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CEN ENA Exam 1

Multiple Choice 175 questions Medicine & Health Sciences > Emergency Nursing by Sean Valentine
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Multiple Choice (175)

Question 1
Which of the following is an indirect cause in the development of acute respiratory distress syndrome (ARDS)?
  • Sepsis ✓
  • Near-drowning
  • Oxygen toxicity
  • Pulmonary edema
Correct Answer
Sepsis
A. Pulmonary edema is a consequence, not a cause, of increased permeability of the alveolar–capillary barrier, allowing fluid to pass into the alveoli. B. Submersion injury can directly alter surfactant function, resulting in impaired gas exchange. C. ARDS is a complication of a systemic infection. Conditions such as sepsis and pancreatitis can lead to higher incidence of ARDS, making them indirect causes of ARDS. Other indirect pulmonary assaults include eclampsia, shock, massive blood transfusion, anaphylaxis, uremia, and disseminated intravascular coagulation. D. High levels of oxygen can cause direct injury to alveoli. Category: Respiratory Emergencies, Respiratory distress syndrome
Question 2
Which patient presenting to the emergency department with a chief complaint of moderate to severe headache would most likely require emergent intracranial imaging?
  • History of ventriculoperitoneal shunt ✓
  • Lumbar puncture performed one day ago
  • New onset of insomnia
  • History of trigeminal neuralgia
Correct Answer
History of ventriculoperitoneal shunt
A. Any patient who presents with symptoms of a headache and has a ventriculoperitoneal shunt should have a CT scan of the head to rule out hydrocephalus and shunt malfunction. B. Though it can be painful, trigeminal neuralgia is considered a nonemergency cause of headache. Initial treatment is focused on pain relief. If imaging is required, MRI is usually recommended. C. Insomnia is considered a nonemergent cause of headaches and usually does not require emergent imaging. D. Headache after a lumbar puncture is not uncommon and is considered a nonemergent cause of headaches. Category: Neurological Emergencies, Headache (e.g., temporal arteritis, migraine)
Question 3
A 6-week-pregnant patient presents with an incomplete spontaneous abortion. An important pharmacological consideration is the administration of Rho (D) immune globulin, based on which criteria?
  • A mother who has a blood type that is Rh positive
  • A fetus that has a blood type that is Rh(D) negative
  • A father who has a blood type that is Rh(D) negative
  • A mother who has a blood type that is Rh(D) negative ✓
Correct Answer
A mother who has a blood type that is Rh(D) negative
A. Rh incompatibility occurs between the mother and the fetus. The decision to administer Rho (D) immune globulin is based on the Rh compatibility between the mother and fetus only. B. Rho (D) immune globulin is given to prevent the Rh-negative mother from forming antibodies against an Rh-positive fetus. Rh status is only a problem when the mother is Rh negative and the fetus is Rh positive. C. Rho (D) immune globulin is indicated to prevent the blood of the Rh-negative mother from forming antibodies that will attack the blood of an Rh-positive fetus. The decision to immunize a mother is based on the Rh status of the mother, not that of the fetus. D. All women who have a blood type of Rh(D) negative who are diagnosed with an early pregnancy loss and have not been sensitized should receive Rho (D) immune globulin Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Obstetrical, Threatened/spontaneous abortion
Question 4
Which treatment is appropriate for a patient with large thrombotic stroke (NIHSS >15) whose symptoms began 6 hours ago?
  • Administer four tablets of 81 mg aspirin, requesting that the patient chew them first, then swallow
  • Administration of corticosteroids to reduce cerebral swelling
  • Rapid expert consultation for possible mechanical thrombectomy ✓
  • Administer alteplase 0.9 mg/kg intravenously over 60 minutes, with 10% given as a bolus over 1 minute
Correct Answer
Rapid expert consultation for possible mechanical thrombectomy
A. Alteplase cannot be given to patients whose symptoms began more than 4.5 hours ago because of increased risk of intracerebral hemorrhage. B. Patients whose symptoms began within the previous 24 hours and present with NIHSS 15 or greater should be evaluated for large vessel occlusion and treated with mechanical thrombectomy unless contraindicated. C. Aspirin should not be given to someone with a large stroke because of increased risk of aspiration. D. Corticosteroids are not an evidence-based treatment for stroke. Category: Neurological Emergencies, Stroke
Question 5
What immunization can be given to prevent respiratory syncytial virus (RSV) in high-risk patients?
  • Influenza
  • Palivizumab ✓
  • Haemophilus influenzae type b (Hib)
  • Diphtheria, tetanus, and pertussis (DTaP)
Correct Answer
Palivizumab
A. The Hib vaccine prevents serious infections caused by Haemophilus influenzae type b virus, including meningitis, pneumonia, and epiglottitis. The Hib vaccine is recommended for all children under 5 years old in the United States, and it is usually given to infants starting when they are 2 months old. B. DTaP is used to reduce the risk of developing diphtheria, tetanus, and pertussis. This vaccine is not given to prevent RSV. C. Palivizumab reduces the seriousness of lower respiratory tract infections caused by RSV in high-risk children with lung or heart disease or who were premature at birth. Palivizumab is a monoclonal antibody that is administered in five monthly doses during RSV season. D. Although most persons who become infected with influenza viruses will recover without sequelae, influenza can cause serious illness and death, particularly among older adults, very young children, pregnant women, and those with chronic medical conditions. Routine annual influenza vaccination is recommended for all persons aged ≥ 6 months who do not have contraindications. Category: Respiratory Emergencies, Infections
Question 6
A patient sustained an injury to their right ankle that occurred while running. Radiograph reveals an avulsion fracture of the patient’s distal tibia. The nurse is aware that the most appropriate treatment for this injury would be:
  • active range-of-motion exercises and weight-bearing.
  • warm soaks to the extremity 3 times a day.
  • application of an external fixator device.
  • the application of a splint. ✓
Correct Answer
the application of a splint.
A. An avulsion fracture involves the pulling away of a fragment of bone that is connected to the ligament. These injuries require a splint to align and immobilize the injured area, allowing it to heal. Additional treatment for the patient with simple sprains, strains, and fractures is the acronym RICE, which stands for rest, ice, compression (elastic bandage), and elevation. B. Initial treatment would include the application of ice at 20-minute intervals 3–4 times daily. Ice should never be placed directly on the skin. C. The patient’s ability to tolerate full range of motion and/or immediate weight-bearing will depend on the patient’s pain level and severity of injury; therefore, the injury should be treated with a splint. D. The injury does not warrant the application of an external fixator device. An avulsion fracture of the distal fibula can be adequately treated with the application of a splint, which includes immobilizing the joint above and below the area of injury. Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Fractures (e.g., open, closed, fat embolus)
Question 7
A patient sustained a fall that resulted in impalement of a large object into their leg. There is minimal bleeding from the wound. Vital signs are stable. Fluids are infusing via two large-caliber intravenous lines. What is the most appropriate intervention for the emergency nurse to perform?
  • Remove the impaled object
  • Apply a tourniquet above the site of the object
  • Prepare for moderate sedation
  • Prepare the patient to go to surgery ✓
Correct Answer
Prepare the patient to go to surgery
A. Large, impaled objects are typically removed in the operating room so that damage to any underlying structures can be immediately repaired. B. Large, impaled objects should only be removed in the operating room and only after the underlying structures have been adequately assessed. The object may be providing hemostasis to an area, and early removal can result in uncontrolled hemorrhage. C. A tourniquet to the site above the object would not be appropriate unless uncontrolled hemorrhage was present. D. Large, impaled objects are typically removed in the operating room so that damage to underlying structures can be repaired; therefore, preparation for moderate sedation for bedside removal of object or wound care is not necessary. Category: Musculoskeletal and Wound Emergencies, Wound, Penetrating injuries (e.g., guns, nail guns)
Question 8
The family of a critically ill, unresponsive patient disagrees with the patient’s advance directive, which states that no extraordinary measures should be taken in the event of an irreversible coma. The family requests that everything be done to sustain the patient’s life. The best action by the nurse would be to:
  • advise the family that the hospital is obligated to honor the advance directive. ✓
  • request a physician order to override the advance directive.
  • inform the family that they need to obtain a court order to overrule the advance directive.
  • acknowledge the family request and agree to aggressive treatments.
Correct Answer
advise the family that the hospital is obligated to honor the advance directive.
A. Individuals have the right to determine in advance what medical treatment they do or do not want in the event that they are not able to make the decisions at the time. Advance directives become part of the patient’s permanent record. No one should have the power to overrule the decisions of the individual. B. The advance directive must be honored. The advance directive is based on the concept that the person was competent at the time of completing the directive, and the individual has the right to refuse treatment. C. The advance directive overrides other family members’ wishes. If the family members choose to challenge the current decisions, they can go to court to seek guardianship. Although this is a possibility, the best action at this time is to inform the family that we must honor the advance directive. D. The physician order cannot overrule what a competent individual has indicated in their advance directive. Category: Professional Issues, Patient, End-of-life and Palliative Care (e.g., organ and tissue donation, advance directives, care withholding, family presence)
Question 9
Following the traumatic death of a child, the nurse manager arranges for a critical incident stress management debriefing session. Which individuals should be welcomed to attend?
  • Parents of the victim
  • Any staff member who was involved in the care ✓
  • Hospital legal counsel and Child Protective Services
  • Only the physicians and nurses who were involved
Correct Answer
Any staff member who was involved in the care
A. All team members who actively participated in the event should be invited to attend. B. In addition to the physicians and nurses, other care providers who were involved in the event, such as prehospital personnel, respiratory therapists, radiologic technicians, and pharmacists, should be welcomed to participate in the debriefing sessions. C. Unless actively involved in the event, the hospital legal counsel and representatives from Child Protective Services should not attend a debriefing session. D. The debriefing group should be homogenous and consist of individuals who share involvement in the event. Family members of the victim may need similar services, but they should not participate in the hospital-based critical incident stress management. Category: Professional Issues, Nurse, Stress management (e.g., burnout, compassion fatigue, PTSD)
Question 10
A 30-week-gestation patient has a suspected abdominal injury. What diagnostic test would the nurse anticipate to assess for intra-abdominal injury?
  • Diagnostic peritoneal lavage
  • Focused assessment with sonography ✓
  • Computed tomography (CT) scan
  • Complete blood count
Correct Answer
Focused assessment with sonography
A. Complete blood count is an accurate indicator of blood loss, but it takes time to obtain results that accurately reflect blood loss. B. Ultrasonography is a noninvasive means of determining intra-abdominal injury and fetal status. C. Although diagnostic peritoneal lavage is considered safe for the pregnant trauma patient, it is not often used because it does not assess retroperitoneal or intrauterine injury. D. A CT scan exposes the fetus to radiation, so the use of CT is reserved for patients who have positive findings on ultrasound assessment. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Obstetrical, Obstetric Trauma
Question 11
A patient complains of fever, abrupt visual disturbance of their right eye, and a right-side headache rated as a 10/10. The pain is throbbing and worsens when the patient opens their mouth. These symptoms are most consistent with which of the following?
  • Acute glaucoma
  • Trigeminal neuralgia
  • Temporal arteritis ✓
  • Retinal detachment
Correct Answer
Temporal arteritis
A. Acute angle-closure glaucoma presents with severe eye pain, diminished peripheral vision, nausea, and vomiting. B. The trigeminal nerve innervates the forehead, cheek, and jaw skin. Facial pain follows the trigeminal nerve pathway. C. A patient with retinal detachment will complain of flashing lights, floaters, or a veil coming down on the eye. Retinal detachment is not associated with the presence of a headache or pain with chewing. D. The symptoms of temporal arteritis can include fever, sudden visual disturbance or permanent loss of vision in one eye, a throbbing headache that is usually in the temples, and jaw pain that sometimes occurs with chewing. Category: Neurological Emergencies, Headache (e.g., temporal arteritis, migraine)
Question 12
A patient with a history of alcoholism is accompanied by family, who report finding the patient confused and disoriented. On assessment, the patient’s abdomen is distended, sclera are yellow, and the patient is becoming more difficult to arouse. Which of the following options is the priority intervention for this patient?
  • Prepare to intubate the patient ✓
  • Draw laboratory specimens
  • Insert a urinary drainage catheter
  • Insert a gastric drainage tube
Correct Answer
Prepare to intubate the patient
A. Laboratory specimens would have significant value in the total picture of patient care, however, it is not the highest priority in this case. Adequate oxygenation and ventilation, along with preservation of a patent airway, is the most emergent need for this patient. B. Based on presentation, this patient most likely has cirrhosis with hepatic encephalopathy. No matter the cause, for any patient who has a decrease in mentation, becomes more difficult to arouse, or in any way cannot maintain or protect their own airway, intubation with mechanical ventilation should be considered the top priority. Adequate oxygenation and ventilation are imperative. C. A urinary drainage catheter will need to be inserted to monitor the patient’s intake and output; however, the priority is to maintain a patent airway. D. Maintaining an airway is the highest priority for this patient. Insertion of a gastric tube may be indicated after intubation, but the abdominal distention is most likely due to ascites, and the gastric tube will not help that. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Cirrhosis
Question 13
An emergency nurse is caring for a patient who reports weakness in the lower extremities that has worsened over the past week. The patient reports recent influenza infection. What intervention should be the emergency nurse’s priority?
  • Prepare for lumbar puncture
  • Initiate droplet precautions
  • Monitor respiratory function ✓
  • Initiate fall precautions
Correct Answer
Monitor respiratory function
A. Droplet precautions are indicated for active influenza-like illnesses, but the priority is to monitor the respiratory status. The patient reported a recent influenza infection, not active infection. B. Fall precautions are indicated because of progressive muscle weakness, but respiratory status is the higher priority. Reference Ledford, L. (2020). Neurologic emergencies. In V. Sweet & C. There is a risk of Guillain–Barré syndrome (GBS) following various respiratory or gastrointestinal infections. The priority is to monitor the respiratory function and maintain respirations. The hallmark symptom of GBS is symmetric, progressive weakness, along with depressed or absent deep tendon reflexes usually ascending from the legs. Mechanical ventilation will be required in 20–30% of patients. D. There may be elevated protein levels in the cerebral spinal fluid 1 week after symptom onset, but the priority is maintenance of respirations because of the risk of respiratory muscle weakness. Category: Neurological Emergencies, Neurological disorders (e.g., multiple sclerosis, myasthenia gravis, Guillain-Barré syndrome)
Question 14
In caring for a patient diagnosed with a transient ischemic attack (TIA), the emergency nurse should anticipate an order for which medication?
  • Acetylsalicylic acid (aspirin) ✓
  • Furosemide (Lasix)
  • Alteplase (Activase)
  • Nimodipine (Nimotop)
Correct Answer
Acetylsalicylic acid (aspirin)
A. Nimodipine is a calcium channel blocker used to reduce vasospasm in patients who have experienced a subarachnoid hemorrhage; it is not indicated in the treatment of a TIA. B. Diuretics such as furosemide are not indicated in the treatment of patients who have experienced a TIA. C. Up to 10% of patients experiencing TIA will have a stroke within 2 days, and up to 20% who experience a TIA will have a stroke within 90 days. Low-dose aspirin is an antiplatelet agent used to reduce the risk for stroke. D. Alteplase is administered to patients with acute ischemic stroke but not to patients who have experienced a TIA. Category: Neurological Emergencies, Transient ischemic attack (TIA)
Question 15
A child has ingested an unknown quantity of their grandmother’s metoprolol. The nurse prepares to administer which antidote for this toxicity?
  • Glucagon ✓
  • Calcium gluconate
  • Sodium bicarbonate
  • Phytonadione
Correct Answer
Glucagon
A. In cases of tricyclic antidepressant overdose, sodium bicarbonate is given for acidosis and to maintain a proper acid–base balance. B. Calcium gluconate is the appropriate antidote in the presence of hyperkalemia or hypermagnesemia but is not appropriate for use in beta-blocker toxicity. C. Phytonadione, Vitamin K, is the appropriate antidote for warfarin (Coumadin) and for long-acting anticoagulant overdose. D. Glucagon is the appropriate antidote for beta-blocker toxicity because it has positive inotropic and chronotropic effects. The mechanism of action bypasses beta-adrenergic blockade, thereby activating non–beta receptors, improving atrioventricular conduction and increasing myocardial contractility. Category: Mental Health Emergencies, Intentional overdose and ingestions
Question 16
A patient arrives via emergency medical services after ingesting a large quantity of venlafaxine (Effexor). The patient recently increased the dose of venlafaxine for worsening depression. The patient is anxious, crying, and requesting to speak with a psychiatrist. Which intervention is the highest priority for the emergency nurse caring for the patient?
  • Initiate safety and seizure precautions
  • Assist the patient in establishing self-control
  • Obtain a 12-lead electrocardiogram (ECG) ✓
  • Assess the patient’s level of suicidality
Correct Answer
Obtain a 12-lead electrocardiogram (ECG)
A. Venlafaxine overdose can cause a prolongation of the QT interval, placing the patient at risk for lethal ventricular dysrhythmias. Therefore, the patient should be immediately placed on a cardiac monitor and a 12-lead ECG should be performed to identify the presence of any lethal dysrhythmia. B. Although close observation is important for the patient’s safety, the patient should be first assessed for the presence of any lethal dysrhythmia. Seizures are frequently seen in venlafaxine overdose, so seizure precautions should be initiated. C. Worsening depression places the patient at risk for suicide. Although the nurse should assess for suicidality, the nurse should first place the patient on a cardiac monitor and obtain an ECG to rule out any lethal dysrhythmia. D. Although establishing a sense of control is the overall goal of caring for patients with mental health emergencies, medical stabilization of the patient should be implemented first. Category: Mental Health Emergencies, Mood disorders (e.g., bipolar, depression)
Question 17
An infant arrives via emergency medical services after a reported fall from a bed. The patient opens their eyes spontaneously, moves all extremities, and is crying but consolable. Bruising is noted to the flanks, and radiographic exam reveals posterior rib fractures. Which of the following is the priority follow-up diagnostic test?
  • Coagulation studies
  • Computed tomography (CT) scan of the head
  • Skeletal survey ✓
  • Kidney function studies
Correct Answer
Skeletal survey
A. The infant is active and alert and has a pediatric GCS of 14. A skeletal survey will identify any skull fractures, and a CT scan of the head might then be ordered. B. Posterior rib fractures in an infant are highly suspicious of child maltreatment. A skeletal survey should be performed to identify any other injuries, current or older. C. Bruising is indicative of an injury but could also be related to an underlying medical condition. Coagulation studies can be done if the medical history suggests a need, but this history and exam are indicative of suspected maltreatment. D. Kidney function studies are not indicated at this time. If injury to the kidneys is suspected, these can be ordered along with other testing. Category: Professional Issues, Patient, Abuse and neglect
Question 18
An unconscious adult patient is being considered as an organ donor. The patient has not made a decision regarding donation, so the initial request for consent should be asked of which family member?
  • Parents of the patient
  • Spouse ✓
  • Legal guardian
  • Adult child
Correct Answer
Spouse
A. The Uniform Anatomical Gift Act recommends that the donor’s spouse be the priority contact when requesting consent for donation. B. The Uniform Anatomical Gift Act recommends that if the donor does not have a spouse, the donor’s adult child should be the primary contact when requesting consent for donation. Reference Lim, A., Cameron, K., & Reilly, R. (2018). Organ and tissue donation. In V. Sweet (Ed.), Emergency nursing core curriculum (7th ed., pp. 80–89). Elsevier. C. The legal guardian would be asked to provide consent for donation if the donor does not have a spouse, adult child, parent, adult sibling, or grandparent to provide consent. D. The parents of an adult donor would be asked to provide consent for donation if the donor does not have a spouse or an adult child to provide consent. Category: Professional Issues, Patient, End-of-life and Palliative Care (e.g., organ and tissue donation, advance directives, care withholding, family presence)
Question 19
A 62-year-old patient presents with decreased mentation and dry, cracked lips. Vital signs are: HR 128 beats per minute, RR 20 breaths per minute, BP 100/78, and SpO2 95%. Laboratory results include blood sugar of 880 mg/dL and elevated serum osmolality, hemoglobin, hematocrit, and blood urea nitrogen. Arterial blood gas readings are within the normal range. Which intervention should the nurse implement first?
  • Sodium bicarbonate, 1 amp
  • Potassium hydrochloride 40 mEq over 1 hour
  • Normal saline bolus, 1L ✓
  • Insulin drip at 0.1 units/kg/hr
Correct Answer
Normal saline bolus, 1L
A. This patient’s presentation and laboratory results are consistent with hyperglycemic hyperosmolar syndrome. Dehydration is the first concern and must be addressed initially. This should be instituted before insulin therapy to correct the dehydration and prevent further loss of water into the cell. Dehydration predisposes the patient to many complications, including thrombotic events. B. An insulin drip is important, however, administration of fluids is the first priority because of the osmotic shifts that can occur when insulin is given first. The movement of water into the cells when insulin is provided can worsen the dehydration and increase the risk for negative outcomes for the patient. C. This patient’s diagnosis is most likely hyperglycemic hyperosmolar syndrome. The potassium level for the patient with this syndrome is usually normal or high; therefore, a potassium replacement such as this would be contraindicated. Reference Recznik, D. There are no abnormalities in the arterial blood gas report. This patient’s diagnosis is most likely hyperglycemic hyperosmolar syndrome. This diagnosis does not usually create abnormalities of blood pH because of the presence of enough circulating insulin to deter the development of ketones in the blood that leads to acidosis. Category: Medical Emergencies, Endocrine disorders
Question 20
A patient presents with a complaint of right-sided weakness that started the previous night. The patient tells the nurse that their symptoms have improved somewhat since they started. What should the nurse suspect?
  • Bell’s palsy
  • Hemorrhagic stroke
  • Transient ischemic attack ✓
  • Ischemic stroke
Correct Answer
Transient ischemic attack
A. A hemorrhagic stroke typically causes a severe headache that may be described as "the worst headache of my life." B. An ischemic stroke would cause neurologic deficits that do not completely resolve. C. A transient ischemic attack causes a neurologic deficit that typically resolves within 24 hours. D. Bell’s palsy causes one-sided facial drooping and would not completely resolve within 24 hours. Category: Neurological Emergencies, Transient ischemic attack (TIA)
Question 21
A patient presents with sharp chest pain that began last night and worsens with breathing and movement. He recently increased the intensity of his weightlifting. Medical history includes hypertension, hyperlipidemia, and previous myocardial infarction (MI). His vital signs are stable, and respirations are unlabored. What is the priority intervention for this patient?
  • Initiate intravenous access with a large-caliber catheter
  • Obtain an electrocardiogram (ECG) ✓
  • Administer nonsteroidal anti-inflammatory drugs
  • Encourage deep breathing
Correct Answer
Obtain an electrocardiogram (ECG)
A. Although the patient is providing a clinical history consistent with costochondritis, he has a history of previous MI. A priority intervention would be to obtain an ECG to rule out a current MI. B. Starting a large-caliber IV is not a priority intervention because the patient is stable. Obtaining a 12-lead ECG to rule out cardiac etiology of the symptoms is the priority intervention. Reference Cerepani, M. J. (2018). Orthopedic emergencies. In V. Sweet (Ed.), Emergency nursing core curriculum (7th ed., pp. 387–397). Elsevier. C. Costochondritis is caused by an inflammation in the costal cartilage. Anti-inflammatory medication is an effective treatment for costochondritis and could be administered later to treat the patient’s pain. However, an ECG to rule out the presence of a MI is the priority intervention. D. Pain with costochondritis may be increased with deep inspiration. Encouraging deep breathing to prevent atelectasis is a good intervention to include in discharge instructions for costochondritis, but obtaining the ECG is the priority intervention. Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Inflammatory conditions
Question 22
You are assisting in the resuscitation of an adult patient in cardiopulmonary arrest. High-quality chest compressions are being performed, and the patient has an advanced airway in place. What it the correct ventilation rate?
  • 1 breath every 5 seconds or 12 breaths per minute
  • 1 breath every 3 seconds or 20 breaths per minute
  • 1 breath every 10 seconds or 6 breaths per minute
  • 1 breath every 6 seconds or 10 breaths per minute ✓
Correct Answer
1 breath every 6 seconds or 10 breaths per minute
A. This is faster than the recommended 10 breaths per minute. B. The recommended rate for assisting ventilations in the cardiac arrest patient is 10 breaths per minute. C. This is slower than the recommended rate of 10 breaths per minute. D. After placement of an advanced airway, it is recommended that the provider deliver 1 breath every 6 seconds (10 breaths/minute) while continuous chest compressions are being performed (Class IIb, LOE C-LD). Category: Cardiovascular Emergencies, Cardiopulmonary arrest
Question 23
A patient is admitted to the emergency department following a house fire. Following the primary assessment, the patient is suspected of having carbon monoxide poisoning. What is the priority intervention for the emergency nurse to perform?
  • Administer high-flow oxygen via nonrebreather mask ✓
  • Prepare intubation equipment at the bedside
  • Administer low-flow oxygen via nasal cannula
  • Apply continuous pulse oximetry
Correct Answer
Administer high-flow oxygen via nonrebreather mask
A. The primary intervention for carbon monoxide poisoning is the administration of 100% oxygen, which is best achieved via a nonrebreather mask. Pulse oximetry will evaluate the patient’s oxygen saturation status but will not reflect the carbon monoxide level in the blood. B. The treatment for carbon monoxide poisoning is the administration of 100% oxygen, which is best achieved via a nonrebreather mask. If the patient’s condition deteriorates, intubation may be indicated at that time. C. Low-flow oxygen via a nasal cannula will not deliver 100% oxygen to the patient. The treatment for carbon monoxide poisoning is the administration of 100% oxygen, which is best achieved via a nonrebreather mask. D. The treatment for carbon monoxide poisoning is the administration of 100% oxygen. Category: Respiratory Emergencies, Inhalation injuries
Question 24
A male patient arrives via emergency medical services in full spinal precautions following a motor vehicle collision. Which assessment finding would lead the nurse to suspect that the patient has a spinal cord injury?
  • Hypertension
  • Tachycardia
  • Cool, moist skin
  • Priapism ✓
Correct Answer
Priapism
A. Temporary disruption of the sympathetic nervous system causes bradycardia and hypotension. B. Patients with a complete spinal cord lesion lose all motor and sensory functions below the level of the lesion. The presence of a continued penile erection (priapism) can occur with loss of sympathetic nervous system control and may indicate a spinal cord lesion. C. Temporary disruption of the sympathetic nervous system causes bradycardia and hypotension. D. Neurogenic shock results in peripheral vasodilation and inability to sweat below the level of the injury, resulting in warm, dry skin. Category: Neurological Emergencies, Head and spinal cord trauma
Question 25
A 78-year-old patient diagnosed with a rib fracture is being discharged from the emergency department following a fall. Which home treatment is the best option for this patient?
  • Thoracic binder
  • High-dose opioids
  • Incentive spirometer ✓
  • Prophylactic antibiotics
Correct Answer
Incentive spirometer
A. Opioid medications may be indicated to allow adequate coughing and deep breathing; however, high doses in older adults should be used cautiously because of the risk of respiratory depression. B. Treatment for rib fractures is aimed at the reduction of complications. A major complication of rib fractures is the development of pneumonia. The risk is due to pain associated from deep inspiration and coughing negatively impacting airway clearance. Older adult patients are more at risk for complications. C. Thoracic binders are contraindicated because they do not allow adequate chest expansion, which increases the risk for complications. D. Prophylactic antibiotics are not recommended. Reference Denke, N. J. (2020). Thoracic trauma. In V. Sweet & Category: Respiratory Emergencies, Respiratory Trauma
Question 26
A patient with a history of cirrhosis of the liver arrives with nausea and copious, bright red upper gastrointestinal bleeding. Vital signs are: BP 90/62 mm Hg, HR 142 beats per minute, RR 32 breaths per minute, SaO2 92% without supplemental oxygen, and T 100.5°F (38.1°C). The emergency nurse anticipates that this patient’s initial therapy would include which of the following medications?
  • Octreotide (Sandostatin) ✓
  • Acetaminophen (Tylenol)
  • Pantoprazole (Protonix)
  • Lactulose
Correct Answer
Octreotide (Sandostatin)
A. Administration of acetaminophen should be done with extreme caution in a patient with known or suspected liver disease. Fatal hepatotoxicity may occur with use of acetaminophen in patients with liver disease. B. When administered to a patient with chronic liver disease, lactulose is an effective treatment to reduce neurotoxic effects of an elevated serum ammonia level and improve the patient’s mental status. It is not a treatment for bleeding esophageal varices. C. Medications such as pantoprazole (Protonix) that decrease gastric secretions are used for disease processes that are nonvariceal in nature. This medication would be useful in gastroesophageal reflux disease (GERD), ulcers, and esophagitis. D. Octreotide is a first-line medication in treating suspected bleeding from esophageal varices. Administration of this medication causes constriction of the splanchnic circulation, thereby reducing the pressure from portal hypertension and resulting in decreased bleeding from the varices. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Esophageal varices
Question 27
A patient complains of inability to move the left side of the face. Assessment reveals an inability to close the left eye, lift the left eyebrow, or wrinkle the left side of the forehead. The nasolabial folds are flattened, and a mouth droop on the left side is present. The patient reports a recent upper respiratory infection. Which of the following is the most likely cause of this patient’s symptoms?
  • Bell’s palsy ✓
  • Trigeminal neuralgia
  • Temporal arteritis
  • Transient ischemic attack
Correct Answer
Bell’s palsy
A. Transient ischemic attack results from altered cerebral blood flow. It is associated with signs and symptoms that mimic a stroke, typically resolving within 6–24 hours. B. Temporal arteritis usually presents with severe pain, headache, fever, and sudden onset of visual disturbances. C. Trigeminal neuralgia involves one or more of the three trigeminal nerve branches and causes hypersensitivity of the face that results in excruciating pain. It does not affect the ability to move the face or give the appearance of paralysis. Trigeminal neuralgia is also referred to as tic douloureux, and its cause is unknown. D. This patient’s symptoms are consistent with Bell’s palsy, also known as idiopathic facial paralysis, and a unilateral weakness or paralysis of the facial muscles. Bell’s palsy is believed to be caused by a virus that triggers swelling of the facial nerve (cranial nerve VII), resulting in nerve compression and ischemia. Category: Maxillofacial and Ocular Emergencies, Maxillofacial, Facial nerve disorders (e.g., Bell’s palsy, trigeminal neuralgia)
Question 28
An older adult reports unintentionally waking up at 4:00 each morning, experiencing decreased energy and feelings of hopelessness since her husband passed away last year. After a complete physical assessment, the nurse considers which of the following to be contributing to the patient’s symptoms?
  • Anxiety
  • Depression ✓
  • Stress
  • Aging
Correct Answer
Depression
A. Patients suffering from depression often experience feelings of hopelessness, early morning wakefulness, and decreased energy. Depression is a treatable medical condition, and based on the symptoms the patient has reported, further screening is warranted. B. Depression is not a normal part of aging. Although older adults are at an increased risk for depression because of chronic health conditions and life changes, such as the death of their spouse, depression is a medical condition that can and should be recognized and treated in persons of all ages. C. Early-morning waking, decreased energy, and hopelessness are strongly correlated with depression, not anxiety. Further screening can help determine if the patient is experiencing depression as well as anxiety. Reference Pritts, W. S. (2020). Behavioral health emergencies. In V. Sweet & D. The patient may be experiencing stress as a result of her symptoms and the life changes she is experiencing. The symptoms she is reporting are more severe than day-to-day stress. Depression in older adults is often mistaken for a natural reaction to illness or life changes, by both healthcare providers and patients. Category: Mental Health Emergencies, Mood disorders (e.g., bipolar, depression)
Question 29
Following chest tube insertion, a trauma patient has an initial output of 1000 mL of blood. What is the most appropriate intervention made by the emergency nurse?
  • Clamp the chest tube to maintain euvolemia
  • Continue to monitor output hourly
  • Prepare for additional chest tube insertion
  • Prepare the patient for surgery ✓
Correct Answer
Prepare the patient for surgery
A. Initial return of 1000 mL of blood indicates active bleeding and requires surgical intervention. B. The most common cause of hemothorax is injury to an intercostal vein or artery, which usually results in minimal bleeding. Immediate blood return with chest tube insertion of 1000 to 1500 mL or blood loss of 200 mL/hr for 3–4 hours is an indication for surgical interventions. C. Surgical intervention is indicated to repair the active bleed. Reference Denke, N. J. (2020). Thoracic trauma. In V. Sweet & D. Clamping the chest tube is only done in rare instances and is not an appropriate nursing action at this time. Category: Respiratory Emergencies, Respiratory Trauma
Question 30
Patient presents with a 5-day history of a vesicular lesions around their right trunk associated with severe pain. The lesions are oozing serous fluid and have not crusted over. Which of the following responses indicates that the patient has understood the discharge instructions?
  • “I can apply a dressing over weeping lesions before going to work at the daycare tomorrow.”
  • “I will never get the lesions again because this is a one-time episode.”
  • “I can expect to have this rash for the next 8–10 weeks.”
  • “I will not have contact with my friend who is on chemotherapy.” ✓
Correct Answer
“I will not have contact with my friend who is on chemotherapy.”
A. Full resolution of the rash usually occurs within 2–4 weeks. B. Patients can have recurrence of herpes zoster infections; however, they can be decreased through vaccination with the herpes zoster (shingles) vaccine. Reference Centers for Disease Control and Prevention. (n.d.). Shingles (herpes zoster): For healthcare professionals. https://www.cdc.gov/shingles/hcp/index.html C. Painful vesicular lesions following dermatome layers may be diagnosed as herpes zoster (shingles). Patients with active herpes zoster lesions are considered contagious until the lesions have crusted over. D. Patients should not be around those who have not yet contracted varicella because they are contagious until all lesions have crusted over. Category: Environment and Toxicology Emergencies, and Communicable Diseases, Communicable Diseases, Vaccine-preventable diseases (e.g., measles, mumps, pertussis, chicken pox, diphtheria)
Question 31
A 16-year-old patient has been diagnosed with bacterial meningococcal meningitis. The emergency nurse recognizes that the patient’s mother properly understands the educational information regarding her son’s disease process when she states which of the following?
  • “My son no longer has a headache, so he will be able to go home this evening.”
  • “My son does not have a rash, so his friends can visit him in the hospital.”
  • “My son’s fever is controlled, so he may be able to go home tonight.”
  • “My son will be admitted to the hospital for antibiotics and further treatment.” ✓
Correct Answer
“My son will be admitted to the hospital for antibiotics and further treatment.”
A. Visitors will be restricted while the patient is in the hospital because meningococcal meningitis is highly contagious. Only about 50% of these patients present with petechiae and purpura. The absence of purpura and petechiae does not rule out Neisseria meningitides meningococcemia. B. Patients with meningococcemia experience photophobia and headache secondary to the infectious process. This patient will need to be in the hospital for treatment regardless of whether he has a headache. C. Patients with meningococcal disease are highly contagious, require intravenous antibiotics, and may need ventilator and vasopressor support for the presence of septic shock. D. Patients with meningococcal disease are highly contagious, require intravenous antibiotics, and may need ventilatory and vasopressor support for the presence of septic shock. Category: Neurological Emergencies, Meningitis
Question 32
A patient is 5 days postoperative from a colon resection and complains of fever, chills, nausea, and severe, generalized abdominal pain. The emergency nurse suspects that the patient has developed which of the following?
  • Renal calculi
  • Hepatitis
  • Peritonitis ✓
  • Bowel obstruction
Correct Answer
Peritonitis
A. A patient with renal calculi may present with abdominal pain and low-grade fever, but renal calculi are not a postoperative complication associated with abdominal surgery. Pain, caused by distention of the ureter, starts in the flank area, with radiation of the pain to the lower abdomen and groin area. B. Peritonitis is an inflammation or infection of the peritoneum that can occur from a bloodborne pathogen or from leakage of intestinal contents into the abdominal cavity. This patient’s presentation and recent history of abdominal surgery make peritonitis the most likely etiology. C. A patient with hepatitis will present with upper right quadrant pain and a low-grade fever. This patient’s symptoms do not suggest a hepatic etiology. Reference Sweet, V., & Foley, A. (2020). Gastrointestinal emergencies. In V. Sweet & D. A postoperative bowel obstruction due to adhesions or a volvulus is certainly a possibility, but the patient’s presentation with fever and chills suggests an infectious etiology. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Acute abdomen
Question 33
An adult patient with an acute upper gastrointestinal bleed is found to have a hemoglobin level of 6.2. gm/dL. Initial vital signs are: BP 84/420 mm Hg, HR 144 beats/minute, RR 24 breaths/minute, and SaO2 92% on 4 L O2 via nasal cannula. The patient has received 2 units of packed red blood cells. Which of the following clinical signs would suggest that this intervention has had the desired effect?
  • Capillary refill time of 4 seconds
  • Mean arterial pressure (MAP) of 65 mm Hg ✓
  • Arterial pH of 7.25
  • Urine output of 20 mL/hr
Correct Answer
Mean arterial pressure (MAP) of 65 mm Hg
A. Normal capillary refill time is 2–3 seconds. Prolonged capillary refill time is an indicator of tissue perfusion, but it can be affected by a variety of factors. For this reason, it is not considered a reliable indicator of shock resolution. B. A minimal urine output of 30 mL per hour in an adult is considered an end point of shock resuscitation. C. An acute upper gastrointestinal bleed can lead to hypovolemic shock. A MAP of 60–65 mm Hg is an acceptable reading in hypovolemic shock states and would indicate that a positive end result had been gained. The initial blood pressure reading had a MAP of 55 mm Hg. D. The presence of acidosis in shock is a result of poor tissue perfusion and hypoxia. Normal pH levels are between 7.35 and 7.45; a pH level lower than 7.35 is indicative of acidosis. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Bleeding
Question 34
A patient presents with sudden onset of flushing, headache, abdominal cramping, vomiting, and diarrhea after having eaten tuna sushi about 1 hour ago. You suspect the patient may have poisoning from which organism?
  • Giardia lamblia
  • Histidine ✓
  • Campylobacter
  • Hepatitis A
Correct Answer
Histidine
A. Hepatitis A travels in feces and can be easily spread from person to person. It is generally caused by shellfish, raw produce, contaminated water, and infected contacts. Symptoms include diarrhea, jaundice, dark urine, abdominal pain, and flulike illness, and may take 2–4 weeks following exposure to appear. B. Giardia occurs from exposure to contaminated food or water and results in diarrhea, vomiting, copious flatulence, abdominal cramping, fever, and malaise. C. Scrombroid poisoning is a common seafood-associated set of symptoms that occur after ingestion of fish of the Scrombridae family (tuna, mackerel, mahi, and bonito). Histadine is normally found in the dark meat of these fish. When the fish are stored improperly, histadine converts to histamine. Symptoms usually begin within 30 minutes of ingestion. Treatment is with diphenhydramine and cimetidine or famotidine. D. Campylobacter infection occurs from contaminated raw poultry that has come in contact with animal feces but can also come from unpasteurized milk and contaminated water. Symptoms occur within 2–5 days of being exposed to the contaminated food and include diarrhea (ranging from mild to severe and sometimes bloody), cramping, nausea, vomiting, and fever. Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment, Temperature-related emergencies
Question 35
Signs and symptoms of numbness and tingling, whitish, waxy skin color, and large blisters after being outside for several hours shoveling snow are associated with which of the following conditions?
  • Immersion foot
  • Superficial frostbite ✓
  • Chilblains
  • Deep frostbite
Correct Answer
Superficial frostbite
A. Superficial frostbite usually involves the fingertips, ears, nose, cheeks, or toes. In addition, the skin will retain some resistance when pressure is applied to the area. The skin has a white or waxy appearance, and large blisters can form in the exposed areas depending on the length of exposure to the cold environment. B. Deep frostbite is more serious than superficial frostbite and involves muscle, fat, bones, and tendons as well as skin. Deep frostbite can result in cellular injury and death of tissue. C. Chilblains are generally a self-limiting form of mild frostbite that resolves with symptomatic treatment. The skin exhibits localized areas of itching, painful redness, and recurrent edema on exposed areas, such as earlobes, fingers, and toes. D. Immersion foot (“trench foot”) usually occurs when the feet are wet and subjected to cold temperatures for prolonged periods inside a nonbreathing boot or shoe. The foot initially appears pale and wrinkled. Tissue sloughing can develop if the condition is allowed to persist. Dry shoes and socks are necessary to prevent this condition from occurring. Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment, Temperature-related emergencies
Question 36
An adolescent reports having frequent worries concerning various situations; some are realistic concerns, and some are not. The patient experiences these feelings on most days, while in social situations and while alone. The patient denies associated physical symptoms such as chest pain, shortness of breath, or muscle pain. Which of the following indicates the patient is responding positively to interventions for generalized anxiety disorder?
  • Describes feeling awkward only in social interactions with adults ✓
  • Remains busy in the hope that this will prevent them from focusing on their anxiety
  • Experiences feelings of generalized anxiety at least 6 days a week
  • Experiences feelings of increased anxiety when alone
Correct Answer
Describes feeling awkward only in social interactions with adults
A. The patient’s anxiety should be decreasing when in isolation. B. Previously, the patient reported frequent worry in social situations and in isolation. The patient now describes feeling awkward only in interactions with adults, which may be a normalized response for some adolescents. Generalized anxiety disorder is defined as excessive and persistent anxiety and worry about a variety of situations and topics that lasts more than 6 months. C. Six days out of the week is a majority of the time and would be considered persistence in the patient’s symptoms. D. Increasing engagement in activities may help mitigate feelings of anxiety; however, the goal is to identify anxiety-producing situations and implement strategies that minimize those stressors or use techniques that can be employed once the excessive worry starts to set in. Category: Mental Health Emergencies, Anxiety disorders (e.g., PTSD, anxiety, panic attack)
Question 37
Which intervention should the nurse perform for a patient immediately following a knee joint aspiration?
  • Elevate the extremity above the level of the heart
  • Apply pressure to the aspiration site for 2 minutes ✓
  • Place a heat pack on the aspiration site for 15 minutes
  • Place an ice pack on the aspiration site for 15 minutes
Correct Answer
Apply pressure to the aspiration site for 2 minutes
A. Placing heat on an aspiration site following the procedure is not recommended because it can increase blood flow to the area and increase the risk of bleeding. B. Applying direct pressure for at least 2 minutes to stop further bleeding at the site is the first intervention to perform following the procedure. Other interventions, including application of ice and a pressure dressing, should be completed once the bleeding has stopped. C. Application of an ice pack is an appropriate intervention after the dressing has been applied, but applying pressure to the aspiration site is the priority intervention. D. Elevation of the extremity above the level of the heart is thought to reduce swelling, but applying direct pressure to the site for 2 minutes followed by the application of a pressure dressing is the priority intervention. Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Inflammatory conditions
Question 38
Which patient is most likely to have a higher rate of mortality when infected with respiratory syncytial virus (RSV)?
  • An adult with a history of heart failure (HF)
  • A toddler with a history of eczema
  • An infant with congenital heart disease (CHD) ✓
  • A child with severe asthma
Correct Answer
An infant with congenital heart disease (CHD)
A. RSV is the most common cause of bronchiolitis caused by a viral infection, which affects nearly all children by the age of 2. A 4-year-old child with severe asthma is less likely to develop RSV. B. Patients with CHD are already prone to having hypoxemia, decreased cardiac output, and decreased cardiac function that results in decreased oxygen delivery to tissue. Because of this combination of factors, the development of RSV is more likely to result in a higher rate of mortality in an infant with CHD. C. Though the development of RSV primarily affects very young infants and children under the age of 2, it is seen in adults. Adults with HF have a higher risk of developing more severe complications related to RSV infection, but mortality rates are higher in infants and children. D. Although eczema is associated with asthma, it does not increase the risk of developing RSV. Category: Respiratory Emergencies, Infections
Question 39
A patient presents complaining of abdominal pain, poor appetite, and fatigue. On exam, the nurse notes ascites, icteric sclera, and altered mental status. Based on these symptoms, the nurse suspects which of the following conditions?
  • Hepatitis
  • Pancreatitis
  • Cholecystitis
  • Cirrhosis ✓
Correct Answer
Cirrhosis
A. Symptoms of cholecystitis include a sudden onset of abdominal pain that is usually associated with ingestion of fatty or fried foods. Pain is located in the epigastrium and/or upper right quadrant and may be referred to the right shoulder or supraclavicular area. B. Systemic manifestations of liver cirrhosis vary depending on the stage of the disease. Early symptoms include weakness, fatigue, and a low-grade fever. As the disease progresses, additional symptoms may include abdominal distention due to ascites, jaundice, changes in mental status due to elevated serum ammonia levels, and spontaneous bruising that is attributed to clotting dysfunction. C. Hepatitis is usually associated with a viral infection or alcohol dependency. Clinical presentation is malaise, fever, vomiting, and diarrhea. The presence of jaundice, ascites, mental status changes, and spider angiomas are more consistent with cirrhosis. D. Pain associated with pancreatitis is generally located in the left upper abdomen or epigastrium and may radiate through to back. Coagulation disorders, jaundice, and changes in mental status are not typical assessment findings with pancreatic disease. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Cirrhosis
Question 40
A patient presents to the emergency department after a motor vehicle collision. The patient has jugular vein distention, tachycardia, and hypotension. What additional assessment finding would cause the emergency nurse to suspect that the patient has cardiac tamponade instead of a tension pneumothorax?
  • Diminished breath sounds on one side
  • Muffled heart sounds ✓
  • Tachypnea
  • Pulsus paradoxus
Correct Answer
Muffled heart sounds
A. Diminished breath sounds on the affected side may occur in tension pneumothorax but are not found in cardiac tamponade. Reference Casey, R. M. (2020). Thoracic and neck trauma. In J. S. Blansfield (Ed.), Trauma Nursing Core Course provider manual (8th ed., pp. 121–140). Jones & Bartlett Learning. B. Tachypnea may be a compensatory physical finding in both cardiac tamponade and tension pneumothorax. C. Pulsus paradoxus is a reduction of systolic blood pressure of more than 10 mm Hg on inspiration and may occur in both cardiac tamponade and tension pneumothorax. Pulsus paradoxus results from the changes in pressure within the thoracic cavity that are due to obstructive mechanisms interfering with the filling of the heart, such as in cardiac tamponade and tension pneumothorax. D. Cardiac tamponade is caused by fluid buildup in the pericardial sac surrounding the heart. The excess fluid increases pressure on the heart, decreasing cardiac output due to a decrease in filling ability. Beck’s triad is associated with cardiac tamponade, in which the patient may have muffled heart sounds (due to the fluid surrounding the heart causing a decrease in the intensity of heart sounds), hypotension (due to the decrease in cardiac output), and jugular vein distention (due to impaired venous return to the heart). Category: Cardiovascular Emergencies, Pericardial tamponade
Question 41
A patient presents to the emergency department with assessment findings of tachycardia, dyspnea, sudden onset of chest pain, and left lower extremity pain and swelling. The emergency nurse recognizes that the patient most likely has symptoms of which condition?
  • Pulmonary embolism ✓
  • Myocardial infarction
  • Congestive heart failure
  • Pleural effusion
Correct Answer
Pulmonary embolism
A. Chest pain, tachycardia, and dyspnea may be present in myocardial infarction; however, unilateral lower extremity pain and swelling would not be expected. B. Chest pain, tachycardia, dyspnea, and leg swelling may be present in congestive heart failure; however, the leg swelling would be expected in the bilateral lower extremities, as opposed to a unilateral lower extremity. C. Symptoms of a pulmonary embolism often mimic those of other conditions. However, unilateral lower extremity pain and swelling, along with chest pain, tachycardia, and dyspnea, are indicative of a pulmonary embolism caused by a deep vein thrombosis. D. Chest pain, tachycardia, and dyspnea may be present in pleural effusion; however, unilateral lower extremity pain and swelling would not be expected. Reference Foley, A., & Sweet, V. (2020). Respiratory emergencies. In V. Sweet & Category: Respiratory Emergencies, Pulmonary embolus
Question 42
A patient presents to the emergency department with symptoms consistent with Bell’s palsy. The emergency nurse recognizes that this is likely related to inflammation of which cranial nerve?
  • VI (abducens)
  • VII (facial nerve) ✓
  • III (oculomotor)
  • V (trigeminal)
Correct Answer
VII (facial nerve)
A. Cranial nerve V controls chewing, jaw clench, lateral jaw movement, corneal reflexes, and face sensation. B. Cranial nerve VI controls lateral eye deviation. C. Cranial nerve III controls pupillary constriction and most extraocular eye movements. D. Bell’s palsy is the result of inflammation of cranial nerve VII, the facial nerve. Category: Neurological Emergencies, Neurological disorders (e.g., multiple sclerosis, myasthenia gravis, Guillain-Barré syndrome)
Question 43
A patient with type 2 diabetes presents with fatigue and peripheral edema following an abdominal computerized tomography with contrast 2 days prior. The nurse considers that these symptoms may be related to which of the following conditions?
  • Contrast-induced nephropathy ✓
  • Cardiorenal syndrome
  • Acute tubular necrosis
  • Acute interstitial nephritis
Correct Answer
Contrast-induced nephropathy
A. Contrast-induced nephropathy is classified as intrinsic kidney injury and involves structural damage to the glomerulus, vessels, or kidney tubules. The risk for contrast-induced nephropathy is increased for individuals with diabetes and/or the presence of heart diseases. B. Cardiorenal syndrome is a complex pathophysiological disorder of the heart and kidneys in which acute or chronic dysfunction of one organ causes acute or chronic dysfunction of the other. This scenario fits the diagnoses of contrast-induced nephropathy. C. Acute interstitial nephritis is a result of medications binding to antigens in the kidney or acting as antigens deposited in the interstitium, causing an immune reaction. Most cases are caused by exposure to certain nephrotoxic drugs. D. Acute tubular necrosis is defined as acute kidney injury characterized by acute tubular cell injury and dysfunction. The most common causes are hypoperfusion to the kidneys related to the presence of sepsis and hypotension. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Genitourinary, Renal calculi
Question 44
A patient presents with abdominal pain, nausea, and inability to lie in a supine position. Leukocytosis and elevated levels of amylase and lipase are noted on the laboratory results. Which of the following electrolyte abnormalities should the emergency nurse be most concerned about with this patient?
  • Hyperphosphatemia
  • Hypophosphatemia
  • Hypocalcemia ✓
  • Hypercalcemia
Correct Answer
Hypocalcemia
A. This patient is exhibiting manifestations of pancreatitis. One of the complications of this disease entity is hypocalcemia due to the presence of free fatty acids (from the release of lipase); these fatty acids bind with the small amount of available calcium in the body, creating hypocalcemia. B. Etiologies for hyperphosphatemia are hypoparathyroidism and renal failure. This electrolyte is not affected with pancreatitis. C. Hypophosphatemia causes include alcoholism, burns, diuretics, and forms of malnutrition or starvation. This electrolyte is not implicated in pancreatitis. D. Pancreatitis can create a situation of hypocalcemia rather than hypercalcemia when free fatty acids formed from the release of lipase bind with available calcium. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Peritonitis
Question 45
A patient presents with feelings of tiredness, shortness of breath, and chest pain. The patient states that the chest pain is crushing, with radiation to the neck and arms; it varies with position and has increased from 4/10 to 7/10 within the past 24 hours. The 12-lead electrocardiogram (ECG) reveals ST segment elevation in leads I, II, V2–V5, and aVf. The nurse would suspect that the patient has which of the following?
  • Inferior wall STEMI
  • Pericarditis ✓
  • Inferolateral STEMI
  • Unstable angina
Correct Answer
Pericarditis
A. Unstable angina would show ST segment depression or possible T-wave inversion, or the ECG might be normal. B. An inferior wall myocardial infarction would demonstrate ST segment evaluation in leads II, III, and aVf, with reciprocal changes in leads I and aVL. The patient’s ECG shows that the lead elevation is not limited to II, III, and aVF. C. There is no distinct ECG pattern for inferolateral STEMI. The ST segment elevation is not limited to leads I, II, V2–V5, and aVf. Reference Foley, A., & Sweet, V. (2020). Cardiovascular emergencies. In V. Sweet & D. Patients with pericarditis present with chest pain that varies with position. The 12-lead pattern shows ST segment elevation in all leads except aVr and V1. Category: Cardiovascular Emergencies, Pericarditis
Question 46
A patient diagnosed with pleural effusions secondary to heart failure exacerbation is being discharged. The emergency nurse identifies that the patient teaching has been successful when the patient states:
  • “When I have an exacerbation, I will need to have to have my pleural effusion drained.”
  • “I will have chronic pleural effusions because of my heart failure.”
  • “I can decrease the chance of developing pleural effusions by managing my heart failure.” ✓
  • “If I develop chest pain and shortness of breath, I know I have a pleural effusion.”
Correct Answer
“I can decrease the chance of developing pleural effusions by managing my heart failure.”
A. Chest pain and shortness of breath require further examination to confirm that the patient is not experiencing a cardiac event, such as a myocardial infarction. The patient should be instructed to return to the emergency department to rule out potential life-threatening emergencies. B. Proper management of heart failure with diuretics and sodium restriction will result in decreased occurrence of pleural effusions. C. Pleural effusions are often mild and do not always require drainage. Reference Milici, J. J. (2018). Respiratory emergencies. In V. Sweet (Ed.), Emergency nursing core curriculum (7th ed., pp. 452–472). Elsevier. D. Proper management of heart failure with diuretics and sodium restriction will result in decreased occurrence of pleural effusions. Category: Respiratory Emergencies, Pleural effusion
Question 47
A patient presents with complaints of abdominal pain and anorexia and states that their urine is dark, and bowel movements have a lighter color. Objective data reveal tenderness to the right upper quadrant and icteric sclera. History is negative for alcohol or illegal substances. The patient returned 2 weeks earlier from a trip to South America as part of a medical mission team. Which of the following disease processes would carry the highest suspicion for the emergency nurse?
  • Hepatitis A ✓
  • Hepatitis B
  • Hepatitis D
  • Hepatitis C
Correct Answer
Hepatitis A
A. The hepatitis A virus is carried through the fecal–oral route and is contracted through contact with an infected person or via ingestion of contaminated food or liquids. International travel on a medical mission trip should increase the emergency suspicion for this type of hepatitis. The patient also does not have risk factors that might increase suspicion for other forms of this disease. The manifestations discussed usually occur after the prodromal period of malaise, arthralgia, nausea, and vomiting. B. The hepatitis B virus is transmitted through contact with blood or body fluids, such as saliva, vaginal secretions, semen, amniotic fluid, or synovial fluid, that have been infected with the virus. This virus can also be transferred through intravenous drug use. C. Hepatitis C is spread primarily through contact with blood through the use of unsterilized needles, needle sharing, or the use of medical equipment that has been contaminated with the hepatitis C virus. D. Hepatitis D is a virus that occurs concurrently with hepatitis Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Hepatitis
Question 48
The severity of injury or potential injuries from external radiation exposure is based on time, distance, and:
  • duration of exposure. ✓
  • type of clothing worn.
  • access to potassium iodide.
  • exposure to alpha radiation.
Correct Answer
duration of exposure.
A. Alpha particles only penetrate the skin at a shallow depth. B. Potassium iodide is only useful if there is a release of radioactive iodine, such as in a nuclear plant explosion. C. The type of clothing worn does not typically affect the severity of the injury. D. Severity of injuries related to radiological exposure is based on the amount of time exposed, the distance from the radiation, and the duration of the exposure. Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment, Temperature-related emergencies
Question 49
A 5-year-old patient in third-degree heart block presents via emergency medical services. The patient is hypotensive and very pale in color. The emergency provider requests that external pacing be initiated for this patient. What step would the emergency nurse perform next?
  • Set the current rate at 100 mA
  • Apply the pacing electrodes to the patient ✓
  • Select a pacing rate of 70 beats per minute
  • Turn on synchronization prior to pacing
Correct Answer
Apply the pacing electrodes to the patient
A. J., Levy, A., Mahgoub, M., Meckler, G. D., Roberts, K. E., Sutton, R. M., Schexnayder, S. M., & Pediatric Basic and Advanced Life Support Collaborators. (2020). Part 4: Pediatric basic and advanced life support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 142(16 Suppl. 2), S469–S523. https://doi.org/10.1161/CIR.0000000000000901 B. Applying the pacing electrodes is the first step. After the pads are placed, the rate would be determined by the emergency provider. A rate of 70 might be used for adults, but for pediatrics, it is usually age based and should be titrated to an adequate blood pressure. The rate can be found on a length-based resuscitation tape. This patient’s rate should start around 100 beats per minute. C. Applying the pacing electrodes is the first step. Most patients require a current between 40 and 80 mA, but you should start low and work your way up until you achieve capture. D. Synchronization is used for cardioversion or applying an electrical shock, not for pacing. Synchronization identifies the R-wave of the cardiac cycle for discharge of the current. Reference Topjian, Category: Cardiovascular Emergencies, Cardiopulmonary arrest
Question 50
The cardiac monitor of a patient newly diagnosed with an acute myocardial infarction reveals a second-degree atrioventricular type II block. Which area of the myocardium has most likely been affected by the acute myocardial infarction?
  • Inferior
  • Lateral
  • Anterior ✓
  • Posterior
Correct Answer
Anterior
A. A second-degree type II AV block would be caused by the decreased blood flow from the left coronary artery to the septum, causing necrosis of the bundle of HIS and bundle branches. B. The right coronary artery supplies blood to the AV node. The electrocardiogram would show ST elevations in leads II, III, and aVF. C. The left circumflex branch of the left coronary artery supplies blood to lateral wall. The electrocardiogram would show ST elevations in leads I, aVL, V5, and V6. D. The right coronary artery supplies blood to the inferior and posterior walls. The electrocardiogram would show reciprocal V1, V2, without a Q-wave, but a tall R-wave, and ST depressions with an upright T-wave. Category: Cardiovascular Emergencies, Acute coronary syndrome
Question 51
An emergency patient received epinephrine 1:1000 intravenous push for signs and symptoms of severe anaphylactic reaction. The patient developed ventricular fibrillation, was stabilized, and was discharged from the hospital within a few days of the event. The emergency nurse should do which of the following?
  • Document on an event report and note in the chart that the report was completed
  • Document in the patient’s medical record that an error occurred
  • Report the error in the hospital event reporting system ✓
  • Report to the state board of pharmacy to prevent future medication errors
Correct Answer
Report the error in the hospital event reporting system
A. Errors, regardless of whether they result in patient harm, should be reported, tracked, and monitored to prevent future harm. B. Unusual events should be documented in the organization’s incident or occurrence report, not in the healthcare record. In the patient’s chart, never refer to the existence of an incident report. Only chart the facts of the incident. C. This is an internal event that should be evaluated for causes and an appropriate action plan developed to help prevent future errors. D. Unusual events should be documented in the organization’s incident or occurrence report, not in the healthcare record. Just the facts should be in the record. Category: Professional Issues, System, Risk management
Question 52
A patient was struck on the left side of the head with a baseball bat. Witnesses report that the patient had a brief loss of consciousness, and on awakening, the patient was alert and oriented. En route to the hospital and on arrival, the patient is becoming increasingly confused and has a dilated left pupil. What should the nurse suspect?
  • Subarachnoid hemorrhage
  • Epidural hematoma ✓
  • Diffuse axonal injury
  • Subdural hematoma
Correct Answer
Epidural hematoma
A. A mild diffuse axonal injury would present with a loss of consciousness that lasts for several hours, up to 24 hours. There may be abnormal posturing, and amnesia may be present. B. A subdural hematoma is typically caused by traumatic brain injury and is most common in the elderly and those who abuse alcohol. An insidious onset of headache with progressive worsening is most consistent with a subdural hematoma. C. A subarachnoid hemorrhage is commonly caused by aneurysmal rupture, not a traumatic injury. 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 having a sudden, severe onset and is commonly referred to as the “thunderclap” headache. D. An epidural hematoma is usually caused by blunt force trauma to the temporal or parietal area of the skull that results in temporal or parietal bone fracture and injury to the middle meningeal artery. A sudden loss of consciousness followed by a period of lucidity is most consistent with the presence of an epidural hematoma. Category: Neurological Emergencies, Neurogenic shock
Question 53
Which of the following endocrine disorders results in dilutional hyponatremia?
  • Cushing’s syndrome
  • Diabetes insipidus (DI)
  • Adrenal crisis
  • Syndrome of inappropriate antidiuretic hormone (SIADH) ✓
Correct Answer
Syndrome of inappropriate antidiuretic hormone (SIADH)
A. DI is a life-threatening condition in which insufficient antidiuretic hormone (ADH) is produced by the hypothalamus, or it is not released by the posterior pituitary gland. Treatment is fluid replacement and ADH replacement with medications such as desmopressin acetate (DDAVP). B. SIADH is a life-threatening condition in which the pituitary gland releases excessive amounts of antidiuretic hormone. The patient will present with dilutional hyponatremia and water intoxication, which can lead to seizures. Treatment depends on the severity of the hyponatremia. C. Adrenal crisis, also known as acute adrenal insufficiency, is a life-threatening condition caused by a decrease in cortisol and aldosterone levels. Although there is a decrease in sodium, it is not due to a dilutional etiology. Treatment for adrenal crisis includes fluid replacement, treatment of hyperkalemia, and hydrocortisone administration. D. Cushing’s syndrome is the result of a prolonged exposure to glucocorticoids (either endogenous or exogenous), which causes the patient to develop a Cushingoid appearance. There is an increased amount of adipose tissue to the face, upper back, and base of the neck. Category: Medical Emergencies, Endocrine disorders
Question 54
The emergency nurse is assisting with the neurological assessment of an unconscious patient with a severe head injury. The nurse recognizes that which assessment finding is the most ominous neurological sign?
  • Positive corneal reflex
  • Extensor response to pain ✓
  • Flexion response to pain
  • Positive oculocephalic reflex
Correct Answer
Extensor response to pain
A. Abnormal extension posturing, formerly called decerebrate posturing, is rigid extension of the arms and legs. These signs indicate decerebrate posturing, which indicates disruption of the motor fibers in the midbrain; this is an ominous neurological sign. B. A positive oculocephalic reflex, also known as a doll’s eye, indicates that the brain stem is intact. When the head is turned, the eyes will deviate away from the direction the head is turned. When the eyes move in the same direction that the head is turned, this is a negative doll's eye response and indicates brain stem involvement. C. Corneal blink is normal; loss of corneal blink would indicate brain stem involvement. Reference Broering, B. (2020). Head trauma. In V. Sweet & A Foley (Eds.), Sheehy’s emergency nursing: Principles and practice (7th ed., pp. 401–418). Elsevier. D. Abnormal flexion posturing, formerly called decorticate posturing, indicates interruption of the cortical nerve fibers and intact pathways through the brain stem. Abnormal extension posturing is the most ominous sign. Category: Neurological Emergencies, Neurogenic shock
Question 55
A patient presents to triage with a puncture wound to the hand and a large, bloodstained bandage covering the wound. What is the priority assessment for the nurse to perform?
  • Ask the patient how the puncture wound occurred ✓
  • Ask the patient when they received their last tetanus immunization
  • Ask the patient the last time they ate or drank
  • Assess the brachial pulse in the affected extremity
Correct Answer
Ask the patient how the puncture wound occurred
A. Determination of mechanism of injury is important to ascertain extent of the injury and will help identify the likelihood of a foreign body being embedded in the wound. B. It is important to determine the patient’s tetanus immunization history; however, this can be performed after the wound has been assessed. C. Determining last fluid and solid intake is indicated if the patient will require surgery or anesthesia to repair the wound. Reference Denke, N. J. (2020). Wound management. In V. Sweet & D. Assessment of the brachial pulse is not warranted for a puncture wound of the hand because that pulse point is proximal to the wound. Depending on the location and severity of the wound, the radial pulse should be assessed in the affected hand. Category: Musculoskeletal and Wound Emergencies, Wound, Wound bleeding (e.g., uncontrolled external hemorrhage)
Question 56
A patient presents to the emergency department experiencing an acute ST elevation myocardial infarction. Your facility has no cardiac catheterization capability, and weather is preventing a timely transfer to another facility. You anticipate administering fibrinolytic therapy, understanding that the desired door-to-needle time is less than:
  • 30 minutes. ✓
  • 45 minutes.
  • 90 minutes.
  • 60 minutes.
Correct Answer
30 minutes.
A. If the patient meets the criteria for fibrinolytic therapy, a door-to-needle time (initiation of fibrinolytic agent) of 30 minutes is recommended currently, though this might move to 20 minutes. B. A preferred door-to-needle time of 45 minutes exceeds the desired time of 30 minutes. C. It is preferred that if fibrinolytic therapy is used for the treatment of STEMI, a door-to-needle time of 30 minutes is the target goal. D. The preferred door-to-balloon time for the treatment of STEMI is 90 minutes; for fibrinolytic therapy, the goal is a door-to-needle time of 30 minutes. Category: Cardiovascular Emergencies, Acute coronary syndrome
Question 57
A patient is being treated for the fifth time in 3 weeks for an episode of acute hypertension, with a BP of 210/130 mm Hg. The patient verbalizes compliance with the prescribed antihypertensive medications. An abdominal ultrasound and computed tomography scan confirm the presence of pheochromocytoma. Which statement made by the patient indicates the need for further instruction?
  • “In addition to the high blood pressure, the headaches and excessive sweating were also signs of this tumor.”
  • “It is possible that I will lose both my adrenal gland and my kidney as a result of treatment for this tumor.”
  • “I’ll have to await biopsy results to determine if this tumor is malignant.”
  • “I will need to increase my antihypertensive medication in order to control my blood pressure.” ✓
Correct Answer
“I will need to increase my antihypertensive medication in order to control my blood pressure.”
A. Pheochromocytoma is a tumor of the adrenal gland that causes excessive catecholamine secretion, which results in severe hypertension unrelieved by the administration of traditional antihypertensive medications. The hypertensive crisis is treated with phentolamine, an alpha-blocking agent, and possibly nitroprusside. B. The majority of pheochromocytoma tumors are benign. The presence of metastasis would indicate the presence of a malignancy. C. Adrenalectomy and tumor resection are the standard treatment for pheochromocytoma. In some cases, complete removal of the kidney is indicated to ensure that all pheochromocytoma tumor cells have been removed. D. Hypertensive crisis, in association with severe headache, palpitations, and diaphoresis, is consistent with a diagnosis of pheochromocytoma. Category: Medical Emergencies, Endocrine disorders
Question 58
A patient presents with progressive ascending muscular weakness, muscular pain, and dyspnea on exertion over the past two weeks. The patient recently had an upper respiratory infection. What is the most likely cause for this patient’s symptoms?
  • Spinal cord degeneration
  • Guillain–Barré syndrome ✓
  • Myasthenia gravis (MG)
  • Multiple sclerosis (MS)
Correct Answer
Guillain–Barré syndrome
A. Spinal cord degeneration may cause increased muscular weakness, but it is not associated with muscular aches and pain. B. MS may cause increased muscular weakness; however, it is usually associated with the presence of muscular spasms. The symptoms generally occur over a longer period in patients with MS, and MS is not associated with a recent viral illness. C. This is a common presentation for Guillain–Barré syndrome. The patient may also experience a sensitivity to light touch. The nurse should be prepared for the presence of possible respiratory compromise and the need for airway support. D. MG is an autoimmune disorder caused by a defect in neuromuscular transmission. The most common form is ocular MG, as evidenced by ptosis and diplopia. MG is not associated with leg numbness or an inability to walk. Category: Neurological Emergencies, Neurological disorders (e.g., multiple sclerosis, myasthenia gravis, Guillain-Barré syndrome)
Question 59
An elderly patient is being evaluated after a trip and fall onto carpet at home. The patient has left hip pain and is unable to bear weight on the injured hip. The nurse anticipates that the patient has which type of injury?
  • Pelvic fracture
  • Hip contusion
  • Lumbar spine fracture
  • Hip fracture ✓
Correct Answer
Hip fracture
A. A fractured hip is consistent with the mechanism of injury and presenting symptoms. Patients with osteoporosis and postmenopausal women are at increased risk for a fracture after a fall. B. Lumbar spine fracture is not consistent with this mechanism of injury. C. A contusion can be painful; however, it would be unlikely to significantly affect a patient’s weight-bearing status. D. Pelvic fractures are more common with falls from a height and are more likely to occur with a trip and fall mechanism onto a hard surface. Typically, patients will present with pain localized to one hip, and girdle pain. Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Fractures (e.g., open, closed, fat embolus)
Question 60
A patient is being discharged following treatment for a jellyfish sting. Which statement would demonstrate to the emergency nurse that the patient understands the discharge instructions?
  • “Apply ice packs and hydrocortisone cream to the area.”
  • “If tentacles are still present, I will rub them off with the palms of my hands.”
  • “If I get stung again, I will wash the area with hot water.” ✓
  • “Once I have been stung by a jellyfish, I am immune to the venom from future stings.”
Correct Answer
“If I get stung again, I will wash the area with hot water.”
A. Washing the area with hot water is recommended. Some home remedies include household vinegar, baking soda slurry, or meat tenderizer paste. B. If tentacles are present, skin protection must be used to prevent further envenomation to the rescuer. It is recommended that gloves or forceps be used when removing tentacles. C. Although the ice packs and hydrocortisone cream may supply symptomatic relief, immediate treatment for a jellyfish sting is to rinse the affected area with a hot shower. D. The body does not develop an immunity to the venom and would react each time following envenomation from a jellyfish. Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment, Envenomation emergencies
Question 61
A patient arrives following involvement in a rollover motor vehicle collision. The patient has sustained a partial amputation of the left forearm. Emergency medical services personnel report that direct pressure and elevation of the forearm have failed to control the bleeding, and the nurse observes pulsatile hemorrhaging. What is the priority intervention for this patient?
  • Prepare to assist with suturing the wound
  • Elevate the extremity above the level of the heart
  • Apply a pressure dressing to the forearm
  • Apply a tourniquet to the forearm ✓
Correct Answer
Apply a tourniquet to the forearm
A. Elevation is a recommended intervention with direct pressure. However, this intervention has already failed to control hemorrhage in this patient; therefore, the application of a tourniquet is indicated. B. The priority focus in a partial amputation is to control hemorrhage through direct pressure over the bleeding site or with direct compression of the artery. Partial amputations may result in uncontrolled bleeding that is due to retraction of severed arteries. In a complete amputation, the severed arteries will constrict and retract. C. Direct pressure is a first-line intervention. However, this intervention has already failed to control hemorrhage in this patient; therefore, the application of a tourniquet is indicated. D. Suturing the wound without ligating the severed artery (pulsatile bleeding) would be ineffective to control the bleeding. Reference Cline, K. M. (2020). Musculoskeletal trauma. In J. S. Blansfield (Ed.), Trauma Nursing Core Course provider manual (8th ed., pp. 189–208). Jones & Bartlett Learning. Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Amputation
Question 62
A patient presents, accompanied by law enforcement, after they were found urinating on vehicles at a stoplight. The patient states, “Voices told me to urinate on the cars.” The patient reports that they recently stopped taking prescribed medication, stating, “I don’t need it anymore. I’m better now.” The patient has a history of schizophrenia and is prescribed risperidone (Risperdal). The patient lives with their siblings, who act as their caretakers. They ask what happened to cause the patient to act in this manner and what can be done to prevent similar incidents in the future. The most appropriate response by the nurse is:
  • “They must take their medication as prescribed.” ✓
  • “They must be reminded that the police will be called.”
  • “They need to be placed in a mental health facility.”
  • “Nothing can be done to control the symptoms of schizophrenia.”
Correct Answer
“They must take their medication as prescribed.”
A. With an adequate support system and medication compliance, the patient should not require long-term care at an inpatient facility. Many patients with schizophrenia are able to live relatively normal lives. B. Many mentally ill individuals do find themselves in the criminal justice system, but this does little to help them or society. Appropriate health care, including symptom management with medication, is indicated for this patient. In this case, law enforcement was correct to bring the patient to the emergency department for evaluation instead of arresting the patient. Reference Pritts, W. S. (2020). Behavioral health emergencies. In V. Sweet & C. Although schizophrenia cannot be cured, it can be managed, and the symptoms controlled with proper treatment and medication. D. The family must take measures to ensure that the patient takes their antipsychotic medication as prescribed, and this may require supervised medication administration. It is important that family members understand importance of consistent medication administration, even if the patient feels better or misses doses. The family may also wish to discuss with the patient’s psychiatric healthcare provider an alternative to daily medication, such as long-acting medication via injection. Category: Mental Health Emergencies, Thought disorders (e.g., psychosis, schizophrenia)
Question 63
When evaluating research to improve a clinical process, which question is the most important to consider first?
  • Can the findings from the study be translated into a change in clinical practice?
  • Can the results be benchmarked with other hospitals?
  • Is the study design appropriate to the research question? ✓
  • How do the findings relate to current clinical practice guidelines?
Correct Answer
Is the study design appropriate to the research question?
A. It is important to find a study design that is not only appropriate to the question, but also feasible to implement in the practice setting. B. Research findings are not useful if they are not in compliance with current guidelines for clinical practice. However, if the study design is flawed, there is no need to evaluate the findings. C. Benchmarking results of a change in practice with other like facilities is part of the evaluation once the change in practice has been implemented. D. Knowledge is first gained from the critical appraisal of applicable research and then translated into a recommendation for change in clinical practice. If the study design is determined to be inappropriate, there is no need to evaluate the findings. Category: Professional Issues, Nurse, Evidence-based practice
Question 64
A patient presents with a sudden onset of right-sided lower abdominal pain and a past medical history of ovarian cyst. She notes intermittent stabbing pain that has become unbearable, with persistent nausea and multiple episodes of vomiting. The nurse has a high clinical suspicion that the patient’s current symptoms are most likely related to which of the following?
  • Ovarian torsion ✓
  • Endometriosis
  • Ectopic pregnancy
  • Appendicitis
Correct Answer
Ovarian torsion
A. A patient with endometriosis may be asymptomatic until the 2–7 days premenses. The discomfort is not acute and is usually bilateral. B. Ovarian torsion is a gynecological emergency that most often occurs secondary to an ovarian cyst. Patients experience a sudden onset of severe unilateral lower abdominal pain that is frequently accompanied by nausea, vomiting, and a low-grade fever. Diagnostic delay of ovarian torsion can lead to ischemia of the ovary with resulting infection, ovarian necrosis, and infertility. C. Symptoms of appendicitis can vary, starting with diffuse, periumbilical pain that later becomes more intense and localized to the lower right quadrant. Nausea, vomiting, fever, and rebound tenderness may also be present. These symptoms may mimic those of ovarian torsion, but the history of an ovarian cyst makes ovarian torsion, not appendicitis, the more likely diagnosis. D. Presentation with an ectopic pregnancy frequently includes a history of being approximately 12 weeks’ gestation, with pelvic pain and/or vaginal bleeding. Because of the history of ovarian cyst, ovarian torsion is a higher probability. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gynecology, Ovarian disorders (e.g., cyst, torsion, rupture)
Question 65
Which of the following assessment findings would cause the emergency nurse to become suspicious for the presence of possible child maltreatment?
  • Small vesicles surrounded by reddened skin on the face of a toddler
  • Bruising on the ears and neck of an infant ✓
  • Bruises in various stages of healing on the knees and legs of a toddler
  • Red, blotchy, circular lesions on the torso of an infant
Correct Answer
Bruising on the ears and neck of an infant
A. The presence of bruising found on the face, ears, torso, or neck of a child younger than 4 years of age and that is inconsistent with the patient history is considered a red flag for the presence of possible child maltreatment and should be further investigated. B. Numerous lesions that are reddened, blotchy, and circular in appearance is the description of erythema multiforme and is not consistent with the presence of child maltreatment. C. Numerous small vesicles surrounded by the presence of reddened skin is the description of impetigo and is not consistent for the presence of child maltreatment. D. By the age of 18 months, the infant has now become a toddler and is able to run. The head that is larger in proportion to the rest of their body makes the toddler more susceptible to falling and the subsequent development of numerous bruises in various stages of healing. Category: Professional Issues, Patient, Abuse and neglect
Question 66
In caring for a patient with sickle cell disease who is in vaso-occlusive crisis, which of the following would be the priority intervention?
  • Application of heat to extremities
  • Pain medication ✓
  • Blood transfusion
  • Antibiotics
Correct Answer
Pain medication
A. Patients in sickle cell crisis may require a blood transfusion. Ensuring that the blood is warmed during the transfusion will assist in alleviating some of the patient’s discomfort; however, the administration of pain medication is the priority. B. Antibiotics may be indicated if the patient is febrile or has focal infection, or if infection is suspected. The priority intervention, given the scenario provided, is to provide pain medication. C. The application of warmth to the affected areas is an appropriate nonpharmacological pain management strategy, but the administration of pain medication will provide greater relief for a patient in severe pain. D. Patients in sickle cell crisis experience severe pain caused by the “sickling” or clumping of red blood cells, which results in decreased oxygen delivery to tissue. The hypoxia that develops results in severe pain. Therefore, pain management is a priority for patients in sickle cell crisis. Patients experiencing severe pain will require opioids or ketorolac (Toradol) for pain control. Category: Medical Emergencies, Hematologic disorders
Question 67
The nurse is assisting a student nurse with placing an indwelling urinary catheter into a female patient. After the patient is cleaned with povidone iodine and the catheter is inserted, the patient states that they are allergic to iodine. What is the next intervention that should be performed for this patient?
  • Report the student nurse for making a patient care error
  • Clean the exposed skin with mild soap and water ✓
  • Prepare to administer epinephrine to the patient
  • Remove the indwelling catheter immediately
Correct Answer
Clean the exposed skin with mild soap and water
A. The emergency nurse and student nurse should have discussed allergies with the patient before the procedure so that an alternative cleansing agent could have been used if preferred by the patient. Although this would have been a better practice decision, the use of iodine cleaner does not constitute a medication error, and the emergency nurse is equally responsible for the integrity of the procedure. B. Iodine can be irritating to the skin, but it is a naturally occurring element and is essential in the production of thyroid hormones. Topical iodine sensitivity may result in a rash. Ingested or infused products containing iodine may result in anaphylaxis. The patient and the student nurse should be reassured that an anaphylactic reaction from the topical exposure to iodine is very unlikely. Washing the affected area will minimize the potential for irritation. C. Removing the catheter is not necessary because the exposure to the iodine was topical, not ingested or internal. D. If the patient develops signs and symptoms of an anaphylactic reaction, epinephrine would most likely be used; however, the patient is currently not having symptoms of an anaphylactic reaction and is unlikely to have one with topical exposure to iodine. Category: Medical Emergencies, Allergic reactions and anaphylaxis
Question 68
A patient presents after prolonged exposure to cold temperatures. Which of the following assessment findings may be seen in moderate hypothermia (28–32°C/82–90°F)?
  • Absent reflexes
  • Shortened QT
  • Oliguria
  • Loss of shivering reflex ✓
Correct Answer
Loss of shivering reflex
A. As the core body temperature decreases below 31°C, shivering decreases and eventually stops around 30° B. Prolonged QT interval is a pathological change that can occur within the cardiovascular system when the body is exposed to prolonged hypothermia. C. Absence of reflexes is seen in severe hypothermia. D. Renal cell dysfunction and decreased levels of vasopressin (ADH) lead to production of a large volume of dilute urine (cold diuresis). Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment, Temperature-related emergencies
Question 69
An older adult female presents to the emergency department with epigastric pain, nausea, and vomiting. A 12-lead electrocardiogram shows ST segment elevation in leads II, III, and aVF, with reciprocal changes in leads I and aVL, ST segment elevation in lead V1, and ST segment depression in lead V2. Prior to transfer to the catheterization lab for emergent percutaneous coronary intervention, which of the following intravenous medications is the most appropriate to administer?
  • Morphine
  • Nitroglycerin
  • Dobutamine ✓
  • Furosemide
Correct Answer
Dobutamine
A. ST segment elevation in leads II, III, and aVF indicate an inferior MI. Also, stand-alone ST elevation in lead V1 (the lead that looks the most at the right ventricle) may indicate right ventricular myocardial infarction (RVMI). In the presence of a RVMI, it is important to maintain adequate RV preload. Dobutamine has been shown to improve right ventricular stroke volume and improves left ventricular function. Preload-reducing agents such as nitrates, diuretics, and morphine should be avoided in RVMI because of risk of hypotension and cardiogenic shock. B. Preload-reducing agents such as nitrates, diuretics, and morphine should be avoided in RVMI because of risk of hypotension and cardiogenic shock. C. Preload-reducing agents such as nitrates, diuretics, and morphine should be avoided in RVMI because of risk of hypotension and cardiogenic shock. D. Preload-reducing agents such as nitrates, diuretics, and morphine should be avoided in RVMI because of risk of hypotension and cardiogenic shock. Category: Cardiovascular Emergencies, Acute coronary syndrome
Question 70
A patient presents with a nosebleed for the past 60 minutes. Measures to stop the bleeding have been unsuccessful, and the patient is repeatedly spitting up blood. The nurse suspects that the patient is experiencing which of the following?
  • Anterior epistaxis
  • Severe rhinitis
  • Nasal foreign body
  • Posterior epistaxis ✓
Correct Answer
Posterior epistaxis
A. Posterior epistaxis involves the ethmoidal arteries of the roof of the nasal chamber or the posterior septum, leading to bleeding from the lateral walls. Posterior epistaxis is more profuse than other nosebleeds, resulting in dripping of blood down the throat. Nasal packing to control the bleeding may be required. B. Anterior epistaxis is more common than posterior epistaxis and occurs from the arteries of the anterior and inferior portions of the nasal septum, referred to as Kiesselbach’s plexus. C. Rhinitis is an inflammatory condition resulting in edema of the nasal membranes and nasal discharge that can result in obstruction of the nasal passages. It is most associated with viral and bacterial infections. D. Nasal foreign bodies occur most commonly in small children and are the result of small objects that are placed in the nasal passage, lodging in the turbinates. The foreign body can remain in place for an extended period, resulting in nasal edema, nasal tenderness, and bleeding from repeated attempts to remove the object. Category: Maxillofacial and Ocular Emergencies, Maxillofacial, Epistaxis
Question 71
A 52-year-old patient arrives with weight loss and urinary tract infection secondary treatment for esophageal cancer. The patient consents to receiving intravenous antibiotics but continues to refuse the placement of a feeding tube for nutrition. As the nurse caring for this patient, you have an ethical issue regarding this plan of care. What should you do next?
  • Send the patient for the procedure and consult with the hospital’s ethics committee.
  • Continue to care for and provide support to this patient. ✓
  • Enlist the patient’s family to convince them to have the feeding tube placed.
  • Refuse to care for the patient while in the emergency department.
Correct Answer
Continue to care for and provide support to this patient.
A. The nurse’s primary commitment is to the patient, whether an individual, family, group, or community. The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient. The nurse would violate the nurse–patient relationship by speaking with the family. B. The nurse’s obligation is to ensure the primacy of the patient’s interests regardless of conflicts that arise between clinicians or patient and family. This collaboration “requires mutual trust, recognition, respect, transparency, shared decision-making and open communication among all who share concern and responsibility for health outcomes; this includes physician collaboration.” Reference Matamoros, L. (2020). Ethical considerations. In V. Sweet & C. This answer focuses on the right to self-determination. This patient has the capacity to understand his diagnosis and participate in the decision for his care (the feeding tube). D. “The nurse promotes, advocates for, and protects the rights . . . of the patient.” As this interpretative statement indicates, nurses do not need to agree with patient choices, but they are required to set aside any bias or prejudice. The nurse cannot refuse to care for the patient but can request another assignment. Category: Professional Issues, Patient, End-of-life and Palliative Care (e.g., organ and tissue donation, advance directives, care withholding, family presence)
Question 72
A patient has been diagnosed with a traumatic knee effusion secondary to a ligamentous sports injury. The emergency provider aspirates fluid surrounding the knee. The nurse knows the patient understands the discharge teaching when they state which of the following?
  • “I will need to have a follow-up surgical procedure done under anesthesia.”
  • “The aspiration will most likely provide only temporary relief.” ✓
  • “Nonsteroidal anti-inflammatory drugs will eliminate extra fluid from the area.”
  • “The knee immobilizer will compress any new or remaining fluid.”
Correct Answer
“The aspiration will most likely provide only temporary relief.”
A. If the ligamentous injury is severe, surgery may be indicated; however, knee aspirations are usually all that is needed for the effusion. B. Aspiration will most likely provide only temporary relief and have no impact on clinical outcome. Aspiration may be useful in establishing a diagnosis for nontraumatic effusions that develop with an unknown origin; however, this effusion is related to a recent sports injury. C. Application of a knee immobilizer and the use of crutches to limit movement and protect the joint while it heals may be indicated; however, a knee immobilizer will not compress or minimize the amount of fluid. D. Nonsteroidal anti-inflammatory drugs (NSAIDs) are often prescribed to help decrease inflammation and pain; however, there is no evidence that NSAIDS are beneficial in the elimination of excess fluid from the area. Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Inflammatory conditions
Question 73
Research has indicated a positive correlation between emergency department patient satisfaction and which characteristic demonstrated by the emergency department staff?
  • Fluency in alternative languages
  • Female rather than male gender
  • Highest level of education
  • Caring attitude ✓
Correct Answer
Caring attitude
A. Empathy and a caring attitude of staff toward patients has repeatedly scored highly as a predictor of patient satisfaction in the emergency department, outweighing wait times in multiple surveys. B. Perceived technical skills of the healthcare provider are positively associated with patient satisfaction, but this has not been correlated with the provider’s education level. C. Among certain populations, female physicians are preferred as care providers, but gender preference has not been extensively studied among nursing personnel. D. Language barriers are recognized as a barrier to patient satisfaction but to date have not been studied as a significant predictor of patient satisfaction. Category: Professional Issues, Patient, Patient satisfaction
Question 74
A patient arrives at the emergency department with chest pain, pedal edema, hypotension, and jugular venous distention. Lungs are clear to auscultation without rales or rhonchi. This patient has most likely experienced an acute myocardial infarction to which area of the heart?
  • Posterior wall of the left ventricle
  • Inferior wall of the right ventricle ✓
  • Anterior wall of the left ventricle
  • Lateral wall of the left ventricle
Correct Answer
Inferior wall of the right ventricle
A. The classic triad of an acute right ventricle myocardial infarction is hypotension, absence of pulmonary congestion, and jugular venous distention. B. Left ventricular dysfunction commonly causes venous pulmonary congestion, resulting in the presence of rales and rhonchi. C. Left ventricular dysfunction commonly causes venous pulmonary congestion, resulting in the presence of rales and rhonchi. D. Left ventricular dysfunction commonly causes venous pulmonary congestion, resulting in the presence of rales and rhonchi. Category: Cardiovascular Emergencies, Acute coronary syndrome
Question 75
A patient states that they are unable to swallow, and drooling is noted from the left side of the mouth. Recent past medical history is significant for a sore throat and fever. What is the priority intervention for this patient?
  • Ensure that the airway is patent ✓
  • Initiate intravenous hydration
  • Administer intravenous antibiotics
  • Arrange for inpatient admission
Correct Answer
Ensure that the airway is patent
A. This patient may have a compromised airway. The history of impaired swallowing and inability to control oral secretions are highly suspicious for the presence of tracheal edema. Prepare for endotracheal intubation if airway occlusion is suspected. B. Empiric antibiotics may be indicated for this patient, but establishing a patent airway is the priority intervention. C. Although patients who are unable to swallow are at risk for dehydration and will require fluid administration, establishing a patent airway is the priority intervention. D. Some patients with impaired swallowing and difficulty controlling oral secretions will require hospital admission. The decision to admit will be determined by the cause of the impaired swallowing and the prognosis. Establishing a patent airway is the priority intervention. Category: Maxillofacial and Ocular Emergencies, Maxillofacial, Maxillofacial infections (e.g., Ludwig’s angina, otitis, sinusitis, mastoiditis)
Question 76
Parents of a 6-month-old infant arrive to triage, stating that the child is not eating and intermittently cries out while flexing knees to the chest as if in severe pain. The emergency nurse should consider which of the following symptoms to be a sign of the need for immediate intervention?
  • Bulging abdominal mass with crying
  • Stool leakage or incontinence
  • Vomiting after every meal
  • Palpable sausage-shaped mass ✓
Correct Answer
Palpable sausage-shaped mass
A. Pyloric stenosis, which is caused by a constriction of the pylorus that creates an obstruction, is common in newborns. Infants with this problem vomit after feedings, are constantly hungry, and do not gain weight. B. An incarcerated hernia in an infant appears as a bulging in the abdomen that increases with crying or attempts at bowel movements. It can also manifest during fits of coughing and laughing. C. Intussusception occurs when a section of the bowel telescopes on itself; if left untreated, gangrene and sepsis can develop. Symptoms consist of a palpable sausage-shaped mass in the abdomen with vomiting, and colicky abdominal pain that presents with the infant intermittently pulling their legs to their chest and crying. The “classic” currant-jelly stools are a late sign. D. Stool leakage and/or incontinence is usually seen with constipation. There is rarely a significant gastrointestinal reason for the hard stools. It is usually related to their diet. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Intussusception
Question 77
When caring for a patient who is a suspected victim of human trafficking (HT), it is important for the emergency nurse to be aware of which of the following?
  • Emergency nurses are often the first healthcare professionals to interact with a victim of HT. ✓
  • Victims of HT trust emergency nurses and will accept interventions for assistance.
  • Victims of HT are most often used for sex trafficking, such as prostitution or forced marriage.
  • HT primarily occurs in emerging nations and is seldom seen in affluent countries.
Correct Answer
Emergency nurses are often the first healthcare professionals to interact with a victim of HT.
A. HT is seen worldwide. It is estimated that more than 600,000 children in the United States are used in the sex industry or in forced labor in agriculture. B. HT is used not only to provide sex workers of all ages, but also for forced labor or debt bondage worldwide. C. HT victims are often subjected to physical violence or neglect, which may result in serious injury or malnutrition that requires emergency department evaluation. D. Victims of HT will generally show fear and distrust for a variety of reasons. They may come from countries where law enforcement is corrupt, or they may have been “brainwashed” by their trafficker into believing that healthcare professionals are not to be trusted. Category: Professional Issues, Patient, Human trafficking
Question 78
Glucagon is administered to a patient who was unable to swallow after eating. Which of the following would indicate the treatment is effective?
  • Blood glucose increases.
  • The patient is able to speak in short phrases.
  • The patient appears less anxious. ✓
  • Drooling is increased.
Correct Answer
The patient appears less anxious.
A. The purpose of glucagon in this instance is to relax the smooth muscles of the esophagus and allow for passage of the food bolus, not to increase the patient’s glucose level. B. An esophageal obstruction would cause anxiety, drooling, and increased respiratory difficulty. Intravenous glucagon relaxes the smooth muscles of the esophagus, allowing the food bolus to pass. The treatment is effective when the patient is less anxious and able to swallow normally. C. This would indicate a worsening condition in which saliva is building up and is unable to be swallowed. D. The expectation is that the patient can speak clearly in complete sentences. If only short phrases are managed, this demonstrates that the patient’s airway is still partially obstructed. Category: Respiratory Emergencies, Aspiration
Question 79
The nurse is preparing to place traction splint on patient who has sustained which type of lower body trauma?
  • Ankle and foot fracture
  • Pelvic fracture
  • Femur fracture ✓
  • Hip fracture
Correct Answer
Femur fracture
A. A traction splint is indicated for midshaft femur fractures or proximal tibia fractures to reduce pain and minimize blood loss. The splint will stabilize the fracture and reduce muscle spasms that contribute to the pain. B. A fractured pelvis should be treated with a pelvic binder, not a traction splint. A fracture of the pelvis with concurrent fracture of the femur is a contraindication for the use of any type of traction splint. C. Fractures of the ankle and foot are contraindicated for the use of a traction splint. The ankle harness and resultant traction may result in excessive pressure to the area and further complicate the injury. D. A traction splint is contraindicated for treatment of a fractured hip. In some cases, if there is a concurrent femur fracture and the provider orders a traction splint, application of a pelvic binder should occur before application of the traction splint. Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Fractures (e.g., open, closed, fat embolus)
Question 80
While caring for a pediatric patient with hemophilia, the nurse identifies the parents’ need for further education regarding their child’s illness when they state:
  • “Ibuprofen is the preferred over-the-counter pain medication for minor injuries.” ✓
  • “Cold compresses may be used to reduce discomfort and swelling after a minor injury.”
  • “Direct pressure is the best way to control bleeding after an injury.”
  • “Our child should get regular exercise, but contact sports might not be the best.”
Correct Answer
“Ibuprofen is the preferred over-the-counter pain medication for minor injuries.”
A. Direct pressure should be the first intervention to control bleeding. B. Patients with hemophilia should be active and participate in exercise, but they should usually avoid contact sports because of the increased risk of bleeding. C. Cold compresses can be used to manage minor injuries and may help control bleeding through vasoconstriction. D. Nonsteroidal anti-inflammatory drugs such as ibuprofen are associated with platelet inhibition and may increase the risk of bleeding in patients with hemophilia. Acetaminophen should be used for fever and pain control related to minor injuries in patients with hemophilia. Category: Medical Emergencies, Hematologic disorders
Question 81
A patient arrives with signs and symptoms of an acute heroin overdose. Which priority intervention should the nurse initiate for this patient?
  • Application of physical restraints
  • Administration of nalmefene (Revex)
  • Maintaining airway and breathing with a bag-mask device ✓
  • Administration of naloxone (Narcan)
Correct Answer
Maintaining airway and breathing with a bag-mask device
A. Patients presenting with heroin overdose are usually lethargic or unresponsive to stimuli and therefore would not warrant physical restraint. Should the patient become agitated or aggressive, physical restraint may be needed at that time. B. Nalmefene is an opioid antagonist that can be administered to this patient; however, maintaining a patent airway and breathing support take priority. C. Naloxone is a rapid-acting narcotic antagonist that can be given via various routes of administration. However, airway patency and breathing support take priority while preparing to administer naloxone. D. Airway and breathing should always be supported during signs and symptoms of an acute overdose. Respiratory signs of acute heroin overdose include respiratory depression, hypotension, and coma. Airway assessment and immediate intervention with a bag-mask device as needed must take priority. Category: Medical Emergencies, Substance use and abuse (e.g., alcohol and drug interactions, side effects, unintentional overdose)
Question 82
A 29-week-pregnant patient arrives after being involved in a low-speed motor vehicle collision. On arrival, the patient is complaining of intermittent abdominal pain that has progressed to increased abdominal cramping with a backache. Fetal heart tones are audible at 120 beats/minute. Which of the following conditions does the nurse suspect is causing her symptoms?
  • Placenta previa
  • Uterine rupture
  • Preterm labor ✓
  • Placental abruption
Correct Answer
Preterm labor
A. Placenta previa presents with bright red vaginal bleeding that is not accompanied by uterine contractions, so there is usually no associated abdominal pain. B. Signs and symptoms of preterm labor include uterine contractions that occur every 10 minutes or less, abdominal cramping, backache, pelvic pressure, and an increase or change in vaginal discharge or bleeding. The patient’s initial complaint of intermittent abdominal pain that increases to stronger cramping and a backache is suggestive of uterine contractions and preterm labor. C. Symptoms of placental abruption include uterine rigidity, backache, abdominal pain or tenderness, vaginal bleeding, and a decreased or absent fetal heart rate. D. Symptoms of uterine rupture include a sudden onset of abdominal pain related to major trauma, vaginal bleeding, fetal bradycardia or asystole, and maternal hypovolemic shock. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Obstetrical, Preterm labor
Question 83
What is the normal life span for red blood cells (RBCs) in patients with sickle cell disease?
  • 25–35 days
  • 5–10 days
  • 35–40 days
  • 10–20 days ✓
Correct Answer
10–20 days
A. The life span of RBCs in patients with sickle cell disease is 10–20 days; the life span of RBCs in patients without sickle cell disease is 120 days. The increased production of erythrocyte precursors (reticulocytes) in patients with sickle cell, coupled with the short life span of RBCs that sickle, leads to increased reticulocyte counts and chronic anemia because production cannot keep up with demand in the shorter RBC life span. B. The life span of RBCs in patients with sickle cell disease is 10–20 days; the life span of RBCs in patients without sickle cell disease is 120 days. C. The life span of RBCs in patients with sickle cell disease is 10–20 days; the life span of RBCs in patients without sickle cell disease is 120 days. D. The life span of RBCs in patients with sickle cell disease is 10–20 days; the life span of RBCs in patients without sickle cell disease is 120 days. Reference Pritts, W. S. (2020). Hematologic and oncologic emergencies. In V. Sweet & Category: Medical Emergencies, Hematologic disorders
Question 84
While caring for an adult patient with an acute asthma exacerbation, the nurse observes that the patient’s respirations have decreased from 40 breaths/minute to 8 breaths/minute. What priority intervention should the emergency nurse take next?
  • Prepare for rapid sequence intubation ✓
  • Increase the patient’s supplemental oxygen
  • Note that the treatments are successful
  • Decrease the patient’s supplemental oxygen
Correct Answer
Prepare for rapid sequence intubation
A. A sudden decrease in respirations does not indicate successful treatment; rather, it indicates that the patient can no longer sustain the ineffective breathing pattern and increased work in breathing. The patient is at risk for a respiratory arrest and requires immediate intubation. B. The patient is experiencing severe respiratory depression and will require high-flow oxygen and possibly ventilation support with a bag-mask device until a more definite airway can be established. C. This patient is experiencing acute respiratory depression with impending respiratory arrest. The patient’s airway will need to be maintained and ventilation supported. D. The patient should already be on high-flow supplemental oxygen. The patient with respiratory depression with impending respiratory arrest will likely require ventilation support with a bag-mask device until a more definite airway can be established. Category: Respiratory Emergencies, Asthma
Question 85
A recent kidney transplant patient who is currently taking antirejection medications presents with complaints of a swollen, painful ankle after tripping at home. Which initial action implemented by the nurse is most appropriate for this patient?
  • Apply an ice pack and elevate the extremity on a pillow.
  • Request a STAT radiograph of the injured ankle.
  • Mask the patient and take them to a private room. ✓
  • Assess the distal pulse of the injured extremity.
Correct Answer
Mask the patient and take them to a private room.
A. Patients who are immunocompromised, such as those taking antirejection drugs, are at risk of becoming ill from exposure to others with even a minor infectious process. The patient should be placed in a private room, where the focused assessment of the injured extremity will be performed. B. The immunosuppressed patient is at risk of contracting an infectious disease from other patients in the triage area and waiting room. Once the patient has been placed in a private room, treatment of the injury, including wrapping a compression bandage around the foot and ankle, applying an ice pack, and elevating the extremity, should be performed. Reference Smith, N. Z. (2018). Hematologic/oncologic emergencies. In V. Sweet (Ed.), Emergency nursing core curriculum (7th ed., pp. 290–305). Elsevier. C. Assessing the distal pulse of the injured extremity is important when assessing the injury; however, an immunosuppressed patient contracting an infectious disease from the other patients in the triage and waiting areas is the greater risk initially. Once the patient has been placed in a private room, the distal pulses should be assessed. D. A radiograph of the injured extremity will most likely be requested, however, protecting the immunosuppressed patient from contracting an infectious disease from the other patients in the triage and waiting areas is the priority. Category: Professional Issues, Patient, Patient safety
Question 86
A patient with a 2-day history of abdominal pain, distention, and vomiting of fecal-smelling material is diagnosed with a small bowel obstruction. Which of the following is the priority intervention for the emergency nurse to perform?
  • Obtain intravenous access ✓
  • Insert a nasogastric tube
  • Administer an antiemetic medication
  • Apply oxygen using a face mask
Correct Answer
Obtain intravenous access
A. A life-threatening complication of an intestinal obstruction is hypovolemia due to the presence of third spacing. The priority intervention for the nurse is to begin fluid resuscitation with crystalloid fluids to avoid hypovolemic shock. B. Antiemetic medications may be indicated if the patient continues to vomit, however, fluid resuscitation is the priority and should be the nurse’s first intervention. C. Insertion of a nasogastric tube may be indicated to decompress the stomach and bowel, however, because of the intense third-spacing effects associated with a bowel obstruction, the priority intervention is to begin crystalloid fluid resuscitation to avoid hypovolemic shock. D. There is no immediate indication that the patient is hypoxic. The priority intervention is to begin fluid resuscitation to avoid hypovolemic shock. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Obstructions
Question 87
A patient with a history of chronic obstructive pulmonary disease arrives via emergency medical services in severe respiratory distress and with a decreased level of consciousness. Which of the following arterial blood gas (ABG) results would be expected with carbon dioxide narcosis?
  • pH 7.35; pCO2 40 mm Hg; HCO3 38 mEq/L; pO2 94 mm Hg
  • pH 7.47; pCO2 30 mm Hg; HCO3 40mEq/L; pO2 110 mm Hg
  • pH 7.20; pCO2 108 mm Hg; HCO3 65 mEq/L; pO2 52 mm Hg ✓
  • pH 7.40; pCO2 50 mm Hg; HCO3 40mEq/L; pO2 66 mm Hg
Correct Answer
pH 7.20; pCO2 108 mm Hg; HCO3 65 mEq/L; pO2 52 mm Hg
A. A normal pH and slightly elevated pCO2 values are evident; the pO2 represents hypoxia. In a patient with COPD, the pO2 may represent a patient’s normal baseline value. B. The ABG values reflect hypercapnia, hypoxia, and severe respiratory acidosis. Signs of abnormally high carbon dioxide initially may begin with headache and dizziness, followed by mental confusion, increasing somnolence, and coma. C. An elevated pH, low pCO2, and elevated pO2 values are consistent with the presence of respiratory alkalosis and hyperventilation. D. These are normal ABG values. Category: Respiratory Emergencies, Chronic obstructive pulmonary disease (COPD)
Question 88
A hiker presents with a possible snake bite to the left lower leg. The patient is noted to have two puncture wounds to the left calf, with edema and ecchymosis, and describes a metallic taste in their mouth. The greatest threat to this individual is
  • internal bleeding. ✓
  • nausea and vomiting.
  • edema to the left lower calf.
  • blood-filled vesicles proximal to the bite.
Correct Answer
internal bleeding.
A. Based on the presentation, this patient was bitten by a pit viper. Their venom can cause a severe consumptive coagulopathy that can affect different parts of the coagulation pathway and lead to internal bleeding. B. Edema to the affected area represents a local reaction to the snake bite. If the edema becomes severe, it can lead to compartment syndrome. C. Blood-filled vesicles can develop within hours of the bite but represent a local reaction to the snake bite. D. Nausea and vomiting are systemic reactions to the snake bite but do not represent a severe systemic reaction. Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment, Envenomation emergencies
Question 89
A patient arrives in the emergency department complaining of pain in the left leg. The nurse suspects an arterial occlusion. Which of the following positions is indicated for this patient?
  • Place the patient in a slight Trendelenburg position
  • Elevate the head of the bed with the legs slightly elevated
  • Place the patient supine with the affected leg slightly elevated
  • Elevate the head of the bed slightly, with the affected leg slightly lower ✓
Correct Answer
Elevate the head of the bed slightly, with the affected leg slightly lower
A. Any elevation that results in the affected limb being higher than the patient’s head will act to decrease whatever blood flow could still flow through remaining collateral circulation. B. Any elevation of the legs will act to decrease the blood flow that could still flow through remaining collateral circulation. C. Any elevation of the legs will act to decrease the blood flow that could still flow through remaining collateral circulation. D. Elevating the patient’s head slightly with the affected limb slightly lower will help to maximize the blood flow to the affected limb. Category: Cardiovascular Emergencies, Thromboembolic disease (e.g., deep vein thrombosis [DVT])
Question 90
A chest radiograph is performed on a patient who complains of fever and a productive cough. The emergency provider identifies the presence of a left lower lobe opacity on the chest radiograph. The emergency nurse is aware that this finding is consistent with which disease process?
  • Pneumonia ✓
  • Congestive heart failure
  • A normal chest X-ray
  • A foreign body
Correct Answer
Pneumonia
A. Opacity on a chest X-ray, along with the patient’s symptoms of fever and productive cough, is consistent with pneumonia. B. In a patient with congestive heart failure, the chest X-ray would have the presence of bilateral pleural effusions or pulmonary edema. C. A consolidated lung or opacity is consistent with pneumonia and is not a normal finding on a chest X-ray. Reference Foley, A., Sweet, V. (2020). Respiratory emergencies. In V. Sweet & D. The image is described as an opacity; this is consistent with the presence of pneumonia, not a foreign body. Category: Respiratory Emergencies, Infections
Question 91
Which of the following findings would the emergency nurse expect to find in a patient who is experiencing a hypertensive crisis?
  • Diastolic blood pressure of 100 mm Hg
  • Normal electrocardiogram (ECG)
  • Presence of S3 and S4 heart sounds ✓
  • Increased urinary output
Correct Answer
Presence of S3 and S4 heart sounds
A. In patients with severe hypertension, it is anticipated that their urinary output will be less than normal and not increased. B. The presence of S3 and S4 heart sounds is an indicator of heart failure and signifies the presence of cardiovascular compromise secondary to uncontrolled blood pressure. C. The ECG of a patient in hypertensive crisis will not be normal. Changes that may be seen include ischemic changes, ST segment and T-wave abnormalities, and axis deviation. D. A hypertensive crisis is defined as diastolic blood pressure that is greater than 120 mm Hg. Hypertension is defined in part by a diastolic blood pressure that is greater than 90 mm Hg. Category: Cardiovascular Emergencies, Hypertension
Question 92
Which of the following findings would alert the emergency nurse that the patient complaining of chest pain is experiencing signs and symptoms of pericarditis?
  • Widespread ST segment elevation ✓
  • Reciprocal electrocardiogram (ECG) changes in the opposing leads
  • Chest pain that decreases with inspiration
  • Chest pain that increases when the patient leans forward
Correct Answer
Widespread ST segment elevation
A. Chest pain will increase with inspiration, not decrease, in a patient with pericarditis. B. Reciprocal ECG changes in the opposing leads occur in the presence of an acute myocardial infarction but not in patients with pericarditis. C. Patients with pericarditis will indicate that their chest discomfort is lessened when they are able to lean forward. A pericardial friction rub may increase in intensity when the patient leans forward. D. In the presence of pericarditis, there is widespread ST elevation in all leads except aVR and V1. There may be peaked T-waves present in aVR and V1. Category: Cardiovascular Emergencies, Pericarditis
Question 93
A patient arrives with a severe asthmatic attack and immediately has a cardiopulmonary arrest. There is no pulse or spontaneous respirations. What is the priority intervention?
  • Obtain intravenous access
  • Begin chest compressions ✓
  • Initiate albuterol nebulizer
  • Begin bag-mask ventilations
Correct Answer
Begin chest compressions
A. Any patient in cardiopulmonary arrest should have basic CPR initiated starting with compressions. B. Any patient in cardiopulmonary arrest should have basic CPR initiated, starting with compressions. The nebulizer is not indicated at this point because it requires the patient to breathe in the medication. C. Any patient in cardiopulmonary arrest should have basic CPR initiated, starting with compressions. Bag-mask ventilations should be initiated, but compressions are the first intervention. D. Any patient in cardiopulmonary arrest should have basic CPR initiated, starting with compressions. Intravenous access should be attempted, but chest compressions come first. Category: Cardiovascular Emergencies, Cardiogenic shock and obstructive shock
Question 94
Following a stressful event in the emergency department, the manager schedules a critical incident stress debriefing session for the involved staff. During the session, the conversation should focus on:
  • identified opportunities for process improvement.
  • defining normal and abnormal reactions to a stressful event.
  • the medical and nursing care that was provided to the patient.
  • the thoughts, feelings, and reactions of the involved staff. ✓
Correct Answer
the thoughts, feelings, and reactions of the involved staff.
A. Critical incident stress management, or CISM, is a learning and recognition process for reactions to stress; participants are not told how they should deal with feelings but are given additional resources in case they have difficulty coping with the feelings or behaviors. Reference Cardinal, S. (2018). What is CISM? Understanding CISM. http://www.criticalincidentstress.com/what_is_cism_ B. Critical incident stress management (CISM) is an intervention protocol developed specifically for dealing with traumatic events. It is a formal, highly structured, professionally recognized process for helping those involved in a critical incident to share their experiences, vent emotions, learn about stress reactions and symptoms, and receive a referral for further help if required. It is not psychotherapy; it is a confidential, voluntary, and educative process sometimes called “psychological first aid.” C. Critical incident stress management, or CISM, deals with feelings only and does not focus on any part of the patient care process. It is not psychotherapy; it is a confidential, voluntary, and educative process sometimes called “psychological first aid.” D. Critical incident stress management, or CISM, deals with feelings only and does not focus on any part of the patient care process. It is not psychotherapy; it is a confidential, voluntary, and educative process sometimes called “psychological first aid.” Category: Professional Issues, Nurse, Stress management (e.g., burnout, compassion fatigue, PTSD)
Question 95
A young male presents stating that he is experiencing severe pain in his right testicle. The pain began suddenly, awakening him from sleep. Which of the following conditions should the emergency nurse suspect?
  • Epididymitis
  • Priapism
  • Testicular torsion ✓
  • Sexually transmitted infection (STI)
Correct Answer
Testicular torsion
A. Priapism is a painful and sustained erection not associated with sexual arousal. B. Epididymitis, an inflammatory condition of the epididymis, occurs gradually, presents as a dull type of ache in the scrotum, and is often associated with discharge. It usually occurs in older males between the ages of 19 and 40, although it can occur in younger males as well. C. Testicular torsion occurs because of a sudden twisting of the spermatic cord, resulting in vascular compromise to the male testis. Testicular torsion can occur during sleep or be the result of trauma or sudden movement. The patient experiences abdominal or scrotal pain, nausea, and vomiting and may have an upwardly retracted testicle. If left untreated, testicular torsion will result in sterility. D. Males frequently experience dysuria, urethral itching, and symptoms of epididymitis in the presence of an STI. The most common causes of an STI are C. trachomatis and N. gonorrhoeae. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Genitourinary, Testicular torsion
Question 96
A patient presents via emergency medical services in full spinal immobilization after falling from a tree. The patient is not under the influence. The nurse anticipates removal of the cervical collar from this patient based on which of the following findings?
  • Intoxicated and complaining of neck discomfort from the collar
  • Alert, oriented, no complaints of pain, and no neurologic abnormalities ✓
  • Alert, oriented, moving all extremities, and complaining of midline tenderness
  • Intoxicated, no complaints of pain, and moving all extremities
Correct Answer
Alert, oriented, no complaints of pain, and no neurologic abnormalities
A. A patient may have a cervical injury but is able to move extremities. Intoxication alters their level of consciousness and makes them unreliable to accurately participate in their exam. If symptoms are present, even with a negative imaging study, the clinician must assume that a cervical spine injury is present. Reference Clarkson, B. An intoxicated patient is considered to have an altered level of consciousness and may make an inaccurate cervical assessment. Therefore, the collar should remain on until the patient’s level of alertness returns to baseline. C. Removal of a cervical collar requires the absence of cervical spine pain or other symptomatology. If symptoms are present, the clinician must assume that a cervical spine injury is present. D. According to the American College of Surgeons, removal of a cervical collar requires the absence of cervical spine pain or other symptomatology. An acute fracture or instability is unlikely in a patient who is awake, alert, and not under the influence and who does not have pain, midline tenderness, distracting injury, or other neurologic abnormalities. Category: Neurological Emergencies, Head and spinal cord trauma
Question 97
An unresponsive patient arrives via emergency medical services. The paramedics report that the patient became unresponsive while eating dinner. The emergency nurse suspects a possible foreign body aspiration. After opening the airway, what is the next intervention by the nurse?
  • Blind finger sweep to check for presence of a foreign body
  • Administer 100% oxygen via nonrebreather mask
  • Attempt to visualize any foreign body in the airway ✓
  • Insert a nasopharyngeal airway
Correct Answer
Attempt to visualize any foreign body in the airway
A. The airway should be visualized for an obvious cause of obstruction before the administration of oxygen. B. Visualization of a possible foreign body in the airway should always be performed before other airway interventions to prevent possible dislodging of the item further into the patient’s trachea. C. A blind finger sweep can potentially dislodge a foreign body further into the airway and should not be performed. D. The airway should be inspected for obvious obstruction before the insertion of any airway adjunct. Category: Respiratory Emergencies, Obstruction
Question 98
Using the Simple Triage and Rapid Treatment (START) algorithm, an adult patient who has spontaneous breathing after positioning of the airway has been performed would be evaluated into which triage category?
  • Expectant
  • Minor
  • Delayed
  • Immediate ✓
Correct Answer
Immediate
A. In the expectant triage category, the adult patient is unlikely to survive given the severity of injuries and/or the level of available care. In this question, the patient would have been classified in the expectant triage category if they remained apneic after positioning of the airway was performed. B. In the minor triage category, the patient has relatively minor injuries; they are considered the “walking wounded” and possibly able to assist in their own care. C. In the delayed triage category, the patient’s transport can be delayed; although this category includes serious and potentially life-threatening injuries, the patient is not considered likely to deteriorate over several hours. D. The adult START algorithm has four levels of disaster triage: expectant (black), immediate (red), delayed (yellow), and minor (green). In the immediate triage category, the adult patient can be helped by immediate intervention and requires medical attention within minutes of arrival. Category: Respiratory Emergencies, Respiratory Trauma
Question 99
What is the most appropriate diagnostic test used to diagnose pneumonia?
  • Respiratory culture
  • Thoracentesis
  • Computed tomography (CT) scan of the chest
  • Chest radiograph ✓
Correct Answer
Chest radiograph
A. A CT scan of the chest can identify the presence of pneumonia; however, it will expose the patient to a higher dose of radiation than a chest radiograph. B. Thoracentesis is an invasive procedure used to remove fluid from the pleural space; it will not diagnose the presence of pneumonia. C. Radiograph imaging exposes a patient to much less radiation than other radiological studies and is considered the best initial diagnostic tool in diagnosing diseases of the chest. D. A respiratory culture will help determine if there is a bacterial cause for the pneumonia but is not a good initial test to determine if the patient has it. Chest radiograph is quick and easy, whereas the culture will take time to return. Category: Respiratory Emergencies, Infections
Question 100
An emergency department patient who is awaiting hospital admission suddenly displays ventricular tachycardia on the cardiac monitor. The patient is alert, and vital signs are stable. There is a shortage of amiodarone, and another antiarrhythmic in the pharmacy formulary must be used. Which of the following is the best medication for the emergency nurse to use to treat the patient’s ventricular tachycardia?
  • Epinephrine
  • Lidocaine ✓
  • Esmolol
  • Metoprolol
Correct Answer
Lidocaine
A. Esmolol is indicated for sinus tachycardia, supraventricular tachycardia, atrial fibrillation, and atrial flutter. It also has an off-label use for refractory ventricular tachycardia, but not as a first-line medication for that condition. B. Metoprolol is used to treat atrial fibrillation or flutter, hypertension, and heart failure and is indicated after acute myocardial infarction. C. Lidocaine would be indicated for this patient because there is a shortage of amiodarone. Lidocaine is an antiarrhythmic used to treat ventricular dysrhythmias. D. Epinephrine would be contraindicated for a conscious stable patient in ventricular tachycardia. Epinephrine would increase the patient’s heart rate and not prevent or eliminate the ventricular tachycardia. Category: Cardiovascular Emergencies, Dysrhythmias
Question 101
When caring for a patient who is suspected of being in septic shock, which laboratory study should be obtained within 3 hours of the patient’s presentation to the emergency department?
  • Lactate level ✓
  • White blood cell count
  • Platelet count
  • Hemoglobin and hematocrit level
Correct Answer
Lactate level
A. A decreased platelet count may be indicative of disseminated intravascular coagulation but does not indicate the presence of sepsis or septic shock. B. The lactate level is an indicator of cellular hypoxia. It should be obtained within 3 hours of arrival to the emergency department. A lactate level greater than 4 mmol/L is a predictor of a higher patient mortality rate. C. An increased white blood cell count may indicate an infection but is not a specific indicator for the presence of sepsis or septic shock. D. R., Mcintyre, L., Ostermann, M., Prescott, H. C., Schorr, C., Simpson, S., Wiersinga, W. J., Alshamsi, F., Angus, Category: Medical Emergencies, Sepsis
Question 102
A 23-year-old female presents complaining of heavy vaginal bleeding 2 hours after delivering a newborn at home with a nurse midwife. The birth was uncomplicated; the infant was full term, and the placenta was delivered following the delivery. On exam, the uterus is soft and does not contract with fundal massage. Vital signs are: BP 80/36 mm Hg, HR 128 beats per minute, RR 28 breaths per minute, SaO2 90% on room air, and T 36.8°C (98.2°F). Which of the following complications should the emergency nurse suspect in this patient?
  • Trauma to perineum
  • Atonic uterus ✓
  • Cervical tear
  • Disseminated intravascular coagulopathy (DIC)
Correct Answer
Atonic uterus
A. DIC is most often a consequence of placental abruption, eclampsia, or amniotic fluid embolism. There was no indication that this patient experienced any of these complications. Bleeding with this entity would also involve other areas of bleeding as well. B. Immediate postpartum hemorrhage, a soft uterus that does not contract and evidence of shock are symptoms consistent with the presence of an atonic uterus. C. Trauma to the perineum would be suspected with immediate postpartum hemorrhage, delivery of a complete placenta, and a contracted uterus. D. Cervical tear would be suspected when there is evidence of immediate postpartum hemorrhage, delivery of a complete placenta, and a contracted uterus. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Obstetrical, Hemorrhage (e.g., postpartum bleeding)
Question 103
A patient and their family return to the ED 72 hours after a diagnosis of gastroenteritis. The patient is lethargic and continues to have copious amounts of vomiting and uncontrollable diarrhea. The patient is cool to touch and pale. Which of the following is the priority nursing intervention for this patient?
  • Establish intravenous access
  • Obtain a full set of vital signs
  • Position the patient on their side ✓
  • Provide high-flow oxygen
Correct Answer
Position the patient on their side
A. Continued vomiting and a decreased level of consciousness place this patient at risk for aspiration; therefore, positioning the patient on their side to protect the airway and prevent possible aspiration is the priority intervention. B. This patient is exhibiting clinical signs of hypovolemia, so obtaining intravenous access and beginning fluid resuscitation will be required. However, continued vomiting and a decreased level of consciousness place the patient at high risk for aspiration. Positioning the patient on their side as a means of airway protection is the priority intervention. C. The patient is exhibiting evidence of hypovolemia. A full set of vital signs should be obtained, but the priority intervention for a patient who is lethargic and vomiting is protecting the airway by placing the patient on their side. D. Oxygen and cardiac monitoring may be indicated in this patient; however, because of the patient’s decreased level of consciousness and risk for aspiration, placing the patient on their side is the priority intervention. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Bleeding
Question 104
A 32-week-pregnant patient arrives in cardiac arrest. Cardiopulmonary resuscitation is in progress. Which of the following options would provide for the most effective chest compressions for this patient?
  • Place the patient on her left side and perform compressions
  • Place the patient on her back on a hard surface and displace the uterus to the left ✓
  • Place the patient on her right side and perform compressions
  • Position the patient on her back on a hard surface with her head elevated 30 degrees
Correct Answer
Place the patient on her back on a hard surface and displace the uterus to the left
A. Placing the patient on her back with manual displacement of the uterus provides for effective compressions and reduces the compression of the gravid uterus on the aorta, inferior vena cava, and pelvic veins, thereby improving circulatory perfusion to the patient. B. With the patient positioned on her back, the gravid uterus will compress the aorta, inferior vena cava, and pelvic veins, reducing blood flow to the placenta and return flow to the heart. Raising the patient’s head to a semi-Fowler’s position—about 45 degrees—will not enhance the ability to provide adequate compressions. C. Placing this patient on her left side would not provide the back support that is required for effective compressions. It is difficult to provide adequate compressions at an angle. D. This position will not provide the back support required for effective compressions, and displacing the gravid uterus to the right is not as effective as displacement to the left. Adequate compressions cannot be provided with a patient on their side. Reference American Heart Association. (2020). High performance teams: Cardiac arrest associated with pregnancy. In Advanced cardiac life support provider manual (pp. 144–149). First American Heart Association Printing. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Obstetrical, Neonatal resuscitation
Question 105
A patient presents complaining of severe right lower back pain with radiation into the groin area and dysuria. The patient’s vital signs are within normal limits, and the patient is afebrile. The emergency nurse suspects that the patient has which of the following disease processes?
  • Third-degree lumbar strain
  • Renal calculi ✓
  • Pyelonephritis
  • Dissecting aortic aneurysm
Correct Answer
Renal calculi
A. Pain associated with a kidney stone is often described as severe and located over the flank area, with radiation to the groin, labia, or scrotum. Pain usually worsens with voiding. The patient would be febrile only if an infection was also present. B. A patient with a kidney infection would present with lower back pain that may radiate to the groin area; however, because pyelonephritis is an infection, fever and chills would also be present. C. A patient with a dissecting abdominal aortic aneurysm may complain of severe back pain radiating to the groin area but may also have anuria, severe apprehension, tachycardia, hypertension, and loss of major pulses distal to the aneurysm. D. Back pain would be present in a patient with a lumbar strain. However, it would not be associated with radiation of that pain to the groin or painful urination. Movement would increase pain. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Genitourinary, Renal calculi
Question 106
A patient who has been using anabolic steroids to build muscle mass presents with complaints of “not feeling well.” Which of the following laboratory results is considered an adverse effect of anabolic steroids?
  • Hyperglycemia ✓
  • Hyperkalemia
  • Decreased serum creatinine
  • Decreased serum bilirubin
Correct Answer
Hyperglycemia
A. Excess steroids can cause an alteration in carbohydrate metabolism, resulting in elevated glucose levels. B. Bilirubin levels will increase because of the adverse effect of anabolic steroids on the liver. C. Serum creatinine is influenced by the amount of muscle mass a person has and will increase with anabolic steroid use. D. Anabolic steroid use causes hypokalemia by shifting potassium intracellularly. Category: Medical Emergencies, Substance use and abuse (e.g., alcohol and drug interactions, side effects, unintentional overdose)
Question 107
An infant has been diagnosed with pertussis (whooping cough). The patient is alert and has rhinitis, an intermittent cough, and brief periods of apnea. Vital signs are BP 92/58 mm Hg, HR 120 beats/minute, RR 28 breaths/minute, SpO2 99%, and T 37.6°C (99.6°F). What is the priority intervention for this patient?
  • Administer antibiotics ✓
  • Prepare for intubation
  • Restrict caloric intake
  • Administer fluid bolus
Correct Answer
Administer antibiotics
A. Pertussis is a respiratory infection caused by Bordetella pertussis bacteria. A macrolide antibiotic is indicated for proven or suspected pertussis to eliminate the organism from the nasopharynx and prevent the spread to others. B. The patient assessment does not indicate the need for emergent airway management. Periods of brief apnea are common in pertussis and require close monitoring. Airway management and mechanical ventilation may be indicated in severe cases. C. Patients with pertussis can have a regular diet as tolerated. D. The patient may require intravenous fluid replacement for dehydration or fluid maintenance, but the assessment does not indicate the need for emergent fluid resuscitation. Category: Environment and Toxicology Emergencies, and Communicable Diseases, Communicable Diseases, Vaccine-preventable diseases (e.g., measles, mumps, pertussis, chicken pox, diphtheria)
Question 108
Which of the following assessment findings would be most concerning to the nurse when caring for a patient with bipolar disorder who has received an antipsychotic medication for control of acute mania?
  • Facial grimacing
  • Drowsiness
  • Elevated temperature ✓
  • Urinary retention
Correct Answer
Elevated temperature
A. Dystonic reactions, including facial grimacing, are sometimes noted as a side effect of most antipsychotics. This needs to be treated and monitored but is not life-threatening in most patients. B. Hyperthermia in the patient who received an antipsychotic is concerning for neuroleptic malignant syndrome, a rare, life-threatening complication. The classic clinical presentation of the patient with neuroleptic malignant syndrome includes altered mental status, fever, autonomic dysfunction, and muscle rigidity (also referred to as “lead pipe rigidity”). C. Anticholinergic symptoms, including urinary retention, are common side effects of most antipsychotics. This needs to be monitored but is not life-threatening in most patients. Reference Pritts, W. S. (2020). Behavioral health emergencies. In V. Sweet & D. Drowsiness and sedation are expected side effects of most antipsychotics. This needs to be monitored but is not life-threatening in most patients. Category: Mental Health Emergencies, Mood disorders (e.g., bipolar, depression)
Question 109
The ED care team is preparing for insertion of a Sengstaken-Blakemore (SB) tube in a patient with bleeding esophageal varices. Which of the following interventions should be completed prior to insertion of the SB tube?
  • Nasogastric tube
  • Antibiotic therapy
  • Endotracheal intubation ✓
  • Chest radiograph
Correct Answer
Endotracheal intubation
A. Endotracheal intubation is a must before insertion of the SB tube. B. A chest X-ray would not be necessary prior to placing the SB tube. It is, however, imperative to perform a chest X-ray after the tube is placed to ensure its proper location. C. The SB tube has a port for the removal of gastric contents and air. A nasogastric tube is inserted after the SB tube to check for bleeding above the gastric balloon of the SB tube but not before. D. Antibiotic therapy may be started but is not necessary prior to insertion of the SB tube. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Bleeding
Question 110
Discharge instructions are provided for a patient with Rocky Mountain spotted fever. The provider has prescribed doxycycline 100 mg 2 times per day for 14 days. Which of the following statements indicates that the patient understands the directions regarding doxycycline?
  • “I should avoid being in the sun for long periods while taking this medication.” ✓
  • “It is important to take my medication right after I take an antacid to decrease stomach upset.”
  • “I should not eat or drink citrus products while I am taking doxycycline.”
  • “If I feel better in 7 days, I can stop taking the antibiotic.”
Correct Answer
“I should avoid being in the sun for long periods while taking this medication.”
A. There are no contraindications for having citrus products while taking doxycycline. B. Doxycycline can cause sensitivity to the sun, so patients should be instructed to avoid prolonged sun exposure while on the medication and to use sun protection, such as a hat and long-sleeved shirt. C. Doxycycline should not be taken with antacids because it will decrease the absorption of the antibiotic. They should wait at least 2 hours before or after. D. Antibiotics should be taken for the full length of the prescription unless directed otherwise by the provider. Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment, Temperature-related emergencies
Question 111
A young child is brought in with ear pain. On exam, the nurse notices blistering and the appearance of burns on the bilateral wrists of the child. The parents state they used crushed garlic on the child’s wrists to treat the infection at home. The nurse should:
  • notify the local law enforcement agency of the concern of child maltreatment.
  • request that the hospital social worker assess the child for physical neglect.
  • explain why this type of remedy may be considered harmful. ✓
  • document in the medical record that “signs of abuse were noted on physical exam.”
Correct Answer
explain why this type of remedy may be considered harmful.
A. The healthcare team must be knowledgeable about and aware of cultural and religious practices in their evaluation of potential maltreatment before requesting an open investigation of abuse. B. Topical garlic, which can result in blisters or garlic burns, is a practice used among Yemenite Jews to treat infectious disease. The practice is well intended in the culture, but it is important to explain that this practice can be harmful. C. A number of circumstances or conditions may be mistaken for child maltreatment. It is important not to make a diagnosis until cultural considerations have been evaluated. D. Documentation should not include “signs of abuse.” The documentation should use descriptions that identify the size, shape, color, and location of any wounds. Category: Professional Issues, Patient, Cultural considerations (e.g., interpretive services, privacy, decision making)
Question 112
During a pediatric cardiac arrest, one of the nurses realizes that the patient looks similar to the son they recently lost because of a terminal illness. The nurse is unable to stay focused on the necessary resuscitation tasks for this patient. During debriefing, the team discusses the nurse’s challenges. The best response to encourage resiliency is:
  • “Don’t forget, we are a team, and you are part of our team. If you are feeling overwhelmed and want to talk, we are here for you. Or we can help you arrange a more private discussion.” ✓
  • “Management didn’t give you enough time to grieve, staff members don’t take initiative to help, and you are tired and overwhelmed. Have you considered looking to work somewhere else that will support you in a better way?”
  • “This experience should help you get back to the bedside. You are a ‘super-nurse.’ You can take care of anyone who rolls through these doors.”
  • “We need more situational 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.”
Correct Answer
“Don’t forget, we are a team, and you are part of our team. If you are feeling overwhelmed and want to talk, we are here for you. Or we can help you arrange a more private discussion.”
A. 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. This leads to the development of compassion satisfaction and resiliency. B. 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 and compassion fatigue. C. Trauma nurses with higher levels of burnout have a significantly higher variability in secondary traumatic stress (STS). Identifying factors that support the nurse’s burnout will exacerbate the STS. D. Although it is necessary to recognize that the dynamics of the code response were subpar, the delivery of the message should be reworded with consideration of the charge nurse’s secondary traumatic stress experience. Perhaps a different forum could be considered for process improvement. Category: Professional Issues, Nurse, Stress management (e.g., burnout, compassion fatigue, PTSD)
Question 113
A 28-week-pregnant patient presents with rapid weight gain and marked facial edema, persistent headaches, blurred vision, and shortness of breath. On exam, she is found to have hyperactive reflexes. Vital signs are: BP 182/124 mm Hg, HR 124 beats per minute, RR 28 breaths per minute, SpO2 94% on room air. Which of the following medications would be initiated to treat the hypertension?
  • Lorazepam
  • Magnesium sulfate
  • Labetalol ✓
  • Calcium gluconate
Correct Answer
Labetalol
A. Calcium gluconate is indicated as an antidote to the effects of magnesium toxicity. It does not treat or prevent additional seizures. B. Magnesium sulfate is the medication of choice for the prevention of seizures in the preeclamptic patient or to treat seizures in the eclamptic patient. It is not recommended for lowering blood pressure. C. Lorazepam is administered to control ongoing seizures. It is not recommended as the first-line therapy for the prevention of subsequent seizure activity unless magnesium sulfate is ineffective. D. Labetalol would be an acceptable medication to treat the severe hypertension in this antepartum patient. Two goals of therapy for these patients are to reduce the diastolic blood pressure in order to ensure adequate utero-placental perfusion, and to prevent seizures, for which magnesium sulfate is used. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Obstetrical, Preeclampsia, eclampsia, and HELLP syndrome
Question 114
Which of the following statements is an example of therapeutic communication involving a patient with suicidal ideations?
  • "We can send you to a facility that deals with substance abuse."
  • "Do you want to be in a room alone?"
  • "I know how you feel. My brother committed suicide."
  • "Do you have a plan for harming yourself?" ✓
Correct Answer
"Do you have a plan for harming yourself?"
A. Therapeutic communication is defined as the face-to-face process of interaction that focuses on advancing the physical and emotional well-being of a patient. Nurses use therapeutic communication techniques to provide education and support to patients, while maintaining objectivity and professional distance. Asking the patient if they have a plan is the most therapeutic choice; the others are not focused on advancing the well-being of the patient. B. Therapeutic communication is defined as the face-to-face process of interaction that focuses on advancing the physical and emotional well-being of a patient. Nurses use therapeutic communication techniques to provide education and support to patients, while maintaining objectivity and professional distance. This statement takes the focus off the patient and places it on the nurse. C. Therapeutic communication is defined as the face-to-face process of interaction that focuses on advancing the physical and emotional well-being of a patient. Nurses use therapeutic communication techniques to provide education and support to patients, while maintaining objectivity and professional distance. The nurse needs to be present and focused on the patient for therapeutic communication. D. Therapeutic communication is defined as the face-to-face process of interaction that focuses on advancing the physical and emotional well-being of a patient. Nurses use therapeutic communication techniques to provide education and support to patients, while maintaining objectivity and professional distance. This statement does not encourage the patient to discuss what is going on. Category: Mental Health Emergencies, Homicidal and Suicidal ideation
Question 115
A 19-year-old female presents with a 10-hour history of nausea, and periumbilical pain that has become progressively worse and has slowly moved to the RLQ. Vital signs are: BP 120/72 mm Hg, HR 111 beats/minute, RR 22 breaths/minute, and T 100.4°F (38°C). What lab value would the nurse expect to see elevated in a patient with this condition?
  • Lipase
  • Transaminase
  • Microscopic hematuria
  • Neutrophils ✓
Correct Answer
Neutrophils
A. Elevated lipase level is consistent with acute pancreatitis. The patient with pancreatitis may describe the pain as severe, dull, and located in the center or epigastric area radiating to the back. B. Microscopic hematuria may support a diagnosis of renal colic or pyelonephritis. C. The cause of abdominal pain can present a challenge due to the many organs in the abdomen, but this presentation is consistent with acute appendicitis. An elevated white blood count with an elevated neutrophil count is seen in about 70% of patients. D. Transaminitis is seen in liver pathology, such as acute liver infection. Presenting symptoms with an acute liver infection would include right upper quadrant pain, dark urine, and jaundice. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Acute abdomen
Question 116
Which of the following diagnoses is defined as the abrupt deterioration in renal function resulting in azotemia?
  • Acute kidney injury ✓
  • Interstitial cystitis
  • Pyelonephritis
  • Chronic kidney disease
Correct Answer
Acute kidney injury
A. Acute kidney injury, formerly known as acute renal failure, is the deterioration of renal function that occurs in a period of hours to days and results in the accumulation of nitrogenous wastes (azotemia) within the body. If identified early, it is often reversible. B. Chronic kidney disease is defined as “abnormalities in kidney function or structure for greater than 3 months.” In addition to the abnormalities seen in acute kidney injury, the patient will have abnormal electrolytes, urine sedimentation, and albumin. C. Interstitial cystitis presents as an urgent and persistent need to void. Most lab testing will be negative, though hematuria may be present. Treatment is focused on symptomatic relief. D. Pyelonephritis is an infection of the upper urinary tract. Complications can result in scarring of the renal tissue and lead to permanent renal injury. Category: Medical Emergencies, Renal failure
Question 117
The nurse is aware that a patient with a documented acute psychotic episode may be admitted involuntarily based on the patient meeting which of the following criteria?
  • Patient has no permanent residence.
  • Lack of capacity to make treatment decisions. ✓
  • Patient does not have a psychiatrist.
  • Agreement made to not harm themselves.
Correct Answer
Lack of capacity to make treatment decisions.
A. Whether or not the patient currently has a psychiatrist should have no bearing on whether they are involuntarily admitted. Admission should be based on their decisional capacity and if they are a risk to themselves or others. B. If the patient is not a danger to themself or others, they do not meet criteria for involuntary hospital admission. C. The American Psychiatric Association has developed a model to help determine whether a patient suffering a psychotic episode requires an involuntary hospital admission. The criteria include mental illness; danger to self and others; refusal to consent; treatability; lack of capacity to make treatment decisions; and hospitalization as the least restrictive treatment. D. Homelessness is not a criterion for involuntary admission. However, it may be a factor that could contribute to placing a patient at risk of having a psychotic episode if they are not taking medications or attending follow-up appointments. Category: Mental Health Emergencies, Thought disorders (e.g., psychosis, schizophrenia)
Question 118
A patient presents with a complaint of inability to void for the last 4–6 hours. He has a history of hypertension, benign prostatic enlargement, and irritable bowel syndrome. Medications include metoprolol, Bactrim DS, tamsulosin, and an over-the-counter (OTC) “nighttime cold and flu med.” Which of these medications puts this patient at risk for urinary retention?
  • Trimethoprim/sulfamethoxazole (Bactrim DS)
  • Tamsulosin (Flomax)
  • Diphenhydramine (Benadryl) ✓
  • Metoprolol (Lopressor)
Correct Answer
Diphenhydramine (Benadryl)
A. Trimethoprim/sulfamethoxazole is prescribed to treat bladder or urinary tract infections. Urinary retention is not listed as one of the side effects of this medication. B. Metoprolol is a beta-adrenergic antagonist. This classification of drugs does not adversely affect the genitourinary system. C. Tamsulosin is a prostate-specific alpha-1 adrenergic blocking agent that helps to shrink an enlarged prostate and relieve urinary retention. D. Diphenhydramine, found in many OTC cold medications, is a potent antihistamine with anticholinergic effects. Anticholinergics also relax the detrusor muscles of the bladder and tighten the internal bladder sphincter. This action can make urination more difficult, especially in men with an enlarged prostate. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Genitourinary, Urinary retention
Question 119
A patient with shortness of breath is being treated for severe pneumonia. The patient had a kidney transplant 5 months ago, secondary to polycystic kidney disease. The emergency nurse is aware that the most likely cause of the patient’s current illness is which of the following?
  • Community-acquired infection
  • Catheter-associated infection
  • Nosocomial infection
  • Opportunistic infection ✓
Correct Answer
Opportunistic infection
A. Catheter-associated infections are usually a complication of the surgical procedure and would show up within the first few weeks after transplant. B. Nosocomial infections are those thought to be contracted while in the hospital. These would most likely develop within the first month. C. In the transplant patient, opportunistic infections such as cytomegalovirus, pneumocystis, or aspergillus develop, starting about 1 month up to 12 months posttransplant. The is the peak time for immunosuppression. D. Community-acquired infections typically develop at least one year after the transplant. Category: Medical Emergencies, Immunocompromise (e.g., HIV/AIDS, oncology/chemotherapy, transplant patient)
Question 120
A patient walks into triage with swelling and ecchymosis of the left eye and states that they were involved in an altercation approximately 1 hour before arrival. The nurse is aware that the priority for this patient is to perform which of the following?
  • Assessment of visual acuity ✓
  • Assessment for other injuries
  • Instilling cycloplegic eye drops
  • Application of ice to the affected eye
Correct Answer
Assessment of visual acuity
A. The patient is ambulatory and verbal, so the secondary assessment can be delayed until visual acuity assessed. B. Although ice will help reduce the edema, visual acuity must be measured before definitive treatment is initiated. C. Visual acuity is the vital sign of the eye. When direct trauma to the eye has occurred, the Snellen test for visual acuity should be completed as soon as possible, along with assessment for extraocular movement. Concern should be for hyphema, globe rupture, or orbital fractures. D. Cycloplegic drugs such as atropine will cause dilation of the pupil and may impair the patient’s ability to perform the visual acuity test. Category: Maxillofacial and Ocular Emergencies, Ocular, Ocular Trauma (e.g., hyphema, laceration, globe rupture)
Question 121
Which of the following would be an appropriate medication dose for a 3-year-old, 15 kg patient who presents with a fever and ear pain?
  • Acetaminophen 300 mg by mouth
  • Acetaminophen 100 mg by mouth
  • Ibuprofen 225 mg by mouth
  • Ibuprofen 150 mg by mouth ✓
Correct Answer
Ibuprofen 150 mg by mouth
A. Ibuprofen is an appropriate medication for treating fever and pain in the pediatric population over the age of 6 months. The recommended dose is 5–10 mg/kg. B. Acetaminophen is an appropriate medication for treating fever and pain in the pediatric patient, however, the recommended oral dose is 10–15 mg/kg. C. Ibuprofen is an appropriate medication for treating fever and pain in the pediatric patient over the age of 6 months, however, the recommended dose is 5–10 mg/kg. Reference Hamm, R. (2020). Pain. In V. Sweet & D. Acetaminophen is an appropriate medication for treating fever and pain in the pediatric patient, however the recommended oral dose is 10–15 mg/kg. Category: Medical Emergencies, Sepsis
Question 122
A patient presents with status epilepticus. The nurse administers lorazepam (Ativan) 2 mg intravenously. What is the expected result of this intervention?
  • Seizure activity ceases ✓
  • Urinary incontinence
  • Patient is awake and alert
  • Tachycardia
Correct Answer
Seizure activity ceases
A. Benzodiazepines are effective in stopping seizure activity by decreasing epileptiform discharges and limiting their spread. B. Urinary incontinence often happens during a seizure and is not an indication that the seizure activity has stopped. C. Tachycardia would have been present during the seizure, but heart rate should return to normal once the seizure has stopped. D. A tonic-clonic seizure is followed by a postictal phase. The patient will not awaken as a result of benzodiazepine use. Category: Neurological Emergencies, Seizure disorders
Question 123
Which mechanism of injury is least likely to result in a patient sustaining multiple contusions in various stages of healing?
  • Child maltreatment
  • Elder abuse
  • Intimate partner violence
  • Isolated blunt force assault ✓
Correct Answer
Isolated blunt force assault
A. In addition to episodes of elder abuse, the elderly population is also at high risk for falls related to gait instability or cognitive or sensory impairment; both can result in contusions in various stages of healing. B. An isolated blunt force trauma would result in contusions with a uniform healing rate. C. A pattern of assaultive or coercive behavior by an individual against a current or former intimate partner would result in multiple contusions in various stages of healing. D. Child maltreatment is defined as any harm that occurs to a child as the result of physical, emotional, or sexual abuse or neglect. Physical abuse may result in multiple contusions in various stages of healing. Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Ligament tendon injuries (e.g., sprains, strains, ruptures)
Question 124
A patient presents with tonic-clonic seizure activity. The nurse is aware that the priority intervention for this patient is to perform which of the following?
  • Administer oxygen
  • Position them on their back
  • Administer a benzodiazepine
  • Position them on their side ✓
Correct Answer
Position them on their side
A. Positioning the patient on their side for safety and the prevention of injury is the immediate priority. B. The patient must be positioned for safety. Positioning a patient on their back will not keep the airway open. Side lying is better. C. The patient must be positioned for safety. During the acute phase of seizure activity, many patients have altered respiratory patterns. The administration of supplemental oxygen may not immediately increase the patient’s oxygen saturation level. D. Administration of a benzodiazepine is indicated to assist in controlling the seizure activity; however, the first priority is patient safety. Category: Neurological Emergencies, Seizure disorders
Question 125
Which of the following assessment findings would the nurse anticipate in a patient experiencing alprazolam withdrawal?
  • Hyperreflexia ✓
  • Sluggish movement
  • Bradycardia
  • Hypotension
Correct Answer
Hyperreflexia
A. Tremors, hyperreflexia, anxiety, agitation, muscle weakness, tachycardia, and hypertension are all common signs and symptoms of benzodiazepine withdrawal. B. Hypertension is a more common finding than hypotension in the presence of benzodiazepine withdrawal. C. Tachycardia and hypertension are common signs of benzodiazepine withdrawal syndrome. Bradycardia would not be expected. D. Agitation is common in benzodiazepine withdrawal; however, sluggish movement would not be indicative of withdrawal syndrome. Category: Medical Emergencies, Withdrawal syndrome
Question 126
A female patient presents with dyspnea and anxiety. Initial vital signs are: BP 112/88 mm Hg, HR 124 beats/minute, RR 28 breaths/minute, SpO2 85% without supplemental oxygen. The patient has a pleural friction rub with bibasilar crackles. The patient admits to using oral contraceptives. Which intervention is the most definitive method for identifying the patient’s diagnosis?
  • 12-lead electrocardiogram (ECG)
  • Chest radiograph
  • Chest computerized tomography ✓
  • D-dimer
Correct Answer
Chest computerized tomography
A. The signs and symptoms of a pulmonary embolism include dyspnea, tachycardia, tachypnea, and anxiety. A 12-lead ECG may show T-wave and P-wave changes, new-onset right bundle branch block, and ST segment changes; however, those changes are nonspecific. B. The signs and symptoms of a pulmonary embolism (PE) include dyspnea, tachycardia, tachypnea, and anxiety. Sudden shortness of breath and chest pain are also associated with PE. Crackles may be present on auscultation. One risk factor of PE is the use of estrogen (oral contraceptives). Diagnosis of PE is made if there is a filling defect in the pulmonary arterial tree on a spiral CTA (computed tomography with angiography) scan. C. The signs and symptoms of a pulmonary embolism (PE) include dyspnea, tachycardia, tachypnea, and anxiety. In a patient with a PE, the chest radiograph may be normal. D. The signs and symptoms of a pulmonary embolism (PE) include dyspnea, tachycardia, tachypnea, and anxiety. D-dimer results are elevated in patients with PE, but this test is nonspecific because other factors, such as pregnancy, surgery, advanced age, cancer, and various inflammatory conditions, also increase values of D-dimer. Category: Respiratory Emergencies, Pulmonary embolus
Question 127
A patient diagnosed with hypertensive crisis has a blood pressure of 192/138 mm Hg. A repeat blood pressure is unchanged from the original. The patient has no past medical history, takes no medications, and has no allergies. Which drug would the nurse anticipate being immediately administered to control this patient’s condition?
  • Nifedipine oral
  • Lisinopril oral
  • Labetalol intravenous ✓
  • Nitroglycerin sublingual
Correct Answer
Labetalol intravenous
A. Lisinopril is an oral agent that may be used in combination with a diuretic to control blood pressure, however, it is not easily titratable and not indicated in the management of hypertensive crisis. Reference Foley, A., & Sweet, V. (2020). Cardiovascular emergencies. In B. IV pharmacologic medications such as nitroprusside, nitroglycerin, and labetalol are rapidly active and can be titrated for safe, effective blood pressure reduction. C. Nitroglycerin sublingual may cause a very rapid drop in blood pressure for those patients who have not previously been exposed, and it cannot be titrated for safe, effective blood pressure reduction in hypertensive crisis. D. Although nifedipine can be used as an antihypertensive agent, because it is an oral medication, it is not easily titratable for safe management of a hypertensive crisis. It is seeing a resurgence in treating severe maternal hypertension if IV access is not readily available. Category: Cardiovascular Emergencies, Hypertension
Question 128
While discharging a 12-year-old pediatric patient with hemophilia B (Christmas disease), the child states, “I don’t understand what type of disease I have . . . what is it?” Which statement made by the nurse is correct in explaining hemophilia B to the patient?
  • “Hemophilia B is a blood disorder you developed over time. We don’t know who will get the disease and who will not.”
  • “Hemophilia B is a blood disorder that causes decreased factor VIII and abnormal platelets.”
  • “Hemophilia B is a blood disorder you were born with. You are missing factor VIII, which is needed to stop the bleeding when you get injured.”
  • “Hemophilia B is a blood disorder you were born with. You are missing factor IX, which is needed to stop the bleeding when you get injured.” ✓
Correct Answer
“Hemophilia B is a blood disorder you were born with. You are missing factor IX, which is needed to stop the bleeding when you get injured.”
A. The missing factor in hemophilia B is factor IX; factor VIII deficiency occurs in patients with hemophilia B. Hemophilia B is a congenitally inherited coagulation disorder in which children are missing factor IX. Hemophilia B affects boys more than girls and interferes with the ability of the body to form a stable blood clot. It is a genetic sex trait that is passed from the mother to her male children. C. Von Willebrand disease is a less acute coagulation disorder in which there is decreased factor VIII and impaired platelet aggregation. The disease manifests in both males and females. D. Hemophilia B is a congenital coagulation disorder in which children are missing factor IX. Hemophilia B affects boys more than girls and interferes with the ability of the body to form a stable blood clot. It is a genetic sex trait that is passed from the mother to her male children. Category: Medical Emergencies, Hematologic disorders
Question 129
The nurse is assessing a pressure injury on the heel of a patient’s foot. The full thickness wound bed measures 5 cm × 5 cm with a depth of 2 cm and is covered in slough. The nurse would document this pressure injury as:
  • a stage 3 pressure injury.
  • a suspected deep tissue injury.
  • unstageable. ✓
  • a stage 4 pressure injury.
Correct Answer
unstageable.
A. A stage 3 pressure injury is inconsistent with the injury described. A stage 3 pressure injury involves damage to the subcutaneous tissue and can include necrosis of tissue that does not go through the underlying fascia. The wound appears deep but does not extend to bone. B. Full-thickness tissue loss in which the base of the pressure injury is covered by slough is considered an unstageable wound. C. A stage 4 pressure injury is inconsistent with the injury described. A stage 4 pressure injury involves full-thickness skin loss with extensive damage to tissue, muscle, bone, or any supporting structure. D. Deep tissue injury is inconsistent with the injury described. A deep tissue injury can result from pressure or a shear mechanism and can include the presence of a bruise, hematoma, gangrene, or abscess. The involved area is painful and warm to touch when compared with surrounding tissue. Category: Musculoskeletal and Wound Emergencies, Wound, Wound bleeding (e.g., uncontrolled external hemorrhage)
Question 130
For an adult patient who has sustained an electrical burn, what is the best way to calculate adequate fluid resuscitation volume?
  • Titrate fluid administration to maintain urine output 4–5 times normal
  • Give 4 mL/kg body weight × percent body surface area burned
  • Give 3 mL/kg body weight × percent body surface area burned
  • Titrate fluid administration to maintain urine output 2–3 times normal ✓
Correct Answer
Titrate fluid administration to maintain urine output 2–3 times normal
A. This is the formula for fluid replacement in thermal burns for adults. Because of internal damage with an electrical burn, basing the replacement on body surface area burned would not be an accurate way to estimate the hydration needs of the patient. B. A urine output of 4–5 times normal is not recommended. It should be maintained at 2–3 times normal. C. Calculating the amount of tissue damage is difficult in the presence of an electrical burn because much of the damage is internal. The usual formulas for calculating fluid resuscitation for burns won’t work, so maintaining adequate urine output at 2–3 times normal is one way to assess that the patient is adequately hydrated. Normal urine output is 0.5-1.0 mL/kg/hr for adults. D. This is the formula for fluid replacement in thermal burns for pediatrics. This patient is an adult, and with electrical burns, you cannot accurately determine body surface area burned. Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment, Electrical injuries
Question 131
For a patient diagnosed with diverticulitis, the emergency nurse should anticipate which of the following dietary orders from the care provider?
  • Diet avoiding nuts and seeds
  • High-fiber diet
  • Nothing by mouth (NPO) ✓
  • Full liquid diet
Correct Answer
Nothing by mouth (NPO)
A. At the time of hospital discharge, a high-fiber diet will most likely be recommended to this patient to prevent future episodes of diverticulitis. During the acute inflammatory stage of the disease, however, the patient should be kept NPO to rest the bowel. B. There is little evidence to support the theory that eating foods containing nuts and seeds can precipitate the development of diverticulitis. In this acute inflammatory stage, the bowel should be rested and the patient kept NPO. C. A patient with diverticulitis should be kept NPO to rest the bowel. There is also the possibility of perforation, obstruction, hemorrhage, or peritonitis, which might require surgical intervention. D. Resting the bowel is the priority of care for a patient with diverticulitis; therefore, the patient should be kept NPO. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Diverticulitis
Question 132
The nurse is performing triage during a disaster situation. The triage system being used will result in the best outcomes for the greatest number of patients. This is an example of which ethical framework?
  • Intuitionist
  • Duty based
  • Rights based
  • Utilitarian ✓
Correct Answer
Utilitarian
A. During a disaster situation, the triage system that provides for the greatest good for the greatest number of patients is referred to as a utilitarian framework. B. A duty-based framework describes the nurse’s acts based on the right to do something or to refrain from doing something. C. A rights-based ethical framework is one that respects the patient’s basic inherent rights, such as the right to refuse treatment. D. Intuitionist is an ethical framework in which the nurse would use their judgment on a case-by-case basis. Category: Professional Issues, Nurse, Ethical dilemmas
Question 133
A patient arrives with sudden onset of chest pain and difficulty breathing. Patient assessment reveals tachypnea, decreased breath sounds, and hyperresonance on percussion over the left lung fields. Which diagnostic procedure should the emergency nurse anticipate for this patient?
  • Echocardiogram (ECG)
  • Chest radiograph (CXR) ✓
  • Computerized tomography (CT)
  • Ventilation/perfusion scan
Correct Answer
Chest radiograph (CXR)
A. A CXR is the first-line diagnostic procedure for a pneumothorax. CT may be obtained after the chest radiograph for additional detail or to observe for underlying organ damage if a pneumothorax is the result of trauma. B. A ventilation/perfusion scan is used to examine the circulation of air and blood within a patient’s lungs and is useful in evaluation for a pulmonary embolism. This test is not used to diagnose a pneumothorax. C. Dyspnea, tachypnea, decreased breath sounds, and hyperresonance with percussion are all signs and symptoms of a pneumothorax. CXR is necessary to establish a definitive diagnosis and to develop a plan of care. D. An ECG is necessary in the presence of dyspnea and tachypnea because these symptoms can be indicative of a cardiac event. However, decreased breath sounds and hyperresonance on percussion indicate the cause to be pulmonary in nature, and a CXR is the preferred diagnostic procedure. Category: Respiratory Emergencies, Pneumothorax
Question 134
The nurse suddenly realizes that they have administered an incorrect dose to their patient. The nurse struggles with having to tell the patient that a medication error has occurred. Based on which of the following ethical principles should the nurse tell the truth?
  • Justice
  • Veracity ✓
  • Fidelity
  • Beneficence
Correct Answer
Veracity
A. Beneficence is described as the desire of the nurse to do what is in the best interest of the patient. B. Veracity is the ethical principle defined as truth telling, which includes revealing all medical errors. C. Fidelity occurs when the nurse practices loyalty or accountability. D. Justice is described as fairness, such as treating all patients the same regardless of background. Category: Professional Issues, Nurse, Ethical dilemmas
Question 135
A patient with a history of intravenous drug use presents to the emergency department with pleuritic chest pain, fever, and tender nodules on the pads of the fingers. The emergency nurse anticipates that the patient will be worked up for what type of illness?
  • Empyema
  • Infective endocarditis ✓
  • Community-acquired pneumonia
  • Vasculitis
Correct Answer
Infective endocarditis
A. Patients with pneumonia may present with pleuritic chest pain and fever. However, Osler nodes (tender nodules on the fingers or toes) are not known to occur with pneumonia. B. Infective endocarditis presents with clinical manifestations of pleuritic chest pain, fever, night sweats, and malaise. Infective endocarditis is associated with tender nodules on the pads of the fingers or toes called Osler nodes. Patients with a history of intravenous drug use, valvular disease, or prosthetic valves are at risk for developing endocarditis. C. Empyema is a collection of pus in the pleural cavity. It is usually associated with pneumonia but can also be seen with thoracic surgery or thoracic trauma. IV drug use is a risk factor for empyema, but the nodules on the fingers (Osler nodes) are associated with infective endocarditis. D. Vasculitis is inflammation of blood vessels and is not associated with Osler nodes (tender nodules on the fingers or toes). Category: Cardiovascular Emergencies, Endocarditis
Question 136
Which of the following is the priority for a briskly bleeding extensive leg laceration producing a large amount of blood from the wound?
  • Maintaining circulation to the foot
  • Irrigating the wound thoroughly
  • Assessing neurovascular status distal to the injury
  • Controlling exsanguinating hemorrhage ✓
Correct Answer
Controlling exsanguinating hemorrhage
A. Briskly bleeding extensive leg lacerations that produce a large amount of blood from the wound are a significant risk for life-threatening, exsanguinating hemorrhage. Control of life-threatening hemorrhage takes priority over irrigation of the wound, which can make bleeding more severe. B. Briskly bleeding extensive leg lacerations that produce a large amount of blood from the wound are a significant risk for life-threatening, exsanguinating hemorrhage. Assessing neurovascular status does not take priority over lifesaving hemorrhage control. Reference Edwards, C. (2020). Surface and burn trauma. In J. S. Blansfield (Ed.), Trauma Nursing Core Course provider manual (8th ed., pp. 209–230). Jones & Bartlett Learning. C. Briskly bleeding extensive leg lacerations that produce a large amount of blood from the wound are a significant risk for life-threatening, exsanguinating hemorrhage. Control of life-threatening hemorrhage takes priority over irrigation of the wound, which can make bleeding more severe. D. Briskly bleeding extensive leg lacerations that produce a large amount of blood from the wound are a significant risk for life-threatening, exsanguinating hemorrhage. Hemorrhage control to save the patient's life will take priority over saving the extremity. Category: Musculoskeletal and Wound Emergencies, Wound, Wound infections
Question 137
An unresponsive geriatric patient arrives from home. The patient is difficult to arouse and has a weak and thready pulse. The patient’s caregiver provides a copy of a legal document, signed by the patient, that specifically outlines the treatment they want if they are unable to speak for themself. Which document is the nurse reviewing for accuracy?
  • Physician order for life-sustaining treatment
  • Durable power of attorney for health care
  • Prehospital Do Not Resuscitate order
  • Living will ✓
Correct Answer
Living will
A. An out-of-hospital Do Not Resuscitate order communicates to prehospital personnel that saving measures, such as cardiopulmonary resuscitation or medication administration, intubation, or defibrillation, should be initiated in the event of a cardiopulmonary arrest. B. A living will is a legal document that is prepared while a patient is able to competently make decisions. In a living will, the individual documents what treatments they wish in the event that they are at the end of life and unable to communicate. C. A durable power of attorney for health care designates a surrogate decision maker for the patient in the event that the patient is unable to make decisions. It does not grant consent for or prohibit specific medical treatment. D. Surrogate decision-maker statues allow for an individual or group of individuals (usually family members) to make end-of-life decisions for a patient who, at the end of life, is unable to communicate and has not prepared an advance directive. Category: Professional Issues, Patient, End-of-life and Palliative Care (e.g., organ and tissue donation, advance directives, care withholding, family presence)
Question 138
A patient presents with complaints of moderate vaginal bleeding, abdominal pain, and bruising on her arms and legs. History includes a spontaneous abortion 3 days ago. Which of the following circumstances places this patient at risk of developing disseminated intravascular coagulation (DIC)?
  • Endometritis
  • Retained placental fragments ✓
  • Missed Rh immune globulin injection
  • Administration of methotrexate
Correct Answer
Retained placental fragments
A. Rh immune globulin should be administered within 72 hours to all Rh-negative women who deliver or have an abortion. This prevents the mother from developing antibodies that can result in a devastating hemolysis in the fetus. The injection may have an adverse effect of DIC. B. Retained placental fragments can trigger DIC and is also one of the most common causes of postpartum hemorrhage. C. Methotrexate would not have been used for this patient. It is sometimes used in the treatment of ectopic pregnancy, not for spontaneous abortions. D. Endometritis, a uterine infection, could present with vaginal bleeding, fever, chills, and a tender abdomen, but it is not considered a risk for developing DIC. Category: Medical Emergencies, Hematologic disorders
Question 139
An adult presents to triage complaining of diarrhea, lack of appetite, weight loss, and stomach pain for the past week after recently returning from a camping trip. Which diagnostic study is suggested?
  • Computerized tomography
  • Blood culture
  • Stool for ova and parasites ✓
  • Clean catch urine
Correct Answer
Stool for ova and parasites
A. The patient is presenting with classic symptoms of Giardia intestinalis, also known as Giardia duodenalis or Giardia lamblia. Diagnosis of Giardia intestinalis is typically made using stool ova and parasite (O&P) examination. B. Computerized tomography may be needed for this patient; however, it would not be useful in diagnosing Giardia intestinalis. C. Blood culture could be indicated but would not be beneficial in diagnosing Giardia intestinalis. D. Urine analysis may be indicated for this patient; however, it would not be useful in determining the cause of this patient’s symptoms. Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment, Temperature-related emergencies
Question 140
The emergency nurse is assigned to care for a patient with a traumatic brain injury. The emergency nurse provides interventions to avoid hypoperfusion of the brain. These interventions have been effective when the patient achieves which of the following?
  • Capillary refill of 4 seconds
  • Mean arterial pressure (MAP) of 70 ✓
  • Normal sinus rhythm
  • PaCO2 level of 33 mm Hg
Correct Answer
Mean arterial pressure (MAP) of 70
A. Normal PaCO2 levels are 35–45 mm Hg; lower PaCO2 levels decrease cerebral blood flow, resulting in cerebral ischemia. B. The brain requires sufficient blood pressure to maintain adequate cerebral perfusion. The best measurement to determine adequate blood flow to the brain is cerebral perfusion pressure (CPP). It is calculated by subtracting the patient’s intracranial pressure from their MAP. Normal CPP is 50–70 mm Hg. C. Sinus rhythm can be present in cerebral hypoperfusion and would not necessarily indicate that sufficient blood is reaching the brain. Reference Broering, B. (2020). Head trauma. In V. Sweet & D. Normal capillary refill for adults is 2–3 seconds. A capillary refill of greater than 3 seconds is an indication of decreased perfusion. Category: Neurological Emergencies, Increased intracranial pressure (ICP)
Question 141
A patient states that they were cleaning the bathroom when liquid cleaner splashed into their eye. The patient is complaining of severe pain in the affected eye. The nurse prepares for which priority intervention?
  • Instilling topical anesthetic drops
  • Updating tetanus immunization status
  • Obtaining a baseline visual acuity
  • Eye irrigation with normal saline ✓
Correct Answer
Eye irrigation with normal saline
A. Do not delay eye irrigation to obtain the patient’s visual acuity. Alkali substances will continue to penetrate the eye until they have been completely removed and neutralized. B. Instilling topical anesthetic drops to the eye will relieve the patient’s discomfort, however, eye irrigation should not be delayed. Removal and neutralization of the chemical will also help alleviate pain. C. Eye irrigation with normal saline, lactated Ringer’s solution, or even tap water if the other two solutions aren’t readily available should begin immediately. Many household cleaners are alkali substances and will continue to penetrate the eye. D. An update to the patient’s tetanus immunization status can be completed following completion of the eye irrigation, which is the priority. Category: Maxillofacial and Ocular Emergencies, Ocular, Burns
Question 142
A patient complains of abdominal pain, nausea, and vomiting. An abdominal computed tomography (CT) scan with intravenous (IV) contrast has been ordered. The patient’s renal laboratory values return and indicate that the creatinine is 0.8mg/dL, and the blood urea nitrogen (BUN) is 10 mg/dL. Which statement made by the nurse indicates an understanding of these lab results and how they relate to the CT scan?
  • “Renal function is adequate, so the patient can receive contrast during the CT scan.” ✓
  • “I will contact the provider to determine if a diuretic can be administered prior to the scan.”
  • “Renal function is impaired, so the patient should not receive IV contrast.”
  • “The patient should receive a bolus of isotonic saline prior to receiving IV contrast.”
Correct Answer
“Renal function is adequate, so the patient can receive contrast during the CT scan.”
A. Normal creatinine range is 0.6–1.2mg/dL; the patient’s value is safely within these parameters, so IV contrast administration would not be contraindicated based on this value. B. Normal creatinine range is 0.6–1.2mg/dL. Normal BUN range is 7–20mg/dL. The normal BUN-to-creatinine ratio is 10:1. The patient is considered hydrated, the kidneys are working, and it is safe for the patient to receive IV contrast. C. There is no indication for a diuretic to be administered prior to the administration of the IV contrast. D. Normal creatinine range is 0.6–1.2mg/dL and BUN range is 7–20mg/dL. There is no indication that a bolus of normal saline IV fluid is indicated prior to administration of contrast. However, IV fluid may be ordered following the CT scan to facilitate the elimination of the contrast from the renal system. Category: Medical Emergencies, Renal failure
Question 143
A patient presents to the emergency department following a syncopal episode. The cardiac monitor shows sinus rhythm with a rate of 83 and changing configuration of the P-waves. Four different P-wave morphologies are noted in lead II during a 15-second strip recording. What is the rhythm interpretation?
  • Wandering atrial pacemaker ✓
  • Frequent premature atrial contractions (PACs)
  • Multifocal atrial tachycardia
  • Atrial fibrillation
Correct Answer
Wandering atrial pacemaker
A. Wandering atrial pacemaker is characterized by the presence of at least three different P-wave morphologies occurring within the same lead. The PR interval may vary slightly depending on the location of the atrial excitation away from the patient’s natural pacemaker, or the SA node. The rhythm is usually benign unless tachycardia occurs, resulting in multifocal atrial tachycardia. B. PACs occur earlier than the patient’s normal heartbeat with a shortened PR interval and will have a different configuration from the patient’s usual configured P-wave, whereas the QRS complex will resemble the patient’s usual cardiac beats. C. Wandering atrial pacemaker is characterized by the presence of at least three different P-wave morphologies occurring within the same lead. Multifocal atrial tachycardia presents similarly to wandering atrial pacemaker, except that the heart rate will be between 100 and 160 beats/minute. D. Atrial fibrillation is characterized by “irregular irregularity” and is described as a chaotic rhythm with the absence of an identifiable P-wave; instead, there are fibrillation waves and an irregular ventricular response related to irregular atrial conduction through the AV node. This results in an irregular heartbeat and a decrease in stroke volume. Reference Wesley, K. (2022). Atrial rhythms. In K. Wesley (Ed.), Huszar’s ECG and 12-lead interpretation (6th ed., pp. 88–103). Elsevier. Category: Cardiovascular Emergencies, Dysrhythmias
Question 144
When triaging patients of a mass casualty incident, patients can be placed into one of four categories: green (minor), yellow (delayed), red (immediate), and:
  • purple (critical).
  • blue (palliative).
  • gray (expectant).
  • black (expectant). ✓
Correct Answer
black (expectant).
A. The black (expectant) category is assigned when the victim is unlikely to survive, given the severity of their injuries, the level of available care required, or both. At this time, palliative care is provided to the patient without benefit of additional interventions. B. There is not a purple designation for use in triaging victims of mass casualty incidents. Reference Jacobson, S. F. (2020). Disaster management. In J. S. Blansfield (Ed.), Trauma Nursing Core Course provider manual (8th ed., pp. 347–376). Jones & Bartlett Learning. C. There is no blue category to designate palliative care given in the triage of mass casualty incident patients. The black (expectant) category is assigned when the victim is unlikely to survive given the severity of their injuries, the level of available care required, or both. At this time, palliative care is provided to the patient without benefit of additional interventions. D. Although some agencies have discussed adding a gray category (expectant) to divide the expectant and deceased categories, at this time, there are only four triage colors: green, yellow, red, and black. The expectant and deceased are combined in the black category. Category: Professional Issues, System, Disaster management
Question 145
Which of the following is the priority intervention for a patient who was struck by lightning?
  • Clean and dress all burn wounds
  • Institute continuous cardiac monitoring ✓
  • Monitor urinary output
  • Obtain radiographic studies of injured areas
Correct Answer
Institute continuous cardiac monitoring
A. Cardiac dysrhythmias are associated with lightning strike injuries and can be life threatening. Continuous cardiac monitoring should be the priority of care for this patient. A 12-lead electrocardiogram may also be ordered to assess for signs of potential myocardial damage as a result of the lightning strike. B. Radiographic studies are indicated for this patient but are not the priority of care. C. Wound care is appropriate for lightning strike injuries and to ensure that the patient’s tetanus immunizations are up to date, but the priority of care is to rule out the presence of life-threatening cardiac dysrhythmias. Reference Bailey, C. (2020). Electrical and lightning injuries. In J. D. Tintinalli, O. J. Ma, Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment, Electrical injuries
Question 146
A patient has ingested a large amount of amitriptyline (Elavil). Which assessment finding should the nurse anticipate in this patient?
  • Peaked T-waves
  • Shortened PR interval
  • Prolonged QT interval ✓
  • Bradycardia
Correct Answer
Prolonged QT interval
A. In tricyclic antidepressant overdose, cardiotoxicity can occur, resulting in decreased cardiac conduction. Dysrhythmias include prolonged PR, QRS, and QT intervals, ST- and T-wave abnormalities, and heart blocks. In the early stages of tricyclic overdose, the patient may experience episodes of sinus tachycardia. B. An expected sign of tricyclic antidepressant overdose is tachycardia due to anticholinergic effects. C. Tricyclic antidepressant overdose will produce prolonged PR intervals. D. Peaked T-waves are associated with hyperkalemia, not usually with tricyclic antidepressant overdose. Category: Mental Health Emergencies, Intentional overdose and ingestions
Question 147
An unresponsive adult female is brought in by ambulance after she was found unresponsive. According to the prehospital report, the patient’s undergarments were not intact, and there is suspicion that the patient may have been sexually assaulted. Because the patient is unable to consent to the collection of forensic evidence, how should the emergency nurse proceed?
  • A law enforcement officer is able to provide consent for the collection of evidence.
  • Follow your hospital policy regarding collection of evidence from an unconscious patient. ✓
  • Nurses are obligated to collect the evidence regardless of whether consent is obtained.
  • Do not collect forensic evidence without consent of the victim or their next-of-kin.
Correct Answer
Follow your hospital policy regarding collection of evidence from an unconscious patient.
A. In the case of sexual assault, the patient must consent to examination and the collection of forensic evidence unless the next-of-kin has the legal authority to consent for them. B. Forensic evidence collection on an unconscious patient can be problematic. Different areas have different laws regarding what you can and cannot do in this situation. It is recommended that hospitals develop sexual assault policies and procedures for unconscious patients that outline when and what kind of evidence can be obtained and under what circumstances. C. In the case of sexual assault, the patient must consent to examination and the collection of forensic evidence. Nurses are not legally obligated to collect forensic evidence without patient consent. D. Informed consent from the patient must be obtained before evidence collection. Law enforcement officers are not authorized to provide consent for the sexual assault examination or collection the of evidence. Category: Professional Issues, Patient, Forensic evidence collection
Question 148
When using lung protective ventilator settings in the patient with acute respiratory distress syndrome, the nurse would expect which setting for the tidal volume (TV)?
  • 12 mL/kg based on patient’s predicted weight
  • 6 mL/kg based on patient’s current measured weight
  • 6 mL/kg based on patient’s predicted body weight ✓
  • 12 mL/kg based on patient’s current measured weight
Correct Answer
6 mL/kg based on patient’s predicted body weight
A. A tidal volume of 12 mL/kg is used in a controlled ventilation strategy and could potentially cause volume-trauma in the patient with acute respiratory distress syndrome. B. Using the patient’s measured weight could result in an overestimation of the TV required. C. A TV of 12 mL/kg reflects a controlled ventilation setting; using a measured weight may cause use of a TV that is too high. D. TV of 6 mL/kg will help prevent further damage to lung tissue. The TV is based on the patient’s predicted weight to avoid overestimating the TV needed. Lung size depends on a person’s height and sex and does not change with weight gain or loss. Category: Respiratory Emergencies, Respiratory distress syndrome
Question 149
A client presents to the emergency department with an uncomplicated, recurrent migraine episode. What treatment should the nurse prepare to provide?
  • 0.9% normal saline
  • Metoclopramide ✓
  • Morphine sulfate
  • Butalbital compound
Correct Answer
Metoclopramide
A. Opioids have been proved to be ineffective in treating migraine and are associated with higher levels of return ED visits. B. Excessive use of caffeine-containing OTC medications and medications containing butalbital should not be routinely used for headache because these medications may induce medication overuse headaches. Reference Ledford, L. (2020). Neurological emergencies. In V. Sweet & C. Current recommendations for the treatment of acute migraine in the ED are metoclopramide or prochlorperazine and subcutaneous sumatriptan. Diphenhydramine or midazolam may be given to prevent or treat akathisia (restlessness). D. IV fluid administration is not necessary unless the patient has symptoms of dehydration. Category: Neurological Emergencies, Headache (e.g., temporal arteritis, migraine)
Question 150
A patient is experiencing extreme eye irritation after splashing pool chemicals into their right eye. The eye has been irrigated using 2 L of an isotonic fluid. The nurse identifies that this intervention has been successful when the pH of the eye reaches which level?
  • 6.3
  • 7.1 ✓
  • 6.9
  • 7.6
Correct Answer
7.1
A. The pH of the eye is normally neutral (7.0–7.3). It is important to neutralize the chemical and return the pH to a neutral level to avoid further eye injury. The pH level of the eye should be tested periodically during the irrigation process to help determine if the chemical has been neutralized and removed from the eye. B. A pH of 6.9 indicates that the environment of the eye is acidic. Further irrigation of the eye is necessary to reach a pH range of 7.0–7.3. C. A pH of 7.6 indicates that the eye is alkalotic. Further irrigation of the eye is necessary to reach a pH range of 7.0–7.3. D. A pH of 6.3 indicates the environment of the eye is acidic. Further irrigation of the eye is necessary to reach a pH range of 7.0–7.3. Category: Maxillofacial and Ocular Emergencies, Ocular, Burns
Question 151
A nurse suspects an elderly patient is being abused by their children. How does the Health Insurance Portability and Accountability Act (HIPAA) affect the legal responsibilities of mandatory reporting?
  • The nurse is able to share protected health information with law enforcement when reporting suspicion of abuse. ✓
  • The nurse must first obtain verbal consent from the patient before sharing protected health information with law enforcement.
  • The nurse should leave all reporting of suspicion of abuse up to the physician because they know what can and cannot be shared with law enforcement under HIPAA.
  • The nurse must first obtain signed written consent from the patient before sharing protected health information with law enforcement.
Correct Answer
The nurse is able to share protected health information with law enforcement when reporting suspicion of abuse.
A. Reporting abuse is mandatory reporting for the healthcare professional. When reporting suspicion of abuse to law enforcement, the nurse is not required to obtain verbal or written consent from the patient or family. B. Reporting abuse is mandatory reporting for the healthcare professional. When reporting suspicion of abuse to law enforcement, the nurse is not required to obtain either verbal or written consent from the patient or family. C. Reporting abuse is mandatory reporting for all healthcare professionals. When reporting suspicion of abuse to law enforcement, the nurse does not need prior consent from the patient or family. D. Reporting abuse is mandatory reporting for all healthcare professionals. Anyone on the healthcare team can and should report all suspicions of known or suspected abuse. Reference McConnell, T. C. (2020). Legal and regulatory constructs. In V. Sweet & Category: Professional Issues, System, Federal regulations (e.g., HIPAA, EMTALA)
Question 152
A patient wearing wet swim trunks presents to triage with shallow respirations and chest retractions; skin is pale and cool. Initial vital signs are: BP 95/56 mm Hg, HR 150 beats/minute, RR 40 breaths/minute, SpO2 85% without supplemental oxygen, T 35.8°C (96.5°F). The patient is lethargic, and lung sounds are diminished bilaterally with crackles at the bases. Based on this presentation, what is the primary concern for this patient?
  • Closed head injury
  • Asthma
  • Pneumonia
  • Pulmonary edema ✓
Correct Answer
Pulmonary edema
A. There is no report of trauma, injury, loss of consciousness, or head trauma; therefore, the presence of a closed head injury is highly unlikely. B. No history is provided, but based on the presentation and the wet swim trunks, there is concern for a possible water submersion injury. Patients with submersion injury may present with respiratory distress, pulmonary edema, hypothermia, and hypotension. Inhaled water damages the alveolar-capillary membrane, which increases permeability, resulting in fluid-filled alveoli. C. The patient has no fever or history of any recent infectious process that would indicate a concern for pneumonia. D. The patient is tachypneic and in respiratory distress; however, symptoms of asthma include wheezing, which is not present. Reference Foley, A., & Sweet, V. (2020). Respiratory emergencies. In V. Sweet & Category: Respiratory Emergencies, Noncardiac pulmonary edema
Question 153
Patient safety, satisfaction ratings, and a decreased number of patients leaving without being seen (LWBS) and against medical advice (AMA) are all part of performance improvement initiatives in the emergency department. One way emergency departments are trying to decrease the number of LWBS and AMA patients, as well as increase patient safety and patient satisfaction, is to:
  • provide warm blankets in the waiting room and patient rooms.
  • obtain frequent vital sign measurements.
  • offer food and drinks in the waiting room.
  • perform hourly rounding. ✓
Correct Answer
perform hourly rounding.
A. Providing warm blankets to patients can be part of hourly rounding. However, hourly rounding in both the emergency department and the triage area has been proved to increase patient satisfaction scores and decrease LWBS and AMA visits in the emergency department. Reference Brosinski, C., & Riddell, A. (2019). Incorporating hourly rounding to increase emergency department patient satisfaction: A quality improvement approach. Journal of Emergency Nursing, 46(4), 511–517. https://doi.org/10.1016/j.jen.2019.08.004 B. Although doing vital signs can be a part of hourly rounding, hourly rounding in both the emergency department and the triage area has been proved to increase patient satisfaction scores and decrease LWBS and AMA visits in the emergency department. C. Hourly rounding in both the emergency department and the triage area has been proved to increase patient satisfaction scores and decrease LWBS and AMA visits in the emergency department. D. Emergency departments typically will not offer food and drinks in the waiting room because most patients are told not to eat or drink anything until they have been examined by the emergency provider. Hourly rounding in both the emergency department and triage has been proved to increase patient satisfaction scores and decrease LWBS and AMA visits in the emergency department. Category: Professional Issues, System, Performance and process improvement
Question 154
A patient with bipolar disorder is being treated for a manic episode. Which statement made by the patient to the nurse indicates the need for additional patient education?
  • “Since I had the manic episode, it’s unlikely that I will have a depressive phase.” ✓
  • “I will maintain appointments with my psychotherapist to help manage my mood disorder.”
  • “While taking the lithium medication, I must have blood drawn to check my sodium level.”
  • “I will take my medication regularly to avoid the severe highs and lows of my disorder.”
Correct Answer
“Since I had the manic episode, it’s unlikely that I will have a depressive phase.”
A. Psychotherapy, along with drug therapy, is a standard part of the treatment regimen for a patient with bipolar disorder. Reference Pitner, J. V. (2018). Psychiatric/psychosocial emergencies. In V. Sweet (Ed.), Emergency nursing core curriculum (7th ed., pp. 437–451). Elsevier. B. Lithium is a mood-stabilizing drug typically prescribed for bipolar disorder. Maintenance of lithium levels minimizes the mood swings and subsequent behavior, such as manic episodes, that occur with bipolar disorder. C. Hypernatremia and any conditions that result in dehydration may lead to increased lithium levels. Patients on lithium should have their sodium level monitored regularly. D. Patients with bipolar disorder may have severe and intense mood swings and behavior ranging from mania to deep depression. Having one manifestation of the disorder does not minimize the risk of experiencing the other. Category: Mental Health Emergencies, Mood disorders (e.g., bipolar, depression)
Question 155
What is a hallmark sign that would indicate to the emergency nurse that a patient is developing acute respiratory distress syndrome (ARDS)?
  • Cough, syncope, and petechiae noted on the anterior chest wall
  • Hypoxemia unresponsive to increased oxygen concentration ✓
  • Pulmonary edema accompanied by pitting edema in all extremities
  • Prolonged, increasing periods of apnea with hypoxemia
Correct Answer
Hypoxemia unresponsive to increased oxygen concentration
A. There are many causes of respiratory failure. Other reasons for respiratory failure should be excluded when establishing a diagnosis of ARDS. B. Cough, syncope, and chest wall petechiae are found in fat emboli following long-bone fractures. Reference Foley, A., & Sweet, V. (2020). Respiratory emergencies. In V. Sweet & C. The presence of pulmonary edema on chest radiograph, in conjunction with the presence of pitting edema in the patient, increases the likelihood that the pulmonary edema is related to inadequate left ventricular function. D. The patient with ARDS will have decreased lung compliance, refractory hypoxemia, severe acute respiratory distress, and pulmonary parenchymal consolidations. Refractory hypoxemia is hypoxemia that does not improve with high concentrations of oxygen. Category: Respiratory Emergencies, Respiratory distress syndrome
Question 156
A patient is experiencing severe dyspnea and is thought to be in acute heart failure (HF). What intervention should the emergency nurse perform first?
  • Begin an isotonic crystalloid infusion
  • Administer a loop diuretic
  • Place the patient in an upright, sitting position ✓
  • Administer an IV dose of digoxin
Correct Answer
Place the patient in an upright, sitting position
A. Digoxin is a positive inotrope that may have some benefits with improving symptoms of heart failure, but it is not considered a first-line therapy unless used in heart failure patients with atrial fibrillation. B. The most common presenting symptom of acute HF is dyspnea, and respiratory failure is the most frequent life-threatening condition. Immediate management of acute HF to prevent respiratory failure involves repositioning the patient by placing them in an upright, sitting position to allow for optimal ventilation. This can be done first while preparing for other immediate interventions. C. Because most patients in acute HF will have significant volume overload that contributes to severe respiratory symptoms, administration of a loop diuretic is recommended. However, repositioning the patient to improve ventilation should be done first while preparing to administer a diuretic. D. Most patients in acute HF will have significant volume overload that contributes to respiratory distress. Therefore, judicious administration of fluid volume is extremely important to avoid worsening fluid overload. Category: Cardiovascular Emergencies, Heart failure
Question 157
An older adult patient reports sudden loss of vision in their right eye 30 minutes before arrival. What would be the priority nursing intervention for this patient?
  • Perform a full neurological assessment
  • Evaluate the patient for any trauma to the eye or orbit
  • Facilitate an immediate computed tomography (CT) scan of the head ✓
  • Obtain the patient’s past medical history
Correct Answer
Facilitate an immediate computed tomography (CT) scan of the head
A. Evaluating the patient for trauma to the eye or orbit involves gross inspection and a slit lamp examination, which would not be the priority at this time. B. Stroke is a leading cause of death in the United States, and approximately 87% of all strokes are ischemic. Early identification of a stroke allows for possible treatments, such as tissue plasminogen activator or thrombectomy. A stroke represents a life-threatening situation and requires an immediate CT scan of the head. C. Obtaining the patient’s past medical history would be indicated, but it must not delay time to CT for a suspected ischemic stroke. D. Performing a full neurological assessment is indicated, but it must not delay time to CT for a suspected ischemic stroke. Category: Neurological Emergencies, Stroke
Question 158
How long must a patient exhibit signs of a depressive state before the diagnosis of clinical depression is made?
  • 2 days
  • 2 months
  • 2 weeks ✓
  • 2 years
Correct Answer
2 weeks
A. A diagnosis of clinical depression is made following consistent depressive symptoms that are exhibited by the patient all day, most of the day, every day for a period of 2 weeks or longer. Signs and symptoms include, but are not limited to, feelings of worthlessness and helplessness, decreased interest in previously pleasurable activities, excessive feelings of guilt, constant loss of energy, and sleep disturbances. The appearance of a sad or depressed mood is only one indicator of the presence of clinical depression. B. If a patient has been depressed for 2 months or longer, the patient should have already sought assistance for their persistent feelings of depression. Once a patient has been depressed for 2 weeks, they should be directed to seek medical treatment. C. Patients who are depressed for 2 years or longer are often diagnosed with a major depressive disorder such as dysthymic disorder, which is defined as a chronic mild depressive state. Symptoms include feelings of depression or sadness almost every day, loss of enjoyment in activities, daily sleep disturbances, and weight gain or loss within a short period. D. A patient may be depressed for brief periods as a reaction to acute grief, such as the recent death of a loved one, the recent loss of a job, or a major life change. Two days is not long enough for the diagnosis of clinical depression to be made. Category: Mental Health Emergencies, Mood disorders (e.g., bipolar, depression)
Question 159
A patient with a history of severe dementia who is nonverbal is diagnosed with a small bowel obstruction. The most reliable method for the nurse to assess pain in this patient is through which of the following?
  • Observation of pain-associated behaviors ✓
  • Asking caregivers to evaluate the patient’s level of pain
  • Use of a nurse-initiated pain management protocol
  • Patient’s self-report using a validated pain scale
Correct Answer
Observation of pain-associated behaviors
A. For a patient who is nonverbal and unable to self-report the presence of pain, the use of a behavior observation tool, such as the Pain Assessment in Advanced Dementia (PAINAD), is a valid means of assessing pain. B. Nurse-initiated pain management protocols can shorten the time that the patient must wait before receiving pain medication, however, the protocol is a nursing intervention that must first be based on an accurate pain assessment. C. Reliable information may be obtained from family members or caregivers but should be used only when other techniques, such as self-reporting of pain and observation of pain-associated behaviors, cannot be used or do not provide useful information. D. The use of a self-reported pain scale may not be appropriate because a patient with severe dementia may lack the capacity to understand the pain scale and appropriately communicate about the pain experienced. Category: Professional Issues, Patient, Pain management and procedural sedation
Question 160
What would be a late sign of an increase in intracranial pressure?
  • Motor posturing ✓
  • Headache
  • Nausea
  • Sluggish pupils
Correct Answer
Motor posturing
A. Late signs and symptoms of increased intracranial pressure include dilated, nonreactive pupils, unresponsiveness, abnormal motor posturing, and Cushing’s triad (widening pulse pressure, reflex bradycardia, and a decreased respiratory effort). B. Early assessment findings of increased intracranial pressure include headache, nausea, vomiting, sluggish pupils, amnesia, behavioral changes, and an altered level of consciousness. C. Early assessment findings of increased intracranial pressure include headache, nausea, vomiting, sluggish pupils, amnesia, behavioral changes, and an altered level of consciousness. D. Early assessment findings of increased intracranial pressure include headache, nausea, vomiting, sluggish pupils, amnesia, behavioral changes, and an altered level of consciousness. Category: Neurological Emergencies, Increased intracranial pressure (ICP)
Question 161
A patient has received discharge teaching following closure of a forehead laceration with adhesive glue. The nurse knows the patient understands the instructions when they state which of the following?
  • “I will not remove the dressing over the glue for 5 days.”
  • “I can shower in 24 hours as long as I keep the glue from getting soaked.” ✓
  • “I will return to the emergency department for removal of adhesive glue in 3 days.”
  • “I will apply a layer of antibiotic ointment to the laceration daily.”
Correct Answer
“I can shower in 24 hours as long as I keep the glue from getting soaked.”
A. It is not necessary to return to the emergency department for removal of the adhesive glue; it will slough off 5–10 days after application. Reference Denke, N. J. (2020). Wound management. In V. Sweet & B. The use of antibiotic ointment is not recommended following the use of adhesive glue because it will result in removing the adhesive glue from the wound. C. Patients need to remove the dressing to observe for signs of wound infection. Facial wounds may not even require a dressing over the glue. D. Patients may shower, but they need to protect the glue from getting soaked. They should pat the area dry but avoid scrubbing. Swimming should be avoided. Category: Musculoskeletal and Wound Emergencies, Wound, Lacerations
Question 162
An unrestrained driver in a head-on motor vehicle collision arrives with complaints of lower abdominal and pelvic pain. Vital signs are: BP 70/52 mm Hg, HR 140 beats/minute, RR 29 breaths/minute, SpO295%, T 36°C (96°F). Assessment reveals equal breath sounds bilaterally, a weak and rapid central pulse, and cool moist skin. The secondary survey is significant for an unstable pelvis on lateral compression. One large-caliber intravenous line is infusing isotonic crystalloid solution. Which of the following is the priority intervention for this patient?
  • Insertion of a second intravenous line
  • Preparation for surgical intervention
  • Application of a pelvic binder ✓
  • Administration of fluids by rapid infuser
Correct Answer
Application of a pelvic binder
A. Two large-caliber intravenous lines are indicated for severe hemorrhagic trauma; however, the priority intervention is to stop the bleeding by reducing the volume of the pelvis. B. This patient is hemodynamically unstable, so binding with a sheet or commercial device to stabilize the pelvis and control hemorrhage is indicated. An open-book pelvic fracture can result in life-threatening hemorrhage if not stabilized. C. After bleeding is controlled (pelvic binder) and volume replacement is initiated, definitive management, such as surgical intervention, to control further hemorrhage is indicated. Reference Bratcher, D. Hemorrhagic shock should be managed with volume (blood) replacement, and prevention and correction of hypothermia and hypoxemia. The first priority for this patient is to close the pelvic volume. Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Ligament tendon injuries (e.g., sprains, strains, ruptures)
Question 163
Which of the following blood dyscrasias is defined as a decreased platelet count of less than 150,000/uL of blood?
  • Thrombocytopenia purpura ✓
  • Disseminated intravascular coagulation
  • Leukemia
  • Anemia
Correct Answer
Thrombocytopenia purpura
A. Leukemia is a malignant disorder of the white blood cells that results in an excessive and abnormal growth of leukocyte precursors, or “blasts” (immature white cells), within the bone marrow. B. Normal platelet count is between 150,000 and 450,000/uL. Thrombocytopenia purpura is defined as decreased platelet production within the bone marrow. The decreased platelet count may be caused by an accelerated destruction of platelets or an increased splenic sequestration of platelets. C. Disseminated intravascular coagulation is a complex disorder of the clotting system in which both clotting and hemorrhaging occur simultaneously. D. Anemia is a reduction of the red blood cell (RBC) count that is caused by an acute or chronic condition. The reduction in available RBCs leads to a decrease in oxygen transport to tissue. Reference Smith, N. Z., & Powell, K. K. (2018). Hematologic/oncologic emergencies. In V. Sweet (Ed.), Emergency nursing core curriculum (7th ed., pp. 290–305). Elsevier. Category: Medical Emergencies, Hematologic disorders
Question 164
A patient presents with acute alcohol intoxication. Which priority intervention does the nurse anticipate in the care of this patient?
  • Maintain airway patency ✓
  • Monitor magnesium levels
  • Prevent acute alcohol withdrawal
  • Monitor risk for falls
Correct Answer
Maintain airway patency
A. Chronic alcoholism is the most common cause of hypomagnesemia. Magnesium replacement may be needed but is not a priority intervention. B. Patients with acute alcohol intoxication may have altered level of consciousness and are at risk for aspiration from vomiting. Airway compromise may occur; therefore, maintenance of airway patency is a high priority to ensure adequate ventilation. C. The patient may also be at risk for acute alcohol withdrawal, and appropriate interventions should be taken to prevent this. However, securing airway patency is a higher priority. D. Intoxicated patients are at risk for falls from an altered level of consciousness and awareness. Although this is a valid safety concern, airway patency remains a priority. Category: Medical Emergencies, Withdrawal syndrome
Question 165
A patient presenting to the emergency department was involved in a high-speed motor vehicle collision. The initial assessment reveals that the patient’s pulses are much stronger in the upper extremities than in the lower extremities. Which intervention has the highest priority for this patient?
  • Preparing the patient for surgery or angiography ✓
  • Frequent reevaluation of vital signs and careful observation
  • Thoracic computerized tomography scan
  • Beginning the massive transfusion protocol
Correct Answer
Preparing the patient for surgery or angiography
A. The presence of stronger pulses in the upper extremities compared with the lower extremities is an indication of a thoracic aortic injury. This type of injury is accompanied by a very high mortality rate. Immediate repair of the injury is the highest priority. B. Computerized tomography should only be used to evaluate for thoracic injury in the absence of any obvious physical findings. C. The patient should be carefully monitored, but the priority intervention is the repair of the thoracic aortic injury. Reference Casey, R. M. (2020). Thoracic and neck trauma. In J. S. Blansfield (Ed.), Trauma Nursing Core Course provider manual (8th ed., pp. 121–140). Jones & Bartlett Learning. D. Although the patient is tachycardic, they are not demonstrating extreme hypotension or outward signs of hemorrhage. Therefore, the initiation of the massive transfusion protocol is not indicated. Death can occur very quickly in the presence of a thoracic aortic injury, so repair of this injury is the priority for this patient. This patient is at high risk for sudden death due to rupture of the thoracic aorta. Category: Cardiovascular Emergencies, Cardiovascular Trauma
Question 166
The emergency department nurse enters the room of an adult patient who was admitted with complaints of shortness of breath. As the nurse enters the room, they observe that the patient is lying supine, and the head of the bed is flat. What is the nurse’s best action?
  • Place the patient on the pulse oximetry monitor
  • Auscultate the patient’s breath sounds
  • Place the patient on the cardiac monitor
  • Elevate the patient’s head of bed ✓
Correct Answer
Elevate the patient’s head of bed
A. The 45-degree semi-Fowler’s position is the most effective position to promote lung expansion by reducing the pressure exerted on the diaphragm from the contents of the abdomen. B. First interventions for patients with shortness of breath should be focused on airway and breathing. C. Although the pulse oximetry may provide some information related to hemoglobin oxygen concentration, the first intervention for patients with shortness of breath should be focused on airway and breathing difficulties. D. First interventions for patients with shortness of breath should be focused on airway and breathing. Lying flat could affect both airway and breathing. Simple repositioning can promote an adequate airway and effective breathing. Assessing breath sounds would be an important intervention once airway and breathing pattern are addressed. Category: Respiratory Emergencies, Asthma
Question 167
A patient presents to triage with symptoms of headache, nausea, vomiting, dizziness, and blurred vision for the last 4 hours. Vital signs are: BP 198/110 mm Hg, HR 80 beats/minute, RR 20 breaths/minute, SpO2 98%, and T 37°C (98.6°F). After assessing the correct size cuff, a second blood pressure in the patient’s opposite arm is obtained with similar readings. Based on these findings, what is the most likely cause?
  • Myocardial infarction
  • Labyrinthitis
  • Migraine headache
  • Hypertensive crisis ✓
Correct Answer
Hypertensive crisis
A. The patient may be having a myocardial infarction, but the nurse is unable to determine this without the presence of a 12-lead electrocardiogram and further testing. B. Hypertensive crisis is defined as elevations in systolic blood pressure greater than 180 mm Hg or a diastolic pressure greater than 120 mm Hg. Hypertensive emergencies are clinical situations in which excessively high blood pressure must be lowered quickly, within 1–2 hours. The elevated blood pressures are accompanied by end organ damage or impending damage if blood pressure is not lowered. C. Labyrinthitis will present as severe dizziness with nausea, vomiting, and disturbances in gait and balance. Severe blood pressure elevation and blurry vision are not usually present. D. Migraine headache will present as moderate to severe headache, with nausea, vomiting, and photophobia. Blood pressure may be elevated, but not usually in this range. Category: Cardiovascular Emergencies, Hypertension
Question 168
A patient with schizophrenia is exhibiting extreme aggressive behavior toward the staff. Ziprasidone (Geodon) is ordered as an intramuscular injection. The nurse is aware that this medication should be used with caution in patients who have previously been diagnosed with which of the following?
  • Pathologic Q-wave
  • Prolonged QT interval ✓
  • Depressed T-wave
  • Prolonged PR interval
Correct Answer
Prolonged QT interval
A. A depressed T-wave might indicate ischemia but has not been shown to be harmful for patients receiving ziprasidone. B. A pathologic Q-wave occurs after a myocardial infarction and, in most cases, is permanent. It has not been identified as a risk factor for patients receiving ziprasidone. C. Ziprasidone can increase the patient’s QT interval, leading to a potentially fatal cardiac event. Cardiac monitoring should be initiated in patients with a history of prolonged QT interval. D. Prolonged PR interval indicates either first- or second-degree heart block. Ziprasidone has not been shown to increase the risk of developing heart block. Category: Mental Health Emergencies, Thought disorders (e.g., psychosis, schizophrenia)
Question 169
In the management of adult cardiac arrest, what is the current recommended dose for either intravenous or intraosseous epinephrine?
  • 1 mg every 2 minutes
  • 1 mg every 3–5 minutes ✓
  • 5 mg every 3–5 minutes
  • 0.1–0.2 mg/kg every 3–5 minutes
Correct Answer
1 mg every 3–5 minutes
A. This dosing plan is faster than recommended. B. This dosing plan is a higher dose than recommended. C. High-dose epinephrine is not recommended for routine use in cardiac arrest (Class III: No Benefit, LOE B-R). D. It is recommended that 1 mg of epinephrine be administered to patients in cardiac arrest every 3–5 minutes (Class 2a; Level of Evidence C-LD). Category: Cardiovascular Emergencies, Cardiopulmonary arrest
Question 170
A patient who was involved in a single-car motor vehicle collision (MVC) presents with hypotension, altered level of consciousness, cyanotic skin, and rapid, faint peripheral pulses. There are no obvious signs of hemorrhage. The nurse anticipates that treatment for this patient will include which of the following?
  • Intravenous crystalloid resuscitation
  • Administration of packed red blood cells
  • Controlled fluid boluses and inotropic support ✓
  • Needle thoracostomy followed by chest tube insertion
Correct Answer
Controlled fluid boluses and inotropic support
A. The patient is not exhibiting signs and symptoms of a tension pneumothorax; therefore, a needle thoracostomy for decompression is not indicated. This patient is exhibiting signs of cardiogenic shock. The MVC most likely was precipitated by a cardiac event. B. This patient is in cardiogenic shock. The MVC most likely was precipitated by a cardiac event. The excess administration of intravenous crystalloids can result in pulmonary edema and increased myocardial ischemia. C. This patient is exhibiting signs and symptoms of cardiogenic shock. The MVC was most likely precipitated by a cardiac event. Treatment consists of the judicious use of controlled intravenous fluid administration to improve preload and inotropic support to improve contractility. D. The patient is not exhibiting signs and symptoms of hypovolemic shock; this patient is in cardiogenic shock. The MVC most likely was precipitated by a cardiac event. The administration of packed red blood cells is not indicated for this patient. Category: Cardiovascular Emergencies, Cardiovascular Trauma
Question 171
Which progressive, degenerative joint disease is characterized by the presence of bone spurs and destruction of articular cartilage?
  • Osteoporosis
  • Rheumatoid arthritis
  • Joint effusions
  • Osteoarthritis ✓
Correct Answer
Osteoarthritis
A. Also known as degenerative joint disease, osteoarthritis is the most common joint disease and results in the degeneration of the articular cartilage and the presence of bone spurs in joints. B. Rheumatoid arthritis is a chronic, systemic autoimmune disease characterized by inflammation of the synovial membrane and articular cartilage of the joints. Osteoarthritis results in the degeneration of the articular cartilage and the presence of bone spurs in joints. C. Osteoporosis results from inadequate production of bone, excessive removal of bone, or a combination of both. It results in thin bones. Populations at risk include postmenopausal women, persons who take steroids, and persons who use alcohol. Osteoarthritis results in the degeneration of the articular cartilage and the presence of bone spurs in joints. D. Joint effusions involve the collection of fluid in a joint as a result of an inflammatory process, previous surgery, or trauma. Effusions most commonly occur in the knee joint. Extreme stretching of the knee ligaments may result in microscopic tears of the meniscus, with consequent synovial fluid collection. Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Inflammatory conditions References Arruda, T. (2018). Medical emergencies. In V. Sweet (Ed.), Emergency nursing core curriculum (7th ed., pp. 334–348). Elsevier. Cerepani, M. J. (2018). Orthopedic emergencies. In V. Sweet (Ed.), Emergency nursing core curriculum (7th ed., pp. 387–397). Elsevier.
Question 172
An elderly male sustained a femur fracture after a fall down the stairs. The man has a sudden onset of chest pain and shortness of breath. What is the priority intervention for this patient?
  • Obtain an electrocardiogram
  • Administer supplemental oxygen ✓
  • Place the patient in left lateral decubitus position with head down
  • Administer pain medication
Correct Answer
Administer supplemental oxygen
A. This patient is exhibiting signs of a pulmonary/fat embolus, which can occur after long bone trauma. Administering supplemental oxygen is the highest priority. B. This patient is exhibiting signs of a pulmonary/fat embolus, which can occur after long bone trauma. Left lateral decubitus position with head down, referred to as the Durant maneuver, is indicated if the presence of an air embolism is suspected. This maneuver is not indicated for the presence of a blood clot that results in a pulmonary embolism. Reference Milici, J. J. (2018). Respiratory emergencies. In V. Sweet (Ed.), Emergency nursing core curriculum (7th ed., pp. 452–472). Elsevier. C. This patient is exhibiting signs of a pulmonary/fat embolus, which can occur after long bone trauma. An electrocardiogram will need to be completed, but maintaining airway, breathing, and circulation is a higher priority nursing action. D. This patient is exhibiting signs of a pulmonary/fat embolus, which can occur after long bone trauma. Administering pharmacologic therapy such as anticoagulants, fibrinolytics, and analgesics is indicated in the presence of a pulmonary embolus. However, maintaining airway, breathing, and circulation is the priority nursing action. Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Fractures (e.g., open, closed, fat embolus)
Question 173
A patient with schizophrenia is experiencing delusions and auditory hallucinations. The provider orders olanzapine (Zyprexa) 10 mg intramuscularly. Two hours later, the patient develops facial grimacing, tongue protrusion, and torticollis. Which medication should the emergency nurse anticipate administering to this patient?
  • Olanzapine (Zyprexa) 10 mg IM
  • Ziprasidone (Geodon) 10 mg IM
  • Lorazepam (Ativan) 1 mg PO
  • Diphenhydramine (Benadryl) 50 mg IV ✓
Correct Answer
Diphenhydramine (Benadryl) 50 mg IV
A. This patient is experiencing an acute dystonic reaction and should not be treated with ziprasidone. B. This patient is experiencing an acute dystonic reaction from the earlier dose and should not be treated with an additional dose of olanzapine. C. This patient is experiencing an acute dystonic reaction and should not be treated with lorazepam. D. This patient is experiencing an acute dystonic reaction to the olanzapine. Intravenous benztropine has significant anticholinergic properties that will reverse the dystonic reaction within 20 minutes. Benztropine (Cogentin) can also be used for the dystonic reaction but is less readily available in the emergency department. Category: Environment and Toxicology Emergencies, and Communicable Diseases, Toxicology, Carbon monoxide
Question 174
The emergency nurse is providing information to a patient regarding signs and symptoms of blunt cardiac injury. The emergency nurse is aware that the information has been properly understood when the patient states which of the following?
  • “I will notify you if I begin to experience abdominal pain that goes to my shoulder.”
  • “I will notify you if I begin to experience a headache.”
  • “I will notify you if I experience a lowering of my heart rate.”
  • “I will notify you if I notice an increase in my heart rate.” ✓
Correct Answer
“I will notify you if I notice an increase in my heart rate.”
A. The most common finding in a patient with blunt cardiac injury is sinus tachycardia. Additional assessment findings include chest pain that is unrelieved by nitroglycerin, hypotension, difficulty breathing, and possible signs and symptoms of cardiac tamponade. Depending on the degree of blunt cardiac injury, the 12-lead electrocardiogram may also show indications of ST segment elevation or T-wave changes in leads V1, V2, and V3, and a right bundle branch block pattern. B. The most common finding in a patient with blunt cardiac injury is sinus tachycardia, not sinus bradycardia. C. Abdominal pain that is referred to the shoulder is a common finding in abdominal trauma because of diaphragmatic irritation of the phrenic nerve, but it is not a common finding in patients who have experienced blunt cardiac injury. D. The onset of a headache can be an indicator of hypertension. A patient with blunt cardiac injury will demonstrate hypotension, not hypertension. Category: Cardiovascular Emergencies, Cardiovascular Trauma
Question 175
A patient with a fracture of C7 has been diagnosed with neurogenic shock. What is the priority intervention for this patient?
  • Administer corticosteroids
  • Administer atropine
  • Start vasopressor infusion
  • Initiate fluid resuscitation ✓
Correct Answer
Initiate fluid resuscitation
A. Patients in neurogenic shock, a form of distributive shock, present with hypotension and bradycardia due to loss of sympathetic tone and an unopposed parasympathetic response. Fluid resuscitation is the priority intervention. Atropine may be needed to counteract vagal tone, such as before suctioning. Vasopressors, if needed, would be started after fluid resuscitation. Steroids are no longer recommended because they can increase the risk for infection and other complications. B. Patients in neurogenic shock, a form of distributive shock, present with hypotension and bradycardia due to loss of sympathetic tone and an unopposed parasympathetic response. Fluid resuscitation is the priority intervention. Steroids are no longer recommended because they can increase the risk for infection and other complications. C. Patients in neurogenic shock, a form of distributive shock, present with hypotension and bradycardia due to loss of sympathetic tone and an unopposed parasympathetic response. Fluid resuscitation is the priority intervention. Atropine may be needed to counteract vagal tone, such as before suctioning. Reference Clarkson, D. Patients in neurogenic shock, a form of distributive shock, present with hypotension and bradycardia due to loss of sympathetic tone and an unopposed parasympathetic response. Fluid resuscitation is the priority intervention. Vasopressors, if needed, would be started after fluid resuscitation. Category: Neurological Emergencies, Head and spinal cord trauma

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