CEN ENA Exam 2

Question 1

What is the priority nursing intervention for a patient with the complaint of ammonia splashed into their eyes while washing windows?

Patching the patient’s eyes
Flush the eyes with normal saline for at least 30 minutes ✓
Flush the eyes with normal saline until the patient is comfortable
Flush the patient's eyes with cold tap water until the patient is comfortable

Correct Answer

Flush the eyes with normal saline for at least 30 minutes

A. Although tap water can be used to flush an alkali substance from the eye, normal saline is the irrigation fluid of choice and should be used as soon as possible. B. Ammonia is an alkaline substance. Alkaline substances can penetrate the cornea quickly and cause extensive damage, leading to permanent blindness. The normal saline flush should continue until the ocular pH is within normal range of 7.5–8.0, or neutral. In some cases, it may take 1–2 L or more of normal saline to return the eye to its normal pH balance. C. The eyes should be irrigated until the pH is around 7.5–8.0. The patient’s comfort level is not an indicator of when irrigation should stop. D. Patching the eye is not indicated as treatment for a chemical burn to the eye. Ammonia has a high pH and can injure the internal and external structures of the eye very quickly. Category: Maxillofacial and Ocular Emergencies, Ocular, Burns

Question 2

A patient has been diagnosed with diabetes insipidus after sustaining a severe head injury. Which of the following interventions should the emergency nurse prepare for in the care of this patient?

A 3% sodium chloride infusion
Insulin drip
Intravenous desmopressin ✓
Monitor serum glucose levels

Correct Answer

Intravenous desmopressin

A. A 3% sodium chloride infusion is a hypertonic solution. Fluid losses in diabetes insipidus should be replaced with hypotonic fluids. B. Serum glucose levels are not expected to vary in the presence of diabetes insipidus. C. Diabetes insipidus is a condition of salt and water metabolism, not glucose. Insulin is not required for treatment. D. Neurogenic diabetes insipidus is related to inadequate production of antidiuretic hormone (ADH). Desmopressin is a synthetic analogue of ADH. Volume depletion is accompanied by elevated sodium levels. Correction of fluid imbalance in the patient with diabetes insipidus is aimed at reduction of serum sodium level by 0.5 mEq/L per hour. Category: Medical Emergencies, Endocrine disorders

Question 3

Your patient has a set of vital signs that include BP 246/114 mm Hg and SpO299% on room air. Which of the following assessments would be most indicative of a hypertensive emergency?

Wheezing
Urine output of 30 mL/hr
Sinus tachycardia
T-wave inversion ✓

Correct Answer

T-wave inversion

A. Hypertensive emergency occurs when the blood pressure is acutely markedly elevated and there are signs of end organ damage. Sinus tachycardia alone does not indicate end organ failure. B. Hypertensive emergency occurs when the blood pressure is acutely markedly elevated and there are signs of end organ damage, such as cardiac ischemia. T-wave inversion and presence of Q-waves are signs of cardiac ischemia. C. Hypertensive emergency occurs when the blood pressure is acutely markedly elevated and there are signs of end organ damage. Wheezing alone is not considered end organ failure, however, severe dyspnea or pulmonary edema would be. D. Hypertensive emergency occurs when the blood pressure is acutely markedly elevated and there are signs of end organ damage. This is a normal urine output for an adult. Category: Cardiovascular Emergencies, Hypertension

Question 4

While evaluating the urine output of a patient who has sustained an electrical burn, the nurse observes that the patient's urine has changed color and is now dark brown. Based on this change, the nurse should anticipate which order from the provider?

Administer sodium bicarbonate to acidify the urine
Give fluids to produce a urine output of 300–400 mL/hr
Obtain venous blood for analysis to screen for myoglobin ✓
Change intravenous fluids to Ringer’s lactate solution

Correct Answer

Obtain venous blood for analysis to screen for myoglobin

A. Rhabdomyolysis with myoglobinuria is a complication of electric burns that can lead to tissue ischemia in the kidneys and renal failure. Urine that contains myoglobin will appear dark brown or red. Obtaining serum myoglobin and creatine kinase levels will assist in determining the presence of rhabdomyolysis. B. Sodium bicarbonate will usually be added to IV to alkalinize the urine, not to acidify it. The goal is to keep the urine pH above 8.0. C. The muscle destruction that comes from rhabdomyolysis releases potassium and produces hyperkalemia. Ringer’s lactate solution has potassium and can worsen this, so IV fluids should be normal saline. D. Increasing fluid volume will help to improve renal perfusion and maintain glomerular filtration; however, with rhabdomyolysis, an aggressive urine output for an adult is 100–300 mL/hr, but at least 20 mL/hr is considered adequate. Category: Maxillofacial and Ocular Emergencies, Ocular, Burns

Question 5

Which of the following is the priority intervention to complete before a computerized tomography (CT) scan to rule out an acute stroke?

Obtain a finger-stick glucose ✓
Draw baseline laboratory tests
Perform an electrocardiogram (ECG)
Establish intravenous access

Correct Answer

Obtain a finger-stick glucose

A. Establishing intravenous access is not necessary prior to the initial CT scan because it does not require contrast. Hypoglycemia can mimic stroke symptoms, so a finger-stick glucose should be done before scanning. B. Because hypoglycemia can mimic the signs and symptoms of a stroke, obtaining a finger-stick glucose should be done prior to the CT scan. If the reading is low, treatment for hypoglycemia will be administered first to see if symptoms resolve. C. If the patient has chest pain, an ECG can be performed, but it is not a priority in the diagnosis of an acute stroke. Hypoglycemia can mimic stroke symptoms, so obtaining a finger-stick glucose should be done first. D. It is important get baseline labs, but because hypoglycemia can mimic stroke symptoms, obtaining a finger-stick glucose should be done first. Category: Neurological Emergencies, Stroke

Question 6

An adult patient arrives with complaints of constipation with colicky abdominal pain and distention for the past 48 hours and is diagnosed with a large bowel obstruction. Vital signs are: BP 118/80 mm Hg, HR 116 beats/minute, RR 18 breaths/minute, T 37°C (98.7°F), SpO2 93%. What is the priority intervention for this patient?

Establish intravenous access and begin fluid resuscitation ✓
Insert a nasogastric tube
Administer oxygen via nonrebreather mask
Prepare the patient for a computed tomography scan with contrast

Correct Answer

Establish intravenous access and begin fluid resuscitation

A. This patient may tend to hypoventilate because of abdominal pain and pressure, but there is no clinical indication of hypoxia; therefore, the administration of oxygen is not a priority intervention. B. Patients with an intestinal obstruction are at an immediate risk for the development of hypovolemic shock due to abdominal third-spacing. The patient is not currently hypotensive, but the etiology of the diagnosis and the tachycardia suggest that the patient is at an increased risk for developing hypovolemia. C. Computed tomography scans have a high sensitivity for diagnosing the level and cause of an intestinal obstruction; however, this would be done after the patient has been hemodynamically stabilized with intravenous fluids infusing. D. Bowel decompression with nasogastric suction is part of the patient's treatment plan, but fluid resuscitation is the immediate need and therefore the priority intervention. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Obstructions

Question 7

The nurse is caring for an infant with bilateral partial thickness burns to both feet, estimated to be 8% total body surface area. The patient is alert and crying in pain. The priority intervention for this patient is to:

prepare the patient for immediate transfer to a burn center.
apply moistened room-temperature dressings to the burned areas. ✓
initiate a large-caliber intravenous line of normal saline.
remove clothing and apply ice to the burned areas.

Correct Answer

apply moistened room-temperature dressings to the burned areas.

A. Depending on the nature of the burns, the patient may require transfer to a burn center; however, stopping the burning process and minimizing pain by removing the burn exposure to air is the highest priority for this patient. B. Applying moist room-temperature dressings to the burned area will stop the burning process and provide immediate pain relief. Cool or cold water may precipitate hypothermia in pediatric patients. C. The patient may require an intravenous line, but cooling the burn area is a higher priority. Ringer’s lactate solution is the fluid of choice for burn resuscitation. D. It is appropriate to remove clothing over burns to stop the burning process, but ice should not be applied to burns. Category: Maxillofacial and Ocular Emergencies, Ocular, Burns

Question 8

When caring for a patient with chronic pancreatitis, the emergency nurse should question an order for which analgesic medication?

Ondansetron
Ketorolac
Morphine sulfate ✓
Hydromorphone

Correct Answer

Morphine sulfate

A. The use of morphine sulfate for pain control in pancreatitis is questionable; at this time, it is discouraged because it may cause spasm of the sphincter of Oddi, increasing pressure within the pancreas and intensifying the patient's abdominal pain. B. Narcotics are often used for the intense pain of pancreatitis. Hydromorphone (Dilaudid) is preferred over morphine and fentanyl because of their potential to increase the pain. C. Nausea and vomiting often accompany an exacerbation of pancreatitis. Ondansetron (Zofran) would be a good choice for an antiemetic. Also, when narcotics are used, they can induce nausea as a side effect, so premedicating for this potential is a good option. D. Nonnarcotic medications are recommended analgesics for chronic pancreatitis. Ketorolac is a nonsteroidal anti-inflammatory medication that can be administered orally, intramuscularly, or as a onetime intravenous push dose of 30 mg. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Pancreatitis

Question 9

The emergency nurse is caring for a patient with a submersion injury. Despite high-flow oxygen, the patient continues to appear hypoxic. Which lab value would indicate a need for intubation after a submersion injury?

PaO2 above 60 mm Hg with a PaCO2 above 50 mm Hg
PaO2 above 60 mm Hg with a PaCO2 below 50 mm Hg
PaO2 below 60 mm Hg with a PaCO2 below 50 mm Hg
PaO2 below 60 mm Hg with a PaCO2 above 50 mm Hg ✓

Correct Answer

PaO2 below 60 mm Hg with a PaCO2 above 50 mm Hg

A. A PaCO2 below 50 mm Hg indicates effective work of breathing. B. A PaO2 above 60 mm hg indicates effective work of breathing. C. A PaCO2 below 50 mm Hg indicates effective work of breathing. D. In the symptomatic patient, indications for intubation include the following: signs of neurologic deterioration or inability to protect the airway; inability to maintain a PaO2 above 60 mm Hg or SpO2 (oxygen saturation) above 90% despite high-flow supplemental oxygen; and a PaCO2 above 50 mm Hg. Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment, Submersion injury

Question 10

Which of the following presentations would the nurse expect for a patient with hyperosmolar hyperglycemic syndrome (HHS)?

Type 2 diabetic with serum glucose level of 450 mg/dL, serum osmolality of 285 mOsm/kg, and positive ketones
Type 2 diabetic with serum glucose of 673 mg/dL, serum osmolality of 400 mOsm/kg, and negative ketones ✓
Type 1 diabetic with serum glucose of 400, serum osmolality of 200 mOsm/kg, and negative ketones
Type 1 diabetic with serum glucose of 550 mg/dL, serum osmolality of 340 mOsm/kg, and positive ketones

Correct Answer

Type 2 diabetic with serum glucose of 673 mg/dL, serum osmolality of 400 mOsm/kg, and negative ketones

A. Patients with HHS are type 2 diabetics and will present with serum glucose over 600 mg/dL, serum osmolality levels greater than 320 mOsm/kg, and negative ketones. E. B. The classic presentation of hyperosmolar hyperglycemic syndrome/hyperosmolar hyperglycemic nonketotic coma (HHS/HHNC) is a type 2 diabetic with serum glucose levels greater than 600 mg/dL, a serum osmolality greater than 320 mOsm/kg, and negative ketones. C. Patients with HHS are type 2 diabetics and will present with serum glucose over 600 mg/dL, serum osmolality levels greater than 320 mOsm/kg, and negative ketones. D. Patients with HHS are type 2 diabetics and will present with serum glucose over 600 mg/dL, serum osmolality levels greater than 320 mOsm/kg, and negative ketones. Category: Medical Emergencies, Endocrine disorders References Perez, W. A. (2018). Endocrine emergencies. In V. Sweet (Ed.), Emergency nursing core curriculum (7th ed., pp. 207–218). Elsevier. Recznik, C. T. (2020). Endocrine emergencies. In V. Sweet & A. Foley (Eds.), Sheehy’s emergency nursing: Principles and practice (7th ed., pp. 297–310). Elsevier. Category: Medical Emergencies, Endocrine disorders

Question 11

An arterial blood gas (ABG) test is performed on a patient who is obtunded, and results are: pH 7.12; pCO2 50 mm Hg; HCO3 27 mEq/L. What is the interpretation of this ABG?

Partially compensated respiratory acidosis ✓
Respiratory alkalosis
Metabolic acidosis
Partially compensated metabolic alkalosis

Correct Answer

Partially compensated respiratory acidosis

A. The pH and pCO2 reveal acidosis. For the result to be driven by a metabolic cause, the HCO3 would need to be less than 22 mEq/L. Reference Milici, J. J. (2018). Respiratory emergencies. In V. Sweet (Ed.), Emergency nursing core curriculum (7th ed., pp. 452–472). Elsevier. B. The pH and pCO2 reveal the presence of acidosis, not alkalosis. For the result to indicate a respiratory alkalosis, the pH would need to be greater than 7.45, and the pCO2would have to be less than 35. C. The pH and pCO2 reveal the presence of respiratory acidosis (pH is decreased and PCO2 is elevated). The HCO3 is elevated, indicating that this respiratory abnormality is only partially compensated because the pH still abnormal. D. The pH and pCO2 reveal the presence of acidosis, not alkalosis, in this patient. Category: Respiratory Emergencies, Noncardiac pulmonary edema

Question 12

A patient presents with recent onset of diffuse abdominal pain, tenderness, distention, and fecal-smelling emesis. Which of the following assessment findings would the nurse expect to accompany these symptoms?

Hyperactive bowel sounds ✓
Hypoactive bowel sounds
Elevated blood pressure
Decreased white blood cell count

Correct Answer

Hyperactive bowel sounds

A. This patient is exhibiting symptoms of a bowel obstruction. Hyperactive bowel sounds can accompany bowel obstructions, especially in the early stages. Absent bowel sounds may occur later. Pain, tenderness, distention, and emesis with the odor of fecal contents are all potential manifestations of an obstruction. B. Bowel obstruction, which is usually manifested by this patient’s symptoms, would most likely be associated with hypotension because of the nausea and inability to take in fluids. C. Leukocytosis would be the expected laboratory value for a patient with a bowel obstruction. This patient’s symptoms reflect a diagnosis of bowel obstruction. D. A bowel obstruction would present with positive air-fluid levels on an upright abdominal radiograph, along with dilated, fluid-filled loops of bowel. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Esophageal varices

Question 13

The Emergency Medical Treatment and Active Labor Act (EMTALA) states that a hospital may transfer a clinically unstable patient if which criterion is met?

The patient's triage evaluation indicates that the patient will deteriorate if not transferred.
The patient's health insurance will not cover the costs at the transferring facility.
The patient's family lives far from the current facility and would suffer an undue burden to travel.
The patient's condition requires services not available at the transferring hospital. ✓

Correct Answer

The patient's condition requires services not available at the transferring hospital.

A. To be in compliance with EMTALA, the patient and/or family can request a transfer to another facility; however, the transferring physician must document that the benefits of transfer outweigh the risks. The transfer of an unstable patient solely for reasons of family convenience does not comply with EMTALA regulations. Reference McConnell, T. C. (2020). Legal and regulatory constructs. In V. Sweet & B. The decision to transfer a clinically unstable patient must be made without regard for the patient's ability to pay. C. EMTALA allows for a clinically unstable patient to be transferred to another facility to obtain care or services not available at the current facility. D. Triage is an important tool for establishing treatment priorities; however, EMTALA requires that the patient receive a medical screening exam to determine if an emergency condition exists. Category: Professional Issues, System, Federal regulations (e.g., HIPAA, EMTALA)

Question 14

The triage nurse assesses four different patients, each with a respiratory-related complaint. Which patient would be the most concerning to the triage nurse?

The infant with cough and congestion for 2 days who sleeps through the triage assessment
The geriatric patient with a room air oxygen saturation of 88%
The asymptomatic pediatric patient who became short of breath while running at school
The adult patient with a history of asthma who can only reply with 1–2 word answers ✓

Correct Answer

The adult patient with a history of asthma who can only reply with 1–2 word answers

A. Pediatric patients with significant hypoxemia may demonstrate decreased respiratory effort, bradycardia, and possible periodic apnea. An infant who remains asleep during the triage assessment is not showing any signs of acute respiratory distress. B. Normal aging processes cause anatomical and physiological changes in the respiratory system. Gas exchange is not as effective in geriatric patients because of an increase in alveolar dead space. Although a room air oxygen saturation of 88% is generally considered low, it may be baseline for the geriatric patient. There is nothing to indicate that this patient is more acutely ill than the patient who can only speak in short sentences. C. This patient may have exertional or exercise-induced asthma. Because the patient is asymptomatic when assessed by the triage nurse, the patient with two-word dyspnea should be considered more acutely ill. Reference Denke, N. J. (2018). Nursing assessment and resuscitation. In V. Sweet (Ed.), Emergency nursing core curriculum (7th ed., pp. 1–22). Elsevier. D. The inability to converse in a complete sentence or even short phrases indicates that breathing is compromised, and immediate intervention is required. Category: Respiratory Emergencies, Asthma

Question 15

A patient with Parkinson's disease has been prescribed the dopamine agonist medication ropinirole (Requip). Discharge instructions should include what important information regarding the potential side effects of this medication?

There are no documented interactions between ropinirole and herbal medications.
Patients taking ropinirole should avoid sun exposure because of an increased risk for sunburn.
Insomnia is a common problem associated with the administration of ropinirole.
Orthostasis, which may cause the patient to fall, is a potential side effect of ropinirole. ✓

Correct Answer

Orthostasis, which may cause the patient to fall, is a potential side effect of ropinirole.

A. Patients with Parkinson's disease may experience orthostatic hypotension from taking medications such as carbidopa-levodopa, and the addition of a dopamine agonist (ropinirole) may intensify this adverse reaction. B. Taking ropinirole does not increase the risk for sunburn. C. Ropinirole may cause dizziness, drowsiness, or fainting, but it will not cause insomnia. D. There are many possible interactions, so the patient should tell their provider about any medications (including over-the-counter medications) that they are taking. Category: Neurological Emergencies, Neurological disorders (e.g., multiple sclerosis, myasthenia gravis, Guillain-Barré syndrome)

Question 16

Which parameter is appropriate to maintain in the ongoing monitoring of a patient who has been designated an organ donor?

Arterial PaO2 between 85 and 90 mm Hg
Systolic blood pressure greater than 90 mm Hg ✓
Core temperature of 32°C
Urine output of 0.1 mL/kg/hr

Correct Answer

Systolic blood pressure greater than 90 mm Hg

A. The potential organ donor should receive high-flow oxygen via mechanical ventilation to maintain the PaO2 greater than 100 mm Hg. B. The goal of therapeutic hypothermia is to preserve neurologic functioning following cardiopulmonary arrest. It is not indicated in the preparation of the patient who has been designated as an organ donor. C. To maximize organ perfusion, it is recommended that the systolic blood pressure be maintained at greater than 90 mm Hg. D. Urine output should be maintained at 0.5 ml/kg/hr. Category: Professional Issues, Patient, End-of-life and Palliative Care (e.g., organ and tissue donation, advance directives, care withholding, family presence)

Question 17

An older patient residing at a nursing home arrives with acute altered mental status and chest pain. Vital signs are: T 100.9°F, HR 102 beats/minute, BP 152/96 mm Hg, RR 24 breaths/minute, SpO2 91% on room air. The nurse notes crackles at the right lower lung field. What medication should the nurse anticipate for this patient?

Ceftriaxone ✓
Furosemide
Nitroglycerin
Aspirin

Correct Answer

Ceftriaxone

A. The patient is exhibiting signs of pneumonia: fever, chest pain, altered mental status in the older client, tachycardia, and tachypnea. Treatment includes antibiotic administration (after blood cultures are collected). Ceftriaxone is a cephalosporin antibiotic for treatment of pneumonia. B. Nitroglycerin is used for angina pectoris with acute myocardial infarction, not pneumonia. C. Furosemide (Lasix) is indicated for fluid overload, such as in heart failure. This patient presentation is more consistent with pneumonia, and the patient should receive antibiotics. D. Aspirin is used for the treatment of acute coronary syndrome, not pneumonia. Category: Respiratory Emergencies, Infections

Question 18

Which of the following assessment findings of a joint leads the nurse to suspect that a patient has septic arthritis?

Swelling, warmth, and full range of motion
Swelling, ecchymosis, and pain
Tenderness on palpation and full range of motion
Erythema, warmth, and limited range of motion ✓

Correct Answer

Erythema, warmth, and limited range of motion

A. Physical assessment findings with joint infection include erythema, warmth, swelling, tenderness, and limited range of motion. Assessment may also reveal evidence of trauma, such as an abrasion or puncture wound near the area that could provide an entry point to the joint space for bacteria. B. Swelling, ecchymosis, and pain are consistent with trauma. C. Swelling, warmth, and full range of motion are consistent with bursitis. D. Tenderness on palpation and limited range of motion are consistent with joint infection. Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Inflammatory conditions

Question 19

Discharge teaching for a patient diagnosed with peptic ulcer disease and started on a prescription of pantoprazole includes:

“Take the pantoprazole when you first start to feel the heartburn.”
“Cigarette smoking will worsen your ulcer disease.” ✓
“Milk or milk products will help coat your stomach.”
“You may take acetaminophen or ibuprofen for occasional pain.”

Correct Answer

“Cigarette smoking will worsen your ulcer disease.”

A. The patient should be advised to take acetaminophen as needed for pain but should avoid nonsteroidal anti-inflammatory drugs such as ibuprofen, which are known to contribute to the development of peptic ulcers and prolong bleeding time. B. Dairy products have not been shown to help alleviate pain related to peptic ulcer disease and may increase stomach acid production, causing increased pain and gastric mucosa irritation. C. Proton pump inhibitors are activated by food intake, so they should be taken 20–30 minutes before the first meal of the day. D. Smoking tobacco is known to increase gastric acid production, which will prolong the healing time for ulcers and increase the likelihood of reoccurrence. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Bowel perforation

Question 20

A patient is displaying manic behavior, making threatening gestures, and shouting threats of physical harm to the staff. Which of the following is the most appropriate action for the nurse to take when approaching the patient?

Place your hands in your pockets when talking
Stand directly in front of the patient
Approach the patient alone to gain their trust
Speak in direct, simple sentences ✓

Correct Answer

Speak in direct, simple sentences

A. Standing off slightly to the side may be perceived as less threatening and will make the provider a smaller target than standing directly in front of the patient. B. Patients with actual or potential for violence should never be approached alone. Assistance should be nearby in case the patient's behavior escalates or becomes assaultive. C. Placing your hands in your pockets does not promote relaxed, calm communication and may be considered a threatening stance. The patient should see that you are not concealing a weapon, and hands should be kept visible at your side. D. Clear, calm speech is communication directed at de-escalating potentially violent behavior. Commands should be direct, simple, and nonthreatening. Category: Mental Health Emergencies, Aggressive and violent behavior

Question 21

Which of the following conditions is caused by the trapping of fecal material?

Appendicitis
Diverticulitis ✓
Gastroenteritis
Crohn’s disease

Correct Answer

Diverticulitis

A. Gastroenteritis is caused by a viral inflammation of the stomach and intestinal lining that leads to an imbalance of normal intestinal flora. Patients will experience abdominal pain, nausea, vomiting, and/or diarrhea. B. Appendicitis occurs because of an obstruction and distention of the lumen of the appendix, leading to ischemia and bacterial invasion of the appendix. As the inflammation progresses, the appendix becomes nonviable until it ruptures, emptying infectious material into the abdominal cavity. Reference Herrington, A. (2020). Gastrointestinal emergencies. In V. Sweet & C. Diverticulosis occurs in approximately 50% of all Americans between 60 and 80 years of age. It is caused by an outpouching of the large bowel, resulting in the formation of small pockets in which fecal content may become trapped; this leads to the development of an inflammatory response, causing diverticulitis. D. Crohn’s disease is an inflammation of the mucosal lining of the bowel, usually from an infection or with an inflammatory cause. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Diverticulitis

Question 22

The strongest basis for evaluating appropriate interventions when researching for evidence-based practice comes from which of the following sources?

Retrospective and concurrent chart reviews
Quality improvement and risk data
Systematic reviews ✓
Benchmarking data

Correct Answer

Systematic reviews

A. Systematic reviews consist of a series of individual studies that provide a meta-analysis of the currently available research. B. If research is currently unavailable, the use of retrospective and concurrent chart reviews, along with other sources of evidence, can assist in developing best practices. However, systematic reviews provide the source of the most robust data for evidence-based practice. C. If research is currently unavailable, the use of quality improvement and risk data, along with other sources of evidence, can assist in developing best practices. However, systematic reviews provide the most robust data for evidence-based practice. D. Systematic reviews provide the most robust evidence. If research is currently unavailable, the use of benchmarking data, along with other sources of evidence, can assist in developing best practices. Reference Robinson, R. (2020). Research. In V. Sweet & Category: Professional Issues, Nurse, Evidence-based practice

Question 23

What is the priority intervention for a patient with a fractured second toe?

Applying a rigid foot and ankle splint
Stabilization with plaster of Paris cast
Taping the fractured toe to an adjacent toe ✓
Applying a pillow splint to the foot

Correct Answer

Taping the fractured toe to an adjacent toe

A. A pillow splint is indicated for a calcaneus fracture. B. A rigid foot and ankle splint is indicated for a calcaneus fracture. C. For fracture of the second to fifth toes, treatment is buddy-taping to the adjacent toe, with gauze padding between the toes. D. A cast is indicated for extremity fractures. Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Fractures (e.g., open, closed, fat embolus)

Question 24

The most concerning finding on assessment for a 28-week-pregnant female involved in a motor vehicle collision would be which of the following?

Fetal heart rate of 140 beats/minute
Fetal movement of approximately 10 "kicks" in a 1-hour period
Maternal report of uterine contractions
Maternal systolic blood pressure of 80 mm Hg by palpation ✓

Correct Answer

Maternal systolic blood pressure of 80 mm Hg by palpation

A. Approximately 10 kicks over a 2-hour period is considered a positive sign of fetal activity and well-being. B. Uterine contractions are a frequent complication of obstetrical trauma, and the patient should be monitored, but they are not necessarily an indicator of fetal distress. Premature labor is suspected if the contractions exceed 6–8/minute. C. Fetal heart rate that is either greater than 160 beats/minute or less than 120 beats/minute is suggestive of fetal distress. D. The mechanism of injury and blood pressure of 80 mm Hg would be highly suggestive of maternal hypovolemic shock. In pregnancy, selective uterine vasoconstriction occurs in response to hemorrhage, resulting in fetal hypoxia. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Obstetrical, Obstetric Trauma

Question 25

Naloxone (Narcan) has just been administered to a patient with a suspected overdose of heroin. Which patient response would indicate to the nurse that the naloxone is having its intended effect?

Bradycardia
Adequate respirations ✓
Aggressive behavior
Somnolence

Correct Answer

Adequate respirations

A. Tachycardia would be an expected effect following naloxone administration. B. Naloxone is used to reverse the effects of the heroin; however, it can produce narcotic withdrawal syndrome in patients who are chronic users, so patients can become agitated, aggressive, and combative. You want to titrate the dose to prevent aggressive behavior. C. Naloxone is used to reverse the effects of the heroin, but you want to titrate the dose to produce adequate oxygenation and respirations. You do not want to bring on full withdrawal symptoms, which can cause the patient to become combative. D. Central nervous system depression occurs as a result of heroin overdose. After naloxone is given, a patient's level of consciousness should increase or improve. Category: Medical Emergencies, Substance use and abuse (e.g., alcohol and drug interactions, side effects, unintentional overdose)

Question 26

A patient presents with a bite to the forearm after attempting to save his dog from a coyote. While reviewing his medication list, the emergency nurse notes that he is on prednisone. Which of these medications would have a reduced response when given in conjunction with prednisone?

Amoxicillin-clavulanate (Augmentin) antibiotic
Human diploid cell culture vaccine ✓
Diphtheria, tetanus, and pertussis (DTaP) vaccine
Tetanus, diphtheria, and pertussis (Tdap) vaccine

Correct Answer

Human diploid cell culture vaccine

A. Tdap is an appropriate intervention for a wound from a potentially contaminated source and should not cause any problem with vaccine effectiveness. B. DTaP is an appropriate intervention for a wound from a potentially contaminated source and should not cause any problem with vaccine effectiveness. C. The concomitant use of corticosteroids and the human diploid cell culture (rabies) vaccine may produce a reduced effectiveness of the vaccine. The anti-inflammatory properties of the corticosteroid will interfere with the development of active immunity from the rabies immune globulin or human diploid cell vaccine. D. Amoxicillin-clavulanate (Augmentin) is an appropriate antibiotic to be used for an animal bite and should not cause any problem with vaccine effectiveness. Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment, Animal bites (e.g., rabies, infection)

Question 27

A patient with a possible inhalation injury presents as drowsy, with a Glasgow Coma Scale score of 13. An arterial blood gas test is ordered by the provider, which reveals a pCO2 of 55 mm Hg. Which is the priority intervention the nurse should perform?

Administer albuterol 5 mg nebulized breathing treatment
Administer 3 mL N-acetylcysteine (NAC) nebulized breathing treatment
Apply supplemental oxygen
Insert a nasopharyngeal airway ✓

Correct Answer

Insert a nasopharyngeal airway

A. Ensuring a patent airway is the priority intervention, followed by administration of supplemental oxygen until the provider makes the decision to provide a definitive airway for the patient. A pCO2 of 55 mm Hg indicates that the patient is retaining carbon dioxide and will require a definite airway to ensure proper ventilation and oxygenation. B. The patient is not exhibiting signs and symptoms of bronchoconstriction; therefore, albuterol is not indicated for this patient at this time. C. Always ensure that the patient first has a patent airway so that adequate ventilation and oxygenation can occur. D. Clearing the airways is important with an inhalation injury. NAC is a powerful mucolytic agent that can be useful in treatment of inhalation injury. However, NAC is an irritant and can cause bronchoconstriction, so it should be given with a bronchodilator such as albuterol. Therefore, NAC is not the priority intervention at this time. Category: Respiratory Emergencies, Inhalation injuries

Question 28

A 1-week postpartum patient presents with new-onset seizure activity. The patient reported recent headaches, nausea, and visual changes. Blood pressure on arrival is 170/100 mm Hg. After a second tonic-clonic seizure is witnessed by staff, the patient receives intravenous lorazepam (Ativan). Which of the following medications would the nurse expect to administer next?

Diazepam
Nifedipine
Lorazepam
Magnesium sulfate ✓

Correct Answer

Magnesium sulfate

A. This patient is experiencing signs and symptoms of eclampsia, which can occur up to 4–6 weeks postpartum. Lorazepam is administered to control active seizures. Magnesium sulfate is administered to prevent additional seizure activity. B. Diazepam may be used for initial treatment of seizure activity, however, in this scenario, lorazepam has already been administered. C. Lorazepam may be used initially for treatment of acute seizures but may not prevent additional seizure activity. Magnesium sulfate is the preferred medication for the prevention of seizure activity in the eclamptic patient. D. With the rapid onset of action, labetalol and hydralazine are the preferred medications to treat the hypertension associated with eclampsia. Nifedipine would be used if those were unsuccessful or if an IV site is unavailable. Prevention of seizures is the next priority after medicating for the present seizure activity. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Obstetrical, Preeclampsia, eclampsia, and HELLP syndrome

Question 29

A survivor of interpersonal violence arrives in the emergency department. Which of the following descriptions of physical assault is the most concerning?

Attempted to strangle me ✓
Threw me against a wall
Pistol-whipped me
Punched me in the face

Correct Answer

Attempted to strangle me

A. Strangulation is considered a high-risk factor for, and the most predictive of, eventual homicide. B. Any physical assault is concerning, but strangulation is the most predictive for homicide. C. Any physical assault is concerning, but strangulation is the most predictive for homicide. D. Any physical assault is concerning, but strangulation is the most predictive for homicide. Category: Professional Issues, Patient, Abuse and neglect

Question 30

During discharge teaching with a patient treated for diarrhea, the patient asks if he can take bismuth subsalicylate (Pepto Bismol®). The nurse informs the patient that they cannot take the drug if they are allergic to which medication?

Diphenhydramine
Acetaminophen
Aspirin ✓
Penicillin

Correct Answer

Aspirin

A. Aspirin is an ingredient in Pepto Bismol®. Aspirin is a common cause of allergic reactions and anaphylaxis. B. Acetaminophen is not an ingredient in Pepto Bismol. C. Diphenhydramine is not a component of Pepto Bismol. Diphenhydramine is often used to treat allergic reactions and is not usually the cause of an allergic reaction. D. Although penicillin is a common cause of allergic reactions and anaphylaxis, it is not a component of Pepto Bismol. Category: Medical Emergencies, Allergic reactions and anaphylaxis

Question 31

Which of the following statements made by a patient recently diagnosed with pericarditis indicates that the patient has an accurate understanding of the disease?

“I will take the hydralazine as prescribed.”
“I will take the colchicine as prescribed.” ✓
“I can relieve my pain by taking deep breaths.”
“I can relieve my pain by lying flat.”

Correct Answer

“I will take the colchicine as prescribed.”

A. Hydralazine can cause pericarditis. Other medications that are associated with the development of pericarditis include procainamide (Pronestyl) and anticoagulants. B. Taking a deep breath can exacerbate chest pain caused by pericarditis. Other causes of increased chest pain associated with pericarditis include coughing, swallowing, and movement. C. Pain is relieved by having the patient sit up and lean forward. Lying flat will increase the patient's chest discomfort. D. As a first-line treatment for pericarditis, colchicine is used in conjunction with nonsteroidal anti-inflammatory medications to reduce inflammation and treat recurrent symptoms. Other treatments include antipyretics and antibiotics. Category: Cardiovascular Emergencies, Pericarditis

Question 32

A woman at 22 weeks' gestation presents with complaints of severe abdominal pain and dark red vaginal bleeding following a motor vehicle collision 24 hours ago. Fundal height is just above the umbilicus, and the uterus is rigid. The nurse in concerned that the patient may have which of the following conditions?

Preterm labor
Placenta previa
Placental abruption ✓
Uterine rupture

Correct Answer

Placental abruption

A. Placenta previa occurs when the placenta implants in the lower aspect of the uterus, partially or totally covering the opening to the mother's cervix. The patient commonly presents with vaginal bleeding, but it is usually painless. Placenta previa does not occur as a result of trauma; rather, the first evidence is seen in the eighth month, when the cervix begins to dilate in preparation for delivery. B. Uterine rupture can occur as a result of compressive forces that cause a tear in the uterine wall. Vaginal bleeding may or may not be present. Assessed fundal height is normal for this gestation, but in uterine rupture would be difficult to assess because of asymmetry of the uterus. Symptoms would present immediately, not 24 hours later. C. Placental abruption is the separation of the placenta from the abdominal wall. Bleeding is usually dark because the blood coming from behind the placenta is older. Abruption should be considered in any pregnant woman involved in trauma who presents with abdominal pain and vaginal bleeding. Most abruptions are evident within 6–8 hours of the traumatic event and are commonly the result of abdominal compression caused by the lap belt restraint. D. Preterm labor is a common complaint after trauma. There may be mild bleeding or bloody show, but not significant amounts. Pain is described as cramping or pressure, not severe in nature. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Obstetrical, Obstetric Trauma

Question 33

In caring for a patient with a history of hemophilia presenting with hemarthrosis, the nurse would be most concerned if the patient had which of the following?

Decreased range of motion
Throbbing pain
Paresthesia ✓
Increasing edema

Correct Answer

Paresthesia

A. Edema is an expected sign with hemarthrosis because of the volume of blood in the joint space. B. Throbbing pain is an expected complaint with the presence of hemarthrosis. C. In the patient with hemarthrosis, paresthesia could be indicative of compartment syndrome due to bleeding and requires immediate assessment. Pain, paresthesia, paralysis, pulselessness, pallor, and pressure are all indicators of compartment syndrome. If left untreated, compartment syndrome can lead to a permanent disability. D. Decreased range of motion and limited function are expected symptoms with hemarthrosis. Category: Medical Emergencies, Hematologic disorders

Question 34

A patient presents stating that they recently ate at a local restaurant associated with an outbreak of hepatitis A but are currently asymptomatic. What verification is required to determine the patient’s eligibility for the vaccine?

If the patient has existing chronic liver disease
If the patient is allergic to eggs or shellfish
When the patient ate at the restaurant ✓
What specific foods the patient consumed at the restaurant

Correct Answer

When the patient ate at the restaurant

A. Administration of the hepatitis A vaccine is not contraindicated for a patient with an allergy to eggs or shellfish. B. According to the Centers for Disease Control and Prevention recommendation, persons with chronic liver disease who have never had hepatitis A should be vaccinated because these individuals have a higher risk of death from fulminant liver failure as a result of contracting hepatitis A. C. Current guidelines from the Centers for Disease Control and Prevention recommend that individuals exposed to hepatitis A who have not been previously vaccinated should receive the hepatitis A vaccine or immune globulin as soon as possible within 2 weeks of exposure. D. Hepatitis A is associated with poor sanitation and contaminated food, water, and seafood. The virus is transmitted by contact with fecal-oral secretions. A specific food may be the original source of the virus, but poor hygiene among the food handlers will transmit the virus to other foods. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Hepatitis

Question 35

An 18-month-old child is suspected of having a head injury. Which symptom would indicate the need for a computerized tomography (CT) scan?

Mild headache
Recognizing parents
Positive Babinski reflex
Loss of consciousness ✓

Correct Answer

Loss of consciousness

A. A child not acting normally (per the parent or caregiver) would be an indicator of a more severe injury requiring a head CT scan. B. Any loss of consciousness can be associated with a risk for significant head injury, requiring a head CT scan. C. Following a minor head trauma, children may complain of some pain. Pain is not a valid indicator of the severity of a head injury. D. A positive Babinski reflex is considered normal up to the age of 2 years and would not warrant a head CT scan. Category: Neurological Emergencies, Head and spinal cord trauma

Question 36

Which of the following medications would you anticipate for a female 48 hours postdelivery presenting with abdominal pain, fever, chills, and a foul-smelling vaginal discharge?

Oxytocin
Antiviral medication
Rh immune globulin
Broad-spectrum antibiotics ✓

Correct Answer

Broad-spectrum antibiotics

A. Oxytocin is administered to the postpartum patient to increase uterine tone and control postpartum hemorrhage. B. Antiviral medications, such as oseltamivir, are indicated in the treatment of influenza. Fever and chills may be experienced by patients with influenza; however, a bacterial infection must be suspected in a postpartum patient with fever and vaginal discharge. C. Rh immune globulin is administered to all Rh-negative women to prevent the formation of antibodies that can be harmful to an Rh-positive fetus. Rh incompatibility does not cause the symptoms experienced by this patient. D. Broad-spectrum antibiotics are effective against a broad range of organisms, which can result in the treatment of a variety of microorganisms that are either gram negative or gram positive. Classification of broad-spectrum antibiotics includes both penicillin and sulfa-related medications. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Obstetrical, Postpartum infection

Question 37

Which of the following assessment findings would be consistent with the presence of anterior cord syndrome following an all-terrain vehicle collision?

Motor paralysis and a loss of pain and temperature sensation ✓
Pronounced motor impairment in the upper body
Weakness or paralysis on the same side as the cord injury
Preserved motor function below the level of the injury

Correct Answer

Motor paralysis and a loss of pain and temperature sensation

A. Brown-Séquard syndrome is consistent with hemiparaplegia (weakness or paralysis) on the same side as the cord injury, and hemianesthesia (loss of sensation) on the opposite side of the cord injury, but below the level of injury. B. A diagnosis of anterior cord syndrome is consistent with motor paralysis and a loss of pain and temperature sensation below the level of the injury, with a preservation of proprioception, touch, and vibratory sense. C. Central cord syndrome results from a cervical spine injury and is consistent with more pronounced motor impairment in the upper body as compared with the lower body, with variable sensory loss below the level of the injury. D. Posterior cord syndrome is consistent with preserved motor function below the level of the injury, with a loss of sensory function. Category: Neurological Emergencies, Head and spinal cord trauma

Question 38

A patient with a tension pneumothorax is being treated with placement of a 14-gauge catheter at the second intercostal space midclavicular line superior to the rib. No noticeable whoosh of air is noted, and the patient status remains unchanged. Which of the following interventions would be the next best option for the successful treatment for this patient?

Attempt new needle placement into the fifth intercostal space anterior to the midaxillary line
Remove the needle and retry at the second intercostal space midclavicular line inferior to the rib
Attempt the needle placement into the fifth intercostal space anterior axillary line superior to the rib ✓
Remove the needle and insert a chest tube into the second intercostal space midclavicular line

Correct Answer

Attempt the needle placement into the fifth intercostal space anterior axillary line superior to the rib

A. Emergent needle thoracostomy for treatment of a tension pneumothorax should be placed into the second intercostal space midclavicular line superior to the rib. The nerves and blood vessels lie inferior to the rib and should be avoided. If this does not render improvement in the patient and no whoosh of air is expelled, the preferred alternative site is the fifth intercostal space at the anterior axillary line superior to the rib. B. Emergent needle thoracostomy for treatment of a tension pneumothorax should be placed into the second intercostal space midclavicular line superior to the rib. If the initial insertion was unsuccessful, try a different site. The preferred alternative site is the fifth intercostal space at the anterior axillary line superior to the rib. C. Emergent needle thoracostomy for treatment of a tension pneumothorax should be placed into the second intercostal space midclavicular line superior to the rib. The preferred alternative site is the fifth intercostal space at the anterior axillary line superior to the rib. D. Correct placement of the definitive treatment of chest tube insertion is at the fifth intercostal space anterior to the midaxillary line. For some patients, the length of the catheter is not long enough to go through muscular or thick chest walls in the upper chest area, which comprises the second intercostal space. Therefore, the fifth intercostal area is thinner, with a better chance of attaining placement into the pleural cavity. A chest tube is definitive treatment. However, time is of the essence, and the thoracostomy is necessary, with chest tube insertion to be placed after the emergency treatment. Category: Respiratory Emergencies, Respiratory Trauma

Question 39

A 5-year-old male fell on his bicycle, striking his perineal area against the crossbar. He presents with difficulty voiding and hematuria. Which of the following is the most likely cause of his symptoms?

Pelvic ring fracture
Rectal tear
Testicular torsion
Urethral tear ✓

Correct Answer

Urethral tear

A. A rectal tear would present with bleeding but would not be hematuria. This bleeding would occur outside the body, and not with urination. B. Though fractures of the pelvis can present with hematuria, they usually require more force than would occur with striking the crossbar of a bicycle. 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 pain, nausea, and vomiting. If left untreated, testicular torsion will result in male sterility. D. Urethral injury commonly occurs as the result of blunt force trauma; it occurs more frequently in males than in females because of the longer male urethra, found outside the body. Hematuria is a common finding in this injury. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Genitourinary, Genitourinary Trauma

Question 40

A patient presents complaining of cough and fever for the past 3 days. Initial vital signs are: BP 112/78 mm Hg, HR 102 beats/minute, RR 22 breaths/minute, SpO296% without supplemental oxygen, T 101.3°F (38.5°C). Lung sounds have crackles in the right lower lobe on inspiration, and the left lung is clear. Based on this presentation, the nurse anticipates that this patient most likely has which disease process?

Pneumonia ✓
Asthma exacerbation
Emphysema
Tension pneumothorax

Correct Answer

Pneumonia

A. A patient with asthma would most likely be wheezing. The patient's lung sounds have crackles, indicating congestion, but no wheezing is auscultated. Asthma exacerbation clinical manifestations do not include fever. B. A patient with emphysema will present with dyspnea without cough. Auscultation may reveal expiratory wheezes. C. A patient with tension pneumothorax would be hemodynamically unstable and would have decreased breath sounds over the collapsed lung, have tracheal deviation, and be in extreme respiratory distress. Reference Foley, A., & Sweet, V. (2020). Respiratory emergencies. In V. Sweet & D. Patients with pneumonia typically present with fever, chills, cough, dyspnea, and pleuritic chest pain. Those symptoms, however, are not all inclusive. Crackles that do not clear with coughing may be present in the lung with consolidation. Category: Respiratory Emergencies, Infections

Question 41

Which mnemonic is used by JumpSTART to assess a child's level of responsiveness?

AVPU ✓
PAT
GCS
APGAR

Correct Answer

AVPU

A. APGAR is a mnemonic used to assess newborns after delivery: appearance, pulse, grimace, activity, and respiratory effort. It is not included in the JumpSTART algorithm. B. The pediatric version of the Glasgow Coma Scale (GCS) is used in pediatric assessments but is not included in the JumpSTART algorithm. C. AVPU (alert, verbal, pain, unresponsive) is the common mnemonic used to determine the mental status of a child. This mnemonic is used to determine whether the child is alert, responds to verbal stimuli, responds to painful stimuli, or is unresponsive. In disaster management, a patient who is alert or responds to verbal stimuli and meets all other triage criteria would be triaged as a green or yellow patient. A child who only responds to painful stimuli or is unresponsive would be triaged as a red patient. D. PAT is the pediatric assessment triangle and is used by nurses as an across-the-room assessment in the traditional triage setting to evaluate the child's skin color/circulation, work of breathing, and general appearance. PAT is not used to assess a child's level of responsiveness. Category: Professional Issues, System, Disaster management

Question 42

Which of the following would be the result of an injury to the middle meningeal artery in a patient with head trauma?

Subarachnoid hemorrhage
Epidural hematoma ✓
Subdural hematoma
Ischemic stroke

Correct Answer

Epidural hematoma

A. An epidural hematoma is usually caused by blunt force trauma to the temporal or parietal area of the skull, which results in injury to the middle meningeal artery. A sudden loss of consciousness followed by a period of lucidity is most consistent with an epidural hematoma. B. 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. C. 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. D. In this scenario, there are no identified risk factors for stroke, and stroke is not a common phenomenon in the young adult population. Category: Neurological Emergencies, Neurogenic shock

Question 43

A patient with blunt thoracic trauma presents to the emergency department with hypotension, tachypnea, agitation, tachycardia, muffled heart sounds, and jugular venous distention. The patient's lungs are clear. Which of the following is the most likely cause of these symptoms?

Tension pneumothorax
Pulmonary contusion
Aortic disruption
Pericardial tamponade ✓

Correct Answer

Pericardial tamponade

A. A patient with tension pneumothorax would present with diminished or absent breath sounds on the affected side. B. A pulmonary contusion can occur with blunt thoracic trauma, but it does not present with muffled heart tones or jugular vein distention. Pulmonary contusions evolve over time and are not usually evident initially. C. A patient with aortic disruption would present in profound shock, with pale, moist skin and flat neck veins. D. Pericardial tamponade occurs in trauma patients when there is rapid accumulation of fluid within the pericardial sac. Classic signs are hypotension, muffled heart tones, and distended neck veins, along with diminished levels of consciousness, dyspnea, and tachypnea as cardiac output diminishes further. Category: Cardiovascular Emergencies, Cardiovascular Trauma

Question 44

The nurse expects which arterial blood gas (ABG) value in a patient with diabetic ketoacidosis (DKA)?

pH 7.40, pCO2-40, HCO3-29
pH 7.50, pCO2-50, HCO3-26
pH 7.29, pCO2-29, HCO3-14 ✓
pH 7.36, pCO2-36, HCO3-24

Correct Answer

pH 7.29, pCO2-29, HCO3-14

A. pH 7.29, pCO2-29, HCO3-14 indicates metabolic acidosis. The patient in DKA will present with a pH less than 7.35 (acidosis), a pCO2 level less than 35 as the result of Kussmaul (deep, rapid type) breathing, and an HCO3 level less than 22. B. pH 7.38, pCO2-36, HCO3-24 indicate normal ABG results. C. pH 7.49, pCO2-40, HCO3-29 indicate metabolic alkalosis. D. pH 7.29, pCO2-50, HCO3-26 indicate respiratory acidosis. Category: Medical Emergencies, Endocrine disorders

Question 45

Which of the following medications may cause worsening of a patient's dementia symptoms?

Tacrine (Cognex)
Donepezil (Aricept)
Alprazolam (Xanax) ✓
Rivastigmine (Exelon)

Correct Answer

Alprazolam (Xanax)

A. Donepezil is an indirect-acting cholinesterase inhibitor that is indicated in the treatment of dementia. Its action slows the progressive loss of Ach-producing neurons in the brain that are related to memory. B. Rivastigmine is an indirect-acting cholinesterase inhibitor that is indicated in the treatment of dementia. Its action slows the progressive loss of Ach-producing neurons in the brain that are related to memory. C. Alprazolam is a benzodiazepine medication used to treat anxiety. Benzodiazepines have been shown to increase the risk of developing dementia and can worsen symptoms, especially with long-term use. D. Tacrine is an indirect-acting cholinesterase inhibitor that is indicated in the treatment of dementia. Its action slows the progressive loss of Ach-producing neurons in the brain that are related to memory. Category: Neurological Emergencies, Neurological disorders (e.g., multiple sclerosis, myasthenia gravis, Guillain-Barré syndrome)

Question 46

During the discharge process, a patient diagnosed with influenza reveals that they are the primary care provider for their parent, who is being treated with chemotherapy for cancer. The nurse is aware that the patient understandss the discharge instructions when they state:

"My siblings do not need to receive the flu vaccine since they have not been in contact with me."
"I will not care for my mother while I have flu symptoms. I will have my siblings care for her." ✓
"I need to take frequent rest periods while I am caring for my mother."
"I need to bring my mother to the emergency department to be evaluated for the flu."

Correct Answer

"I will not care for my mother while I have flu symptoms. I will have my siblings care for her."

A. The patient should not expose their immunocompromised mother to influenza. If their siblings have not been vaccinated for influenza this year, they should obtain the vaccination as soon as possible. Their mother's physician should be contacted immediately to find out if she has received the influenza vaccine this year. B. The patient should not care for their mother while they have active influenza. C. The patient's mother may need to be evaluated if she has flulike symptoms. Bringing her to the emergency department if she is not ill poses a significant risk of exposing her to other infectious illnesses. D. The siblings should be advised to receive the influenza vaccination as soon as possible for their own health and to prevent potential exposure of the illness to their mother. Category: Medical Emergencies, Immunocompromise (e.g., HIV/AIDS, oncology/chemotherapy, transplant patient)

Question 47

A patient had a posterior short leg splint applied for a distal tibia fracture. The patient now complains of increasing pain, and the toes are cool to touch, with capillary refill greater than 5 seconds. What is the priority action for the nurse to take?

Elevate the extremity
Assess for loss of sensation
Remove the splint ✓
Notify the physician

Correct Answer

Remove the splint

A. The extremity should be elevated, but after the splint is removed. The priority is to relieve the compromised circulation to the extremity. B. The nurse should perform a neurovascular assessment before and after splint application. If the nurse notes decreased or absent pulses, color changes, temperature changes, or increased pain after the splint is applied, the splint should immediately be removed. Restoring circulation to the limb is the highest priority. C. Evaluating for loss of sensation is important after the splint is removed. The priority is to relieve the compromised circulation to the extremity. D. The physician should be notified after the splint has been removed. The first priority intervention is to remove the splint and restore circulation to the extremity. Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Fractures (e.g., open, closed, fat embolus)

Question 48

Which of the following conditions does the nurse expect for a patient with normal visual acuity, bilateral eye pain, redness, swelling, and a burning sensation on exam?

Choroiditis
Orbital cellulitis
Conjunctivitis ✓
Anterior uveitis

Correct Answer

Conjunctivitis

A. Orbital cellulitis is an acute infection of the eye itself, causing a bulging eyeball (proptosis), painful ocular movements, edema, and decreased visual acuity. It is a serious medical emergency because the infection can extend into the brain. B. Anterior uveitis, also known as iritis, is the unilateral, painful inflammation of the iris. The affected eye is reddened and tearing, and the patient complains of photophobia. The eyelid will appear edematous, visual acuity is decreased, the cornea may be clear or hazy, and the pupil may be small, irregular, or sluggishly reactive to light. C. Choroiditis, also referred to as posterior uveitis, is a rare condition characterized by unilateral painful inflammation affecting the choroid in the uveal tract. Patients with systemic autoimmune diseases such as rheumatoid arthritis, systemic lupus, and ankylosing spondylitis may be predisposed to developing choroiditis. D. Conjunctivitis, or the inflammation of the conjunctiva, may be bilateral or unilateral and is characterized by drainage that may be watery or purulent, and crusting of the eyelid, especially following sleep. The patient will have pain in the affected eye, with a feeling of sand or grit, and the eyelid is edematous. Visual acuity is not affected, and the pupils and cornea are normal. Category: Maxillofacial and Ocular Emergencies, Ocular, Ocular Infections (e.g., conjunctivitis, iritis)

Question 49

An adult patient presents with diplopia 24 hours after eating home-canned fruit. Dysphonia, arm weakness, nausea, and vomiting are also noted upon exam. What would the emergency nurse suspect could be causing these symptoms?

Clostridium perfringens
Clostridium tetani
Clostridium difficile
Clostridium botulinum ✓

Correct Answer

Clostridium botulinum

A. Botulism is caused by Clostridium botulinum and is usually associated with home-canned food. Cranial nerve palsies are noted on physical exam; in the early stages, the patient has difficulty seeing and speaking, along with skeletal muscle weakness and nausea and vomiting. B. Gas gangrene is caused by Clostridium perfringens with an incubation period of 1 day to 6 weeks. Symptoms include rapidly developing tense edema, leading to hypoxia, fever, vomiting, and severe pain. C. Clostridium difficile affects older adults in hospitals or long-term care facilities. Infection typically occurs after use of antibiotic medications, causing watery diarrhea and mild abdominal cramps. D. Tetanus is caused by Clostridium tetani, which can be found in soil with an incubation period of 2–14 days. Symptoms range from muscle spasms, to headache, and neck and back pain. Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment, Temperature-related emergencies

Question 50

A patient arrives with a stab wound to the left chest. The prehospital provider reports that the patient had a brief episode of hypotension that responded to an intravenous fluid bolus with crystalloid solution. The primary and secondary surveys show no other acute injury. The patient is awake and alert, and complains of chest pain. The patient arrives tachycardic, slightly dyspneic, pale, and clammy, and blood pressure is currently 90/42. Which procedure should the nurse anticipate will be immediately performed?

Anterior-posterior and lateral chest X-ray
Focused assessment with sonography for trauma ✓
Computerized tomography angiogram of the chest
Computerized tomography of the chest

Correct Answer

Focused assessment with sonography for trauma

A. Although a computed tomography scan of the chest may show pericardial effusion and/or cardiac tamponade, there is significant time delay involved in acquiring this study in a potentially time-sensitive injury. B. A chest radiograph may fail to show significant changes in the cardiac shadow and is not as useful as ultrasound in the evaluation for pericardial effusion and/or cardiac tamponade. C. Focused assessment with sonography for trauma exam is a rapid, accurate, and inexpensive diagnostic tool used to detect the presence of blood, including that in the pericardial sac. Because of the location of the stab wound, the patient is at increased risk of injury to the pericardial sac and/or heart. The patient remains relatively unstable, so this test is recommended to detect the presence of a pericardial tamponade. D. Although computerized tomography angiogram of the chest may show vascular injury, it is not an appropriate test for an unstable patient. Category: Cardiovascular Emergencies, Cardiovascular Trauma

Question 51

A 10-week-gestation patient presents with continuous nausea and vomiting for the past 3 days with dry mucous membranes. Vital signs are: BP 94/76 mm Hg, HR 116 beats/minute, and RR 20 breaths/minute. Which of the following intravenous solutions would be most appropriate for this patient?

0.9% sodium chloride ✓
5% dextrose in 0.45% sodium chloride
0.45% sodium chloride
5% dextrose in water

Correct Answer

0.9% sodium chloride

A. This pregnant patient's 3-day history of vomiting, hypotension, tachycardia, and tachycardic pulse suggest hypovolemia. An isotonic solution, such as 0.9% sodium chloride solution, will help to provide increased intravascular volume and restore vital signs to normal levels. Dextrose-containing solutions may be used later in the care of this patient to deal with the presence of ketosis. B. 5% dextrose in water (D5W) solution is a hypotonic solution. This is more useful when intracellular rehydration is needed because it will pull fluid volume into the cells and out of the vascular system. Vital signs can deteriorate with the use of this replacement fluid. C. 0.45% sodium chloride is a hypotonic solution that would not be effective in restoring intravascular volume to this patient. It could cause further hypotension and tachycardia in this patient. D. 5% dextrose in 0.45 sodium chloride is a hypertonic solution that will not replace the intravascular volume needed by this patient. This solution can pull fluid into the extravascular space from the cells. It can be used to replace electrolytes and can induce a diuretic effect, which would be deleterious to this patient. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Obstetrical, Hyperemesis gravidarum

Question 52

An elderly patient is experiencing palpitations, tremors, and hyperactivity. The patient has a history of depression, anxiety, and hypertension and is currently prescribed levothyroxine (Synthroid), fluoxetine (Prozac), amlodipine (Norvasc), and the herbal supplement St. John's wort. The nurse suspects that the patient is experiencing which of the following?

Tardive dyskinesia
Neuroleptic malignant syndrome (NMS)
Thyroid storm
Serotonin syndrome ✓

Correct Answer

Serotonin syndrome

A. NMS is a rapidly developing, life-threatening syndrome of profound muscle stiffness, hyperthermia, and tremor produced by the use of an antipsychotic agent. This patient is not taking an antipsychotic agent. B. Extrapyramidal symptoms are the most common side effects seen with dopamine-receptor blocking medications. Tardive dyskinesia is a subgroup of extrapyramidal effects, and the symptoms include involuntary twitching and movement that can affect the facial and tongue muscles and sometimes the extremities and trunk. This patient is not on a dopamine-receptor blocking medication. C. Thyroid storm is a complication of hyperthyroidism, resulting in rapidly increasing thyroid hormone levels. Elderly patients may experience apathetic hyperthyroidism, resulting in their symptoms going unnoticed. Patients with thyroid storm experience episodes of cardiac dysfunction (heart failure), central nervous system dysfunction, and gastrointestinal disorders. D. Serotonin syndrome is a medical emergency that occurs when high levels of serotonin accumulate in the body. Serotonin is a hormone that stabilizes the mood. In the elderly, high levels of serotonin can occur as a result of polypharmacy or drug metabolism. Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor. The herbal supplement St. John's wort can potentiate the effects of selective serotonin reuptake inhibitors, placing the patient at risk for developing serotonin syndrome. Category: Mental Health Emergencies, Mood disorders (e.g., bipolar, depression)

Question 53

A patient with a history of Crohn's disease complains of a gradual onset of colicky abdominal pain and vomiting for the past 48 hours. Which condition is this presentation most likely attributed to?

Acute appendicitis
Peritonitis
Pancreatitis
Bowel obstruction ✓

Correct Answer

Bowel obstruction

A. The classic symptom of acute appendicitis is pain that initially is periumbilical but eventually localizes in the right lower abdomen. It is often accompanied by a low-grade fever. B. Pancreatitis is characterized by the sudden onset of constant, severe epigastric pain due to irritation and edema of the pancreas. This patient's pain is localized in the abdominal rather than epigastric area, and onset was gradual rather than sudden. C. Vomiting and colicky abdominal pain that is poorly localized are the classic signs of small bowel obstruction (SBO). Causes of SBO may include adhesions that originate from previous abdominal surgery or from an inflamed intestine, such as in Crohn's disease. D. A perforation of the intestine or other abdominal organs will result in the leakage of contents into the abdominal cavity and the development of peritonitis. Peritonitis is often characterized by the sudden onset of severe abdominal pain, fever, chills, nausea, and vomiting. This patient is afebrile, so an infection is less likely at this time. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Obstructions

Question 54

A patient arrives via emergency medical services following an all-terrain vehicle crash. Which of the following assessment findings would be consistent with the presence of central cord syndrome?

Hemiparaplegia on the same side as the cord injury
Paralysis and loss of pain sensation below the level of injury
Pronounced motor impairment in the upper body ✓
Preserved motor function below the level of the injury

Correct Answer

Pronounced motor impairment in the upper body

A. Brown-Séquard syndrome is consistent with hemiparaplegia (weakness or paralysis) on the same side as the cord injury, and hemianesthesia (loss of sensation) on the opposite side of the cord injury but below the level of injury. B. Central cord syndrome results from a cervical spine injury and is consistent with more pronounced motor impairment in the upper body as compared with the lower body, with variable sensory loss below the level of the injury. C. Posterior cord syndrome is consistent with preserved motor function below the level of the injury, with a loss of sensory function. D. A diagnosis of anterior cord syndrome is consistent with motor paralysis and a loss of pain and temperature sensation below the level of the injury, with a preservation of proprioception, touch, and vibratory sense. Category: Neurological Emergencies, Head and spinal cord trauma

Question 55

A patient repeatedly states, "The voices are telling me to shoot my kids tonight when they are sleeping." The patient refuses to discuss any other topic. There is no change in the patient's tone of voice, inflection, or facial expressions. The nurse recognizes that the patient is exhibiting which of the following symptoms of an acute schizophrenic event?

Delusions
Hallucinations ✓
Anhedonia
Thought disorganization

Correct Answer

Hallucinations

A. Delusions are the belief that things are true even when there is evidence they are not. This patient is not exhibiting delusional behavior. B. An individual who is demonstrating thought disorganization would leap from one idea to another. This patient is stuck on one issue. C. This patient is describing hallucinations, which include seeing, hearing, smelling, or tasting something that isn’t there. The voices they are hearing are telling them to harm their family. D. Anhedonia is the lack of joy or pleasure in life. This patient is not exhibiting or indicating why they want to harm their children, other than that the voices are telling them to do so. Category: Mental Health Emergencies, Homicidal and Suicidal ideation

Question 56

In caring for a patient with an intentional ingestion of a nonsteroidal anti-inflammatory medication, it is important to monitor for which of the following findings?

Thrombocytosis
Renal failure ✓
Hepatic injury
Dysrhythmias

Correct Answer

Renal failure

A. Ingestions of large quantities (greater than 300 mg/kg) of nonsteroidal anti-inflammatory drugs are considered severe, and these patients are at risk of developing renal failure. Ingestions less than 100 mg/kg are considered nontoxic. B. Patients who have ingested large quantities of a nonsteroidal anti-inflammatory drug are at risk for thrombocytopenia, not thrombocytosis. C. Patients who have ingested more than 150 mg/kg of acetaminophen are at risk for developing hepatoxicity. D. Cardiac dysrhythmias, specifically conduction disturbances, are common in the presence of beta-blocker and calcium-channel-blocker toxicity. Dysrhythmias are not common in patients who have ingested a large quantity of nonsteroidal anti-inflammatory drugs. Category: Mental Health Emergencies, Intentional overdose and ingestions

Question 57

Which priority action will the nurse take after administration of factor VIII to a patient with hemophilia?

Wrap an elastic bandage over a folded piece of gauze on the site
Place a commercial adhesive bandage (Band-Aid) on the intravenous site for 1–2 minutes
Cover with gauze and paper tape to the intravenous site
Apply firm pressure to the intravenous site for 3–5 minutes ✓

Correct Answer

Apply firm pressure to the intravenous site for 3–5 minutes

A. One to two minutes of direct pressure with a commercial adhesive bandage is not sufficient to control bleeding at the venipuncture site of a patient with hemophilia. B. Placing a piece of gauze and paper tape may minimally assist with controlling bleeding at the site, but direct pressure should be applied for 3–5 minutes. C. Venipuncture or intravenous sites in hemophilia patients may continue to bleed under the skin and produce abnormal swelling, bruising, or a hematoma. Steady, firm pressure for 3–5 minutes should be sufficient to control bleeding at the site. Arterial puncture sites may require direct pressure for 10 minutes or longer to control bleeding at the site. D. A dressing secured with an elastic bandage may not be sufficient to control the bleeding at the site. Category: Medical Emergencies, Hematologic disorders

Question 58

The ED provider has ordered a dose of adenosine for a patient with chest pain, tachycardia, and suspected atrial flutter. What would the nurse expect to observe on the cardiac monitor after this intervention?

Sawtooth pattern ✓
Irregular baseline
Normal sinus rhythm
Steady decrease in heart rate

Correct Answer

Sawtooth pattern

A. In the treatment of rapid atrial flutter, the administration of adenosine would slow the atrioventricular conduction for only a few seconds, which would allow for identification of the rhythm's origin. The patient's cardiac rhythm would then revert to what was identified before the administration of the adenosine. B. Adenosine does not terminate or convert atrial flutter. Adenosine will only cause a brief slowing of the atrioventricular conduction, allowing the sawtooth pattern of atrial flutter to be identified. C. Adenosine administration would slow the atrioventricular conduction to allow for the rhythm identification. An irregular baseline would indicate atrial fibrillation, not atrial flutter, which would have a sawtooth pattern. D. Adenosine does not terminate an atrial fibrillation or atrial flutter cardiac rhythm. Adenosine will only cause a slowing of the atrioventricular conduction, allowing for the identification of the origin for the patient's cardiac rhythm. Category: Cardiovascular Emergencies, Dysrhythmias

Question 59

The nurse is providing discharge instructions to a patient with a fractured tibia/fibula. Which of the following statements indicates the patient's understanding of the care required for a plaster cast?

“I can use a heating pad every 2 hours over the injured area.”
“I should wiggle my toes every 4 hours.”
“I have to cover the cast with plastic in the shower.” ✓
“I can use a ruler to scratch inside my cast.”

Correct Answer

“I have to cover the cast with plastic in the shower.”

A. Cold packs can be applied for 30 minutes every 2–3 hours. Heat should be avoided. B. Patients should be instructed not to put anything inside their cast. This could cause an injury that may lead to infection because they will not be able to observe the area. C. Patients should wiggle their toes at least every hour. It will help identify problems with circulation, movement, and sensation. D. A plaster cast must be covered with plastic if there is a chance it may get wet because moisture can compromise the integrity of the plaster. Patients should be instructed to cover their cast with plastic when in the bath/shower and when outside in wet weather (rain or snow). Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Fractures (e.g., open, closed, fat embolus)

Question 60

In caring for a patient with Addisonian crisis, the nurse is aware that the highest priority of care for this patient is to perform which of the following?

Adrenal corticotropin hormone stimulation test
12-lead electrocardiogram (ECG) ✓
Abdominal computerized tomography
Listen to heart sounds

Correct Answer

12-lead electrocardiogram (ECG)

A. The patient’s heart sounds may be very soft because of circulatory issues that occur with Addisonian/adrenal crisis, but this is not a priority intervention. The patient is at risk for hyperkalemia, so obtaining a 12-lead ECG would be the priority. B. Patients in Addisonian crisis, also referred to as adrenal crisis, have significantly low levels of cortisol and aldosterone. Hyponatremia occurs secondary to the low aldosterone levels and places the patient at high risk for hyperkalemia. Obtaining the ECG to evaluate for the presence of peaked T-waves as an indicator of hyperkalemia takes priority. C. Computerized tomography may be done later to identify adrenal hemorrhage or metastasis but is not a priority when the patient is in crisis. The patient is at risk for hyperkalemia, so obtaining a 12-lead ECG would be the priority. D. An adrenal corticotropin hormone stimulation (ACTH) test can be performed on patients without a history of adrenal insufficiency but would not be done while the patient is in crisis. It is also not useful for the emergency provider because of the duration of the test. Category: Medical Emergencies, Endocrine disorders

Question 61

Which sign or symptom would a patient who was exposed to an organophosphate pesticide exhibit?

Bradycardia ✓
Decreased urination
Dilated pupils
Hot, dry skin

Correct Answer

Bradycardia

A. Following exposure to organophosphates, the patient's pupils will constrict, not dilate, as seen in anticholinergic ingestion. B. The presence of bradycardia in a patient who has been exposed to organophosphates is an indication of cholinergic toxicity. The dominant clinical features exhibited in cholinergic exposure are bradycardia and MUDDLES (miosis, urination, defecation, diaphoresis, lacrimation, excitation, and salivation). The patient may require repeated doses of atropine and pralidoxime (2-PAM) to treat the bradycardia. C. Patients who have been exposed to organophosphates will experience excessive urination, as opposed to urinary retention in anticholinergic ingestion. D. Patients who have been exposed to organophosphates will experience excessive diaphoresis, resulting in the patient's skin being very moist to touch. Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment, Chemical exposure (e.g., organophosphates, cleaning agents)

Question 62

Which of the following injuries does the nurse suspect for a patient who was hit in the eye with a baseball and presents with a sunken eye, an upward gaze on exam, and complaints of double vision.

Orbital blowout fracture ✓
Globe rupture
Subconjunctival hemorrhage
Hyphema

Correct Answer

Orbital blowout fracture

A. Globe rupture is a full thickness injury to the sclera, cornea, or both, resulting from blunt or penetrating trauma to the orbit. An irregular or teardrop-shaped pupil is the hallmark sign of globe rupture. Assessment findings also include severe subconjunctival hemorrhage, pain, nausea, and decreased visual acuity. B. Hyphema is a collection of blood in the anterior chamber of the eye and is characterized by blurred vision, pain, and photophobia. Hyphema commonly occurs in response to direct blunt trauma to the eye. C. A blowout fracture is a fracture to the orbital floor. Mechanism of injury is direct blunt force trauma to the orbit, such as being hit by a ball or fist. There is also increased intraocular pressure. Assessment findings include enophthalmos (sunken appearance to the eye), diplopia with an upward gaze, and periorbital ecchymosis. D. Subconjunctival hemorrhage occurs when small blood vessels bleed within the eye. It appears as a bright red, flat patch visualized in the sclera. It may be caused by coughing, sneezing, or a Valsalva maneuver. The blood will normally reabsorb without treatment, and it does not affect the patient's vision. Category: Maxillofacial and Ocular Emergencies, Ocular, Ocular Trauma (e.g., hyphema, laceration, globe rupture)

Question 63

Which of the following is the first-line intervention for a patient with a warm, painful, swollen right great toe?

Limit fluid intake
Arthrocentesis
Opioid analgesic
Anti-inflammatory drug ✓

Correct Answer

Anti-inflammatory drug

A. Arthrocentesis may be used to diagnose gout but is not a priority. B. Patients should be instructed to increase fluid intake to help prevent an exacerbation of gout symptoms. C. This patient is exhibiting signs of gout. It results from an increase in uric acid levels in the blood, leading to urate crystals building up in the joints. Anti-inflammatory drugs are used to decrease inflammation and pain and are usually the first treatment for attacks of gout. Fifty percent of first-time gout attacks occur in a great toe. D. Opioids are not routinely indicated for the treatment of pain related to gout. Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Inflammatory conditions

Question 64

Which of the following statements by a patient would indicate that they understand their diagnosis of acute bronchitis?

“I need to drink a lot of fluids.” ✓
“I should use my albuterol inhaler every 4 hours.”
“I still need a prescription for an antibiotic”
“I will resume smoking once the coughing stops.”

Correct Answer

“I need to drink a lot of fluids.”

A. Smoking is an irritant and will make the cough worse. It should be stopped during treatment, and preferably permanently. B. Beta-adrenergic bronchodilators such as albuterol have little effect on the cough associated with acute bronchitis. If there is wheezing, it might be helpful, but it does not need to be taken every 4 hours. C. Increasing fluid intake with acute bronchitis will help to thin the secretions and make them easier to expectorate. It will also help prevent dehydration. D. Approximately 90% of acute bronchitis is viral in origin. If there is a concomitant bacterial infection, then antibiotics will be ordered, but they should not be ordered routinely. Category: Respiratory Emergencies, Infections

Question 65

A patient arrives by EMS after being hit on the side of the head with a crowbar. Paramedics report that the patient was unconscious at the scene. On arrival, the patient is awake, confused, and complaining of nausea. As the patient is being transported to radiology, the nurse notices that the patient now responds only to pain. What should the nurse suspect?

Epidural hematoma ✓
Subdural hematoma
Intracerebral hemorrhage
Diffuse axonal injury

Correct Answer

Epidural hematoma

A. An intracerebral hemorrhage results in a progressive and rapid decline in level of consciousness. Reference Campbell, M. R. (2020). Head trauma. In J. S. Blansfield (Ed.), Trauma Nursing Core Course provider manual (8th ed., pp. 89–119). Jones & Bartlett Learning. B. An epidural hematoma is a collection of blood between the dura mater and the skull from a laceration of the middle meningeal artery, typically from a temporal bone fracture. Classic symptoms include an initial loss of consciousness, followed by a lucid interval, followed by a decreasing level of consciousness. C. A diffuse axonal injury often results in immediate unconsciousness and prolonged coma state. D. A subdural hematoma is a collection of blood beneath the dura mater caused by a tearing of the bridging veins between the dura mater and the arachnoid space. Symptoms are often more gradual and do not demonstrate a pattern like the epidural hematoma. Category: Neurological Emergencies, Head and spinal cord trauma

Question 66

Which of the following interventions is the priority for a hypotensive patient with altered mental status and polymorphic ventricular tachycardia on the monitor?

Synchronized cardioversion ✓
Magnesium sulfate intravenous
Defibrillation
Amiodarone intravenous

Correct Answer

Synchronized cardioversion

A. Polymorphic ventricular tachycardia, also known as torsades de pointes, is associated with prolonged QT intervals. Magnesium sulfate intravenously has shown some benefits, but with the unstable patient, synchronized cardioversion is the priority. B. Polymorphic ventricular tachycardia, also known as torsades de pointes, is associated with prolonged QT intervals. Defibrillation, which is not synchronized, could convert the patient to a more lethal rhythm, so synchronized cardioversion is the priority intervention. C. Polymorphic ventricular tachycardia, also known as torsades de pointes, is associated with prolonged QT intervals. Amiodarone can prolong the QT interval even further, so it should be avoided. D. Polymorphic ventricular tachycardia, also known as torsades de pointes, is associated with prolonged QT intervals. The hypotensive patient with altered mental status is considered unstable, so synchronized cardioversion is the priority intervention. Category: Cardiovascular Emergencies, Dysrhythmias

Question 67

A patient is being discharged following treatment for a urinary tract infection. The patient is currently taking enoxaparin (Lovenox) postoperatively following a hip replacement. Which statement by the patient demonstrates an understanding of the actions of enoxaparin?

"I am taking enoxaparin because I have a sensitivity to pork."
"I cannot take any products containing aspirin while I am taking the injections." ✓
"I inject the medication under my skin, causing a bubble to form at the site of the injection."
"I should massage the injection site after the injection to minimize the pain."

Correct Answer

"I cannot take any products containing aspirin while I am taking the injections."

A. Enoxaparin is contraindicated in patients with a hypersensitivity to pork or pork products. B. Patients are instructed to avoid aspirin-containing products while on enoxaparin because of increased risk of bleeding. Drug interactions may also occur with other antiplatelet drugs, anticoagulants, and nonsteroidal anti-inflammatory drugs. C. Enoxaparin is to be administered deep subcutaneously in alternating abdominal wall sites. The area is not to be massaged after injection because this may result in excessive bruising at the site due to bleeding under the skin. D. Enoxaparin should be administered in alternating sites in the abdominal wall with a deep subcutaneous injection, not as an intradermal injection. Reference Kizior, R. J., & Hodgon, K. J. (2022). E: Enoxaparin. In R. J. Kizior & K. J. Hodgson (Eds.), Saunders nursing drug handbook 2022 (pp. 392–483). Elsevier. Category: Medical Emergencies, Hematologic disorders

Question 68

Which of the following cardiac rhythm disturbances would be expected for a patient who was exposed to alternating current electricity?

Supraventricular tachycardia
Ventricular fibrillation ✓
First-degree atrioventricular block
Sinus tachycardia

Correct Answer

Ventricular fibrillation

A. First-degree atrioventricular block is a prolonged PR interval with a normal-appearing cardiac rhythm. This benign rhythm would most likely be an incidental finding. B. Alternating current is more dangerous than direct current and has a greater affinity for causing ventricular fibrillation. C. Sinus tachycardia is a normal physiological response to the presence of a stressor. Although fear may cause sinus tachycardia, the dangerous cardiac rhythm disturbance from high-voltage current is ventricular fibrillation. D. Supraventricular tachycardia is a rapid rate initiating from the atria because of an abnormal electrical conduction pathway. Exposure to high-voltage current has a greater affinity for causing ventricular fibrillation. Category: Cardiovascular Emergencies, Dysrhythmias

Question 69

Which statement made by the patient who has been treated for an abdominal laceration indicates that the discharge instructions have been effective?

"I will make an appointment to have the sutures removed in 7–10 days." ✓
"I can expect redness, swelling, and warmth at the site."
"I will keep the wound dry until the sutures are removed."
"I will keep the wound covered until the sutures are removed."

Correct Answer

"I will make an appointment to have the sutures removed in 7–10 days."

A. After the first 48 hours following placement of the sutures, the wound can be washed with mild soap and warm water to keep it clean. The area should be thoroughly dried. B. Foley (Eds.), Sheehy’s emergency nursing: Principles and practice (7th ed., pp. 93–111). Elsevier. C. It is recommended that the wound only be kept covered for the first 48 hours after the sutures have been placed. The patient should be cleaning the site and looking for signs of infection. D. Redness, swelling, and warmth at the site are all signs of infection, a complication of wound healing that should not occur. Reference Denke, N. (2020). Wound management. In V. Sweet & Category: Musculoskeletal and Wound Emergencies, Wound, Lacerations

Question 70

A patient presents with a possible black widow spider bite. The patient is in pain, and the nurse notes two red marks on the patient's right forearm. What other symptoms might you expect to see with this patient?

Severe muscle pain with muscle rigidity ✓
Fever and vomiting
Central blue-gray macule surrounded by pallor
Vomiting and muscle weakness

Correct Answer

Severe muscle pain with muscle rigidity

A. Systemic reactions such as nausea, vomiting, and fever are associated with a brown recluse spider bite, not a black widow spider bite. B. Black widow spider bites usually involve nausea and vomiting with severe muscular pain and rigidity. C. Black widow spider bites are characterized by pain at the site with a halo around the bite. Black widow envenomation will cause systemic toxicity with severe cramping and autonomic dysfunction. D. A brown recluse spider bite can develop a central blue-gray macule surrounded by pallor and erythema, sometimes called a “red, white, and blue sign.” Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment, Envenomation emergencies

Question 71

The nurse is caring for a patient with a terminal disease process. The patient is alert and oriented, and during a conversation with caregivers, the patient suddenly decides that they no longer wish to continue treatment for their disease. This decision made by the patient is an example of which of the following ethical principles?

Nonmaleficence
Autonomy ✓
Fidelity
Utility

Correct Answer

Autonomy

A. Nonmaleficence describes the principle of doing no harm to the patient. B. Fidelity occurs when nurses practice loyalty or accountability for their actions. Reference Matamoros, L. (2020). Ethical consideration. In V. Sweet & C. The ethical principle of utility is defined as when the good of many outweighs the wants and needs of the individual. D. The patient is exhibiting the ability to make decisions for medical care and is exercising autonomy or freedom of choice when deciding to withdraw further treatment. 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 presents complaining of lower abdominal pain that increases in severity during intercourse. She has experienced increased menstrual flow and breakthrough bleeding accompanied by odorous vaginal discharge. Which of the following gynecologic disorders should the nurse suspect?

Vaginitis
Dysfunctional uterine bleeding (DUB)
Bartholin's gland abscess
Pelvic inflammatory disease (PID) ✓

Correct Answer

Pelvic inflammatory disease (PID)

A. PID is associated with abdominal pain that intensifies with movement during intercourse as well as increased menstrual flows and discharge. PID is a nonspecific term used to describe an acute or chronic pelvic infection, such as N. gonorrhoeae or trachomatis. B. A cyst develops in the duct of the Bartholin's gland. The formation of the abscess occurs when the duct becomes occluded because of the presence of vaginal or fecal organisms. The abscess does not affect menstrual bleeding or discharge. C. DUB is defined as abnormal vaginal bleeding that occurs secondary to a hormonal imbalance. Typically, the vaginal bleeding is steady and painless, with no blood clots or the presence of tissue. D. Vaginitis is a normal physiological phenomenon experienced by women of all ages; it results in vaginal itching, vaginal discharge, dysuria, and urinary frequency. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gynecology, Gynecological infections

Question 73

The emergency nurse is preparing to discharge a patient with a diagnosis of diverticulitis. Which of the following statements made by the patient indicates a need for further education?

"I will return to the emergency department if I experience a burning sensation in my throat."
"I will need to get some information on a low-fiber diet to help me control this." ✓
"I will talk with my family about eventually needing surgery so this does not happen again."
"If I develop a fever, I will take two 325 mg tablets of acetaminophen every 4 hours."

Correct Answer

"I will need to get some information on a low-fiber diet to help me control this."

A. A fever with diverticulitis may indicate infection, in which case the patient should be instructed to return to the emergency department. B. Diverticulosis and diverticulitis are common intestinal conditions in the population. Surgery is necessary only when the diverticula rupture. C. A burning sensation in the esophagus is a characteristic of gastroesophageal reflux disease, not diverticulitis. Left lower abdominal pain is characteristic of diverticulitis. D. A high-fiber diet is recommended for patients with diverticulitis after the initial episode has been reduced with a period of nothing by mouth or a liquid diet for bowel rest. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Diverticulitis

Question 74

A female presents at 30 weeks gestation (G1P0) with complaints of a headache and swelling of the hands and face, and blood pressure is 160/90 mm Hg. The emergency nurse anticipates the administration of which of the following medications?

Diltiazem (Cardizem)
Lorazepam (Ativan)
Acetaminophen (Tylenol)
Magnesium sulfate ✓

Correct Answer

Magnesium sulfate

A. The patient is exhibiting signs and symptoms of preeclampsia. Magnesium sulfate is given to decrease the seizure threshold in a patient who has preeclampsia. B. The patient is exhibiting signs and symptoms of preeclampsia. Preeclampsia is frequently associated with elevated liver enzymes. Therefore, administration of acetaminophen, a drug known to cause hepatotoxicity, would be contraindicated for this patient. C. The patient is exhibiting signs and symptoms of preeclampsia. Lorazepam would be indicated if the patient has recurring seizures after a second loading dose of magnesium. D. Diltiazem is not one of the recommended antihypertensive medications for maternal hypertension. Labetalol or nifedipine are recommended by the American College of Obstetricians and Gynecologists. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Obstetrical, Preeclampsia, eclampsia, and HELLP syndrome

Question 75

A patient involved in a motor vehicle crash (MVC) complains of left midquadrant pain with radiation to the left shoulder. Initial blood pressure is 86/64 mm Hg, with a pulse rate of 124 beats per minute. After administration of 1 L of isotonic saline solution intravenously, which of the following assessment parameters would indicate a desired outcome of the intervention?

Capillary refill of 4 seconds
Systolic blood pressure of 84 mm Hg
Pulse pressure of 22 mm Hg
Urine output of 35 mL/hr ✓

Correct Answer

Urine output of 35 mL/hr

A. The systolic blood pressure target for an adult in hypovolemic shock is 90 mm Hg; 84 mm Hg is below that and below the original reading. B. Normal capillary refill time is 2–3 seconds. Increased, or prolonged, capillary refill is an indicator of poor peripheral perfusion and does not suggest that the fluid resuscitation has been effective. C. The clinical signs of end-organ perfusion should be used as a guide to determine the effectiveness of fluid resuscitation. Urine output is a reliable indicator of organ perfusion in the patient with hypovolemic shock. The target output is 30 mL/hr. D. Normal pulse pressure is around 40 mm Hg. With hypovolemic shock, pulse pressure may go up slightly but then decreases. This patient’s original pulse pressure was 22 mm Hg, so it has not changed with the fluids. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Bleeding

Question 76

The nurse is providing discharge instructions to an elderly patient with a diagnosis of Bell's palsy. Which of the following statements would indicate the patient's understanding of the discharge instructions?

"Using artificial tears will prevent a corneal abrasion." ✓
"If I use artificial tears, the Bell’s palsy will heal faster."
"Using the artificial tears will save my eyesight."
"The artificial tears will relieve the pain in my eye."

Correct Answer

"Using artificial tears will prevent a corneal abrasion."

A. Artificial tears will keep the eye moist and minimize the risk of corneal trauma. B. Bell’s palsy does not affect vision, and artificial tears will not have an impact on vision. C. Artificial tears do not impact the healing time for Bell’s palsy. D. The presence of corneal sensory loss due to Bell's palsy can increase the risk of corneal trauma, and difficulty closing the eyelid will result in excessive dryness. Protective measures, such as administration of artificial tears and eye patching, are recommended to prevent corneal trauma in patients with inadequate eye closure. Category: Maxillofacial and Ocular Emergencies, Maxillofacial, Facial nerve disorders (e.g., Bell’s palsy, trigeminal neuralgia)

Question 77

An intoxicated psychiatric patient berates the nurse with profanity after the nurse refuses to administer a repeat dose of pain medication within the appropriate time frame. The patient begins to kick the gurney side rails and spit at the nurse. What is the best response for the nurse?

Ignore the outburst because verbal assaults by intoxicated patients are an expected daily occurrence
Scold the patient for inappropriate behavior and withhold pain medications until the patient's attitude changes.
Report the incident as workplace violence and document the specifics on the incident report form. ✓
No action by the nurse is warranted because the use of profanity is not considered abusive behavior.

Correct Answer

Report the incident as workplace violence and document the specifics on the incident report form.

A. Workplace violence is defined as any physical assault, emotional or verbal abuse, or threatening behavior in the work setting that has the potential to cause physical or psychological harm. The nurse should report the incident through the proper channels. B. It is an inaccurate assumption that verbal assaults are just part of the job. The acceptance of such behavior can have a longitudinal impact on burnout and lead to high attrition rates. C. Despite the patient's inappropriate response, it is unlikely that withholding medication will change the patient's attitude. Furthermore, all patients should be treated with the necessary appropriate care. The inappropriate behavior of the patient should be addressed with a more constructive approach. D. Underreporting incidents of workplace violence places emergency department staff at risk for continuous verbal and physical assaults. Longitudinal studies have shown that ongoing workplace violence, coupled with the demands of working in an emergency department, leads to burnout, compassion fatigue, and high attrition rates. Category: Professional Issues, Nurse, Stress management (e.g., burnout, compassion fatigue, PTSD)

Question 78

Having nurses participate in the bedside handoff end-of-shift report ensures which of the following?

That all essential information is included in the report
The use of a standardized format
That patients and family are included in the handoff ✓
That handoff occurs nurse-to-nurse

Correct Answer

That patients and family are included in the handoff

A. A standardized format such as an SBAR (situation, background, assessment, recommendation) can be used in a written or phone report. The bedside handoff end-of-shift report includes the patient and family in the process. B. Including the patient and family in handoff communication allows the patient to participate in their plan of care and correct inaccurate information, and it allows the patient and family to ask questions. The bedside handoff also provides the nurse with the opportunity to educate the patient and family regarding health information or wellness needs. C. Nurse-to-nurse communication is an important element in the handoff process, but the patient and family also should be included. D. Using a standardized format is the best mechanism for ensuring that essential information is included in the handoff report. A standardized format can be used in a variety of settings, not just at the bedside. Category: Professional Issues, Patient, Transitions of care

Question 79

A patient arrives via ambulance stating that "a dragon took his medication." Paramedics report that the patient is known to them and "always calls when he is high." Per the electronic medical record, the patient has a prescription for aripiprazole (Abilify) that was filled 5 days ago. What is the priority for this patient?

Administer a dose of haloperidol intramuscularly
Ask the patient when they last took their medications ✓
Administer naloxone 2 mg intranasally
Call for a psychiatric consult

Correct Answer

Ask the patient when they last took their medications

A. The patient has a prescription for aripiprazole, which is used to treat schizophrenia. The patient is also having hallucinations and delusions, which are characteristic of schizophrenia. The priority is to find out if the patient is having breakthrough symptoms or if the symptoms are related to drug use. Aripiprazole has a half-life of 75 hours, and after 5 days, the drug concentration may be ineffective. B. There is no indication for the administration of Narcan. Narcan is a reversal agent for narcotics. Getting a good history to understand the circumstances and the progression should take priority. C. This patient will most likely require a psychiatric consult, but getting a good history to understand the circumstances and the progression should take priority. Reference Pritts, W. S. (2020). Behavioral health emergencies. In V. Sweet & D. There is no indication for the administration of haloperidol for this patient at this time. Getting a good history to understand the circumstances and the progression should take priority. Category: Mental Health Emergencies, Thought disorders (e.g., psychosis, schizophrenia)

Question 80

A patient with a history of heart failure presents with worsening dyspnea. A recent echocardiogram showed a reduced left ventricular ejection fraction (systolic heart failure). The nurse should anticipate an order for which of the following medications?

Calcium channel blocker
Nonsteroidal anti-inflammatory drug
Diuretic ✓
Antidysrhythmic

Correct Answer

Diuretic

A. Guidelines recommend diuretic therapy as the cornerstone of therapy for acute heart failure. B. Antidysrhythmic medications contribute to worsening heart failure. C. Most calcium channel blockers have a negative inotropic effect on the heart and may worsen heart failure. D. Nonsteroidal anti-inflammatory drugs may contribute to sodium and water retention and to promoting renal dysfunction, all of which may worsen heart failure. Category: Cardiovascular Emergencies, Heart failure

Question 81

Which of the following statements indicates that the caregivers of a febrile infant understand their discharge instructions?

“Any temperature over (37.5°C) 99.5°F needs to be treated.”
“We can use a cool water sponge bath to lower the fever.”
“Antipyretics will prevent recurrent febrile seizures in at-risk children.”
“A rectal temperature will be the most accurate temperature.” ✓

Correct Answer

“A rectal temperature will be the most accurate temperature.”

A. There is no evidence that giving antipyretics prevents recurrent febrile seizures. Reference Brandt, C. (2020). Fever. In B. Obtaining a rectal temperature is considered the most reliable method to measure an infant's temperature. Rectal temperatures are contraindicated in children who are immunocompromised or who have a bleeding disorder, rectal abnormalities, or trauma. The temporal artery technique is useful but can be affected by many extraneous influences, so it is not the best route to obtain an accurate temperature. C. A temperature greater than 38°C (100.4°F) is generally considered a fever; not all fevers need to be treated. D. A tepid bath (32°C or 90°F) may be used to lower a fever. Cool or cold water should never be used because it can cause shivering, which can increase metabolic rate and lead to an increase in temperature. Category: Medical Emergencies, Sepsis

Question 82

Which of the following places a patient with congenital heart disease and a prosthetic valve at the highest risk for infective endocarditis?

Implanted port ✓
Pulmonary embolism
Wound suturing
Influenza

Correct Answer

Implanted port

A. Infective endocarditis is a risk factor for pulmonary emboli rather than the other way around. B. Suturing a wound is low risk for developing infective endocarditis as long as proper technique is followed. C. Acute bacterial endocarditis presents with symptoms occurring within days to weeks and can present extremely toxic/septic. Risk factors include congenital heart defects, body piercing, poor dental health, long-term venous access, and prosthetic heart valves. D. Infective endocarditis is usually caused by bacteria or fungi. Influenza is a viral infection, and current literature does not show the same correlation with viruses. Category: Cardiovascular Emergencies, Endocarditis

Question 83

Patient education for a client being discharged with a COPD exacerbation should include which component?

Limit fluid intake to 1000 mL per day
Eat small, frequent meals ✓
Take antihistamines for congestion
Maintain strict bedrest

Correct Answer

Eat small, frequent meals

A. Adequate hydration is necessary for respiratory secretion clearance. The patient should not limit fluid intake unless there is associated fluid overload. B. Patients should be encouraged to perform exercise as tolerated to assist with respiratory secretion clearance. C. Small, frequent meals are preferred to large traditional meals to avoid overexerting the patient. D. Antihistamines should be avoided because they inhibit clearance of respiratory secretions. Category: Respiratory Emergencies, Chronic obstructive pulmonary disease (COPD)

Question 84

You are assisting in the resuscitation of a patient in cardiopulmonary arrest. The monitor indicates ventricular fibrillation, and your team administers a defibrillation shock. Immediately after the shock, what should the team member performing chest compressions do?

Pause compressions for 15 seconds for post-shock rhythm analysis
Pause compressions for 15 seconds for post-shock pulse check
Resume chest compressions at a rate of 100–120 compressions per minute ✓
Resume chest compressions at a rate of 80–100 compressions per minute

Correct Answer

Resume chest compressions at a rate of 100–120 compressions per minute

A. Immediate cardiopulmonary resuscitation should be started after delivering a defibrillation shock because prolonged time without compressions diminishes coronary perfusion pressure and decreases the rate of return of spontaneous circulation. B. Prolonged pauses in chest compressions reduce coronary perfusion pressure and reduce survival rates from cardiac arrest. Any pause for a pulse check should be no longer than 10 seconds. C. Performing immediate chest compressions improves blood flow during cardiac arrest and should not be delayed for rhythm analysis unless the patient is showing signs of life. Any pause in compressions should be no longer than 10 seconds. D. Chest compressions should be performed at a rate of 100–120 compressions per minute. Category: Cardiovascular Emergencies, Cardiopulmonary arrest

Question 85

A patient presents with tachycardia, is in a dreamlike state, and is experiencing flashbacks after ingesting an unknown substance while in a nightclub. The nurse suspects the patient may have ingested which substance?

Ketamine ✓
Heroin
Phencyclidine (PCP)
Cocaine

Correct Answer

Ketamine

A. Cocaine ingestion can produce severe paranoia and auditory hallucinations, in addition to seizures, hypertension, and tachycardia. B. Central nervous system depression, respiratory depression, and miosis constitute the classic triad of heroin use. C. Ketamine ingestion can produce a confused and dreamlike state, which makes it a popular drug of choice for recreational use; it is considered a "date rape drug." D. Patients who have ingested PCP can present with extreme agitation, a decreased pain sensation, and the perception of increased physical strength, and they have the potential for extreme violence. Category: Mental Health Emergencies, Intentional overdose and ingestions

Question 86

Discharge instructions for a patient who has been treated for a sickle cell vaso-occlusive crisis should include which of the following statements?

"It is important to remain hydrated." ✓
"Do not exercise, because this could bring on a crisis."
"Place cold packs on affected areas to reduce pain and swelling."
"Take Demerol (meperidine) as prescribed."

Correct Answer

"It is important to remain hydrated."

A. Although it is important to avoid strenuous physical exercise, the patient should be encouraged to exercise regularly and rest as needed. B. During sickle cell vaso-occlusive crisis, the cells become hypoxic and sickling occurs, causing the cells to clump together in the microvasculature. Precipitating factors of sickle cell vaso-occlusive crisis include dehydration, cold environments, infection, high altitudes, and strenuous exercise. It is important that the patient remain well hydrated to avoid dehydration. C. Meperidine should be avoided because of its metabolite normeperidine, which may result in seizures and dysphoria. Sickle cell crisis is a painful complication, and pain management should be individualized using the analgesic ladder, starting with nonnarcotic analgesics. D. Warm, moist heat is effective in reducing pain and swelling. Application of a cold pack should be avoided because it can lead to tissue ischemia. It is important to limit the patient's exposure to cold and to maintain warmth. Category: Medical Emergencies, Hematologic disorders

Question 87

An abdominal computerized tomography (CT) scan with intravenous (IV) contrast is ordered for a patient who presents with nausea, lower extremity swelling, and bilateral flank tenderness. The patient has a history of diabetes and chronic kidney disease (CKD). Which glomerular filtration rate (GFR) value will be least likely to place the patient at risk for further kidney damage due to administration of IV contrast?

GFR 15 mL/minute or less
GFR 60–89 mL/minute ✓
GFR 30–59 mL/minute
GFR 15–29 mL/minute

Correct Answer

GFR 60–89 mL/minute

A. A GFR 30–59 mL/minute reflects stage 3 CKD and indicates a moderate decrease in GFR, with moderate complications in the progression of CKD. Values at this level place the patient at risk for further kidney injury if an intravenous contrast agent is administered. B. GFR 15–29 mL/minute reflects stage 4 CKD and indicates moderate complications in the progression of CKD. GFR at this level would place the patient at risk for further kidney injury in the presence of intravenous contrast administration. C. The normal GFR is 90 mL/min/L or higher. Patients with GFR of 60–90 mL/minute are classified as having stage 2 CKD, indicating mild or decreased GFR. This value would be least likely to result in further kidney damage following the administration of an intravenous contrast agent for imaging studies. D. A GFR of 15 mL/minute or less is classified as stage 5 CKD and indicates kidney failure or end-stage renal disease. Patients with a GFR at this level would likely not receive intravenous contrast for imaging studies because of impaired renal elimination of the contrast following the procedure. Category: Medical Emergencies, Renal failure

Question 88

What is the most common indirect cause of acute respiratory distress syndrome (ARDS)?

Pneumonia
Pancreatitis
Aspiration
Sepsis ✓

Correct Answer

Sepsis

A. Aspiration is a direct cause in the development of ARDS. B. Indirect causes of ARDS include sepsis, disseminated intravascular coagulation, pancreatitis, uremia, anaphylaxis, drug overdose, eclampsia, radiation, trauma, and massive blood transfusions. If ARDS develops, it usually occurs within 7 days of recognition of a risk factor: sepsis or pneumonia. C. Pneumonia is the most common cause of direct lung injury related to the presence of ARDS. D. Pancreatitis can indirectly initiate the development of ARDS, but pancreatitis is not the number one cause for the development of ARDS. Category: Respiratory Emergencies, Respiratory distress syndrome

Question 89

Which medication is most appropriate for use in atrial fibrillation?

Lidocaine HCL (Xylocaine)
Amiodarone (Cordarone)
Diltiazem (Cardizem) ✓
Propranolol HCL (Inderal)

Correct Answer

Diltiazem (Cardizem)

A. Diltiazem is a calcium channel blocker used to slow electrical impulse conduction and decrease the rate of impulse initiation. It is indicated for supraventricular tachycardia (SVT) and atrial dysrhythmias. A nurse should monitor for hypotension, bradycardia, and heart block. B. Propranolol is a beta-adrenergic blocker used to inhibit sympathetic stimulation, reduce heart rate, and decrease myocardial irritability. It is indicated for the management of supraventricular tachycardia and ventricular dysrhythmias. A nurse should monitor for hypotension, bradycardia, and heart block. Reference Foley, A., & Sweet, V. (2020). Cardiovascular emergencies. In V. Sweet & C. Lidocaine HCL is a sodium channel blocker used for ventricular dysrhythmias. It shortens the duration of the dysrhythmia. A nurse should monitor for dizziness, vertigo, confusion, and seizures. D. Amiodarone is a potassium channel blocker used to delay repolarization and prolongation of the action potential that decreases myocardial irritability. It is indicated for ventricular tachycardia and ventricular fibrillation. A nurse should monitor for exacerbation of dysrhythmias and hypotension. Category: Cardiovascular Emergencies, Dysrhythmias

Question 90

A patient arrives via emergency medical services following a motor vehicle collision. The patient reports inability to move both lower extremities and the absence of feeling below the nipple line. Initial vital signs are: BP 90/50 mm Hg, HR 60 beats/minute, RR 26 breaths/minute, SpO296% on 4 L O2 via nasal cannula. A fluid bolus of 500 mL normal saline is infusing intravenously. Which of the following clinical signs would indicate that this intervention has had the desired effect?

Systolic blood pressure of 100 mm Hg ✓
Respiratory rate of 30 breaths/minute
Rectal temperature of 35.0°C (95.0°F)
Pulse rate of 56 beats/minute

Correct Answer

Systolic blood pressure of 100 mm Hg

A. A spinal cord injury that disrupts the sympathetic nervous system (complete lesion at or above the thoracic vertebrae 6 level) can result in neurogenic shock. Neurogenic shock is the result of a loss of vasomotor tone and sympathetic stimulation due to the descending pathways being affected by the vertebral injury. A fluid bolus to fill the intravascular space is a first-line intervention to increase the patient's blood pressure, which then may be followed by the support of a vasopressor to maintain a systolic blood pressure greater than 100 mm Hg. Patients with neurogenic shock may also have bradycardia and peripheral vasodilatation. B. This patient is exhibiting signs of neurogenic shock, which results in the loss of sympathetic innervation to the heart. The body cannot respond to hypotension with a tachycardic response. C. Tachypnea may be associated with signs of a worsening shock state. The presence of tachypnea is more likely to reflect the presence of hypoventilation from injury to the spinal cord. D. A patient with a complete spinal cord injury may exhibit poikilothermia (assuming the temperature of the environment). Therefore, hypothermia in a cold environment or hyperthermia in a warm environment may occur. The nurse must remain vigilant to ensure that the patient remains normothermic. Category: Neurological Emergencies, Head and spinal cord trauma

Question 91

A patient with complaints of sudden onset dyspnea, tachycardia, and upper right sided chest pain returns to his ED room after computerized tomography angiogram (CTA). The patient is now extremely restless, anxious, and short of breath, with a heart rate of 152 beats per minute and blood pressure of 82/64 mm Hg. Which of the following would be the most appropriate intervention for this patient at this time?

Provide an opioid analgesic for patient comfort
Prepare the patient for fibrinolytic therapy ✓
Initiate crystalloid infusion at 75 mL per hour
Administer low molecular weight heparin subcutaneously

Correct Answer

Prepare the patient for fibrinolytic therapy

A. Patients who are deteriorating after a CTA exam with the manifestations of increased shortness of breath, anxiety, hypotension, and severe tachycardia are at high risk for imminent death due to a dislodged pulmonary embolus. A crystalloid infusion at 75 mL/hr is a maintenance dose of crystalloids, not emergent fluid resuscitation. B. Patients who are deteriorating after a CTA exam with the manifestations of increased shortness of breath, anxiety, hypotension, and severe tachycardia are at high risk for imminent death due to a dislodged pulmonary embolus. Antifibrinolytic therapy with tissue plasminogen activator (tPA) is indicated in the unstable patient. C. Patients who are deteriorating after a CTA exam with the manifestations of increased shortness of breath, anxiety, hypotension, and severe tachycardia are at high risk for imminent death due to a dislodged pulmonary embolus. Low molecular weight heparin by subcutaneous route will not treat this patient fast enough. D. Patients who are deteriorating after a CTA exam with the manifestations of increased shortness of breath, anxiety, hypotension, and severe tachycardia are at high risk for imminent death due to a dislodged pulmonary embolus. Opioid analgesics would not be administered to patients with hypotension and severe distress. Category: Respiratory Emergencies, Pulmonary embolus

Question 92

When caring for a victim of a sexual assault, the nurse suspects that the evidence collected may have been contaminated when it was placed in an inappropriate container. What action should the nurse perform next?

Transfer the evidence to the proper container and document the transfer in the medical record
Inform the appropriate personnel that evidence contamination may have occurred ✓
Continue to secure the item because contamination occurs only by contact with other blood or body fluids
Discard the item because it can no longer be entered as evidence in a legal proceeding

Correct Answer

Inform the appropriate personnel that evidence contamination may have occurred

A. The nurse is responsible for collecting forensic evidence according to accepted protocols and for avoiding loss, contamination, or damage of the physical evidence. If contamination is suspected, the nurse is obligated to inform the appropriate personnel. B. In the event of evidence contamination, the nurse must inform the appropriate personnel, which may include law enforcement officials who cannot access a patient's medical record without a court order. C. The nurse is obligated to inform the appropriate personnel that the evidence was potentially contaminated. It is the responsibility of the authorities to determine if the evidence should be preserved or discarded. D. Locard's principle states that when an object comes into contact with any other object, an exchange of material takes place. Therefore, the item would be contaminated by being placed in the wrong container. The nurse should secure the evidence and notify the appropriate personnel. Reference Pedrotty, Category: Professional Issues, Patient, Forensic evidence collection

Question 93

A patient arrives via emergency medical services following a tonic-clonic seizure. Which of the following assessments would indicate that the patient is having a psychogenic nonepileptic seizure?

No response to vocal, tactile, or painful stimulation
Continuous tonic and/or clonic muscle activity
Abrupt return of consciousness without postictal phase ✓
Flaccid arm hits the face when dropped from 12 inches above

Correct Answer

Abrupt return of consciousness without postictal phase

A. Patients with psychogenic nonepileptic seizures, also known as pseudoseizures, respond to verbal, tactile, or painful stimuli. B. Patients with psychogenic nonepileptic seizures, also known as pseudoseizures, will usually show interruptions in the tonic and/or clonic activity due to fatigue or distraction. C. Patients with psychogenic nonepileptic seizures, also known as pseudoseizures, will avoid usually painful stimuli. When you pick up a supposedly flaccid arm and drop it from around 12 inches above the face, protective reflexes usually prevent the arm from hitting the face. D. Some patients may present with psychogenic nonepileptic seizures, also known as pseudoseizures. They may have similar symptoms to true seizures, but there is no disruption of electrical activity in the brain. True tonic-clonic seizures will have a postictal phase. Category: Neurological Emergencies, Seizure disorders

Question 94

The emergency nurse is caring for a patient with severe acute respiratory distress syndrome (ARDS). Which position is the most optimal for gas exchange in this client?

Supine
Semi-Fowler's
Prone ✓
High Fowler's

Correct Answer

Prone

A. The prone position is recommended for the treatment of patients with severe ARDS. This position allows the heart's weight to be pulled anteriorly off the lungs so that they can expand, particularly the left lower lobe. This position was seen almost exclusively in mechanically ventilated patients in the ICU but is now being used in non-mechanically ventilated patients in the ED setting. B. It is recommended that the patient be placed in a position that maximizes ventilation. The specific recommendation is for prone position. C. The supine position is contraindicated in the intubated client because it increases the risk for ventilator-associated pneumonia. D. Prone position is recommended for ARDS patients. High Fowler's position is controversial because it increases intra-abdominal pressure, restricting diaphragm movement. Category: Respiratory Emergencies, Respiratory distress syndrome

Question 95

Which of the following conditions is a rare, life-threatening complication of hypothyroidism?

Thyroid storm
Myxedema coma ✓
Adrenal crisis
Cushing’s syndrome

Correct Answer

Myxedema coma

A. Myxedema coma is a rare, life-threatening complication of hypothyroidism that affects older patients with pulmonary or vascular disease. Patients complain of altered mental status, fatigue, shortness of breath, and weight gain, and they may have tongue swelling. Treatment includes support of ABCs and administration of thyroid hormone replacement. B. Cushing’s syndrome is the result of a prolonged exposure to glucocorticoids (either endogenous or exogenous), causing the patient to develop a Cushingoid appearance. There is an increased amount of adipose tissue on the face, upper back, and base of the neck. C. Adrenal crisis, also known as acute adrenal insufficiency, is a life-threatening condition caused by a decrease in cortisol and aldosterone levels. This results in hypoglycemia and sodium and water loss from the kidneys and gastrointestinal tract. The patient becomes hypotensive and hypovolemic. As the body loses sodium, there is an increase in potassium, leading to hyperkalemia and the development of fatal dysrhythmias. Treatment includes fluid replacement, correction of hyperkalemia, and hydrocortisone administration. D. Thyroid storm, also known as thyrotoxic crisis, is a rare, life-threatening complication of hyperthyroidism. Patients present with agitation, tachydysrhythmias, tachypnea, and fever. Treatment includes support of ABCs, fever control, propylthiouracil, beta-blockers, and iodine. Category: Medical Emergencies, Endocrine disorders

Question 96

A patient arrives with an injury to the 3rd metacarpal joint of the right hand. The patient is unable to bend or straighten the finger and has a loss of sensation to the fingertip. The patient states that they hit another person in the mouth during a fight. Which of the following is considered the most serious cause of these symptoms?

Hemarthrosis of the joint
Infection of the joint ✓
Dislocation of the joint
Fracture of the finger

Correct Answer

Infection of the joint

A. Fracture of the finger will need to be treated, but infection of the joint from a closed-fist injury has a much higher morbidity than a fracture. B. Closed-fist injuries that hit the mouth can leave small puncture marks that the patient may not be concerned about until symptoms appear. Bacteria enter through the puncture wounds and can spread to the tendon sheath, causing these symptoms. C. Dislocation of the joint is usually easily fixed. Infection of the joint from a closed-fist injury has a much higher morbidity than a dislocation. D. Hemarthrosis is more serious than a fracture or dislocation, but infection from a closed-fist injury has a higher morbidity than a fracture. Category: Musculoskeletal and Wound Emergencies, Wound, Wound bleeding (e.g., uncontrolled external hemorrhage)

Question 97

Multiple staff members have been overheard discussing their difficulties sleeping and trouble concentrating after experiencing several infant deaths over the past week. Which intervention do you, as the nurse leader, determine would be most effective/supportive for staff after these pediatric critical events?

Talk to individual staff members and ask if they are feeling affected by the recent infant deaths
Arrange a nonmandatory, formalized critical incident stress debriefing ✓
Discuss the cases and care with individual staff to reassure them that they did all that could have been done
Critique each case to analyze for opportunities for improvement in the care of infant arrests

Correct Answer

Arrange a nonmandatory, formalized critical incident stress debriefing

A. Having problems sleeping and concentrating are symptoms of traumatic stress. Critical incident stress debriefings have been shown to decrease anxiety, depression, and the symptoms of traumatic stress. To be successful, sessions should be scheduled as soon as possible, preferably within 12-24 hours of the event. B. Speaking individually to staff members has not been shown to be as effective as the critical incident stress debriefing. In a group-session environment, individuals involved in the event are able to share their feelings and realize that others are experiencing the same feelings that they are. C. Case critiques is an effective tool for improving the quality of patient care but do not address the staff's symptoms of traumatic stress. D. Discussing the individual cases, the care involved, and reassuring staff that nothing more could be done will not assist in decreasing the symptoms of traumatic stress. Category: Professional Issues, Nurse, Stress management (e.g., burnout, compassion fatigue, PTSD)

Question 98

The triage nurse recognizes that which of the following tasks can be delegated to the emergency medical technician assistive personnel to perform?

Performing the triage assessment
Performing the patient's initial assessment
Determining the patient's triage acuity level
Obtaining the patient's vital signs ✓

Correct Answer

Obtaining the patient's vital signs

A. Emergency medical technicians are trained and competent in taking vital signs, which must then be reported to the nurse for assessment and interpretation. B. Elements of care may be delegated, but the nursing process itself may not be delegated. The triage assessment is a part of the nursing process. Unlicensed assistive personnel cannot perform assessments. C. A triage acuity level must be assigned by a registered nurse. D. Elements of care may be delegated, but the nursing process itself may not be delegated. The initial assessment is a part of the nursing process. Unlicensed assistive personnel cannot perform assessments. Category: Professional Issues, System, Delegation of tasks to assistive personnel

Question 99

A 72-year-old diabetic patient presents with a 3-day history of malaise and vesicular lesions to the left chest and under the left arm. The individual notes that these lesions are associated with severe burning-type pain. Which of the following does the nurse anticipate administering?

Intravenous fluids
Antiviral medication ✓
Corticosteroid
Herpes zoster vaccine

Correct Answer

Antiviral medication

A. The herpes zoster vaccine should be administered after the acute stage of the illness is over and symptoms have resolved. B. Patients with herpes zoster do not require intravenous fluids unless vital signs indicate hypovolemia. Patients would require antiviral medications. C. This patient is exhibiting signs and symptoms of herpes zoster (shingles). The treatment is supportive. Antiviral medications can reduce new lesions and lessen the disease severity if started within 72 hours of onset. Use of analgesic medications is prescribed for pain associated with vesicular lesions and associated nerve pain. D. Geriatric patients with diabetes or other contraindications to corticosteroids should not receive corticosteroids to reduce pain in those patients with herpes zoster. Category: Environment and Toxicology Emergencies, and Communicable Diseases, Communicable Diseases, Vaccine-preventable diseases (e.g., measles, mumps, pertussis, chicken pox, diphtheria)

Question 100

A combat veteran who suffers from posttraumatic stress disorder (PTSD) presents with their wife. The wife reports that her spouse is a "different person" since returning from the war and asks if there is anything that can be done. What is the most appropriate response by the nurse?

"The use of daily medication is successful at resolving the symptoms of PTSD within a few weeks."
"PTSD is an incurable disease. Placement into a psychiatric facility may be the best option for treatment."
"Your husband may be suffering from a traumatic brain injury and not PTSD. Further workup is needed.”
"A combination of therapy, medications, and alternative therapies have been beneficial to many who suffer from PTSD." ✓

Correct Answer

"A combination of therapy, medications, and alternative therapies have been beneficial to many who suffer from PTSD."

A. The patient may require inpatient psychiatric care, but there is no reason to expect that they cannot begin their recovery process and eventually resume a normal life with outpatient therapy. B. Although medications such as selective serotonin reuptake inhibitors (SSRIs) are an important part of most PTSD treatment plans, they alone cannot provide complete recovery. Recovery is a process that may take years. C. PTSD is a complex condition, and there is not a single treatment that guarantees recovery in all patients. Treatments include a combination of psychological, psychopharmacological, and alternative interventions, such as use of service dogs, acupuncture, and hypnosis. Spouses and significant others may also consider treatment because of the risk of developing "secondary PTSD." D. PTSD is a well-documented disorder with clear diagnostic criteria. It is often associated with combat veterans, but may be experienced by victims of violent crimes, mass casualties, severe traumatic situations, abuse, and interpersonal violence. PTSD can occur in veterans with traumatic brain injury. Category: Mental Health Emergencies, Anxiety disorders (e.g., PTSD, anxiety, panic attack)

Question 101

A patient is in cardiac arrest, with good-quality cardiopulmonary resuscitation in progress. The cardiac monitor displays ventricular fibrillation with the presence of pacemaker spikes. The patient has a history of a permanent pacemaker with AED in place. Which of the following is the immediate intervention to be performed next?

Defibrillate the patient ✓
Increase the strength of the pacemaker using a magnet
Wait for the implantable defibrillator to fire
Apply a transcutaneous pacemaker

Correct Answer

Defibrillate the patient

A. J., Morley, P. T., O'Neil, B. The patient is in ventricular fibrillation and requires immediate defibrillation. The patient described has a functioning pacemaker with pacemaker spikes present. The pacemaker is not capturing. Reference Panchal, C. A pacemaker magnet is used to pause or cease pacemaker activity. A magnet would not alter the current or change the settings of a pacemaker. The patient requires immediate defibrillation. D. If the patient arrives in ventricular fibrillation, good-quality cardiopulmonary resuscitation should continue until defibrillation is delivered. Treatment should not be delayed while waiting on the implantable cardioverter defibrillator to fire. Category: Cardiovascular Emergencies, Dysrhythmias

Question 102

A patient is being discharged home with a diagnosis of mild bilateral pleural effusions secondary to chronic disease. Which statement indicates that the patient requires additional teaching?

"Pleural effusions are often asymptomatic and do not require intervention."
"Mild pleural effusions do not need to be monitored with repeat chest X-rays."
"Pleural effusions often occur rapidly and may require drainage if large."
"Healthy lifestyle habits will prevent future pleural effusions." ✓

Correct Answer

"Healthy lifestyle habits will prevent future pleural effusions."

A. Mild pleural effusions occur commonly because of chronic disease. They are typically asymptomatic, and intervention focuses on treating the underlying disease process, not the effusion. B. Mild pleural effusions are typically asymptomatic. Drainage is required if an effusion is large and causing respiratory compromise. C. Pleural effusion is a clinical manifestation of an underlying disease process. Healthy lifestyle habits may decrease the risk of pleural effusions, but effusions are typically unavoidable in chronic disease. D. Mild pleural effusions often resorb spontaneously and do not require intervention or close monitoring with repeat chest X-rays. Reference Light, R. (2021). Pleural effusion. In Merck Manual: Professional Version. Retrieved April 23, 2022, from https://www.merckmanuals.com/professional/pulmonary-disorders/mediastinal-and-pleural-disor ders/pleural-effusion Category: Respiratory Emergencies, Pleural effusion

Question 103

A patient currently receiving home peritoneal dialysis presents with a 24-hour history of abdominal pain and distention, fever, and chills. The nurse would recognize which of the following orders as the priority?

Obtain a sample of peritoneal fluid for culture and sensitivity ✓
Arrange for the patient to receive emergency hemodialysis
Administer broad-spectrum antibiotics
Weigh the patient to assess for fluid retention

Correct Answer

Obtain a sample of peritoneal fluid for culture and sensitivity

A. In most cases, peritoneal dialysis is not interrupted while the patient is being treated for peritonitis. Antibiotic therapy is frequently administered by adding the medication to the dialysate fluid. B. Broad-spectrum antibiotics are indicated in the patient with suspected peritonitis but should not be administered until cultures are obtained. C. Accurate intake and output must be maintained on a patient receiving peritoneal dialysis to assess for fluid retention; however, obtaining a culture of the peritoneal fluid, followed by the initiation of antibiotic therapy, is the priority intervention for the nurse. Reference Baxter, C. (2020). Renal and genitourinary emergencies. In V. Sweet & D. Patients who are receiving peritoneal dialysis are at high risk for infection and the development of peritonitis. Initial actions should include obtaining a sample of peritoneal fluid for culture and sensitivity, followed by the administration of broad-spectrum antibiotics. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Acute abdomen

Question 104

Which of the following conditions manifests with alternating periods of depression and euphoria?

Psychotic behavior
Bipolar disorder ✓
Panic disorder
Paranoia

Correct Answer

Bipolar disorder

A. Panic is the feeling of intense fear. Panic disorder is considered a minimum of three panic attacks within a 3-week period. Signs and symptoms include acute onset of feeling of anxiety and tremulousness, chest pain, shortness of breath, and dizziness. B. Bipolar disorder, also known as a manic-depressive illness, is characterized by alternating mood swings, during which the individual can exhibit bizarre behavior. It is treated with medication and therapy. C. Paranoia is the loss of reality through a delusional thought system. Patients with paranoia believe that someone is out to "get them." D. Psychotic behavior is caused by an acute or chronic pathological process. Category: Mental Health Emergencies, Mood disorders (e.g., bipolar, depression)

Question 105

A patient complains of a painful, red pimple-type growth on the lower eyelid. Which of the following does the nurse suspect?

Hordeolum ✓
Chalazion
Blepharitis
Keratitis

Correct Answer

Hordeolum

A. A hordeolum is often referred to as a "stye." This is a small external abscess that can be painful, red, and swollen. It will usually rupture spontaneously and is treated with a topical ophthalmic antibiotic. B. Keratitis is inflammation of the cornea that results in pain, photophobia, and the presence of mucopurulent drainage with decreased vision in the affected eye. Keratitis is treated with a topical antibacterial, antiviral, or antifungal agent depending on the causative organism. Reference Nolan-Kelly, L. (2020). Ocular emergencies. In V. Sweet & C. Chalazion is an internal hordeolum caused by inflammation of the meibomian gland on the inner surface of the eyelid. It is a localized swelling beneath the eyelid, which is painless and will usually resolve in 3–4 weeks. A topical antibiotic ointment may be prescribed. D. Blepharitis is inflammation of the lid margins. It causes burning, tearing of the eyes, and the sensation that there is a foreign body in the eye. It can also cause the patient to experience pain in the eye and photophobia. If the blepharitis does not resolve spontaneously, antibiotic ointment may be necessary. Category: Maxillofacial and Ocular Emergencies, Ocular, Ocular Infections (e.g., conjunctivitis, iritis)

Question 106

A patient presents to the emergency department with a complaint of severe upper abdominal pain. The patient is very tall, with long arms and long fingers, and has a sternum that appears sunken. Which condition is the nurse concerned about?

Aortic dissection ✓
Myocardial infarction
Pancreatitis
Hiatal hernia

Correct Answer

Aortic dissection

A. The description of this patient is suggestive of Marfan syndrome. People with Marfan syndrome are tall, have long arms (arm span exceeding length of body), legs, fingers, and toes, and a sunken-appearing sternum (pectus excavatum). Connective tissue disorders such as this place patients at risk for both aortic dissection and aortic aneurysm. B. Myocardial infarction is a possibility with a chief complaint of upper abdominal pain and should be ruled out. However, a patient with Marfan syndrome is at high risk for aortic dissection, and this should not be missed. C. Pancreatitis may cause upper abdominal pain. However, a patient with Marfan syndrome is at high risk for aortic dissection, and this should not be missed. D. Hiatal hernia may cause upper abdominal pain. However, a patient with Marfan syndrome is at high risk for aortic dissection, and this should not be missed. Category: Cardiovascular Emergencies, Aneurysm and dissection

Question 107

Which statement made by a new nurse indicates understanding of information related to wound irrigation?

"Wounds should be irrigated with hydrogen peroxide."
"Puncture wounds do not require irrigation."
"I should always wear gloves and eye protection when irrigating wounds." ✓
"A cleansing solution that contains alcohol is best for irrigating wounds."

Correct Answer

"I should always wear gloves and eye protection when irrigating wounds."

A. Puncture wounds should be irrigated vigorously because of the high risk of contamination due to potential embedded material. B. Hydrogen peroxide is damaging to tissues and does not remove anaerobic organisms; therefore, it should not be used for wound cleansing. C. Alcohol solutions are damaging to tissue and should not be used for irrigating wounds. Reference Denke, N. J. (2020). Wound management. In V. Sweet & D. Procedures such as wound irrigation have a high potential to splash body fluids. Therefore, personal protective equipment is essential to prevent contamination. Category: Musculoskeletal and Wound Emergencies, Wound, Lacerations

Question 108

A patient presents with a several-year history of progressive bilateral knee pain, swelling, and decreased range of motion. He reports some relief of symptoms when he takes nonsteroidal anti-inflammatory drugs (NSAIDs). Which of the following conditions should the nurse suspect?

Osteoarthritis ✓
Paget's disease
Rheumatoid arthritis
Osteoporosis

Correct Answer

Osteoarthritis

A. Paget's disease is a chronic disorder that may result in enlarged and misshapen bones. Excessive breakdown and formation of new bone tissue causes the affected bones to weaken, resulting in pain, misshapen bones, fractures, and other bone problems, including ostial arthritis. Paget's disease is typically localized, affecting just one or a few bones, as opposed to osteoporosis, which can affect all the bones. B. Rheumatoid arthritis is an autoimmune disorder characterized by warmth, tenderness, and swelling of the affected joints. C. Osteoarthritis results in changes to bone structure and cartilage that allow bones to rub together, causing pain, swelling, and loss of motion. Treatment includes exercise, weight control, rest, and prescription and over-the-counter NSAIDs. Alternative therapy, such as acupuncture and dilating supplements, and occasionally joint replacement surgery may be helpful. D. Osteoporosis is bone loss resulting in reduced bone integrity. Osteoporosis is usually symptom free during the early stages. Over time, the affected person may have back pain as vertebra start to collapse. Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Inflammatory conditions

Question 109

Which of the following initial assessments should the nurse consider as priority for a patient with the complaint of hand pain following an altercation?

Presence of active bleeding ✓
Presence of a foreign body
Treatment provided prior to arrival
Source of the injury

Correct Answer

Presence of active bleeding

A. Active bleeding requires that pressure be applied to control the bleeding. In addition, the presence of exudate should be determined because this is evidence of a wound infection. B. The presence of a foreign body is important, but assessing for active bleeding should come first to determine any needed intervention. C. The prior treatment of the injury is important to determine what further wound treatment may be indicated, but it is not the priority assessment of the wound. Reference Denke, N. (2020). Wound management. In V. Sweet & D. It is important to determine the mechanism of the injury, but this assessment would not be a higher priority than assessing for and stopping active bleeding. Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Fractures (e.g., open, closed, fat embolus)

Question 110

A patient has sustained burns to the posterior trunk, neck, shoulders, and arms in a house fire. During the initial assessment, the patient is becoming increasingly agitated, their voice has become hoarse, and their sputum is now black-tinged. What is the priority intervention for this patient?

Administer pain medication
Prepare for emergency escharotomy
Secure a patent airway ✓
Administer 100% oxygen

Correct Answer

Secure a patent airway

A. The symptoms of an inhalation injury include dyspnea, hoarse voice, cough, anxiety or agitation, stridor, wheezing, facial burns, singed nasal hairs, and the presence of carbonaceous (black-tinged) sputum. Securing a patent airway is a top priority because increasing airway edema places this patient at risk for airway compromise. B. Pain management is an important aspect of caring for a patient who has sustained a burn injury; however, in this case, the priority intervention is to protect the patient's airway. C. Indications for escharotomy include presence of circumferential eschar, which may impede ventilation or cause vascular compromise. This patient does not have circumferential eschar, but they should be monitored for any impediment to breathing from the anterior chest burns. D. The administration of oxygen is essential in caring for all patients with burns; however, the airway must be secured for oxygen to be adequately delivered to the patient and to have a therapeutic benefit. Category: Maxillofacial and Ocular Emergencies, Ocular, Burns

Question 111

Which of the following interventions does the nurse anticipate following incision and drainage of a large abscess under the axilla?

Adhesive wound glue to close the wound
Packing the site with iodinated gauze ✓
Application of a wet-to-dry dressing
Sutures to close the wound

Correct Answer

Packing the site with iodinated gauze

A. Abscesses are packed with iodinated gauze to prevent premature closure of the skin and to facilitate further exudate drainage. B. A wet-to-dry dressing would not be appropriate for this type of wound. Reference Denke, N. J. (2020). Wound management. In V. Sweet & C. Abscesses are not closed with adhesive wound glue following incision and drainage; the area should be left open to facilitate drainage of any further exudate in the wound bed. Adhesive wound glue is indicated for closure of a simple superficial wounds. D. Abscesses are typically not sutured following incision and drainage to allow for further drainage of any remaining exudate. Category: Musculoskeletal and Wound Emergencies, Wound, Wound infections

Question 112

A patient arrives to the emergency department with an inability to bear weight on their left leg for the past week. The patient's vital signs are: BP 88/60 mm Hg, HR 110 beats/minute, RR 28 breaths/minute, T 37°C (98.6°F), SpO2 91% on room air. Based on the patient's history and assessment, which diagnostic test is the priority for this patient?

Chemistry laboratory panel
Spiral computed tomography (CT) scan ✓
Radiograph of the left leg
Electrocardiogram

Correct Answer

Spiral computed tomography (CT) scan

A. An electrocardiogram will be included in the workup for this patient; however, the patient is exhibiting signs of a pulmonary embolism, so obtaining a spiral CT scan is the priority. Reference Foley, A., & Sweet, V. (2020). Respiratory emergencies. In V. Sweet & B. Laboratory chemistries may be ordered to evaluate the patient's electrolytes but are not the priority diagnostic test for the patient with a suspected pulmonary embolism. C. Although a radiograph of the left leg may be indicated, it is not the priority diagnostic test for the patient with a suspected pulmonary embolism. D. A helical spiral CT is a key diagnostic test for the presence of a pulmonary embolism. The patient's inability to bear weight on their left leg may be an indication of a deep vein thrombosis; the low pulse oximetry and both an increased respiratory rate and an increased heart rate may be related to decreased oxygenation as the result of the pulmonary embolus. Category: Cardiovascular Emergencies, Thromboembolic disease (e.g., deep vein thrombosis [DVT])

Question 113

A patient in full cardiac arrest arrives via emergency medical services. The patient is in asystole. Cardiopulmonary resuscitation is being performed, and a pulse is felt with each chest compression. Vascular access has been established. What is the initial treatment option for this patient?

Administer atropine 1 mg IV
Administer epinephrine (0.01 mg/kg) 1 mg IV ✓
Administer amiodarone 300 mg IV
Defibrillation with 360 joules

Correct Answer

Administer epinephrine (0.01 mg/kg) 1 mg IV

A. Defibrillation is not indicated for asystole. The purpose of defibrillation is to cease fibrillation, allowing the heart's automaticity to return. The heart has no muscular activity during asystole. B. Amiodarone is indicated for the treatment of pulseless ventricular tachycardia or ventricular fibrillation, not for asystole. C. In addition to adequate cardiopulmonary resuscitation, epinephrine 1 mg IV or IO should be administered every 3–5 minutes for a patient in asystole. D. Atropine is not indicated for a patient in asystole. Atropine is indicated for symptomatic bradycardia. Category: Cardiovascular Emergencies, Cardiopulmonary arrest

Question 114

An older adult patient reports a headache of increasing intensity following a recent fall. Which diagnostic test would be the priority for this patient?

Finger-stick blood sugar test
Computed tomography (CT) of the brain ✓
Complete blood count
Magnetic resonance imaging of the brain

Correct Answer

Computed tomography (CT) of the brain

A. A finger-stick blood sugar test may be useful in ruling out hypoglycemia, which is a common cause of confusion in the elderly, but this diagnosis does not support the clinical presentation of this patient. B. A CT of the head is the diagnostic study of choice for confirming the diagnosis of a subdural hematoma, which is the likely diagnosis of this patient. Brain atrophy is a common consequence of aging, putting strain on the bridging veins located between the dura mater and the brain. A traumatic head injury is the most common cause of subdural hematomas, causing the bridging veins to sever and leading to a slow accumulation of blood between the dura mater and the brain. C. Magnetic resonance imaging of the brain may be considered after a diagnosis has been confirmed to monitor the progression of the subdural hematoma. D. A complete blood count may be useful in ruling out an infection, which is a common cause of confusion in the elderly, but this diagnosis does not support the clinical presentation of this patient. Category: Neurological Emergencies, Neurogenic shock

Question 115

A patient with no history of prior seizures begins having a tonic-clonic seizure. What is the nurse's priority intervention for this patient?

Obtain a blood sugar level
Position the patient to avoid injury
Ensure a patent airway ✓
Give a dose of lorazepam

Correct Answer

Ensure a patent airway

A. A dose of a fast-acting benzodiazepine such as lorazepam to stop the seizure should be given, but the priority is to ensure that the patient maintains a patent airway. B. The patient who is seizing should have the area surrounding the body padded to prevent injury; however, the priority is to maintain airway patency. C. The priority of care for a patient who is postictal following a tonic-clonic seizure is to ensure airway patency during stabilization. Positioning the patient on their side may assist with the prevention of aspiration. D. Hypoglycemia is a common cause of seizure. However, the priority of care is to maintain airway patency. Category: Neurological Emergencies, Seizure disorders

Question 116

The nurse recognizes that which blood component contains the highest concentration of fibrinogen for the treatment of the patient with disseminated intravascular coagulation?

Cryoprecipitate ✓
Fresh frozen plasma
Platelets
Whole blood

Correct Answer

Cryoprecipitate

A. Cryoprecipitate contains a higher concentration of fibrinogen than fresh frozen plasma and whole blood. It is made by thawing fresh frozen plasma and removing the precipitated protein. It is the only blood component source of concentrated fibrinogen. B. Fibrinogen is abundant in fresh frozen plasma, yet it is susceptible to hemodilution; therefore, cryoprecipitate is a better option for a highly concentrated source of fibrinogen. C. Cryoprecipitate contains a higher concentration of fibrinogen than platelets. D. Cryoprecipitate contains a higher concentration of fibrinogen than whole blood. Category: Medical Emergencies, Hematologic disorders

Question 117

Which statement made by the parents of a young patient with mastoiditis indicates the need for further teaching?

"We will be able to take our child home this evening." ✓
"My child will need to be seen by a specialist."
"My child will receive routine pain medication."
"Surgery may be needed if the antibiotics don't work."

Correct Answer

"We will be able to take our child home this evening."

A. The child with mastoiditis may require infectious disease and/or ear, nose, and throat specialist consult. B. The pain associated with mastoiditis is typically severe and requires routine pain management. C. Mastoiditis is a complication of otitis media. Children with mastoiditis require intravenous antibiotics and therefore should be hospitalized for at least 48 hours or until they are no longer febrile. There is a risk of erosion of the mastoid process if the infection is not treated effectively. The child may also require an infectious disease consult and/or surgery for a possible mastoidectomy or myringotomy. D. Mastoidectomy or myringotomy may be indicated if the infection progresses or if recurrent persistent otitis media occurs. Reference Winter, J. L. (2020). Dental, ear, nose, throat, and facial emergencies. In V. Sweet & Category: Maxillofacial and Ocular Emergencies, Maxillofacial, Maxillofacial infections (e.g., Ludwig's angina, otitis, sinusitis, mastoiditis)

Question 118

The emergency nurse is caring for a patient who has been diagnosed with a right ventricular infarction. The nurse should question which of the following medication orders?

Aspirin
Nitroglycerin ✓
Heparin
Dobutamine

Correct Answer

Nitroglycerin

A. Right ventricular infarct patients are preload dependent and require volume to continue circulating blood forward. Medications such as nitroglycerine and morphine are not recommended because they affect preload and can worsen right ventricular dysfunction. B. There is no contraindication to the use of heparin in right ventricular infarction. C. Dobutamine is an inotrope that reduces pulmonary vascular resistance and right ventricular afterload and is useful in the treatment of right ventricular infarct. D. There is no contraindication to the use of aspirin in right ventricular infarction. Category: Cardiovascular Emergencies, Acute coronary syndrome

Question 119

A 45-year-old patient presents with a 2-month history of mood swings, palpitations, diaphoresis, temperature changes, and frequent stools. Vitals signs are: BP 130/90 mm Hg, HR 145 beats/minute, RR 20 breaths/minute, T 38°C (100.4°F). Which diagnostic finding is consistent with these symptoms?

Elevated serum troponin level
Elevated serum ammonia level
Decreased serum estrogen level
Decreased thyroid-stimulating hormone level ✓

Correct Answer

Decreased thyroid-stimulating hormone level

A. Symptoms associated with an elevation in the serum ammonia level would include changes in mental status, confusion, nighttime insomnia, and motor disturbances such as gait abnormalities or involuntary hand-flapping (asterixis). B. A troponin level measures heart muscle ischemia. The patient's history is more consistent with hyperthyroidism. A heart rate of 145 beats/minute and report of palpitations do not alone suggest the presence of myocardial ischemia or injury. C. Mood swings and night sweats are symptoms associated with the menopausal period, which is evidenced by a decrease in serum estrogen levels. However, the patient's vital signs and report of frequent stools are highly suggestive of an endocrine disorder, specifically hyperthyroidism. D. The patient's symptoms of tachycardia, diaphoresis, changes in bowel function, and mood swings are highly suggestive of hyperthyroidism. Thyroid-stimulating hormone is suppressed in a patient with hyperthyroidism. Category: Medical Emergencies, Endocrine disorders

Question 120

An unresponsive 4-year-old arrives dusky, with a core temperature of 82.4°F (28°C). The child is placed on a cardiac monitor, which exhibits ventricular fibrillation. What is the priority intervention for this child?

Defibrillate at 2–4 joules per kg ✓
Prepare for endotracheal intubation
Initiate intravenous or intraosseous access
Administer epinephrine IVP push

Correct Answer

Defibrillate at 2–4 joules per kg

A. Severe hypothermia induces a low-flow state, and it can be challenging to detect vital signs. Hypothermia should not be the priority if vital signs are not detected. High-quality CPR, defibrillation, and prevention of additional heat loss are of high priority. B. Intravenous and intraosseous access should not precede defibrillation in the presence of ventricular fibrillation. C. According to the PALS algorithm, an advanced airway is not the priority intervention for ventricular fibrillation associated with hypothermia. D. Epinephrine is the drug of choice for ventricular fibrillation, but defibrillation is the first intervention for a shockable rhythm in hypothermia. Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment, Temperature-related emergencies

Question 121

A geriatric patient is brought from home and is markedly short of breath and using accessory muscles to breathe. Pulse oximetry reading is 80% on 100% oxygen via a nonrebreather mask. The physician determines that the patient is competent and recommends intubation and mechanical ventilation, but the patient refuses, stating, "I am ready to die." What is the most appropriate action by the nurse?

Prepare for rapid-sequence intubation to improve
Obtain consent for intubation from the patient's next of kin
Request to see a copy of the patient's advance directive
Respect the patient's right to refuse intubation ✓

Correct Answer

Respect the patient's right to refuse intubation

A. Assisting with the intubation of the patient against the patient's expressed wishes is in direct conflict with the American Nurses Association code of ethics, which states that the nurse must strive to protect the health, safety, and rights of the patient—which in this case is the patient's right to refuse intubation. Treatment of a patient without their consent, no matter how well-meaning, may be considered battery. B. This patient has the right to refuse intubation. Emergency nurses, in collaboration with all members of the healthcare team, support and carry out a plan of care in accordance with the patient's wishes. C. Competent adults have the ability and authority to make their healthcare treatment decisions, and the emergency nurse is ethically obligated to support the patient's decision. D. This patient has the right to refuse intubation. Emergency nurses, in collaboration with all members of the healthcare team, support and carry out a plan of care in accordance with the patient's wishes. Category: Professional Issues, Nurse, Ethical dilemmas

Question 122

A tension pneumothorax is associated with which type of shock?

Hypovolemic
Distributive
Obstructive ✓
Cardiogenic

Correct Answer

Obstructive

A. Cardiogenic shock occurs when the heart fails to pump effectively. Causes include myocardial infarction and contusion, heart disease, cardiomyopathies, or ruptured papillary muscle. B. Hypovolemic shock is associated with a reduction in circulating volume. Conditions associated with hypovolemic shock include trauma, bleeding with various causes, burns, diarrhea, vomiting, diuresis, and third spacing. C. Distributive shock results from a release of mediators that produce vasodilation. Types of distributive shock include neurogenic shock, anaphylactic shock, and septic shock. Reference Carbino, G. (2020). Shock emergencies. In V. Sweet & D. Obstructive shock occurs when there is an obstruction or compression of the vasculature that prevents adequate cardiac output. With a tension pneumothorax, intrathoracic pressure increases, decreasing cardiac output. Category: Cardiovascular Emergencies, Cardiogenic shock and obstructive shock

Question 123

A patient presents with a 3-week history of left lower quadrant abdominal cramping with frequent episodes of blood- and mucus-containing diarrhea and recent weight loss. These symptoms are indicative of which disorder?

Internal hemorrhoids
Colon cancer
Ulcerative colitis ✓
Salmonella infection

Correct Answer

Ulcerative colitis

A. Infectious diarrhea, such as that caused by a salmonella exposure, is characterized by cramping, colicky abdominal pain and bloody diarrhea. These symptoms usually resolve within 24 hours. B. Ulcerative colitis is an inflammatory condition affecting the large intestine. Left lower quadrant abdominal pain with bloody diarrhea due to the effects of the disease on the lining of the colon are hallmark signs of the disease. Patients can pass between 10 and 20 liquid stools per day. Additional symptoms include weight loss, fever, and tachycardia. C. A change in bowel habits and weight loss, which may include constipation and/or diarrhea, are primary symptoms associated with colon-rectal cancers; however, the diarrhea associated with colon cancer is less frequent than that with ulcerative colitis and does not contain mucus. Abdominal cramping with colon cancer is more likely to be associated with a cancerous lesion causing a bowel obstruction. D. Internal hemorrhoids can cause bleeding, but they usually do not cause pain or abdominal cramping. They are not associated with weight loss. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Peritonitis

Question 124

The nurse is caring for a patient who is being admitted with a diagnosis of acute cholecystitis. Which of the following statements made by the patient indicates a need for further teaching?

"I now know the fried chicken I had last night might have initiated this today."
"I am grateful for the antibiotics since this can cause an infection as well."
"I did not realize age and weight had such a bearing on this diagnosis."
"My family is bringing me a snack to eat while I am waiting." ✓

Correct Answer

"My family is bringing me a snack to eat while I am waiting."

A. Ingestion of fried/fatty foods is a known etiologic factor for an acute episode of cholecystitis. B. Patients with acute cholecystitis may require surgery and therefore need to remain fasting until the consulting physician decides on the plan of action. C. A diagnosis of cholecystitis carries an increased risk for gangrene or perforation, so the patient will require broad-spectrum antibiotics. D. Risk factors associated with the development of cholecystitis include being female, pregnant, or overweight, being older than 40 years, and having an acute illness. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Cholecystitis

Question 125

A patient has sustained a partial amputation of the right forearm. The nurse observes pulsatile hemorrhage. What is the priority intervention for this patient?

Apply a pressure dressing to the amputation ✓
Apply a tourniquet above the amputation
Elevate the affected extremity above the level of the heart
Ask the physician to suture the wound

Correct Answer

Apply a pressure dressing to the amputation

A. The priority focus in a partial amputation is to control hemorrhage through direct pressure over the bleeding site, direct compression of the artery, a pressure dressing, and elevation of the extremity. If bleeding cannot be controlled via these methods, a tourniquet may be required with a blood pressure cuff inflated 30 mm Hg above the systolic blood pressure. B. The priority focus in a partial amputation is to control hemorrhage through direct pressure over the bleeding site, direct compression of the artery, a pressure dressing, and elevation of the extremity. C. Suturing the wound without ligating the severed artery (pulsatile bleeding) would be ineffective in controlling the bleeding. D. The priority is to control hemorrhage and that is initially done with direct pressure to the wound. Elevation is also recommended but direct pressure to the wound is the priority. Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Amputation

Question 126

A patient with a pneumothorax develops jugular vein distention, tachycardia, hypotension, and cyanosis. Based on this assessment, the nurse anticipates that the patient requires which immediate intervention?

Needle thoracostomy ✓
Chest tube insertion
Chest radiograph
Endotracheal intubation

Correct Answer

Needle thoracostomy

A. The patient is experiencing signs and symptoms of a tension pneumothorax. A tension pneumothorax is a life-threatening emergency that occurs when air enters the pleural space during inspiration and is unable to escape during exhalation. The increasing intrathoracic pressure compresses the lungs, heart, and great vessels, resulting in markedly decreased cardiac output. A needle thoracostomy should be performed immediately to relieve pressure and should be left in place until a chest tube can be inserted. B. A tension pneumothorax is a quickly progressing medical emergency that may be deadly if not resolved immediately. Therefore, a needle thoracostomy should be performed as soon as symptoms are realized to relieve intrathoracic pressure, followed by the insertion of a chest tube. C. A tension pneumothorax is a quickly progressing medical emergency that may be deadly if not resolved immediately. Needle decompression should not be delayed in a clinically evident tension pneumothorax to obtain a confirming chest radiograph. 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. Endotracheal intubation is indicated when airway patency becomes unstable or is lost. Jugular vein distention, tachycardia, hypotension, and cyanosis in a patient indicate the presence of a tension pneumothorax; the patient requires an immediate needle thoracostomy. Category: Respiratory Emergencies, Pneumothorax

Question 127

While auscultating lung sounds of a patient with chest pain and shortness of breath, the nurse hears a creaking/grating sound that is present on inspiration and expiration and does not change when the patient coughs. Which of the following is the most likely cause of this sound?

Costochondritis
Pneumothorax
Epiglottitis
Pleurisy ✓

Correct Answer

Pleurisy

A. Pneumothorax would manifest with no lung sounds heard over the affected area of the lung. A pleural friction rub produces a creaking or grating sound on auscultation and is associated with pleural inflammation. B. A pleural friction rub produces a creaking or grating sound on auscultation that is usually heard on inspiration and expiration. It is caused by roughened and inflamed pleural surfaces rubbing together. It is usually associated with pleural inflammation, such as with pleurisy, pneumonia, or pleuritis. C. Epiglottitis would produce stridor, a harsh grating or crowing sound that results from partial obstruction of the trachea or larynx. A pleural friction rub produces a creaking or grating sound on auscultation and is associated with pleural inflammation. D. Costochondritis is an inflammation of the intercostal tissues that produces pain with movement and/or deep breathing. A pleural friction rub produces a creaking or grating sound on auscultation and is associated with pleural inflammation. Category: Respiratory Emergencies, Aspiration

Question 128

A patient with an extensive cardiac history is complaining of shortness of breath. Assessment reveals crackles in the lung bases, 3+ edema to bilateral lower extremities, and an extra heart sound. The nurse decreases the patient's preload by performing which intervention?

Administering dobutamine
Administering nitroglycerin ✓
Elevating the patient's legs
Providing supplemental oxygen

Correct Answer

Administering nitroglycerin

A. Supplemental oxygen is indicated for the patient with shortness of breath; however, it does not affect preload. B. Preload is the amount of blood returning to the right ventricle. It is affected by venous dilation and contraction as well as blood volume. Nitroglycerin is a vasodilator that reduces to amount of blood returning to the heart, which may help with shortness of breath. C. Elevating the patient's legs may increase preload by increasing the blood returning to the heart, which may increase shortness of breath. D. Dobutamine increases contractility, not preload. Category: Cardiovascular Emergencies, Cardiogenic shock and obstructive shock

Question 129

A 5-year-old patient arrives to the emergency department in full cardiac arrest with cardiopulmonary resuscitation in progress; the cardiac monitor displays ventricular fibrillation. The child weighs 44 pounds (20 kg). The emergency nurse is aware that the initial dose of epinephrine (Adrenalin) to be given via intravenous or intraosseous route for this patient would be which of the following?

0.4 mg
0.2 mg ✓
0.02 mg
1.0 mg

Correct Answer

0.2 mg

A. The correct dosage for epinephrine is 0.01 mg/kg or 0.2 mg IV. B. This calculation would result in not enough epinephrine being administered for the patient. The correct dose of epinephrine for a child is 0.01 mg/kg or 0.2 mg. C. This calculation is incorrect and would result in too much epinephrine being administered. The correct dose of epinephrine for a child is 0.01 mg/kg or 0.2 mg. Reference Topjian, D. 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 Category: Cardiovascular Emergencies, Cardiopulmonary arrest

Question 130

A patient presents after a motor vehicle crash with complaints of chest pain and shortness of breath. Vital signs are: BP 82/50 mm Hg, HR 134 beats/minute, RR 38 breaths/minute, O2 87% without supplemental oxygen, T 98.9°F. Assessment reveals absent breath sounds on the left chest. What is the priority intervention?

Needle thoracentesis ✓
Rapid-sequence intubation
Fluid bolus
Pericardiocentesis

Correct Answer

Needle thoracentesis

A. Pericardiocentesis is indicated for cardiac tamponade, which presents with symptoms known as Beck’s triad: hypotension, muffled heart sounds, and distended neck veins. B. Absent breath sounds noted posttrauma is classic for pneumothorax/tension pneumothorax. If left untreated, hypotension, shock, decreased cardiac output, and vascular collapse will follow. A quick treatment is a needle thoracentesis/decompression. A 14- or 16-gauge needle is inserted in the second intercostal space at the midclavicular line to allow air to be expelled from the thoracic cavity. A chest tube may be inserted after the needle thoracentesis. C. Fluids may be needed to replace vascular volume. However, the priority is for the nurse to assist with an emergent needle thoracentesis. D. Rapid-sequence intubation may be necessary, but the needle thoracentesis takes priority. Category: Respiratory Emergencies, Respiratory Trauma

Question 131

What is the significance of the zone of coagulation as it relates to a burn injury?

The full extent of the damage won’t be known for 2–3 days.
The tissue damage is superficial and will heal.
There is irreversible damage to the tissue. ✓
Damage to the tissue is reversible if treated immediately.

Correct Answer

There is irreversible damage to the tissue.

A. The zone of coagulation is the most severe of the three zones of tissue damage that can occur with burns and is irreversible. B. The zone of stasis is the intermediate of the three zones of tissue damage that can occur with burns. There is damage to the tissue, but the full extent of the severity won’t be known for 2–3 days. C. The zone of hyperemia is the least severe of the three zones of tissue damage that can occur with burns. It is characterized by superficial damage that will usually heal on its own without much intervention. D. The zone of coagulation is the most severe of the three zones of tissue damage that can occur with burns. It results in irreversible damage to the tissues and will require grafting. Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment, Electrical injuries

Question 132

An older adult is brought to the emergency department with an altered mental status, fever, and hypotension. The patient had an indwelling urinary catheter inserted 1 week ago for urinary retention and has not been able to eat or drink much for the past 48 hours. Which of the following would place this patient at the greatest risk for sepsis?

Presence of an indwelling urinary catheter ✓
Previous hospitalization for urinary retention
Advanced age of the patient
Lack of food or water for 48 hours

Correct Answer

Presence of an indwelling urinary catheter

A. The elderly and the young may be at greater risk for developing sepsis; all patients with a long-term indwelling device such as a urinary catheter are at risk of developing sepsis regardless of age. B. Previous hospitalization may be a risk factor, but not a greater risk factor than an indwelling catheter. Reference Holleran, R. S. (2020). Management of the critical care patient in the emergency department. In V. Sweet & C. Sepsis is the result of the body's response to infection. Sources of infection may include urine, wounds, a long-term indwelling device such as a urinary catheter or vascular access catheter, and infections from either a bacterial or viral source. D. Dehydration would be more likely to place the patient at risk for hypovolemic shock; it would not place the patient at a higher risk for sepsis. Category: Medical Emergencies, Sepsis

Question 133

A patient who belongs to which of the following religious faiths would most likely refuse to consent to a blood transfusion?

Seventh-day Adventist
Orthodox Jew
Muslim
Jehovah's Witness ✓

Correct Answer

Jehovah's Witness

A. Members of the Seventh-day Adventist religion may refuse certain types of foods or may refuse to have surgery on certain days of the week, but they do not object to receiving a blood transfusion. Reference Giger, J. N., & Haddad, L. G. (2021). Social organization. In J. N. Giger & L. G. Haddad (Eds.), Transcultural nursing (8th ed., pp. 58–88). Elsevier. B. Jehovah's Witnesses will most likely refuse blood transfusion based on their biblical beliefs. C. Persons who are Orthodox Jews do not object to receiving a blood transfusion. D. Members of the Muslim faith do not object to receiving a blood transfusion. Category: Professional Issues, System, Patient consent for treatment

Question 134

A patient with dyspnea has the following vital signs: HR 100 beats/minute; RR 22 breaths/minute; SpO2 90% on room air. The patient is placed on pulse oximetry and capnography monitoring. Upon reevaluation, there is no improvement in the SpO2. Arterial blood gas shows PaCO2 45 and PaO2 89. End-tidal CO2 is 30. Based on this assessment, the nurse suspects that the patient most likely has what pulmonary condition?

Asthma
Pulmonary embolism ✓
Atelectasis
Bacterial pneumonia

Correct Answer

Pulmonary embolism

A. Hypoxemia related to asthma typically improves with supplemental oxygen. In conditions like asthma, there is a low V/Q mismatch. This means that there is low ventilation but normal perfusion. Improving ventilation to the alveoli will help to improve the oxygenation status. B. The patient appears to have a high V/Q mismatch, or "dead space." Ventilated alveoli are not adequately perfused, causing a decrease in PaO2 despite supplemental oxygen. The patient has no improvement in SpO2 despite being placed on oxygen. The PaCO2 is high and the etCO2 is low because a blood clot may be sitting in the pulmonary artery, preventing exchange of CO2 for oxygen. To calculate the dead space: PaCO2 - etCO2/PaCO2. Any value over 30% is abnormal and concerning for pulmonary embolism, which is one cause of dead space. C. Hypoxemia related to pneumonia typically improves with supplemental oxygen. In conditions like pneumonia, there is a low V/Q mismatch. This means that there is low ventilation but normal perfusion. Improving ventilation to the alveoli will help to improve the oxygenation status. D. Hypoxemia related to atelectasis typically improves with supplemental oxygen. In conditions like atelectasis, there is a low V/Q mismatch. This means that there is low ventilation but normal perfusion. Improving ventilation to the alveoli will help to improve the oxygenation status. Category: Respiratory Emergencies, Pulmonary embolus

Question 135

A patient with a history of end-stage cardiac disease is received from a long-term care facility. The patient is awake and answers questions appropriately but is markedly short of breath, with circumoral cyanosis. The provider recommends intubation; however, the patient's advance directive indicates that they do not wish to be intubated. Which is the appropriate action for the nurse to perform?

Administer oxygen via nasal cannula and continue to monitor pulse oximetry
Adhere to the patent's advance directive not to intubate
Assist with the intubation of the patient
Ask the patient if they wish to be intubated ✓

Correct Answer

Ask the patient if they wish to be intubated

A. There is no indication that the patient lacks the cognitive ability to make their healthcare decisions. The advance directive is used only when the patient is unable to make their own healthcare decisions. The patient should be asked about their wishes. They may wish to be intubated; if they refuse intubation, assisting them to a comfortable position, applying oxygen, and monitoring their pulse oximetry would be appropriate. Reference Chan, G. K., & Vega, C. (2020). Palliative and end-of-life care in the emergency department. In V. Sweet & B. There is no indication that this patient lacks the ability to make her healthcare decisions. The patient should be granted the opportunity to make their wishes known concerning intubation, and the healthcare team is obligated to honor the decision. C. Advance directives are only exercised when the patient lacks decision-making ability. This patient is awake and can make their wishes known to the healthcare team. If the patient refuses intubation, assisting them to a position of comfort would be an appropriate intervention. D. The patient should be asked if they wish to be intubated. Advance directives are only exercised when the patient lacks decision-making ability. This patient is awake and can indicate their life-sustaining wishes regarding end-of-life care to the healthcare team. Category: Professional Issues, Patient, End-of-life and Palliative Care (e.g., organ and tissue donation, advance directives, care withholding, family presence)

Question 136

Which of the following procedures would be most concerning for the safety of a patient with chronic hepatitis C?

Inserting a urinary drainage catheter
Inserting a nasogastric tube
Administering a cholesterol-lowering medication
Administering penicillin G procaine ✓

Correct Answer

Administering penicillin G procaine

A. The insertion of a nasogastric tube in a patient with hepatitis C is not contraindicated unless the patient has esophageal varices. Reference Hagler, D., Harding, M. M., Kwong, J., Roberts, D., & Reinsch, C. (2020). Hepatitis, viral. In B. Cholesterol-lowering medications are not toxic to the liver and may reduce hepatic inflammation caused by hepatitis. C. A patient with chronic liver disease may have a prolonged clotting time. Penicillin G procaine is a deep IM injection into a large muscle and places the patient at risk for bleeding. D. There is no contraindication to placing a urinary drainage catheter in a patient with chronic hepatitis. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Hepatitis

Question 137

A patient with no known medical history presents with chest pain. Vital signs are: T 101.5°F (38.6°), HR 102 beats/minute, RR 22, breaths/minute, BP 138/84 mm Hg, and SpO2 97% without supplemental oxygen. The nurse's assessment reveals painful lesions on the fingertips, scattered petechia, and a cardiac murmur. What diagnostic test would be the most appropriate to help guide treatment for this patient?

Electrocardiogram
Urinalysis
Blood cultures ✓
Chest X-ray

Correct Answer

Blood cultures

A. The patient has no medical history, a cardiac murmur, and a fever. Endocarditis should be considered in the presence of a newly discovered murmur and fever. This patient also has the presence of painful fingertip lesions (Osler nodes) and scattered petechia (Janeway lesions). Blood cultures are the most important test in determining the diagnosis. Ensure that cultures are drawn prior to antibiotic administration. B. Chest X-ray would not show specific disease process in the case of endocarditis. C. Electrocardiogram in a patient with endocarditis may show conduction abnormalities associated with septal abscess, but blood cultures are more appropriate. D. Urinalysis may show proteinuria and microscopic hematuria, but these are not specifically linked to endocarditis. Category: Cardiovascular Emergencies, Endocarditis

Question 138

The nurse caring for a patient with esophageal varices would expect which of the following laboratory tests to be abnormal?

Serum amylase
Liver function ✓
H. pylori
Vitamin B12

Correct Answer

Liver function

A. Esophageal varices develop from an obstruction in the portal circulation, most likely caused by liver disease such as cirrhosis. Liver function tests would be elevated in patients with hepatic disorders. B. Abnormalities in serum amylase are elevated in pancreatic disease, not liver disease or associated esophageal varices. C. H. pylori would be present in the patient with gastric problems such as gastritis and ulcers, not hepatic disorders. Reference Flanagan, M. A. (2018). Abdominal emergencies. In V. Sweet (Ed.), Emergency nursing core curriculum (7th ed., pp. 126–141) Elsevier. D. A deficiency in vitamin B12 results from either an inadequate intake of, or the inability of the stomach to absorb, vitamin B12. It is not related to hepatic disease. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Esophageal varices

Question 139

The nurse is preparing a medication for administration and notices that the pharmacist has provided the wrong drug. The nurse recognizes that this error occurred because of a mistake in the process of medication handling and administration, which could have resulted in a medication error. The nurse reports this error to the manager and through the hospital event reporting system. This is an example of which of the following?

The nursing process
Code of ethics
Just Culture ✓
SBAR

Correct Answer

Just Culture

A. The nursing process is directed toward patient care and includes assessment, planning, implementation, and evaluation. The nursing process does not include the reporting of a medication error. B. The reporting of a medication error is not an example of the nursing code of ethics. The nursing code of ethics was developed to carry out nursing responsibilities in the delivery of patient care and includes the quality of nursing care and ethical obligations of the profession. C. SBAR (situation, background, assessment, and recommendation) is a form of nurse-to-provider communication. Reference Bayer, D., Bonalumi, N. M., & Sweet, V. (2018). Professionalism and leadership. In V. Sweet (Ed.), Emergency nursing core curriculum (7th ed., pp. 686–697). Elsevier. D. Just Culture occurs when the frontline staff are empowered to report errors without fear of retaliation. The errors reported may occur anywhere across the hospital system. Category: Professional Issues, Patient, Patient safety

Question 140

A patient discharged 2 days ago following surgery for a fractured tibia/fibula presents to triage with complaints of pain in the affected leg. The patient has a posterior splint applied. Which of the following assessment findings should be reported to the provider?

Warm toes
Mild pain to the surgical site
Paresthesia of the toes ✓
Bounding pedal pulses

Correct Answer

Paresthesia of the toes

A. A hallmark sign of compartment syndrome is pain out of proportion to the extent of the injury and pain on passive range of motion. B. Warm toes would indicate that the patient has adequate tissue perfusion to their feet. Cool skin temperature, pallor, and delayed capillary refill are consistent with poor perfusion. C. Pulses can remain normal in the presence of compartment syndrome. Weak or absent pulses are late signs of compartment syndrome. Bounding pulses are not consistent with compartment syndrome. D. Numbness, tingling, or loss of sensation may occur when nerves and blood vessels are compressed, as occurs with compartment syndrome. With loss of sensation, there may be a relief of pain. This finding is an indication of worsening tissue perfusion, not improved tissue perfusion. It can be caused by casts or splints that become too tight with swelling. Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Fractures (e.g., open, closed, fat embolus)

Question 141

An auto mechanic presents complaining of "flulike symptoms," including headache, nausea, dizziness, fatigue, and mild shortness of breath. The patient reports mild relief since arriving at the hospital. Which of the following is the most likely cause of these symptoms?

Heavy metal toxicity
Carbon monoxide poisoning ✓
Organophosphate poisoning
Cyanide toxicity

Correct Answer

Carbon monoxide poisoning

A. Most people have some level of serum heavy metal. Symptoms of heavy metal toxicity occur through inhalation or ingestion and can be acute or chronic. Symptoms would include nausea, vomiting, diarrhea, tremors, and pulmonary edema. B. Signs of carbon monoxide poisoning include nausea, headache, dizziness, impaired judgment, and flulike symptoms. C. Symptoms of cyanide toxicity are vague central nervous system symptoms, bradycardia, hypotension, and possible seizures. D. Symptoms of organophosphate poisoning follow the acronym MUDDLES: miosis, urination (increased), defecation, diaphoresis, lacrimation, excitation, and salivation. Category: Environment and Toxicology Emergencies, and Communicable Diseases, Toxicology, Carbon monoxide

Question 142

Which assessment finding would you expect to find in a patient with the most common form of Guillain-Barré syndrome (GBS)?

Positive orthostatic vitals ✓
Hyperactive deep tendon reflexes
Hyperactive bowel sounds
Blunted pain sensation

Correct Answer

Positive orthostatic vitals

A. Patient with GBS will most likely have an ileus from dysfunction of the autonomic nervous system. This will manifest with abdominal distention and hypoactive or absent bowel sounds. B. Even though patients with GBS have motor impairment, pain sensation is minimally affected for most patients. Pain is frequently described as aching or cramping, and paresthesias are common. C. Patients with GBS will usually have depressed or absent deep tendon reflexes, along with ascending or descending weakness. D. Patients with GBS usually manifest autonomic dysfunction, which would include postural hypotension. They may also have cardiac dysrhythmia, and an ileus. Category: Neurological Emergencies, Neurological disorders (e.g., multiple sclerosis, myasthenia gravis, Guillain-Barré syndrome)

Question 143

A patient is being evaluated for sudden onset of tremulousness, diaphoresis, and pallor. The blood glucose level is 48 mg/dL, yet the patient is awake and responsive. Past medical history includes type 1 diabetes mellitus, alcoholism, pancreatic tumor, and chronic obstructive pulmonary disease. Which treatment option would be least likely to correct the patient's current problem?

Carbohydrates 15 g orally
Complex carbohydrate meal
Glucagon 1 mg intramuscular ✓
50% dextrose 50 g intravenous

Correct Answer

Glucagon 1 mg intramuscular

A. Glucagon functions through stimulation of the liver, which then releases glycogen to be converted to glucose. The liver is most likely impaired because of the patient’s history of alcoholism and possible liver metastasis. Patients with insulinoma (a tumor of the pancreas) should not receive glucagon because the increase in blood glucose will stimulate release of insulin by the insulinoma, resulting in a further drop in the blood glucose level. B. A complex carbohydrate meal is an acceptable follow-up to either the carbohydrate load or 50% dextrose intravenously. C. 50% dextrose is the treatment of choice for this patient, who is experiencing a hypoglycemic event. D. The patient is awake and can answer questions; therefore, an oral option is acceptable while attempting to obtain intravenous access. Category: Medical Emergencies, Endocrine disorders

Question 144

To control the heart rate of a patient experiencing signs and symptoms of thyroid storm, the nurse prepares to administer which medication?

Verapamil
Adenosine
Epinephrine
Propranolol ✓

Correct Answer

Propranolol

A. Propranolol is a beta-blocker that will assist with counteracting the sympathetic hyperstimulation that occurs with thyroid storm. Propranolol also inhibits sympathomimetic symptoms, treating the patient's tachycardia, and assists in blocking the conversion of T4 to T3. B. Verapamil is a calcium channel blocker and should be avoided in the treatment of thyroid storm, especially in the treatment of patients who are exhibiting signs and symptoms of congestive heart failure. C. Adenosine is indicated in supraventricular tachycardia. Patients with thyroid storm may have heart rates that are 200 beats/minute or greater, resulting from either atrial fibrillation or atrial flutter. Adenosine may initially slow the rate, but it will not alter the heart rhythm of atrial fibrillation or atrial flutter, and it has no direct effect on lowering thyroid hormone levels. D. Epinephrine is a catecholamine that causes vasoconstriction and increased heart rate and blood pressure; if administered, it would result in further compromise in a patient experiencing thyroid storm. Category: Medical Emergencies, Endocrine disorders

Question 145

Placenta previa is characterized by which symptoms?

Vaginal bleeding with passage of fetal tissue
Painless, bright red vaginal bleeding ✓
Painful vaginal bleeding with uterine tenderness
Leaking of amniotic fluid

Correct Answer

Painless, bright red vaginal bleeding

A. In a placental abruption, small arterial vessels are torn as the placenta separates from the uterine wall. Symptoms may include backache, frank dark red vaginal bleeding, painful uterine contractions, sudden colicky abdominal pain, and uterine rigidity. B. Loss of amniotic fluid would indicate rupture of the membranes and is suggestive of impending labor, not placental previa. C. In a patient with placenta previa, the placenta partially or fully covers the internal cervical os. In preparation for labor, the uterus softens, and the cervix thins, which causes a tearing of the placenta, resulting in bright red painless bleeding. D. A spontaneous abortion would present with vaginal bleeding and the passage of clots and/or fetal tissue. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Obstetrical, Abruptio placenta

Question 146

An older adult patient presents with a complaint of jaw pain and a sudden onset of a severe, throbbing headache located in the right temple. The patient is suspected to have temporal arteritis. Which of the following diagnostic tests will confirm the diagnosis?

Computed tomography (CT) scan
Magnetic resonance imaging (MRI) scan
Liver function test
Biopsy of the temporal artery ✓

Correct Answer

Biopsy of the temporal artery

A. Liver function tests can be elevated in 20–30% of cases, but it is not specific to the diagnosis of temporal arteritis. B. Biopsy of the temporal artery, which is performed under local anesthesia, is used to confirm the diagnosis of temporal arteritis (giant cell arteritis). C. A CT scan is generally not helpful in making a diagnosis of temporal arteritis; however, a CT scan can be beneficial in eliminating other possible causes for the patient's symptoms. D. MRI is generally not helpful in making a diagnosis of temporal arteritis; however, an MRI can be beneficial in eliminating other possible causes of the patient's symptoms. Category: Neurological Emergencies, Headache (e.g., temporal arteritis, migraine)

Question 147

Which intervention would be the least appropriate for a patient with a history of hemophilia who presents with hemarthrosis?

Intravenous desmopressin
Compression dressing
Intramuscular pain medication ✓
Cold compress

Correct Answer

Intramuscular pain medication

A. Hemarthrosis, bleeding into a joint, is a common complication seen in patients with hemophilia because of altered coagulation from a functional factor deficiency. Analgesics are often indicated, but intramuscular injections should be avoided in these patients because of the increased risk of bleeding. B. A compression dressing is an appropriate intervention for the patient with hemarthrosis. C. Application of a cold compress is an appropriate intervention for the patient with hemarthrosis. D. Intravenous desmopressin (DDAVP) is appropriate for the patient with hemophilia and hemarthrosis that are not responding to other treatments. DDAVP increases the release of clotting factor VIII. 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 148

A patient is alert and following commands but unable to move the lower extremities following a motor vehicle collision. During the secondary survey, the physician assesses the bulbocavernosus reflex and finds that it is absent. What is the most likely cause of these assessment findings?

Spinal shock ✓
Neurogenic shock
Central cord syndrome
Brown-Séquard syndrome

Correct Answer

Spinal shock

A. A patient with an incomplete spinal cord injury has some sensory and/or motor function below the level of the injury, referred to as sacral sparing. Sacral sparing can be identified by voluntary anal sphincter tone, intact perianal sensation, or present bulbocavernosus reflex. The patient with an incomplete injury may not exhibit sacral sparing when in spinal shock. As spinal shock resolves, sacral sparing may become evident. Spinal shock involves flaccidity after spinal cord injury and may last several months. B. Brown-Séquard syndrome occurs with a partial transection of the cord, causing an incomplete spinal cord injury. There is intact motor function on one side, with decreased sensation on the opposite side. The bulbocavernosus reflex is intact unless there is concurrent spinal shock. C. Central cord syndrome involves a loss of motor function in the upper extremities that is worse than in the lower extremities. Sacral sparing is often present, and bladder function may be affected. The patient does not have sacral sparing in this scenario. D. Neurogenic shock results in impaired cardiac output accompanied by bradycardia and a normal or strong pulse. Loss of sympathetic tone after injury results in blood pooling in the periphery, causing reduced preload and hypotension. This is not the most likely finding in this scenario. Category: Neurological Emergencies, Head and spinal cord trauma

Question 149

While assisting a provider with a lumbar puncture (LP), the nurse notes the cerebrospinal fluid (CSF) to be yellow in color. Which diagnosis is most probable with this finding?

Subarachnoid hemorrhage ✓
Bacterial meningitis
Viral meningitis
Multiple sclerosis

Correct Answer

Subarachnoid hemorrhage

A. Xanthochromia is a yellow coloration of CSF caused by bilirubin from the breakdown of red blood cells. The CSF in bacterial meningitis will be cloudy because of the presence of white blood cells and protein. B. Xanthochromia is a yellow coloration of CSF caused by bilirubin from the breakdown of red blood cells. The CSF with viral meningitis should be clear. C. Xanthochromia is a yellow coloration of CSF caused by bilirubin from the breakdown of red blood cells. It is considered highly suggestive of a subarachnoid hemorrhage that has been present for 8 hours or more. It may also occur with a traumatic LP. If the LP is done within 8 hours of the subarachnoid hemorrhage, the CSF will usually be grossly bloody. D. Xanthochromia is a yellow coloration of CSF caused by bilirubin from the breakdown of red blood cells. The CSF in patients with multiple sclerosis should be clear. Category: Neurological Emergencies, Headache (e.g., temporal arteritis, migraine)

Question 150

A patient presents with cough, wheezing, tachypnea, and dyspnea after cutting grass. Which medication is the priority for this patient?

Inhaled albuterol sulfate ✓
Inhaled racemic epinephrine
Intravenous methylprednisolone
Intravenous magnesium sulfate

Correct Answer

Inhaled albuterol sulfate

A. The patient is exhibiting signs and symptoms of an asthma exacerbation after being exposed to an inhaled irritant. Albuterol is the first-line treatment for asthma exacerbations. B. Corticosteroids are not indicated for the treatment of acute symptoms but may assist with the inflammatory process. C. This patient is exhibiting signs of an asthma exacerbation. Inhaled racemic epinephrine is usually given for croup and to treat post-extubation stridor in newborns. It reduces bronchial and tracheal secretions as well as edema of the airway. It is not used for acute asthma exacerbations. D. IV magnesium sulfate is indicated in the patient with severe exacerbation that is unresponsive to inhaled bronchodilators, but it is not the priority medication. Category: Respiratory Emergencies, Asthma

Question 151

What is the priority nursing intervention for a patient with complaints of a severely painful and blackened thumbnail after hitting it with a hammer?

Removal of the nail
Application of topical anesthetic to the nailbed
Application of ice to the injury ✓
Application of a dry, sterile dressing

Correct Answer

Application of ice to the injury

A. Unless the nail is loose, the pressure is relieved in the nailbed by drilling a small hole through the nailbed. This releases the pressure and any accumulated blood, decreasing pain. B. Application of a dry, sterile dressing may be needed following the release of pressure in the nailbed but is not indicated before this procedure. Reference Cerepani, M. J. (2020). Orthopedic and neurovascular trauma. In V. Sweet & C. The nail has no nerve endings, so the application of a topical anesthetic is not indicated. D. The application of ice to the site of injury is an initial treatment to minimize pain and swelling. Nail trephination may be required to relieve the pressure. Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Ligament tendon injuries (e.g., sprains, strains, ruptures)

Question 152

Which laboratory test would be expected with a diagnosis of cholecystitis?

Decreased hemoglobin
Elevated serum lipase
Decreased white blood cell count
Elevated serum bilirubin ✓

Correct Answer

Elevated serum bilirubin

A. Unless there is evidence of active bleeding, the hemoglobin would not be affected in a patient with cholecystitis and should remain within normal parameters. B. An elevated serum lipase is indicative of pancreatitis, not cholecystitis. C. The white blood cell count in a patient with cholecystitis will be elevated because of leukocytosis. D. Blockage of the common bile duct by a gallstone may result in an elevation in the serum bilirubin level and cause the patient to appear slightly jaundiced. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Cholecystitis

Question 153

A patient arrives at the emergency department via EMS after being pinned under a car. The patient is alert and oriented, and complains of chest pain. His assessment reveals anterior chest wall bruising and tenderness. The nurse also notes sinus tachycardia with premature ventricular contractions on electrocardiogram. Based on the mechanism of injury, these signs and symptoms are most consistent with which disorder?

Cardiac tamponade
Pulmonary contusion
Blunt cardiac injury ✓
Tension pneumothorax

Correct Answer

Blunt cardiac injury

A. Any patient sustaining trauma to the anterior chest should lead to a high index of suspicion for blunt cardiac injury. Common mechanisms of injury include impact with steering wheel, falls, assaults, and direct blows from an object or animal. One of the most sensitive but least specific signs of myocardial contusion is sinus tachycardia, with PVCs, which occurs in approximately 70% of patients. B. Signs and symptoms of tension pneumothorax include decreased or absent breath sounds on the affected side. The patient may complain of chest pain and shortness of breath, and have a feeling of impending doom. The mechanism of injury for a tension pneumothorax is related to a blunt chest wall injury that causes a rupture in the alveoli allowing air to leak from the lung into the pleural cavity. C. Signs and symptoms of pulmonary contusion include dyspnea, hemoptysis, and chest pain, although the patient might also have chest wall ecchymosis. Mechanism of injury is related to a rapid deceleration injury such as one that occurs during a motor vehicle collision. Reference Denke, N. J. (2020). Thoracic trauma. In V. Sweet & D. Signs and symptoms of cardiac tamponade include hypotension, distended neck veins, muffled heart sounds, and tachycardia. Gunshot and stab wounds are the most suggestive for cardiac tamponade. Category: Cardiovascular Emergencies, Cardiovascular Trauma

Question 154

Which medication administered in the treatment of alcohol withdrawal has a rapid onset of action with a short half-life?

Oxazepam (Serax)
Diazepam (Valium)
Chlordiazepoxide (Librium)
Lorazepam (Ativan) ✓

Correct Answer

Lorazepam (Ativan)

A. Chlordiazepoxide is administered orally, and has a peak mechanism of action of 1–4 hours and a long half-life of 30–100 hours. B. Diazepam administered intravenously has a peak mechanism of action of 8 minutes and a half-life of 30–100 hours. The intravenous form of diazepam is a vesicant, and a thrombosis or phlebitis can develop quickly. C. Lorazepam administered intravenously has a peak mechanism of action of 10 minutes and a half-life of 8–20 hours. The drug has to be administered more frequently to maintain the desired effect. D. Oxazepam is administered orally, and has a peak mechanism of action of 1–4 hours and a short half-life of 3–20 hours. Category: Medical Emergencies, Withdrawal syndrome

Question 155

An adult patient presents with complaints of a rash to the hands and arms with intense itching. The nurse notes that the patient has small, red raised lines between the fingers and along the wrist. The nurse should plan to implement which of the following isolation precautions?

No special precautions
Standard and airborne precautions
Standard and contact precautions ✓
Contact precautions only

Correct Answer

Standard and contact precautions

A. Healthcare providers should use standard precautions with all patients. B. This patient is presenting with classic signs of Sarcoptes scabiei (scabies). Scabies is highly infectious and spreads through direct contact with an infected person or through contact with items used by the infected person, such as linens or clothing. C. Scabies is not an airborne infection; therefore, airborne precautions are not necessary. D. Scabies is highly contagious with direct and indirect contact, so both standard and contact precautions are required. Reference Vanairsdale, S. (2018). Communicable and infectious disease emergencies. In V. Sweet (Ed.), Emergency nursing core curriculum (7th ed., pp. 306–333). Elsevier. Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment, Temperature-related emergencies

Question 156

Using the mass casualty Simple Triage and Rapid Treatment (START) triage system for adults, which of the following patients would be classified as a red (immediate) patient?

Unable to ambulate and but able to answer simple questions
Able to ambulate, with a capillary refill of 4 seconds
Apneic after opening airway and delayed capillary refill
Unable to ambulate, with a capillary refill of 3 seconds ✓

Correct Answer

Unable to ambulate, with a capillary refill of 3 seconds

A. A patient who has spontaneous breathing but does not meet the other criteria is a red (immediate) patient. The START triage system has minimal criteria for rapid triage. If a patient can ambulate, they are initially triaged as green. Spontaneous breathing moves to the next item, a respiratory rate of less than 30, capillary refill of less than 2 seconds, and ability to follow commands. B. Patients who can ambulate on initial triage are classified as green. A red patient would not meet the START triage limits of ambulation, respiratory rate less than 30, capillary refill less than 2 seconds, and ability to follow commands. C. Patients who are unable to ambulate but can answer simple questions are categorized as yellow (delayed) within the START Triage algorithm. Reference Jacobson, S. G. (2020). Disaster management. In J. S. Blansfield (Ed.), Trauma Nursing Core Course provider manual (8th ed., pp. 347–376). Jones & Bartlett Learning. D. Patients who do not have spontaneous breathing after repositioning of the airway are classified as black (expectant). This patient may have a thready pulse and would require more resources than rescue personnel would have access to during a mass casualty incident. Category: Professional Issues, System, Disaster management

Question 157

Which of the following is the priority action for a patient diagnosed with Bell's palsy?

Administer narcotic pain medication
Prepare for eye evaluation by an ophthalmologist
Obtain a facial computerized tomography scan
Instill artificial tears and apply a patch ✓

Correct Answer

Instill artificial tears and apply a patch

A. The diagnosis of Bell's palsy is made entirely by physical examination. No diagnostic tests are available to assist in making the initial diagnosis of Bell's palsy. B. No decreased visual acuity or impaired vision is associated with Bell palsy, so an eye exam is not usually indicated. C. The patient with Bell's palsy is unable to completely close the eye. The affected eye must be kept moistened and should be protected with an eye patch. D. Nonnarcotic pain medications should be used initially. Narcotic medications are rarely needed. Category: Maxillofacial and Ocular Emergencies, Maxillofacial, Facial nerve disorders (e.g., Bell’s palsy, trigeminal neuralgia)

Question 158

Which of the following statements indicates that the application of lidocaine, epinephrine, and tetracaine (LET) gel in preparation for wound closure on a pediatric patient has been effective?

Ten minutes have passed after application.
The patient is now sleepy.
Blanching is observed around the wound. ✓
Redness is observed around the wound.

Correct Answer

Blanching is observed around the wound.

A. Topical LET gel will not cause the child to become sleepy. Reference Denke, N. (2020). Wound management. In V. Sweet & B. Allow at least 15–20 minutes after application of LET gel for its properties to take effect and provide adequate anesthesia of the area. C. LET gel has vasoconstrictive properties that result in a blanching effect of the skin, which usually occurs within 20 minutes of application. The absence of blanching indicates incomplete anesthesia of the area. D. LET gel has vasoconstrictive properties and results in a blanching effect of the skin. It does not cause redness around the wound. Category: Musculoskeletal and Wound Emergencies, Wound, Avulsions and degloving injuries

Question 159

Which of the following diagnoses, commonly mistaken for child maltreatment, is the most likely cause of a toddler's presentation of lethargy, pallor, and unexplained bruising?

Osteogenesis imperfecta
Leukemia ✓
Hemophilia
Erythema multiforme

Correct Answer

Leukemia

A. Osteogenesis imperfecta is a hereditary disease that results in skeletal fragility and easily fractured bones. B. Erythema multiforme is a hypersensitivity reaction that manifests with symmetrical blotchy lesions, often seen in a circular pattern described as a target rash. C. Leukemia often presents with lethargy, weight loss, and easy bruising, especially in children. D. Hemophilia often presents with bleeding into the soft tissue, joint space, or intracranial vault. Category: Medical Emergencies, Hematologic disorders

Question 160

A patient presents with a sensation of flashing lights in the right eye that began approximately 2 hours before arrival. The patient denies pain and states that it seems there is a veil coming down across the eye. Which ocular emergency does the nurse suspect?

Amaurosis fugax
Retinal detachment ✓
Open-angle glaucoma
Macular degeneration

Correct Answer

Retinal detachment

A. Patients with open-angle glaucoma generally have no complaints until the disease progresses to the point that vision is impaired. The vision loss is not sudden and usually begins with blurred vision. Reference Nolan-Kelly, L. (2020). Ocular emergencies. In V. Sweet & B. Macular degeneration occurs when the central portion of the retina begins to deteriorate. Visual alterations are typically unilateral and can vary from gradual to sudden onset. Vision loss can range from visual blurring to complete blindness. C. Retinal detachment occurs when the retina suddenly tears and allows vitreous humor to seep between the retina and choroid. The patient generally denies pain and complains of floaters, flashes of light, acute loss of vision, or a veil or curtain across the visual field. If left untreated, permanent vision loss can occur. D. Amaurosis fugax is a monocular, transient loss of vision and is an important warning sign for impending stroke. The patient's loss of vision may last from several seconds to minutes. Category: Maxillofacial and Ocular Emergencies, Ocular, Retinal detachment

Question 161

A normally healthy 6-month-old infant presents with a decreased level of consciousness. The Pediatric Glasgow Coma Scale score is 4. What would be the priority intervention at this time?

Insert an oropharyngeal airway ✓
Initiate intravenous access
Prepare for a definitive airway
Obtain a rectal temperature

Correct Answer

Insert an oropharyngeal airway

A. With a GCS of 4, this patient is unable to maintain a patent airway, so insertion of an oropharyngeal airway will maintain an open airway until a definitive one can be established. B. Based on the patient's presentation and Pediatric Glasgow Coma Scale score, maintaining a patent airway is the priority. Inserting an oropharyngeal airway is the priority until a definitive airway can be established. C. Intravenous access will be needed for this patient, but airway issues are the priority. With a GCS of 4, this infant cannot maintain an open airway, so an oropharyngeal airway should be inserted until a definitive airway can be established. D. A full set of vital signs, including rectal temperature, will be needed for this patient; however, with a GCS of 4, priority goes to maintaining an open airway by inserting an oropharyngeal airway until a definitive airway can be established. Category: Neurological Emergencies, Increased intracranial pressure (ICP)

Question 162

Which of the following interventions is the priority for a patient who presents with a new-onset headache described as 10/10 stabbing pain to both temples and decreased visual acuity with noticeable swelling near the temples?

Prepare for lumbar puncture
Perform a FOUR score
Administer intravenous corticosteroids ✓
Administer intravenous pain medication

Correct Answer

Administer intravenous corticosteroids

A. This patient is exhibiting symptoms of temporal arteritis, an autoimmune disease that results in vasculitis of the temporal arteries. The inflammation affects blood flow to the eyes and can cause permanent blindness if not treated quickly. Corticosteroids are indicated to reduce inflammation. B. This patient is exhibiting symptoms of temporal arteritis. Pain management is important for this patient, but corticosteroids are the priority to reduce the inflammation and prevent blindness. C. This patient is exhibiting symptoms of temporal arteritis. The Full Outline of Unresponsiveness (FOUR) score is an assessment indicated for use in unconscious patients. A maximum numeric value of 4 is assigned to each category when evaluating eye response, motor response, brain stem reflexes, and respiration. D. This patient is exhibiting symptoms of temporal arteritis. Lumbar puncture is indicated as a diagnostic test to rule out meningitis, inflammation of the meninges of the brain and spinal cord. Headache, fever, and nuchal rigidity would trigger the concern to rule out meningitis. Category: Neurological Emergencies, Headache (e.g., temporal arteritis, migraine)

Question 163

A patient presents to the emergency department with fever, chills, dyspnea, and chest pain that increases with activity and on inhalation. The nurse notes sinus tachycardia on the monitor. ST elevation is seen across the electrocardiogram (ECG) except in aVr and V1. A rub is heard in the chest when the patient leans forward. Which diagnosis is most likely?

Myocardial infarction (MI)
Aortic dissection
Acute pericarditis ✓
Pulmonary embolism

Correct Answer

Acute pericarditis

A. A patient with an MI will usually have ST segment elevation or depression typically isolated to anatomic distribution corresponding to the coronary artery with the narrowing or occlusion. Reciprocal ECG changes may be seen in a patient with an MI, but rubs are not heard. B. A patient with a pulmonary embolism may show T-wave inversions, most commonly in the right precordial leads. ST segment elevation is possible but is an uncommon finding in patients with a pulmonary embolism. Pericardial friction rubs are not heard with pulmonary embolism. Reference Foley, A., & Sweet, V. (2020). Cardiovascular emergencies. In V. Sweet & C. A patient with aortic dissection will usually have variable ST segment or T-wave changes; if there is a history of hypertension, the ECG will likely show signs of left ventricular hypertrophy as well. Sinus tachycardia is common in patients with an aortic dissection. However, fever and chills are not a part of presentation of aortic dissection. D. A patient with acute pericarditis presents with fever, chills, dyspnea, and severe chest pain. Keys to this diagnosis include worsening of chest pain on inspiration and increased activity. Pericardial friction rub may be heard best with the patient leaning forward. ST segment elevation of 1-3 mm is commonly seen but is not usually seen in aVr or V1. Category: Cardiovascular Emergencies, Pericarditis

Question 164

A 30 kg child has sustained burns to 40% of their total body surface area (TBSA). Based on the fluid replacement formula, what is the replacement volume of isotonic crystalloid fluids that the child should receive during the first 24 hours?

2400 mL
12,000 mL
1800 mL
3600 mL ✓

Correct Answer

3600 mL

A. One half of the amount of fluid calculated should be given within the first 8 hours from the time of the burn. This would be the amount given in the first 8 hours. B. This is not the correct calculation of fluid resuscitation required for this child. Fluid replacement guidelines for a child under 40 kg during the first 24 hours is: weight in kg × 3 mL × percentage of TBSA burned. C. This amount of fluid is not correct for the fluid resuscitation of this child. Fluid replacement guidelines for a child under 40 kg during the first 24 hours is: weight in kg × 3 mL × percentage of TBSA burned. D. American Burn Association fluid replacement guidelines for a child under 40 kg are: weight in kg × 3–4 mL × percentage of TBSA burned during the first 24 hours. In this case, the formula would be 30 kg × 3 mL × 40 = 3600 mL. One half of this amount would be administered in the first 8 hours from the time of the burn, and the remainder is administered over the next 16 hours. Category: Environment and Toxicology Emergencies, and Communicable Diseases, Environment, Burns

Question 165

A patient presenting with an ovarian cyst may experience which of the following symptoms?

Sharp abdominal pain during intercourse ✓
Abdominal pain and itching with vaginal discharge
Dysuria, flank pain, and fever
Sharp abdominal pain and diarrhea

Correct Answer

Sharp abdominal pain during intercourse

A. A patient with a follicular ovarian cyst will typically present with complaints of sharp abdominal pain that occurs suddenly during sexual intercourse. B. Dysuria, flank pain, and fever are more likely symptoms of a urinary tract infection and/or pyelonephritis. A patient with an ovarian cyst may experience frequent urination if the cyst is large enough to cause pressure to the bladder but will not experience flank pain or fever. C. Abdominal pain and diarrhea are more suggestive of a gastrointestinal disorder. Diarrhea is not a symptom associated with the presence of an ovarian cyst. D. Abdominal pain, itching, and vaginal discharge are more suggestive of a vaginal infection. Ovarian cysts are unlikely to be associated with vaginal discharge and itching. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gynecology, Ovarian disorders (e.g., cyst, torsion, rupture)

Question 166

Which type of primary headache is more common in men than in women?

Cluster headache ✓
Migraine without aura
Tension headache
Migraine with aura

Correct Answer

Cluster headache

A. Except for cluster headaches, all forms of primary headache are more common in females as compared with males. The reasoning behind this is poorly understood. There may be a link to smoking or certain foods. B. Except for cluster headaches, all forms of primary headache are more common in females as compared with males. C. Except for cluster headaches, all forms of primary headache are more common in females as compared with males. D. Except for cluster headaches, all forms of primary headache are more common in females as compared with males. Category: Neurological Emergencies, Headache (e.g., temporal arteritis, migraine)

Question 167

A 2-year-old patient arrives with caregivers who state that the child has had a cough and runny nose since yesterday. Today, the child started shaking and then went limp after a few minutes. On arrival, the child is lethargic. Which of the following is the priority intervention?

Check blood sugar
Initiate intravenous access
Obtain a rectal temperature ✓
Give intranasal midazolam

Correct Answer

Obtain a rectal temperature

A. Children with prolonged seizures should have their blood sugar checked because their glucose stores can become depleted. However, this patient most likely had a febrile seizure, so obtaining a temperature is the priority because it is quick and easy. Obtaining a blood sugar reading takes a little longer. B. Midazolam can be given intranasally to stop seizures when there is no intravenous access. This patient is no longer seizing and so does not need medication. C. Based on this patient history, the child most likely had a febrile seizure. Typical age for such seizures is between 6 months and 5 years, and they usually occur early in the course of a viral or bacterial infection. Obtaining a rectal temperature is quick and easy. Blood sugar should be checked next, especially if the seizure lasted over 5 minutes. D. Intravenous access will most likely be needed for this patient; however, based on history, this patient probably had a febrile seizure. Checking a temperature is quick and easy and is the priority. Category: Neurological Emergencies, Seizure disorders

Question 168

Lactulose 30 mL has been administered to a patient with hepatic encephalopathy. Which of the following laboratory results would indicate a positive effect of this medication?

Decreased serum ammonia level ✓
Decreased serum potassium level
Increased serum albumin level
Increased serum bilirubin level

Correct Answer

Decreased serum ammonia level

A. Hepatic encephalopathy occurs when there is an increase in the amount of toxic substances absorbed from the gastrointestinal system, including ammonia, a known neurotoxin. The elevated level of ammonia in the brain causes changes in cognition, behavior, and motor function that characterize hepatic encephalopathy. Lactulose reduces the transport of ammonia from the colon into the circulation by eliminating it through the feces, thereby reducing the level of serum ammonia. B. Lactulose-induced diarrhea can contribute to hypokalemia, but this would be an adverse effect, not a desired effect, of the medication. C. The laxative effect of lactulose has no direct effect on the serum bilirubin level. D. Reduction of the serum ammonia level by the administration of lactulose will have no direct effect on the serum albumin level. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Cirrhosis

Question 169

A patient presents with constant right upper quadrant pain and left shoulder pain that increases with deep inspiration. The emergency nurse recognizes these symptoms to be related to what diagnosis?

Appendicitis
Pancreatitis
Cholecystitis ✓
Esophagitis

Correct Answer

Cholecystitis

A. The pain associated with esophagitis is located in the substernal area and worsens with swallowing. The symptoms are "heartburn-like" and are similar to those of myocardial ischemia. Reference Herrington, A. (2020). Gastrointestinal emergencies. In V. Sweet & B. The pain associated with pancreatitis is usually described as dull, steady, and located in the left upper quadrant of the abdomen. C. The symptoms associated with an inflamed appendix begin as diffuse abdominal pain that gradually localizes to the right lower quadrant. The pain is aggravated by movement, not by breathing. D. The pain associated with cholecystitis is typically described as steady, severe, and located in the right upper quadrant with radiation to the right shoulder or scapula area. Pain on deep inspiration is caused by movement of the inflamed gallbladder. Category: Gastrointestinal, Genitourinary, Gynecology, and Obstetrical, Gastrointestinal, Cholecystitis

Question 170

The nurse recognizes that which factor places a patient at highest risk for developing osteomyelitis?

Closed fracture
Diabetes mellitus
Intravenous drug use ✓
Hypothyroidism

Correct Answer

Intravenous drug use

A. A history of hypothyroidism is not considered a risk factor for developing osteomyelitis. B. A history of intravenous drug use increases the risk for developing osteomyelitis; using needles that are not clean results in the introduction of bacteria into the body, leading to an infection that can then spread to the skeletal structures. C. Closed fractures are not considered a risk factor for developing osteomyelitis. Open fractures, open wounds, puncture wounds, and some orthopedic surgical procedures can introduce bacteria into the bloodstream, placing patients at risk for osteomyelitis. D. Although diabetes is a risk factor for developing osteomyelitis, a diabetic who controls their blood glucose levels has a decreased risk of infection. Category: Musculoskeletal and Wound Emergencies, Musculoskeletal, Osteomyelitis

Question 171

A patient receiving moderate procedural sedation for a lumbar puncture began the procedure with an oxygen saturation level of 97% on room air; the oxygen saturation is now reading 89%. Which interventions would the nurse perform first?

Apply 100% oxygen via mask
Administer the appropriate reversal agent
Ask the physician to pause the procedure
Attempt to arouse the patient ✓

Correct Answer

Attempt to arouse the patient

A. Reversal agents should be available at the bedside during procedural sedation, but in most cases, every effort is made to not reverse the agent. Reversal agents are not without complications, and when used, they reverse all effects of the medication, including sedation and pain relief. B. The AVPU (alert, verbal, pain, unresponsive) scale is recommended when determining a patient's level of consciousness and ability to maintain the airway. This should be determined, as well as other interventions, prior to asking for a pause of the procedure. C. The low oxygen saturation level is most likely the result of a sedation-induced central nervous system depression and hypoventilation, especially if opioids are used. Arousing the patient by calling their name will stimulate breathing. A patient who is slow to arouse or who requires repeated stimulation may have difficulty maintaining their airway or oxygenation level and may require additional interventions to maintain airway patency. D. The best initial action by the nurse is to stimulate the patient's respirations by arousing them. Applying supplemental oxygen will not help much if the rate or depth of the patient's respirations is not adequate. Category: Professional Issues, Patient, Pain management and procedural sedation

Question 172

A patient presents complaining of cough, shortness of breath, and a headache following a recent sinus infection. The patient reports a 40-year history of cigarette smoking. The nurse notes wheezes bilaterally in the anterior lung fields. Vital signs are: T 99.2°F, HR 101 beats/minute, RR 30 breaths/minute, BP 146/88 mm Hg, SpO2 91% without supplemental oxygen. Which order should take priority?

Formoterol
Methylprednisolone
Albuterol ✓
Furosemide

Correct Answer

Albuterol

A. Methylprednisolone is a corticosteroid. It may be indicated in this patient, but the priority intervention is the inhaled bronchodilator. B. Furosemide is a diuretic indicated for the management of fluid overload, such as with congestive heart failure, not for a COPD exacerbation. C. Formoterol is a long-acting bronchodilator, which is not indicated in the case of an acute exacerbation. It is more suited for management of chronic symptoms. D. Smoking is one of the main causative factors of COPD. The patient also reports a recent URI, a trigger for a COPD exacerbation, which includes symptoms such as shortness of breath, cough, and adventitious breath sounds. Priority treatment is addressing the client's acute dyspnea by delivering a short-acting bronchodilator. Category: Respiratory Emergencies, Chronic obstructive pulmonary disease (COPD)

Question 173

A patient arrives after trying to put out a fire in a closet. The patient complains of headache and nausea, and appears confused. What is the priority intervention for this patient?

Draw a carboxyhemoglobin level
Apply 100% oxygen ✓
Attach pulse oximeter
Prepare for intubation

Correct Answer

Apply 100% oxygen

A. This patient is exhibiting symptoms of smoke inhalation. Drawing a carboxyhemoglobin level should be done to get baseline, but application of oxygen takes priority. B. This patient is exhibiting symptoms of smoke inhalation. Pulse oximetry cannot distinguish between oxygen and carbon monoxide, so readings will not be accurate. C. Based on history and symptoms, this patient is experiencing a smoke inhalation injury. Application of 100% oxygen is the priority for this patient. Carbon monoxide (CO) is released into the air during a fire. Enclosed spaces make inhalation of CO very probable. Oxygen is needed to displace the CO that has attached to the hemoglobin. D. This patient is exhibiting symptoms of smoke inhalation. This patient may eventually require intubation, but application of oxygen is the priority. Category: Respiratory Emergencies, Inhalation injuries

Question 174

A 5-year-old who immigrated from Haiti and is living with 10 extended family members presents with confusion, low-grade fever, and dirty gray-white rubbery membranes covering the pharynx and larynx. What diagnosis does the emergency nurse suspect?

Avian influenza
Diphtheria ✓
Severe acute respiratory syndrome (SARS)
Tuberculosis

Correct Answer

Diphtheria

A. SARS is a viral respiratory disease; the patient will have a cough, wheezing, and fever. B. Avian influenza is also called "bird flu." Symptoms consist of sore throat, fever, headache, and some neurological changes. C. Tuberculosis affects the lungs and respiratory system and presents with a cough that last over several weeks, fatigue, chills, fever, and night sweats. D. Diphtheria is a bacterial infection affecting mucous membranes of the throat and nose. Symptoms include sore throat, fever, weakness, and swollen glands, and thick gray material is noted on the back of the throat. The disease is rare in the United States because of widespread immunizations. Any persons in contact with a person diagnosed with diphtheria should be treated and should not come in contact with others until treatment has been completed. Category: Environment and Toxicology Emergencies, and Communicable Diseases, Communicable Diseases, Vaccine-preventable diseases (e.g., measles, mumps, pertussis, chicken pox, diphtheria)

Question 175

The use of early goal-directed therapy in the management of sepsis patients was implemented as a result of which type of data evaluation?

Federal regulation statutes
Hospital-based performance improvement committees
Internal risk management initiatives
Evidence-based practice (EBP) ✓

Correct Answer

Evidence-based practice (EBP)

A. Organizations may monitor internal data to benchmark against national data, but early goal-directed therapy (EGDT) is a national initiative to improve patient outcomes. B. Federal statues are laws enacted by Congress; early goal-directed therapy (EGDT) is an example of EBP and is not a federal law. C. Before EBP, physicians treated patients according to either individual or organization criteria. EBP established best practice guidelines that improved survival and mortality rates nationally. D. Organizations may monitor internal data to benchmark against national data, but early goal-directed therapy (EGDT) is a national initiative to improve outcomes. Reference Coffey, S. S., & Cohen, K. J. (2018). Evidence-based practice. In V. Sweet & Category: Professional Issues, Nurse, Evidence-based practice

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