The treatment of the injury before arrival is an important part of the assessment but it is not the priority in the care of the patient.
Category: Musculoskeletal and Wound Emergencies, Wound, Wound bleeding (e.g.,
Question 88
A patient presents with complaints of pain, redness, swelling, and warmth to their nondominant hand after being bitten by their cat 3 days previously. The nurse suspects the patient may have:
gas gangrene.
rabies.
pasteurellosis.
✓
wound botulism.
Correct Answer
pasteurellosis.
A. Pasteurellosis is a bacterial infection caused by Pasteurella bacteria. The infection results in tissue necrosis and is linked to animal bites, with cat bites being the most common cause.
B. It is possible to contract rabies from a cat bite if the cat is infected with rabies. However, the presentation is more consistent with wound infection secondary to pasteurellosis, a common infection resulting from a cat bite.
C. Wound botulism results from a significant traumatic or crush injury in which dirt or debris enters the wound. Wound botulism is not associated with animal bites.
D. An infection related to gas gangrene is attributed to Clostridium perfringens organisms found in the intestine or gallbladder. The presence of gas gangrene in a wound is not associated with animal bites.
Category: Musculoskeletal and Wound Emergencies, Wound, Wound infections
Question 89
Which of the following findings would the nurse expect to assess in a patient who had received procedural sedation before the reduction of a right radius and ulna fracture?
The patient is awake, tracking the team.
The patient is unarousable.
Purposeful response following repeated vigorous stimulation.
Purposeful response to verbal/tactile stimulus.
✓
Correct Answer
Purposeful response to verbal/tactile stimulus.
A. General anesthesia results in an unarousable patient even with painful stimuli; airway and ventilation management is required.
B. Deep sedation results in a purposeful response only following repeated vigorous or painful stimulation, and airway interventions may be required to maintain adequate ventilation.
C. Moderate sedation, also known as procedural sedation, results in a purposeful response to verbal or tactile stimulation. Normally, no airway intervention is required in the presence of procedural sedation, and the patient is able to maintain adequate ventilation.
D. Anxiolysis results in awake patients with normal responses. Pain control would not be adequate for a patient experiencing anxiolysis.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Fractures
Question 90
The nurse is caring for a patient who has increasing arm pain following a long-arm splint application 2 days ago for an olecranon fracture. Assessment of the affected extremity reveals +1 radial pulse, a pale hand, and inability to wiggle or move the fingers. The nurse identifies that the priority intervention for this patient is to:
remove or loosen the long-arm splint.
✓
administer pain medication to the patient.
apply ice to the extremity.
elevate the extremity.
Correct Answer
remove or loosen the long-arm splint.
A. Applying ice to the injured extremity causes vasoconstriction of the vessels, which can further limit circulation within the affected arm.
B. The patient may require pain medication, but the priority intervention is to eliminate the constrictive device around the extremity.
C. The patient is experiencing compartment syndrome. The splint may be increasing compartmental pressure and should be removed or loosened immediately. Signs and symptoms of compartment syndrome are pain, pallor, pulselessness, paresthesia, paralysis, and pressure.
D. This patient is exhibiting signs of compartment pressure, and elevating the extremity can decrease arterial blood flow, thereby limiting tissue perfusion. The extremity should not be raised above the level of the heart.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Compartment
Question 91
A patient presents for treatment of a laceration to their eyelid. Assessment of which cranial nerves is the highest priority?
Cranial nerves V and VII
Cranial nerves I and II
Cranial nerves III and VII
Cranial nerves II and III
✓
Correct Answer
Cranial nerves II and III
A. The eye should be assessed for direct trauma and potential impact on visual acuity. Cranial nerve II is the optic nerve, responsible for the patient’s vision. Cranial nerve III is the oculomotor nerve, which regulates pupil size, accommodation, and extraocular movement.
B. Cranial nerve I is the olfactory nerve and is responsible for the sense of smell. This patient’s injury should not have affected the olfactory nerve. Cranial nerve II is the optic nerve and is responsible for the patient’s vision.
C. Cranial nerve V is the trigeminal nerve and is responsible for controlling facial sensation and mastication. Cranial nerve VII is the facial nerve that is responsible for facial movement, taste, lacrimation, and salivation.
D. Cranial nerve III is the oculomotor nerve, which regulates pupil size, accommodation, and extraocular movement. Cranial nerve VII is the facial nerve that is responsible for facial movement, taste, lacrimation, and salivation.
Category: Musculoskeletal and Wound Emergencies, Wound, Lacerations
Question 92
Which of the following assessment findings would lead the nurse to suspect that a patient with a femur fracture may be developing a fat embolus?
Numbness and tingling of the left leg
Bradycardia
Acute dyspnea
✓
Muscle spasms of the left leg
Correct Answer
Acute dyspnea
A. Respiratory distress, including dyspnea and hypoxia, is a classic presentation associated with fat embolus syndrome. Other symptoms can be nonspecific and may mimic other conditions—including pleuritic chest pain, myocardial infarction, and panic attacks—but not headaches. Anxiety, apprehension, and restlessness are common signs and symptoms of a fat embolus.
B. Numbness, tingling, or loss of sensation are signs of compartment syndrome. The symptoms are not associated with the presence of a fat embolus.
C. Patients with a fat embolus will exhibit tachycardia, not bradycardia.
D. Muscle spasms are not consistent with fat embolus.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Fractures
Question 93
A patient arrives from an extended care facility. The nurse is assessing the sacrum of the patient and notes an area of nonblanching erythema. What intervention would be most appropriate to protect the patient’s skin from further pressure injury?
Place the patient in a left lateral recumbent position
✓
Place the patient in the Trendelenburg position
Calculate a Braden score
Insert an indwelling urinary catheter
Correct Answer
Place the patient in a left lateral recumbent position
A. Placing the patient in a Trendelenburg position would not remove pressure from the sacrum.
B. An indwelling urinary catheter is not indicated at this time. Pressure on the sacral area would continue even if a catheter was inserted. Repositioning the patient to protect the area from further injury is the priority intervention at this time.
C. Repositioning is the priority to protect the patient’s skin from further injury.
D. Calculating a Braden score is indicated for this patient to determine the risk for further skin breakdown, but it will not protect the patient from further skin injury. Repositioning the patient to protect the area from further injury is the priority intervention.
Category: Musculoskeletal and Wound Emergencies, Wound, Wound bleeding (e.g.,
Question 94
A patient complains of severe, stabbing pain to the right side of the cheek and jaw after shoveling snow. The patient reports prior episodes of severe pain while eating. The nurse suspects a disorder of which cranial nerve?
Cranial nerve V
✓
Cranial nerve XII
Cranial nerve IX
Cranial nerve VII
Correct Answer
Cranial nerve V
A. Severe, stabbing pain in the cheek and jaw is a common sign and symptom of trigeminal neuralgia, which is rapid repetitive firing of the fifth cranial nerve. The trigeminal nerve controls muscles involved in chewing and carries sensory information from the face to the brain. Exposure to extreme cold, shaving, eating, and washing the face often lead to exacerbations.
B. Cranial nerve VII, or the facial nerve, is responsible for moving the facial muscles, allows the tongue to detect taste, and stimulates production within the salivary glands. Bell’s palsy, a sudden weakness or paralysis of one side of the face, is caused by a problem with the function of cranial nerve VII.
C. The glossopharyngeal nerve, or cranial nerve IX, moves the muscles of the throat and communicates information from the tongue and throat to the brain. Glossopharyngeal neuralgia causes severe pain to one side of the tongue, throat, or ear.
D. Disorders of the hypoglossal nerve, or cranial nerve XII, result in difficulty speaking, chewing, or swallowing and are characterized by atrophy or weakness of the tongue on one side. Cranial nerve XII disorders may be caused by a stroke, brain stem infection, or brain tumor.
Category: Maxillofacial and Ocular Emergencies, Maxillofacial, Facial nerve disorders
Question 95
A patient is complaining of severe back pain that began 2 days ago and has become increasingly worse. The patient is unable to walk unassisted because of a loss of sensation in the groin area. There is no history of heavy lifting, pushing, or pulling. The nurse would be most concerned with which assessment finding?
Achilles’ reflex +3 bilaterally
Distended bladder
✓
Positive left straight leg raise
External sphincter contraction
Correct Answer
Distended bladder
A. Straight leg raise is used to assess for the presence of a disc herniation, which, if found, is not usually emergent; it is treated with conservative measures, such as administration of anti-inflammatory medications and physical therapy.
B. Although this reflex finding is considered stronger than average, it is not necessarily an emergent finding by itself that requires an intervention at this time.
C. The patient may be experiencing urinary retention, indicating the possibility of a more serious medical problem such as cauda equina or conus medullaris syndrome. This finding needs to be further evaluated, especially if the patient is complaining of loss of sensation in the groin area (saddle paresthesia), is unable to start a urinary stream, or has the sensation of the bladder being full. Either syndrome requires immediate treatment.
D. External sphincter contraction, also known as the “anal wink,” indicates a normal response. In the presence of possible spinal cord injury, it would indicate sacral sparing.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Inflammatory
Question 96
A patient complaining of chest pain has a recent history of upper respiratory infection for which they were taking an antitussive medication. Vital signs are BP 150/88 mm Hg, HR 92 beats/minute, RR 20 breaths/minute, SpO 95%, T 38.1°C 2 (100.6°F). The midsternal chest pain increases with deep inspiration and palpation. An electrocardiogram shows regular sinus rhythm, and a chest radiograph and serum troponins are normal. What is the most likely cause of this patient’s chest pain?
Pleurisy
Pulmonary embolism
Myocardial infarction
Costochondritis
✓
Correct Answer
Costochondritis
A. Pleurisy is caused by swelling and inflammation around the lungs that usually feels sharp and often increases in intensity when taking a deep breath.
B. Myocardial infarction pain is often characterized as tightness, crushing, and squeezing, and radiating to the arm, jaw, or back. Electrocardiogram may show changes that indicate an acute myocardial event, and/or laboratory studies may indicate an abnormal rise in cardiac enzymes.
C. Costochondritis is the inflammation of cartilage that connects the ribs to the sternum. Causes may include recent chest injury, heavy lifting, respiratory infection, and strain from repeated coughing. Symptoms include point tenderness with palpation to the chest wall and pain that varies with respiration.
D. Pulmonary embolism is a blood clot in the lungs. Common signs and symptoms include shortness of breath that is often worse with exertion; cough; and chest pain that often worsens with respirations, cough, or change in positions but does not go away with rest. Other symptoms include fever, leg pain/swelling, cyanosis, dizziness, and rapid or irregular heartbeat.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Inflammatory
Question 97
A patient presents after sustaining multiple contusions to their trunk and bilateral extremities from a fall. On reviewing the patient’s list of current prescribed medications, the nurse identifies that the patient is at risk for complications related to their contusions due to which of the following medications?
Clopidogrel (Plavix)
✓
Acetaminophen (Tylenol)
Ciprofloxacin (Cipro)
Hydroxychloroquine (Plaquenil)
Correct Answer
Clopidogrel (Plavix)
A. Hydroxychloroquine is an antimalarial/antiprotozoal medication that is also used to treat inflammation for autoimmune diseases like lupus. This medication would not place the patient at risk for complications related to their contusions.
B. Plavix is an antiplatelet medication that can increase risk of bleeding/hemorrhage. In addition, there is an increased risk for compartment syndrome because of bleeding and swelling in the extremity. Other medications that can place a patient at increased risk for complications related to contusions include warfarin, rivaroxaban, and aspirin.
C. Ciprofloxacin is an antibiotic that has an increased risk of tendon rupture associated with its administration. There is no known risk of complications associated with the presence of contusions when taking ciprofloxacin.
D. Acetaminophen is a non-narcotic analgesic and is not associated with an increased risk of complications in the presence of contusions.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Ligament
Question 98
A patient presents following blunt trauma to the right upper leg and is diagnosed with a contusion. Which statement from the patient verifies to the nurse that the patient understands the discharge instructions?
“I will let the leg dangle, and I will apply loose gauze directly over the injured area.”
“I will apply ice to the bruise, make sure the Ace wrap is secure around my leg, and keep my leg elevated.”
✓
“I will apply heat to my leg, dangle my leg on side of bed, and leave the wound open to air.”
“I will apply heat and ice to my leg and keep a loose gauze dressing over the injured area.”
Correct Answer
“I will apply ice to the bruise, make sure the Ace wrap is secure around my leg, and keep my leg elevated.”
A. Heat can cause vasodilation, which will increase swelling, and so should be avoided. A loose gauze dressing will not provide any benefit to the injured area. Keeping the leg elevated is a correct intervention for this patient’s injury.
B. Applying heat to the contusion can promote vasodilation, which can increase swelling and will not aid in tissue healing. Allowing the leg to be dependent and not keeping it elevated may promote additional swelling. The application of a compression or pressure-type dressing can act to decrease swelling at the site.
C. Applying ice to the injured area will cause vasoconstriction, which will reduce the amount of swelling and possible bleeding. Using compression or pressure dressings and keeping the injured leg elevated also act to reduce bleeding and swelling.
D. Ice will help decrease swelling by causing vasoconstriction. Keeping the leg dependent and not elevated may promote further swelling of the injured area; applying a pressure dressing such as an elastic bandage may help decrease swelling.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Ligament
Question 99
A patient complains of swollen lymph nodes, generalized aches and pains, and a headache. The patient is currently receiving chemotherapy and lives alone with a pet cat. Which statement indicates the patient understands the discharge instructions related to the cause of the infection?
“I’ll have to get rid of the ant farm that I maintain for work.”
“I should have had someone clean the cat litter box instead of doing it myself.”
✓
“I’ll have to have someone help me by walking my dog.”
“I should have had someone clean my fish tank instead of doing it myself.”
Correct Answer
“I should have had someone clean the cat litter box instead of doing it myself.”
A. Aquarium fish typically do not transmit diseases to humans.
B. Toxoplasmosis is caused by the one-celled protozoan parasite Toxoplasma gondii. Humans may acquire toxoplasmosis through contact with undercooked meat, contaminated water, and animal excrement, specifically cleaning a cat litter box. Cats that are allowed to go outside are more likely to be carriers of the parasite. Toxoplasmosis is an opportunistic infection seen in those who are immunocompromised.
C. The patient should not have contact with the dog’s fecal matter, but walking the dog is not contraindicated. If the patient must handle the feces, gloves and a mask should be worn, and hands should be washed frequently.
D. Ant farms are contained. It is unlikely that the patient will contract an infection from the ants.
Category: Medical Emergencies, Immunocompromise (e.g., HIV/AIDS,
Question 100
A geriatric patient presents to triage stating, “I can’t see out of my right eye. It’s like a shade came down over my eye.” The patient’s right pupil is dilated. What is the priority intervention for this patient?
Perform a 12-lead electrocardiogram (ECG) immediately
Assign an Emergency Severity Index (ESI) category 3
Notify the physician/advanced practice provider
✓
Perform a Snellen visual acuity assessment
Correct Answer
Notify the physician/advanced practice provider
A. Sudden painless loss of monocular vision is a sign of central artery occlusion and is an ophthalmology emergency. Blood flow to the retinal artery must be reestablished within 60–90 minutes to prevent permanent loss of vision in the affected eye. An ESI level of 3 would result in delayed treatment. This patient should be assigned an ESI category 1.
B. Sudden painless loss of monocular vision is a sign of central artery occlusion and is an ophthalmology emergency. A 12-lead ECG may diagnose atrial fibrillation or other cardiac dysrhythmia, which may assist in determining the cause of the patient’s sudden loss of vision, but it will not assist in restoring the patient’s eyesight. Definitive treatment should not be delayed.
C. Sudden painless loss of monocular vision is a sign of central artery occlusion and is an ophthalmology emergency. This patient requires immediate lowering of the intraocular pressure using medical management of timolol, acetazolamide, or mannitol, which the ED physician or advanced practice provider can initiate. Consult with an ophthalmologist should be done immediately because medical management is unreliable.
D. Sudden painless loss of monocular vision is a sign of central artery occlusion and is an ophthalmology emergency. Definitive treatment should not be delayed because the sudden loss of vision can lead to permanent vision loss within 60–90 minutes if left untreated. The results of a Snellen visual acuity test will not aid in the patient’s diagnosis and will not alter the necessary treatment that is required.
Category: Maxillofacial and Ocular Emergencies, Ocular, Retinal artery occlusion
Question 101
The presence of labyrinthitis is associated with which of the following?
Headache
Pain with movement of the tragus
Nystagmus
✓
Periauricular cellulitis
Correct Answer
Nystagmus
A. Periauricular cellulitis is found in the presence of otitis externa but is not a symptom of labyrinthitis.
B. Pain is associated with movement of the tragus in the presence of otitis media.
C. The presence of a headache is associated with mastoiditis but is not commonly associated with labyrinthitis.
D. Nystagmus is a common finding with labyrinthitis.
Category: Maxillofacial and Ocular Emergencies, Maxillofacial, Acute vestibular
Question 102
Numerous patients arrive, each with multiple lacerations, following a suspected pipe bomb that was detonated in a crowd. The nurse understands that these injuries are the result of which category of blast injury?
Secondary
✓
Primary
Quaternary
Tertiary
Correct Answer
Secondary
A. Primary blast injury is the result of the overpressurization wave moving across an area. Gas-filled structures such as the lungs, middle ear, and gastrointestinal tract are most susceptible to primary blast injuries.
B. Secondary injuries are caused by projectiles from the area near the blast and/or the device. The nurse should anticipate that multiple foreign bodies could be present in the wounds.
C. Tertiary injuries occur when a victim is thrown into a stationary object. Fractures, amputations, and open or closed head/scalp wounds are examples of tertiary injuries.
D. Quaternary injuries are all explosion-related injuries, illnesses, or diseases that are not directly related to primary, secondary, or tertiary mechanisms.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Ligament
Question 103
Following the application of a short-arm cast for a forearm fracture, a patient complains of numbness and tingling at the tips of the index and middle fingers. The nurse understands that these symptoms indicate compromise of which nerve?
Radial nerve
Ulnar nerve
Peroneal nerve
Median nerve
✓
Correct Answer
Median nerve
A. Assessment of radial nerve function includes check for sensation and motor function at the dorsum of the hand from the thumb to the middle of the ring finger.
B. The peroneal nerve is a division of the sciatic nerve. Check for sensation at the web space between the first and second toes and for sensation of the lateral area of the lower leg and the dorsum of the foot.
C. To assess for motor function of the median nerve, oppose the thumb to the other fingers. Check for sensation at the palmar aspect of the hand, from midthumb to the middle of the ring finger, and the tips of the index, long, and ring fingers.
D. Assessment of ulnar nerve function includes spreading the fingers and assessing sensation at the distal tip of the small finger.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Fractures
Question 104
A patient presents with complaints of swelling, redness, and warmth to the knee. Bursitis of the knee is diagnosed, and the provider performs a knee aspiration in order to:
prevent further infection.
remove the knee cyst.
obtain a Gram stain and culture of the synovial fluid.
✓
administer prophylactic antibiotics directly into the joint space.
Correct Answer
obtain a Gram stain and culture of the synovial fluid.
A. Oral antibiotics are indicated after fluid in the bursa is aspirated and the cause of the infection is identified. Antibiotics are not injected directly into the joint space.
B. Bursitis is inflammation of a bursa, a saclike structure that covers the bony prominence among bones, muscles, and tendons. The bursa contains only a small amount of viscous (synovial) fluid. It is important to determine whether the bursitis is the result of inflammation or infection because the definitive therapy will differ depending on the cause of the bursitis.
C. Inflammation of a bursa is the result of trauma (e.g., a direct blow or a chronic injury associated with prolonged, repetitive use) or infection (bacterial or fungal).
D. Oral antibiotics are indicated after the fluid in the bursa is aspirated and the cause of the infection is identified.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Inflammatory
Question 105
Which statement made by the patient indicates an understanding of the discharge instructions regarding how to avoid further episodes of hypoglycemia?
“I will keep a couple of pieces of candy with me at all times.”
“I will keep my glucose oral gel with me at work, at school, and when I play sports.”
“I will eat small, frequent meals throughout the day.”
✓
“As long as I check my glucose daily, I will not have further hypoglycemic reactions.”
Correct Answer
“I will eat small, frequent meals throughout the day.”
A. Patients with frequent episodes of hypoglycemia should check their blood glucose throughout the day, on arising in the morning, before meals, and again at bedtime.
B. In patients with frequent hypoglycemic reactions, candy may not provide enough carbohydrates to adequately treat their hypoglycemia.
C. Eating 4–6 small meals that contain at least 15 g of carbohydrates and monitoring their blood glucose at least 4 times daily is recommended for patients who experience frequent episodes of hypoglycemia.
D. Administration of the glucose gel may not be enough to increase the patient’s blood glucose levels. Therefore, following the administration of oral glucose gel, at least an additional 15 g of carbohydrate should be offered to the patient. Oral glucose gel should only be administered to a conscious, alert patient who is hypoglycemic.
Category: Medical Emergencies, Endocrine disorders
Question 106
Which medication does the nurse anticipate will be ordered for a patient who is being treated for adrenal crisis?
Dexamethasone (Decadron)
✓
Spironolactone (Aldactone)
Metoprolol (Lopressor)
Nicardipine (Cardene)
Correct Answer
Dexamethasone (Decadron)
A. Spironolactone is an aldosterone receptor antagonist, potassium-sparing diuretic. The patient in adrenal crisis will also be dehydrated, so a diuretic would be contraindicated.
B. Metoprolol is a beta blocker and would not correct the patient’s lack of aldosterone. The patient in adrenal crisis will also be hypotensive, so metoprolol would be contraindicated.
C. Dexamethasone is the drug of choice for adrenal crisis because it does not interfere with plasma cortisol measurements. Hydrocortisone may be used for patients with known adrenal insufficiency.
D. Nicardipine is a calcium channel blocker and would not correct the patient’s lack of aldosterone. The patient in adrenal crisis will also be hypotensive, so nicardipine would be contraindicated.
Category: Medical Emergencies, Endocrine disorders
Question 107
Which of the following serum electrolytes is the highest priority for the nurse to monitor in a trauma patient who has received multiple transfusions of blood products?
Glucose
Sodium
Calcium
✓
Phosphate
Correct Answer
Calcium
A. The anticoagulant often used in banked blood products is citrate, which can bind to serum calcium, resulting in the patient developing hypocalcemia.
B. Glucose levels are not typically affected by the administration of blood products.
C. Sodium levels are not typically affected by the administration of blood products.
D. Phosphate levels are not typically affected by the administration of blood products.
Category: Medical Emergencies, Electrolyte and fluid imbalance
Question 108
A patient presents to triage with a history of increasing fatigue, extreme pallor, and generalized bone pain. The patient is suspected of having undiagnosed leukemia. Which of the following interventions should the nurse prepare for?
Administration of nonsteroidal anti-inflammatory drugs
Bone marrow aspiration
Lumbar puncture
✓
Initiation of the first dose of chemotherapy
Correct Answer
Lumbar puncture
A. Lumbar punctures are commonly performed in the emergency department and are part of a comprehensive workup. Analysis will identify if there are cancer cells in the cerebrospinal fluid. The definitive diagnosis of leukemia is usually done after consultation with a hematologist or oncologist. Once the type of leukemia is identified, a treatment plan is initiated.
B. Definitive treatment such as chemotherapy will be initiated in a stable, controlled inpatient setting after confirmative diagnostic evaluation occurs. Chemotherapy is not initiated in the emergency department unless by a nurse specially trained in the administration of chemotherapy.
C. Acetaminophen may be administered and is preferred over nonsteroidal anti-inflammatory drugs such as ibuprofen. Ibuprofen should be avoided in patients with thrombocytopenia because of the increased risk of bleeding with the administration of NSAIDs.
D. Bone marrow aspiration is a confirmative diagnostic test for leukemia, but this test is not usually completed in the emergency department. It will typically be performed following consultation with a hematologist or oncologist.
Category: Medical Emergencies, Hematologic disorders
Question 109
A patient states they are experiencing a sickle cell crisis. The nurse knows that during a sickle cell crisis, particular cells assume a sickled shape and clump together in the microvasculature. Which of the following cells are affected in this way?
Platelets
Leukocytes
Red blood cells (RBCs)
✓
Neutrophils
Correct Answer
Red blood cells (RBCs)
A. Leukocytes do not assume a sickle shape, nor do they clump together.
B. Platelets do not assume a sickle shape, nor do they clump together.
C. In a patient with sickle cell disease, RBCs contain abnormal hemoglobin (HbS). Exposure to cold temperatures, low O , dehydration, infection, or 2 strenuous exercise precipitates the RBCs’ changing shape into long crystals and clumping together in the microvasculature.
D. Neutrophils do not assume a sickle shape, nor do they clump together.
Category: Medical Emergencies, Hematologic disorders
Question 110
Which of the following assessment findings should the nurse be most concerned about in a patient who presents with a fever of unknown origin?
Tachycardia
Rash
Nasal congestion
Altered mental status
✓
Correct Answer
Altered mental status
A. Altered mental status in any patient is very concerning. In a patient who also presents with fever, the emergency nurse should be concerned about the possibility of a life-threatening problem, such as a central nervous system infection, that could lead to seizures and potential loss of the patient’s airway.
B. Tachycardia is an expected finding in the patient with a fever and usually resolves as the fever resolves.
C. Nasal congestion is often experienced with upper respiratory infections, but this rarely causes serious airway compromise.
D. A rash in the presence of fever can be an indication of the etiology of a viral or bacterial infection. However, neurologic findings, such as altered mental status, may indicate acuity of the presentation and therefore are more concerning.
Category: Medical Emergencies, Sepsis
Question 111
A patient with elevated T and T levels has a temperature of 40.1°C (104.3°F). 3 4 Which medication should be avoided to control this patient’s fever?
Aspirin (acetylsalicylic acid)
✓
Acetaminophen (Tylenol)
Naproxen (Naprosyn)
Ibuprofen (Motrin)
Correct Answer
Aspirin (acetylsalicylic acid)
A. Ibuprofen is a nonsteroidal anti-inflammatory drug that may assist with lowering temperature, decreasing pain, and alleviating inflammation, but it is not the primary antipyretic of choice.
B. Tylenol does not displace the thyroid hormone from binding sites and will assist with fever reduction.
C. Naproxen is a nonsteroidal anti-inflammatory drug that will assist in the management of inflammation and pain. Its primary action is not to lower body temperature as an antipyretic medication would.
D. Aspirin should be avoided because it may further increase T levels by 4 displacing the thyroid hormones from and interfering with protein-binding sites. Increased thyroxine levels will lead to a worsening of the patient’s clinical condition.
Category: Medical Emergencies, Endocrine disorders
Question 112
Which of the following values would best indicate that the patient being treated for ketoacidosis is improving?
Blood pressure of 138/72 mm Hg
Pulse rate of 108 beats/minute
Respiratory rate of 16 breaths/minute
✓
Pulse oximetry of 98% without supplemental oxygen
Correct Answer
Respiratory rate of 16 breaths/minute
A. A patient being treated for diabetic ketoacidosis will demonstrate improvement by the normalization in the patient’s respiratory rate. An increased respiratory rate in a patient with diabetes is a compensatory response to the acidosis.
B. A patient experiencing diabetic ketoacidosis will demonstrate tachycardia (heart rate greater than 100 beats/minute) secondary to the presence of dehydration. A heart rate of 108 beats/minute indicates that the patient continues to be dehydrated.
C. Patients with diabetic ketoacidosis may have hypotension, depending on the degree of dehydration. However, the best indication that the acidotic state is resolving is normalization of the respiratory rate.
D. The PaO of a patient with diabetic ketoacidosis is usually within the normal 2 range. Thus, the pulse oximetry reading would be normal even though a pathophysiological state is occurring. Therefore, oxygen saturation is not the best indicator of patient improvement.
Category: Medical Emergencies, Endocrine disorders
Question 113
Which of the following is the most appropriate action for the nurse to take to preserve the amputated part of an amputated distal middle finger?
Place the amputated part in ice water.
Rinse the amputated part with normal saline, wrap in saline-moistened gauze, place in a plastic bag, and place the bag on a bed of ice.
✓
Place the amputated part in a sterile dressing and then place it in a bag of ice.
Immediately rinse the amputated part with distilled water, place it back onto the injury site, and secure it with a sterile gauze dressing.
Correct Answer
Rinse the amputated part with normal saline, wrap in saline-moistened gauze, place in a plastic bag, and place the bag on a bed of ice.
A. The amputated part is preserved for reimplantation by wrapping it in saline-moistened gauze and placing it in a plastic bag or container. The sealed container is then placed on top of crushed ice and water. This cools the part without causing direct damage to tissue.
B. If the amputated part is placed directly in water or on ice, the tissues can suffer damage, including cellular freezing and cell death, making reimplantation impossible.
C. Distilled water is not used because of its deleterious effect on tissue. The amputated part needs to be cooled. Placing the amputated part back onto the injury site will not cool the amputated digit and will damage the tissue.
D. The amputated part should be rinsed of debris, wrapped in slightly moistened gauze, and placed in a plastic bag; the bag is then placed on a bed of ice.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Amputation
Question 114
Which of the following skin conditions is most closely associated with leukemia?
Jaundice
Petechiae
✓
Erythematous rash
Skin bronzing
Correct Answer
Petechiae
A. Petechiae and ecchymoses are often seen in patients with leukemia related to the presence of thrombocytopenia.
B. Skin bronzing and hyperpigmentation are closely associated with hemochromatosis, the buildup of excessive iron in the body.
C. Jaundice may eventually occur in patients with leukemia, but it is more commonly associated with liver disease.
D. Erythematous rash is not commonly associated with leukemia. This type of rash presents in patients with rubella or rubeola.
Category: Medical Emergencies, Hematologic disorders
Question 115
A hemorrhagic-related sign that indicates the presence of disseminated intravascular coagulation is:
cyanosis.
gangrene of the fingers.
purpura.
✓
renal failure.
Correct Answer
purpura.
A. Two mechanisms, hemorrhagic and thrombotic processes, cause the signs and symptoms of disseminated intravascular coagulation. Hemorrhagic signs result from the inability of the blood to clot, leading to the presence of petechiae, purpura, hemoptysis, and hematuria.
B. Two mechanisms, hemorrhagic and thrombotic processes, cause the signs and symptoms of disseminated intravascular coagulation. Gangrene of the digits results from the second mechanism, which is thrombosis that occurs in the microcirculation of the fingers.
C. Two mechanisms, hemorrhagic and thrombotic processes, cause the signs and symptoms of disseminated intravascular coagulation. Cyanosis results from the second mechanism, which is thrombosis that occurs in the microcirculation of the lungs.
D. Two mechanisms, hemorrhagic and thrombotic processes, cause the signs and symptoms of disseminated intravascular coagulation. Renal failure results from the second mechanism, which is thrombosis that occurs in the microcirculation to the kidneys, resulting in renal failure.
Category: Medical Emergencies, Hematologic disorders
Question 116
A patient who states they are receiving chemotherapy for breast cancer lives alone and has a pet. Which type of pet would be most concerning as a possible source of infection for this patient?
Fish
Dog
Ant farm
Cat
✓
Correct Answer
Cat
A. Aquarium fish typically do not transmit diseases to humans.
B. Toxoplasmosis is caused by the one-celled protozoan parasite Toxoplasma gondii. Humans may acquire toxoplasmosis in several ways, including contact with animal excrement, specifically via cleaning a cat litter box. Cats that go outside are more likely to be carriers of the parasite than cats kept exclusively indoors. Toxoplasmosis is an opportunistic infection seen in those who are immunocompromised.
C. If the dog is house trained, the patient should not have frequent contact with fecal matter. If they walk the dog and must clean up bowel movements, they should be encouraged to wear gloves and a mask and wash their hands frequently.
D. Ant farms are contained. It is unlikely that the patient will contact an infection from the ants.
Category: Medical Emergencies, Immunocompromise (e.g., HIV/AIDS,
Question 117
Which of the following medications would the nurse anticipate administering for a patient’s acute episode of severe agitation?
Fentanyl
Haloperidol
Ketamine
Lorazepam
✓
Correct Answer
Lorazepam
A. Ketamine produces sedative dissociation and analgesia. Some research supports its use for rapid take-down in patients who are an imminent danger to themselves or others, but at present it is not routinely recommended in the use of acute psychotic symptoms.
B. Haloperidol is an antipsychotic agent that may be used to treat acute psychosis, but it takes longer to act than lorazepam. It does have potential side effects, such as dystonia, dysrhythmias, and hyperpyrexia.
C. Lorazepam is a sedative-hypnotic that can be administered orally, intravenously, or by intramuscular injection. It has a relatively rapid onset and a shorter half-life than other medications. It is also used to treat anxiety and alcohol withdrawal, which can sometimes appear to be a psychotic episode.
D. Fentanyl is a potent opioid analgesic that also has a sedative effect. It has severe side effects, including respiratory depression. It is currently not recommended as a medication for psychotic agitation.
Category: Mental Health Emergencies, Thought disorders (e.g., psychosis,
Question 118
A schizophrenic patient who is in a manic phase received haloperidol (Haldol) for their aggressive behavior. Which of the following medications should the nurse be prepared to administer for side effects related to haloperidol?
Ziprasidone
Promethazine
Lorazepam
Diphenhydramine
✓
Correct Answer
Diphenhydramine
A. Lorazepam is a benzodiazepine used in conjunction with haloperidol to treat the symptoms of aggressive behavior. Lorazepam will not reverse the dystonic effects of haloperidol.
B. Individuals receiving the antipsychotic medication haloperidol can experience dystonic reactions, such as tightening of the neck muscles and repetitive uncontrollable extruding of the tongue through the oral cavity. Diphenhydramine and benztropine are used to reverse the dystonic effects of haloperidol.
C. Promethazine is an antihistamine and antiemetic. Promethazine will not reverse the dystonic effects of haloperidol.
D. Ziprasidone is another antipsychotic medication. It is not used to treat the dystonic reaction related to the administration of haloperidol.
Category: Mental Health Emergencies, Homicidal and suicidal ideation
Question 119
What is the most common physical complaint exhibited by children that is symptomatic of both depression and mood disorders?
Recent change in the child’s weight
Increased fatigue
Frequent unexplained “stomach pains”
✓
Changes in sleep
Correct Answer
Frequent unexplained “stomach pains”
A. Complaints of fatigue and changes in sleep patterns may be signs of depression, but the most common physical complaint is stomach pains, followed by a complaint of headaches.
B. Weight loss or gain may be experienced with depression or mood disorders, but the most common physical complaint is stomach pains, followed by a complaint of headaches.
C. Changes in sleep or inability to sleep may be signs of depression, but the most common physical complaint is stomach pains, followed by a complaint of headaches.
D. The most common physical complaint of children being evaluated in the emergency department that is symptomatic of both depression and mood disorders is frequent stomach pains. This is followed by complaints of headaches. A loss of interest in school and poor school performance may also be reported. Parents will often keep their children out of school or have them evaluated by their provider numerous times without physiologic cause of the child’s symptoms.
Category: Mental Health Emergencies, Mood disorders (e.g., bipolar, depression)
Question 120
A patient with a history of bipolar disorder presents with complaints of increased thirst, excessive urination, headache, and vision changes. Which of the following medications is the most likely cause of the patient’s symptoms?
Carbamazepine
Lithium
✓
Haloperidol
Ziprasidone
Correct Answer
Lithium
A. Ziprasidone is a second-generation antipsychotic. Side effects include anticholinergic and extrapyramidal symptoms, but the risk is lower than with the first-generation medications such as haloperidol. Medications in this class can cause QT prolongation and hyperglycemia.
B. Haloperidol is a first-generation antipsychotic. Side effects include the development of anticholinergic effects and extrapyramidal symptoms, including akathisia (increased agitation and restlessness), QT prolongation, and lowering of the seizure threshold.
C. Lithium, a heavy metal and antimanic mood stabilizer, is a medication used for patients with bipolar disorder. Chronic use of this medication can lead to nephrogenic diabetes insipidus. Patients will experience polyuria, dehydration, headaches, vision changes, and, in severe cases, seizures. Hypernatremia, hypercalcemia, and hypokalemia are common electrolyte alterations.
D. Carbamazepine is an antiepileptic medication. Side effects include vision changes, and chronic use can lead to syndrome of inappropriate antidiuretic hormone. Because of the increased release of antidiuretic hormone, water reabsorption is increased. The patient can experience weight gain and dilutional hyponatremia, leading to altered mental status and seizures.
Category: Mental Health Emergencies, Mood disorders (e.g., bipolar, depression)
Question 121
Which of the following diagnostic interventions would have the highest priority for a patient with hemophilia who presents with altered mental status following a fall?
Serum coagulation studies
Arterial blood gas test
Computed tomography (CT) head scan
✓
Cervical spine radiograph
Correct Answer
Computed tomography (CT) head scan
A. Imaging of the cervical spine is indicated in patients who have sustained a fall, but when the patient also has a history of hemophilia and altered mental status, a CT scan of the head to assess for intracranial hemorrhage is the most important diagnostic test. A CT scan of the spine is preferred to plain radiographs in most trauma patients.
B. Serum coagulation studies are indicated in the hemophilic trauma patient; however, when the patient has an altered mental status, a CT scan of the head to assess for intracranial hemorrhage has the highest priority.
C. In the hemophilic trauma patient with altered mental status, a CT scan of the head is the most important diagnostic test to assess for the presence of an intracranial hemorrhage, which is the most common cause of hemorrhage-related death in this population.
D. A blood gas test would help evaluate for the presence of hypoxia as the possible cause of altered mental status in a trauma patient. However, in the hemophilic trauma patient with altered mental status, a CT scan of the head to assess for intracranial hemorrhage has the highest priority.
Category: Medical Emergencies, Hematologic disorders
Question 122
A teenage patient with a history of anxiety was prescribed medication some months ago and now presents with suicidal thoughts. Which of the following medications prescribed for this patient can lead to possible suicidal ideation and actions?
Selective serotonin reuptake inhibitor (SSRI)
✓
Tricyclic antidepressant (TCA)
Beta blocker
Benzodiazepine
Correct Answer
Selective serotonin reuptake inhibitor (SSRI)
A. Benzodiazepines are used to treat acute anxiety; however, they are typically not associated with causing suicidal thoughts in pediatric patients.
B. The beta blocker propranolol (Inderal) is sometimes used to treat anxiety; however, the drug typically does not cause the patient to experience suicidal thoughts. An off-label use for propranolol is the treatment of migraine headaches in children.
C. SSRIs are commonly prescribed for social anxiety disorder and generalized anxiety disorder. SSRIs and serotonin–norepinephrine reuptake inhibitors (SNRIs) have both been found to cause suicidal thoughts and actions, especially in teenagers and young adults, and in patients for whom depression is a comorbid condition. Patients and family members must be informed to watch for signs of suicidal ideation and actions and react immediately if they occur.
D. TCAs are not the first-line treatment for anxiety, but they may be used in place of other treatments that have failed. They are not typically associated with causing suicidal thoughts in pediatric patients.
Category: Mental Health Emergencies, Anxiety disorders (e.g., PTSD, anxiety, panic
Question 123
Which of the following describes acting out the emotions of fear or anger?
Panic
Violence
✓
Paranoia
Anxiety
Correct Answer
Violence
A. Anxiety is the feeling of fear, worry, and apprehension, often accompanied by physical symptoms.
B. Paranoia is the loss of reality through a delusional thought system. The person believes that someone is out to “get” them.
C. Violence is the acting out of the emotions of fear or anger. This behavior is found in individuals who are paranoid, manic, acutely intoxicated, or sociopathic.
D. Panic is the feeling of intense fear, accompanied by chest pain, shortness of breath, dizziness, and other somatic complaints, that often begins without notice.
Category: Mental Health Emergencies, Aggressive and violent behavior
Question 124
An elderly patient presents after being found on the floor for an unknown period. The patient is awake and responsive. Head trauma has been ruled out, and the patient has been diagnosed with rhabdomyolysis. The patient has received a total of 5 L of intravenous crystalloid solution. Which of the following would indicate that the treatment has been effective?
Urine output is 80 mL/hour.
Urine appears clear.
✓
Creatinine clearance is < 25 mL/min.
The urine pH is 6.0.
Correct Answer
Urine appears clear.
A. It is recommended that the urinary output be maintained at 100 mL/hour until myoglobin is cleared.
B. Myoglobin causes the urine to turn dark red or brown. Aggressive fluid resuscitation is necessary to flush out the myoglobin and prevent renal failure.
C. Alkalinization of the urine may help decrease the effects of the myoglobin. The recommended pH level is above 6.5.
D. Normal creatinine clearance ranges from 95 to 150 mL/min. A creatinine clearance level below 10 mL/min indicates moderate renal dysfunction and points to ineffectiveness of treatment.
Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Ligament
Question 125
A patient with an allergic reaction to bee sting is discharged with a prescription for an epinephrine auto injector (EpiPen). Which of the following discharge instructions regarding the use of EpiPen should be provided for this patient?
The EpiPen should be administered at the onset of symptoms following a bee sting, and then the patient should immediately proceed to the nearest emergency department.
✓
The EpiPen should be stored in a safe place at home, so the patient always knows where it is located.
Because the patient has had one severe anaphylactic reaction, they will likely not experience another similar episode.
If symptoms resolve after use of the EpiPen, the patient does not need to seek further care in the emergency department.
Correct Answer
The EpiPen should be administered at the onset of symptoms following a bee sting, and then the patient should immediately proceed to the nearest emergency department.
A. Follow-up in the emergency department is still necessary after using an EpiPen.
B. Anaphylaxis is a life-threatening condition in which the progression of symptoms can occur rapidly. Patients should have the EpiPen with them at all times and should seek follow-up care in the emergency department for further evaluation following its use.
C. The patient should have the EpiPen with them when they are away from home. The patient may experience an allergic reaction away from home and may not have enough time to return home for the EpiPen before allergic symptoms begin to appear.
D. Allergic reactions tend to become more severe with each exposure to the antigen trigger. Therefore, the patient is at risk for a more severe reaction the next time they are stung by a bee.
Category: Medical Emergencies, Allergic reactions and anaphylaxis
Question 126
A patient with a strong smell of alcohol was brought in by emergency medical services after being found “passed out in a park.” The patient’s spouse reports that a large amount of alcohol and sleeping pills were found in the home with a letter telling the family “goodbye” and a will to “get things in order.” Which of the following interventions would be the priority for this patient after medical clearance?
Provide the patient and family with resources for help with alcoholism
Admit the patient to a psychiatric facility
✓
Report the incident to adult protective services
Discharge the patient home with the spouse once they are less intoxicated
Correct Answer
Admit the patient to a psychiatric facility
A. The patient should not be allowed to return home until they are no longer intoxicated and have had a psychiatric evaluation. Returning home at this point could put the patient, the spouse, and others in a dangerous situation.
B. The patient’s history of depression, coupled with their recent actions, strongly indicates that the patient was attempting or planning to attempt suicide in the near future. Heavy alcohol use, risky behavior, giving away personal belongings, saying goodbye to family members, wanting to make a will, stockpiling alcohol and sleeping pills, and the possible suicide note to the spouse all indicate that the patient needs further evaluation and long-term psychiatric treatment.
C. Although alcohol may play a role in the patient’s depression, based on the spouse’s interview, alcohol was not the root cause of the patient’s problems. The patient needs psychiatric treatment for depression and suicidal ideation.
D. Although the patient is making poor decisions, the situation indicates that they are suffering from mental illness rather than incompetence in managing their affairs. Nothing in the situation indicates that the patient’s spouse is an inappropriate caregiver or that there are problems in the home environment. At this time, the patient appears to have an adequate support system but needs psychiatric treatment.
Category: Mental Health Emergencies, Homicidal and suicidal ideation
Question 127
An adolescent with a history of depression presents with numerous deep linear abrasions and scars in various stages of healing on both arms. The patient is quiet, states they feel numb, and denies suicidal thoughts or attempts. The father asks the nurse why his daughter is cutting herself. What is the best explanation for the nurse to provide for this behavior?
“Patients may induce physical pain, which allows them to ‘feel something.’”
✓
“Your daughter is seeking pain medication.”
“When people cut themselves, they are seeking attention.”
“Your daughter attempted suicide by cutting herself.”
Correct Answer
“Patients may induce physical pain, which allows them to ‘feel something.’”
A. The patient has a history of depression and has visible signs of depression while in the emergency department. Self-harm is a behavior closely associated with depression and mental illness, and the behavior should never be ignored.
B. It is important for the patient’s father to understand that the patient’s self-harming behavior is a symptom of her depression. Self-harm, including cutting and burning, is often seen in patients suffering from depression; it is a coping mechanism for their emotional pain, intense anger, and frustration. It is important for the parent to ensure that the patient receives and complies with treatment for her illness. The family should be instructed to return immediately to the emergency department if the patient reports thoughts of suicide, if the patient attempts suicide, or if the patient cutting herself causes a serious injury.
C. Self-harm, such as cutting, is typically not meant as a suicide attempt. Some patients use cutting as a coping mechanism for their depression, but others may escalate their self-harm as their condition worsens. It is important for the patient’s father to be vigilant while monitoring his daughter’s condition and to seek help for any suicidal ideation or attempt immediately.
D. Although some patients do inflict injury on themselves in an attempt to obtain pain medication, this is likely not the case with this patient. The patient has a history of depression and is not reporting pain in the emergency department.
Category: Mental Health Emergencies, Mood disorders (e.g., bipolar, depression)
Question 128
A patient with panic attack presents with hyperventilation and was encouraged by the nurse to use slow and regular breathing. Which of the following interventions would next be most effective is assisting this patient?
Assure the patient that things are going to be OK
Tell the patient that the emergency team is in control, and everything will be fine
Listen to the patient with empathy and concern
✓
Teach the patient the correct way to deal with anxiety
Correct Answer
Listen to the patient with empathy and concern
A. It is important to first build a trusting relationship and acknowledge the patient’s anxiety. The emergency nurse should then help the patient to identify the precipitating event and what previous coping mechanisms have been effective.
B. It is not therapeutic to offer false or excessive reassurance. Instead, the nurse should acknowledge the patient’s anxiety and assure the patient that they are in a safe environment.
C. It is important for the emergency nurse to build a trusting relationship and assure the patient that they are safe.
D. It would be most therapeutic to allow the patient to have some control over the situation and to assist them in identifying the precipitating event and what previous coping mechanisms have been effective. Offering false reassurance is not effective.
Category: Mental Health Emergencies, Anxiety disorders (e.g., PTSD, anxiety, panic
Question 129
Which of the following statements is true regarding posttraumatic stress disorder (PTSD) in the pediatric population?
Children under the age of 3 can exhibit signs of PTSD.
✓
How a parent responds to an infant’s needs after a traumatic event has no effect on the child.
Adolescents are more likely to be affected by PTSD.
School-age children typically have “flashbacks” of the traumatic event.
Correct Answer
Children under the age of 3 can exhibit signs of PTSD.
A. Signs and symptoms of PTSD may occur at any age following a traumatic event. The presentation varies according to developmental age of the child. Children under the age of 3 can experience PTSD, and symptoms in this age group may include inability to soothe, nightmares, sleep disturbances, or regression from previous developmental milestones.
B. This age group may exhibit hypervigilant behavior to prevent another traumatic event. Their recall of the event may not be accurate, but they typically do not experience flashbacks of the actual event.
C. Infants express their unease by crying. The parent comforting the infant can increase the level of attachment that the infant experiences.
D. It is common for adolescent patients to feel anxiety and to be hypervigilant. The adolescent will exhibit symptoms of a stress response, including increased heart rate, sleep disturbances, and frightening thoughts.
Category: Mental Health Emergencies, Situational crisis (e.g., terminal diagnosis,
Question 130
A patient with a primary survey that is within normal limits and no visible acute injury is suspected to be a victim of intimate partner violence. Which of the following is a priority intervention for this patient?
Document the name of the suspected offender in the patient record
Ask hospital security personnel to sit with the patient during the triage interview
Allow the patient to remain dressed in their own clothing during the provider examination
Provide a private area for the assessment interview
✓
Correct Answer
Provide a private area for the assessment interview
A. Bringing security personnel into the triage area may create undue patient anxiety and may call attention to the patient’s situation.
B. Victims of intimate partner violence need to feel safe, and their privacy must be respected. The patient should be moved to a safe and private area to complete the screening and assessment process.
C. Allowing the patient to remain in their own clothing during the provider examination will prevent the inspection of possible hidden injuries. Patients should be instructed to change into a hospital gown for the physical examination.
D. The nurse may document statements made by the patient regarding the offender, but this is a task usually reserved for the police report. The priority is to ensure that the patient feels safe.
Category: Mental Health Emergencies, Aggressive and violent behavior
Question 131
The nurse is caring for a patient with a large pneumothorax, and a chest tube has just been inserted. Which assessment finding would indicate that intervention has been effective?
Increase in heart rate
Absence of fluctuation in water seal chamber
Sucking sound heard with respiration
Decrease in respiratory rate
✓
Correct Answer
Decrease in respiratory rate
A. The presence of a sucking chest sound is an indication of an open pneumothorax. This patient has a closed pneumothorax with a chest tube inserted. In the presence of a closed pneumothorax, a sucking chest sound is an indication of an air leak. It is important to ensure that the dressing is secure around the insertion site and that all chest tube connections are secure. If left untreated, the presence of the sucking chest sound can lead to the development of a tension pneumothorax.
B. With any respiratory difficulty, patients become anxious, tachycardic, and tachypneic. As oxygenation improves, the patient’s heart rate, respiratory rate, and feelings of anxiety should decrease.
C. Water seal level should fluctuate with the patient’s respiration as air escapes from the pneumothorax, resulting in the water seal level rising with inspiration and falling with expiration. This is an indication of chest tube patency and function. Once the affected lung has expanded, this fluctuation will be absent in the water seal chamber.
D. As the pneumothorax resolves, the patient will experience increasing lung capacity with increased gas exchange, resulting in a decrease in the patient’s respiratory rate and effort.
Category: Respiratory Emergencies, Pneumothorax
Question 132
An older adult with dementia is brought to the emergency department by family members who state, “We just can’t handle him at home anymore.” The patient frequently attempts to get out of bed. Which intervention is most appropriate to prevent falls in this patient?
Have family remain with the patient
✓
Place the patient in a vest restraint
Provide the patient with the call light
Place the patient in a geriatric chair near the nurse’s station
Correct Answer
Have family remain with the patient
A. This restraint can be used to prevent falls; however, it can also restrict the patient, creating unneeded distress and agitation. The application of restraints would also require frequent monitoring and restraint documentation.
B. Although this is a best practice, patients with dementia will frequently forget to use the call light, and they may try to get out of the emergency gurney or bed and potentially fall.
C. Family are known faces to this patient. They can remain at bedside and remind the patient to ask for assistance to get out of bed or notify staff if he has any needs.
D. A geriatric (Geri) chair can be used to prevent falls; however, it can also restrict the patient, creating distress and agitation, and a patient placed in a Geri chair would require restraint monitoring. In addition, the emergency nursing station is busy and noisy, potentially leading to a further increase in the patient’s confusion and agitation.
Category: Professional Issues, Patient, Patient safety
Question 133
The emergency nurse understands that the purpose of the Glasgow Coma Scale (GCS) is to:
assess the level of consciousness in all patients.
assess the level of consciousness in head-injured patients.
✓
allow the provider to predict outcomes for the trauma patient.
identify interventions to improve outcomes for unconscious patients.
Correct Answer
assess the level of consciousness in head-injured patients.
A. The GCS assesses level of consciousness and severity of brain injury in patients with a head injury. The GCS further provides assessment data, which allows for early identification of neurological changes, thereby facilitating prompt interventions; it does not predict patient outcomes.
B. The GCS assesses level of consciousness and severity of brain injury in patients who have sustained a head injury. The GCS is not used to assess level of consciousness in all patients.
C. The GCS assesses level of consciousness and severity of brain injury in patients with a head injury. The GCS further provides assessment data, which allows for early identification of neurological changes, thereby facilitating prompt interventions. The GCS does not identify the interventions that need to be performed.
D. The GCS assesses level of consciousness and severity of brain injury in patients with a head injury. The GCS further provides assessment data, which allows for early identification of neurological changes, thereby facilitating prompt interventions. The GCS is the gold standard of neurological assessment for head-injured patients.
Category: Neurological Emergencies, Head and spinal cord trauma
Question 134
The emergency nurse is preparing to administer intranasal midazolam to a patient in status epilepticus. The nurse is aware of which of the following regarding intranasal administration of midazolam?
The dose should only be given in one nostril.
Onset of the drug action may be delayed compared to other routes.
✓
The drug rapidly crosses the blood–brain barrier.
Peak effects are seen in a similar time frame to intramuscular doses.
Correct Answer
Onset of the drug action may be delayed compared to other routes.
A. The administration of medications via nasal, buccal, rectal, and oral routes requires the medication to enter the enteric circulation, where the drug is metabolized by the liver before reaching the systemic circulation; this results in a delay in the onset of action.
B. The intramuscular route bypasses the liver metabolism; therefore, the onset of action will be faster than the intranasal route. Peak time frame for intranasal effects is 30–120 minutes, while that for intramuscular effects is 15–30 minutes.
C. All benzodiazepines cross the blood–brain barrier, but only after they have reached the systemic circulation.
D. It is important to split the dose between the two nostrils, with half being administered in each. The maximum amount that can be administered in each nostril is 1 mL.
Category: Neurological Emergencies, Seizure disorders
Question 135
The emergency nurse is caring for a patient with a confirmed subarachnoid hemorrhage. When reviewing the patient’s history and assessment, the nurse would expect to find:
an insidious onset of headache with progressive worsening.
a sudden, brief loss of consciousness followed by a period of lucidity.
a report of a recent traumatic injury to the head.
a report of the worst headache of the patient’s life.
✓
Correct Answer
a report of the worst headache of the patient’s life.
A. A report of a recent traumatic injury to the head is most consistent with an epidural hematoma or subdural hematoma. The most common cause of a subarachnoid hemorrhage is an aneurysm rupture, not a traumatic head injury.
B. A sudden loss of consciousness followed by a period of lucidity is most consistent with an epidural hematoma.
C. An insidious onset of headache with progressive worsening is most consistent with a subdural hematoma.
D. The patient’s report of the “worst headache of my life” would be the most likely presenting complaint associated with a subarachnoid hemorrhage. The headache associated with a subarachnoid hemorrhage is typically described as a sudden, severe onset and is commonly referred to as the “thunderclap” headache.
Category: Neurological Emergencies, Headache (e.g., temporal arteritis, migraine)
Question 136
A patient presents complaining of a headache since yesterday after being tackled and kicked in the head during a football game. During evaluation of the patient, which of the following would indicate to the nurse the need for a computed tomography (CT) scan of the head?
Intermittent amnesia of the event
Glasgow Coma Scale (GCS) score of 13
✓
Continued report of a headache
Presence of cervical spine pain
Correct Answer
Glasgow Coma Scale (GCS) score of 13
A. A patient with cervical spine pain would require a CT scan of the cervical spine, but not a head CT scan.
B. CT scan of the head is indicated in any patient with suspected minor traumatic brain injury with the following: GCS score is < 15 two hours after the event, suspected skull fracture, repeated episodes of vomiting, older than 65 years of age, drug/alcohol intoxication, or persistent anterograde amnesia. In addition, if the mechanism of injury is significant, a headache may persist for a few days to weeks post-concussion. Amnesia may be present for 24–48 hours after the event.
C. CT scan of the head is indicated in any patient with suspected concussion with the following: GCS score is < 15 two hours after the event, suspected skull fracture, repeated episodes of vomiting, older than 65 years of age, drug/alcohol intoxication, or persistent anterograde amnesia. In addition, if the mechanism of injury is significant, a headache may persist for a few days to weeks post-concussion. Amnesia may be present for 24–48 hours after the event.
D. A patient with intermittent amnesia would require reorientation and observation. Amnesia may be present for 24–48 hours after the event.
Category: Neurological Emergencies, Neurogenic shock
Question 137
A patient presents with shortness of breath. Physical assessment reveals an S 3 heart sound and auscultated bilateral crackles. The nurse suspects:
pulmonary embolism.
left-sided heart failure.
✓
pneumonia.
right-sided heart failure.
Correct Answer
left-sided heart failure.
A. Right-sided heart failure signs and symptoms include peripheral edema, jugular venous distention, ascites, and nausea due to venous congestion.
B. Signs of left-sided heart failure include shortness of breath, dyspnea, an S 3 heart sound (gallop), crackles, and pulmonary edema.
C. Signs and symptoms of pneumonia can include dyspnea, cough, wheezing, pleuritic chest pain, and coldlike symptoms.
D. Signs and symptoms of pulmonary embolism can include dyspnea with tachypnea and possible hemoptysis, pleuritic chest pain, tachycardia, anxiety, apprehension, restlessness, pleural friction rub, and clinical signs and symptoms of deep vein thrombosis.
Category: Cardiovascular Emergencies, Heart failure
Question 138
An unrestrained driver in a motor vehicle accident presents agitated and complaining of sternal pain to palpation, although no crepitus is present. Vital signs are BP 88/62 mm Hg with the presence of a pulsus paradoxus of 15 mm Hg, HR 86 beats/minute, RR 28 breaths/minute with equal breath sounds bilaterally. What is the priority intervention based on these assessment findings?
Pericardiocentesis
✓
Needle thoracentesis
Endotracheal intubation
Bolus of 100 mL warm 0.9% sodium chloride
Correct Answer
Pericardiocentesis
A. Needle thoracentesis is used to relieve a tension pneumothorax, not a cardiac tamponade. The patient has equal breath sounds bilaterally.
B. Blunt chest trauma, especially in the geriatric population, puts the patient at greater risk of developing a pericardial effusion and tamponade. The lack of a seat or shoulder restraint places the patient at risk of striking their sternum against the steering column. Signs and symptoms can include Beck triad (hypotension, JVD, muffled heart sounds), chest pain, dyspnea, and pulsus paradoxus of 10 mm Hg or more. Treatment for patients in extremis is needle pericardiocentesis to relieve the pressure on the heart.
C. The patient’s hypotension is most likely related to the presence of a cardiac tamponade, not hypovolemia. Administration of intravenous fluids will improve cardiac output temporarily, but more than 100 mL will most likely be required because of the hypotension. Aggressive intravascular volume expansion with fluid or blood is recommended.
D. The patient does not exhibit any need for airway control or endotracheal intubation. The priority intervention is to perform a needle pericardiocentesis to relieve the patient’s cardiac tamponade.
Category: Cardiovascular Emergencies, Pericardial tamponade
Question 139
A patient presents with intense pain in their lower abdomen. The patient states it started as a mild ache but has become more severe over the past week. Assessment reveals diffuse abdominal guarding with rebound tenderness and decreased bowel sounds. Computed tomography of the abdomen shows the presence of free air within the peritoneal cavity. The nurse suspects which of the following conditions?
Perforation of bowel
✓
Abdominal aortic aneurysm
Appendicitis
Small bowel obstruction
Correct Answer
Perforation of bowel
A. An aneurysm is caused by a weakening in the arterial wall, resulting in a dilated area of the artery. Pain may be deep and constant, with radiation to the back. A pulsatile mass may be felt in the abdominal area.
B. Gastrointestinal perforation is a full-thickness loss of bowel wall integrity that results in perforation; the most common cause of perforation is a duodenal ulcer. Patients typically present with an acute onset of severe abdominal pain associated with nausea, vomiting, and fever. Peritoneal irritation is found on exam with decreased bowel sounds and diffuse or localized abdominal guarding.
C. Appendicitis is caused by an obstruction and distention of the lumen of the appendix, resulting in ischemia and bacterial invasion of the appendix. Pain is initially dull, and there is pain with movement.
D. A small bowel obstruction can result from either a twisting of the bowel or a mechanical obstruction; the patient experiences cramping and severe bloating because the bowel is unable to move contents forward.
Category: Gastrointestinal, Genitourinary, Gynecology, and
Question 140
The emergency nurse is caring for a patient with increased intracranial pressure following a traumatic brain injury. Which of the following vital signs should the nurse immediately report to the physician?
Temperature of 37.5°C (99.5° F)
Heart rate of 94 beats/minute
Mean arterial pressure of 50 mm Hg
✓
Capnography of 35 mm Hg
Correct Answer
Mean arterial pressure of 50 mm Hg
A. This heart rate is within normal physiological parameters.
B. Target temperature for patients with a traumatic brain injury is 36°F (96.8°F) to 38°C (100.4°F). Temperatures above this range should be reported to the physician.
C. This is a normal reading indicating adequate respiratory effort and gas exchange.
D. Cerebral blood flow can be maintained via autoregulation mechanisms when the mean arterial pressure is between 60 mm Hg and 140 mm Hg. A mean arterial pressure of 50 indicates that the brain is not receiving adequate perfusion.
Category: Neurological Emergencies, Head and spinal cord trauma
Question 141
Which of the following laboratory test results would best indicate improvement in a patient with a snakebite?
Increased creatinine
Increased prothrombin time (PT)
Increased platelet count
✓
Increased international normalized ratio (INR)
Correct Answer
Increased platelet count
A. An increased INR would indicate bleeding potential for a patient. A decreased INR would indicate improvement in a patient being treated for snakebite.
B. An increased PT, as well as increased INR, would indicate potential for bleeding. A decrease in this laboratory test would demonstrate improvement.
C. Rhabdomyolysis is a potential threat with snakebites. Renal injury is a common outcome for rhabdomyolysis. Therefore, an increasing creatinine level would not indicate improvement, but rather a disease process.
D. Snakebites can cause hemotoxic issues with coagulopathies. It would be important to watch laboratory values that would indicate improvement, such as an increased platelet count; increased fibrinogen; decreased INR, partial thromboplastin time, and PT; and a normal or decreasing creatinine level, because rhabdomyolysis is also a potential problem.
Category: Environment and Toxicology Emergencies, and Communicable
Question 142
Which of the following manifestations would be expected in a patient with a near-drowning event?
Hyperthermia
Increased intracranial pressure
✓
Respiratory acidosis
Increased lung compliance
Correct Answer
Increased intracranial pressure
A. Hypoxia associated with near drowning will cause cerebral edema, leading to an increase in intracranial pressure.
B. Metabolic acidosis would be expected in a near-drowning victim, not respiratory acidosis.
C. The presence of hypothermia might be present in a near-drowning victim, but not hyperthermia.
D. Water in the alveoli can damage the alveolar-capillary membrane and lead to decreased lung compliance.
Category: Environment and Toxicology Emergencies, and Communicable
Question 143
Research has demonstrated that patients who report satisfaction with the care they received in an emergency department (ED) are more likely to perform which of the following actions?
Use the ED as a source for primary care
Adhere to their treatment plan
✓
Frequently return to the ED
Require hospital admission
Correct Answer
Adhere to their treatment plan
A. Patients who report satisfaction with their care are more likely to adhere to their discharge instructions, including follow-up and home care interventions.
B. Use of the ED as a provider of primary care is more closely associated with ease of access than satisfaction with a previous experience.
C. The majority of healthcare surveys are sent to a random population of individuals who were seen in the ED within a particular period of time. Most do not differentiate between patients who were admitted to the hospital and those who were discharged.
D. Patients who report satisfaction with the care they received in the ED are found to be more likely to follow their treatment plan and experience improved outcomes.
Category: Professional Issues, Patient, Patient satisfaction
Question 144
Damage control resuscitation (DCR) is a principle of treating hemorrhage that focuses on prevention of shock rather than intervention after it develops. Which of the following interventions is part of the strategy of DCR?
Administration of idarucizumab (Praxbind)
Administration of vitamin K intramuscularly
Rapid infusion of isotonic crystalloid
Providing component therapy
✓
Correct Answer
Providing component therapy
A. Rapid infusion of isotonic crystalloid leads to excessive volumes of crystalloid, resulting in hemodilution, with fewer circulating red blood cells to carry oxygen; worsening acidosis; increased inflammatory response; and increased mortality. It is not damage control resuscitation.
B. Damage control resuscitation includes two strategies to prevent shock: hypotensive resuscitation and hemostatic resuscitation. Vitamin K might be administered, but it should not be given intramuscularly in this situation.
C. Goal-directed therapy is to optimize oxygenation and perfusion by preventing further losses through hemodilutional coagulopathy. Excessive use of isotonic crystalloids or replacement of whole blood loss with only packed red blood cells can produce a hemodilutional coagulopathy in which both platelets and clotting factors are significantly reduced. Hemorrhage control is optimized by giving component therapy using both packed red blood cells and frozen plasma at a 1:1 ratio. Platelets are added for a 1:1:1 ratio, resulting in a hemostatic resuscitation.
D. Damage control resuscitation includes two strategies to prevent shock: hypotensive resuscitation and hemostatic resuscitation. Idarucizumab (Praxbind) is a reversal agent for the anticoagulant dabigatran (Pradaxa); it is not included in either strategy unless the patient is found to be on that medication.
Category: Cardiovascular Emergencies, Cardiovascular trauma
Question 145
A patient is exhibiting signs and symptoms of Cushing reflex/Cushing response. The nurse would expect to see which of the following changes in vital signs?
Narrowing pulse pressure
Irregular respirations
✓
Tachycardia
Hypotension
Correct Answer
Irregular respirations
A. Widening pulse pressure, not narrowing pulse pressure, is a sign of increased intracranial pressure. The three components of Cushing’s triad are (1) bradycardia, (2) widening pulse pressure because of a rise in the systolic blood pressure, and (3) irregular or absent respirations.
B. Hypotension is not associated with the presence of Cushing’s triad. Components of Cushing’s triad are (1) bradycardia, (2) widening pulse pressure because of a rise in the systolic blood pressure, and (3) irregular or absent respirations.
C. Bradycardia, not tachycardia, is a late sign of increased intracranial pressure. Components of Cushing’s triad are (1) bradycardia, (2) widening pulse pressure because of a rise in the systolic blood pressure, and (3) irregular or absent respirations.
D. Late signs of intracranial pressure include the presence of Cushing’s triad: (1) bradycardia, (2) widening pulse pressure because of a rise in the systolic blood pressure, and (3) irregular or absent respirations.
Category: Neurological Emergencies, Increased intracranial pressure (ICP)
Question 146
A patient presents following an all-terrain vehicle collision. During the neurological assessment, the nurse notes motor paralysis and a loss of pain and temperature sensation below the level of T2. However, proprioception and vibratory sense are preserved. What is the most likely spinal cord injury associated with this clinical presentation?
Central cord syndrome
Posterior cord syndrome
Brown–Séquard syndrome
Anterior cord syndrome
✓
Correct Answer
Anterior cord syndrome
A. A diagnosis of anterior cord syndrome is consistent with motor paralysis and a loss of pain and temperature sensation below the level of the injury, with a preservation of proprioception, touch, and vibratory sense.
B. Brown–Séquard syndrome is consistent with hemiparaplegia (weakness or paralysis) on the same side as the cord injury, and hemianesthesia (loss of sensation) on the opposite side of the cord injury but below the level of injury.
C. Posterior cord syndrome is consistent with preserved motor function below the level of the injury, with a loss of sensory function.
D. Central cord syndrome results from a cervical spine injury and is consistent with more pronounced motor impairment in the upper body, as compared with the lower body, with variable sensory loss below the level of the injury.
Category: Neurological Emergencies, Head and spinal cord trauma
Question 147
An older adult patient arrives via emergency medical services with a history of a “brain shunt” and contractures. Recent history indicates that the patient is “less interactive than usual,” has been “sleepy,” and has had no bowel movement for 3 days. The computed tomography scan exam reveals evidence of hydrocephalus, and the abdominal radiograph shows a large amount of feces, causing the ventriculoperitoneal (VP) shunt to kink. The emergency nurse anticipates which intervention for this patient?
An enema to clear feces from the bowel
✓
Immediate transfer of the patient to an ICU
Performing a digital rectal exam
Preparing the patient for surgery to replace the shunt
Correct Answer
An enema to clear feces from the bowel
A. Severe constipation can cause bowel edema, which can result in an occlusion, or kink, forming in the bowel, resulting in a blockage of the VP shunt. The subsequent VP shunt blockage can result in hydrocephalus, leading the patient to demonstrate signs of increased intracranial pressure, including an altered level of consciousness.
B. This action does not address the problem of the patient’s nonfunctioning VP shunt; it merely transfers the patient to another location.
C. Replacement of the shunt will correct the problem but will not address the underlying pathophysiology of excessive feces in the bowel.
D. A digital rectal exam may be used to determine if there is a fecal impaction; however, performing a manual disimpaction will not address the problem of profound constipation, nor will it address the issue of the kink in the VP shunt.
Category: Neurological Emergencies, Increased intracranial pressure (ICP)
Question 148
During the implementation of the massive transfusion protocol (MTP), the nurse should observe for which of the following?
Acidosis
Hypercoagulopathy
Hypokalemia
Hypocalcemia
✓
Correct Answer
Hypocalcemia
A. Potassium levels can increase during long-term storage of blood, potentially causing hyperkalemia during massive transfusion.
B. Banked blood products contain the anticoagulant citrate. Citrate prevents clotting by binding to calcium, which may result in hypocalcemia. During MTP, replacement calcium, such as calcium gluconate or calcium chloride, should be considered.
C. The anticoagulant citrate is converted by the liver to bicarbonate, resulting in alkalosis. Citrate is used in banked blood to prevent clotting, so the patient’s arterial pH should be monitored during implementation of MTP to assess for alkalosis.
D. Massive transfusion should follow a balanced approach, giving packed red blood cells along with platelets and fresh frozen plasma, so clotting factors should remain stable.
Category: Medical Emergencies, Hypovolemic and distributive shock
Question 149
Nitroprusside is ordered for a patient with a hypertensive emergency. This medication works to reduce blood pressure by:
selectively dilating arterioles.
relaxing vascular smooth muscle.
✓
decreasing heart rate.
inhibiting the influx of calcium ions.
Correct Answer
relaxing vascular smooth muscle.
A. A nonselective beta blocker such as labetalol (Normodyne) reduces blood pressure by inhibiting alpha and beta receptors, causing both vasodilation and reduction of the sympathetic stimulation of the heart. Nitroprusside is a vasodilator, not a beta blocker, and does not block the beta receptors in the heart that cause a decrease in heart rate.
B. Nitroprusside is a vasodilator and does not inhibit the influx of calcium ions. A calcium channel blocker such as clevidipine (Cleviprex) works to reduce blood pressure by inhibiting the transmembrane influx of extracellular calcium ions across membranes of myocardial cells and vascular smooth muscle cells without changing serum calcium concentrations. This results in inhibition of cardiac and vascular smooth muscle contraction, thereby dilating main coronary and systemic arteries.
C. Nitroprusside is a vasodilator that works to reduce blood pressure by relaxing vascular smooth muscle, which reduces afterload and preload by producing nitrous oxide. It also dilates coronary arteries. Nitroprusside should be protected from light during administration.
D. Nitroprusside is a vasodilator that works on arteries and veins equally. A vasodilator such as hydralazine (Apresoline) works by dilating arterioles with little effect on veins. It also decreases systemic resistance.
Category: Cardiovascular Emergencies, Hypertension
Question 150
A nurse has an order to administer morphine sulfate to a patient with acute anterior myocardial infarction (MI). The nurse understands that the rationale for administering morphine sulfate to this patient is that it:
decreases vasospasm.
decreases catecholamine release.
✓
constricts coronary vessels.
increases absorption of antiplatelet medications.
Correct Answer
decreases catecholamine release.
A. Morphine and nitroglycerin dilate coronary vessels to increase myocardial oxygen supply.
B. Morphine can decrease the absorption of antiplatelet medications such as clopidogrel used in the treatment of acute coronary syndromes.
C. Morphine can cause spasms of the sphincter of Oddi and the sphincter of the urinary bladder but has minimal effect on coronary vessel vasomotor tone.
D. Morphine sulfate is the analgesic of choice for chest pain in acute MI. Morphine decreases catecholamine release via pain relief, resulting in a decrease in heart rate and afterload. This causes a decrease in myocardial oxygen demand, which may reduce the size of the MI. Also, morphine reduces preload and should be used cautiously in inferior and right ventricular MI because of the risk of severe hypotension.
Category: Cardiovascular Emergencies, Acute coronary syndrome