After falling from a 10' ladder, a patient is brought to the emergency department. The patient is alert, reports back pain, and difficulty moving the
... [Show More] lower extremities. Which additional observation is an indication the patient may be experiencing neurogenic shock?
A. Cool and pale skin
B. Increased systolic blood pressure
C. Poor skin turgor
D. Bradycardia - correct answer D. Bradycardia
A patient who is in hypovolemic shock has the following clinical signs: Heart rate 120 beats/minute, blood pressure 80/55 and urine output 20ml/hr. After administering an IV fluid bolus, which of these signs if noted by the healthcare provider is the best indication of improved perfusion?
A. Right atrial pressure increases
B. Systolic blood pressure increases to 85
C. Urine output increases to 30ml/hr
D. Heart rate drops to 100 beats/minute - correct answer C. Urine output increases to 30ml/hr
A patient is admitted to the emergency department after sustaining abdominal injuries and a broken femur from a motor vehicle accident. The patient is pale, diaphoretic, and is not talking coherently. Vital signs upon admission are temperature 98, heart rate 130 beats/minute, respiratory rate 34 breaths/minute, blood pressure 50/40. The healthcare provider suspects which type of shock?
A. Cardiogenic
B. Hypovolemic
C. Neurogenic
D. Distributive - correct answer B. Hypovolemic
The healthcare provider is caring for a patient with a diagnosis of hemorrhagic pancreatitis. The patient's central venous pressure (CVP) reading is 2, blood pressure is 90/50, lung sounds are clear, and jugular veins are flat. Which of these actions is most appropriate for the nurse to take?
A. Slow the IV infusion rate
B. Administer dopamine
C. No interventions are needed at this time
D. Increase the IV infusion rate - correct answer D. Increase the IV infusion rate
A child is brought to the emergency room by his mother who reports the child was stung by a bee while playing in the back yard. The child has an itchy rash on the face, neck, and chest. Breathing is labored with audible wheezing. Which of these medications should the healthcare provider administer first?
A. Diphenhydramine
B. Albuterol
C. Epinephrine
D. Dopamine - correct answer C. Epinephrine
A patient who has pericarditis related to radiation therapy, becomes dyspneic, and has a rapid, weak pulse. Heart sounds are muffled, and a 12mmHg drop in blood pressure is noted on inspiration. The healthcare provider's interventions are aimed at preventing which type of shock?
A. Distributive
B. Neurogenic
C. Obstructive
D. Cardiogenic - correct answer C. Obstructive
An infant was delivered to a mother with a diagnosis of chorioamnionitis. The infant is lethargic, tachypneic, and has an axillary temperature of 96.8. The healthcare provider suspects septic shock. Which of these assessments is an indication that this infant is compensating by increasing cardiac output?
A. Active precordium
B. Warm, flushed skin
C. Bounding pulses
D. Tachycardia - correct answer D. Tachycardia
A patient is being treated for hemorrhagic shock secondary to multiple rib fractures and a lacerated liver. Two units of packed red blood cells have been administered. Which of these measurements is an indication the patient has received adequate volume replacement?
A. Oxygen saturation 90%
B. Increased serum creatinine
C. Decreased right atrial pressure
D. Decreased serum lactate - correct answer D. Decreased serum lactate
The healthcare provider is caring for a patient who has septic shock. Which of these should the healthcare provider administer to the patient first?
A. Antibiotics to treat the underlying infection.
B. Corticosteroids to reduce inflammation.
C. IV fluids to increase intravascular volume.
D. Vasopressors to increase blood pressure. - correct answer C. IV fluids to increase intravascular volume
A patient who is in cardiogenic shock has a urine output of 20mL/hr. When further assessing the patient's renal function, what additional findings are anticipated? Select all that apply.
A. Decreased urine specific gravity
B. Increased blood urea nitrogen (BUN)
C. Decreased urine sodium
D. Decreased serum creatinine - correct answer B Increased BUN
C. Decreased urine sodium
Which stage of shock is associated with the worsening of tissue hypoperfusion and onset of worsening circulatory and metabolic imbalances, including acidosis?
A. Initial nonprogressive phase
B. Developing phase
C. Progressive stage
D. Irreversible stage - correct answer C. Progressive Stage
What are characteristics of the irreversible stage of shock?
A. The worsening of tissue hypoperfusion and the onset of worsening circulatory and metabolic imbalances, including acidosis
B. The body tries to initiate compensatory mechanisms
C. Nothing can correct the hemodynamic defect
D. Tissue and cell damage is too great tissue and necrosis of the tissue will occur even if the underlying hemodynamic defect is corrected - correct answer D. Tissue and cell damage is too great; tissue and necrosis of the tissue will occur even if the underlying hemodynamic defect is corrected
Your patient is in the progressive stage of shock. If the shock is not corrected and tissue hypoxia occurs, what would happen with the patients metabolism?
A. The tissues will undergo anaerobic metabolism, creating lactic acid and lowering the tissue pH
B. Vasomotor reflex of arteriolar constriction that reduces pooling of blood in the microcirculation
C. Metabolism would be unaffected by the lower oxygen level for the 2-3 hours - correct answer A. The tissues will undergo anaerobic metabolism, creating lactic acid and lowering the tissue pH
Which type of shock is associated with low blood levels?
A. Hypovolemic shock
B. Septic shock
C. Anaphylactic shock
D. Cardiogenic shock - correct answer A. Hypovolemic Shock
You are the charge nurse in an emergency department (ED) and must assign two staff members to cover the triage area. Which team is the most appropriate for this assignment?
A. An advanced practice nurse and an experienced LPN/LVN
B. An experienced LPN/LVN and an inexperienced RN
C. An experienced RN and an inexperienced RN
D. An experienced RN and a nursing assistant - correct answer C. Triage requires at least one experienced RN. Pairing an experienced RN with inexperienced RN provides opportunities for mentoring. Advanced practice nurses are qualified to perform triage; however, their services are usually required in other areas of the ED. An LPN/LVN is not qualified to perform the initial patient assessment or decision making. Pairing an experienced RN with a nursing assistant is the second best option, because the assistant can obtain vital signs and assist in transporting.
You are working in the triage area of an ED, and four patients approach the triage desk at the same time. List the order in which you will assess these patients. a. An ambulatory, dazed 25-year-old male with a bandaged head wound b. An irritable infant with a fever, petechiae, and nuchal rigidity c. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity d. A 50-year-old female with moderate abdominal pain and occasional vomiting
1. A B D C
2. B A D C
3. C D B A
4. C B A D - correct answer 2. An irritable infant with fever and petechiae should be further assessed for other meningeal signs. The patient with the head wound needs additional history and assessment for intracranial pressure. The patient with moderate abdominal pain is uncomfortable, but not unstable at this point. For the ankle injury, medical evaluation can be delayed 24 - 48 hours if necessary.
In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey?
A. Complete set of vital signs
B. Palpation and auscultation of the abdomen
C. Brief neurologic assessment
D. Initiation of pulse oximetry - correct answer C. A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. Vital signs, assessment of the abdomen, and initiation of pulse oximetry are considered part of the secondary survey.
Question 4 CORRECT
A 56-year-old patient presents in triage with left-sided chest pain, diaphoresis, and dizziness. This patient should be prioritized into which category?
A. High urgent
B. Urgent
C. Non-urgent
D. Emergent - correct answer D. Chest pain is considered an emergent priority, which is defined as potentially life-threatening. Patients with urgent priority need treatment within 2 hours of triage (e.g. kidney stones). Non-urgent conditions can wait for hours or even days. (High urgent is not commonly used; however, in 5-tier triage systems, High urgent patients fall between emergent and urgent in terms of the time lapsing prior to treatment).
The physician has ordered cooling measures for a child with fever who is likely to be discharged when the temperature comes down. Which of the following would be appropriate to delegate to the nursing assistant?
A. Assist the child to remove outer clothing.
B. Advise the parent to use acetaminophen instead of aspirin.
C. Explain the need for cool fluids.
D. Prepare and administer a tepid bath. - correct answer A. The nursing assistant can assist with the removal of the outer clothing, which allows the heat to dissipate from the child's skin. Advising and explaining are teaching functions that are the responsibility of the RN. Tepid baths are not usually performed because of potential for rebound and shivering.
It is the summer season, and patients with signs and symptoms of heat-related illness present in the ED. Which patient needs attention first?
A. An elderly person complains of dizziness and syncope after standing in the sun for several hours to view a parade
B. A marathon runner complains of severe leg cramps and nausea. Tachycardia, diaphoresis, pallor, and weakness are observed.
C. A previously healthy homemaker reports broken air conditioner for days. Tachypnea, hypotension, fatigue, and profuse diaphoresis are observed.
D. A homeless person, poor historian, presents with altered mental status, poor muscle coordination, and hot, dry, ashen skin. Duration of exposure is unknown. - correct answer D. The homeless person has symptoms of heat stroke, a medical emergency, which increases risk for brain damage. Elderly patients are at risk for heat syncope and should be educated to rest in cool area and avoid future similar situations. The runner is having heat cramps, which can be managed with rest and fluids. The housewife is experiencing heat exhaustion, and management includes fluids (IV or parenteral) and cooling measures. The prognosis for recovery is good.
You respond to a call for help from the ED waiting room. There is an elderly patient lying on the floor. List the order for the actions that you must perform.
a. Perform the chin lift or jaw thrust maneuver.
b. Establish unresponsiveness.
c. Initiate cardiopulmonary resuscitation (CPR).
d. Call for help and activate the code team.
e. Instruct a nursing assistant to get the crash cart. - correct answer B D A C E
Establish unresponsiveness first. (The patient may have fallen and sustained a minor injury.) If the patient is unresponsive, get help and have someone initiate the code. Performing the chin lift or jaw thrust maneuver opens the airway. The nurse is then responsible for starting CPR. CPR should not be interrupted until the patient recovers or it is determined that heroic efforts have been exhausted. A crash cart should be at the site when the code team arrives; however, basic CPR can be effectively performed until the team arrives.
The emergency medical service (EMS) has transported a patient with severe chest pain. As the patient is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and no palpable pulse. Which task is appropriate to delegate to the nursing assistant?
A. Chest compressions
B. Bag-valve mask ventilation
C. Assisting with oral intubation
D. Placing the defibrillator pads - correct answer A. Nursing assistants are trained in basic cardiac life support and can perform chest compressions. The use of the bag-valve mask requires practice and usually a respiratory therapist will perform this function. The nurse or the respiratory therapist should provide PRN assistance during intubation. The defibrillator pads are clearly marked; however, placement should be done by the RN or physician because of the potential for skin damage and electrical arcing.
An anxious 24-year-old college student complains of tingling sensations, palpitations, and chest tightness. Deep, rapid breathing and carpal spasms are noted. What priority nursing action should you take?
A. Notify the physician immediately.
B. Administer supplemental oxygen.
C. Have the student breathe into a paper bag.
D. Obtain an order for an anxiolytic medication - correct answer C. The patient is hyperventilating secondary to anxiety, and breathing into a paper bag will allow rebreathing of carbon dioxide. Also, encouraging slow breathing will help. Other treatments such as oxygen and medication may be needed if other causes are identified.
An experienced traveling nurse has been assigned to work in the ED; however, this is the nurse's first week on the job. Which area of the ED is the most appropriate assignment for the nurse?
A. Trauma team
B. Triage
C. Ambulatory or fast track clinic
D. Pediatric medicine team - correct answer C. The fast track clinic will deal with relatively stable patients. Triage, trauma, and pediatric medicine should be staffed with experienced nurses who know the hospital routines and policies and can rapidly locate equipment.
A tearful parent brings a child to the ED for taking an unknown amount of children's chewable vitamins at an unknown time. The child is currently alert and asymptomatic. What information should be immediately reported to the physician?
A. The ingested children's chewable vitamins contain iron.
B. The child has been treated several times for ingestion of toxic substances.
C. The child has been treated several times for accidental injuries.
D. The child was nauseated and vomited once at home - correct answer A. Iron is a toxic substance that can lead to massive hemorrhage, coma, shock, and hepatic failure. Deferoxamine is an antidote that can be used for severe cases of iron poisoning. Other information needs additional investigation, but will not change the immediate diagnostic testing or treatment plan.
In caring for a victim of sexual assault, which task is most appropriate for an LPN/LVN?
A. Assess immediate emotional state and physical injuries
B. Collect hair samples, saliva swabs, and scrapings beneath fingernails.
C. Provide emotional support and supportive communication.
D. Ensure that the "chain of custody" is maintained - correct answer C. The LPN/LVN is able to listen and provide emotional support for her patients. The other tasks are the responsibility of an RN or, if available, a SANE (sexual assault nurse examiner) who has received training to assess, collect and safeguard evidence, and care for these victims.
You are caring for a victim of frostbite to the feet. Place the following interventions in the correct order.
a. Apply a loose, sterile, bulky dressing.
b. Give pain medication.
c. Remove the victim from the cold environment.
d. Immerse the feet in warm water 100o F to 105o F (40.6o C to 46.1o C) - correct answer C B D A
The victim should be removed from the cold environment first, and then the rewarming process can be initiated. It will be painful, so give pain medication prior to immersing the feet in warmed water.
A patient sustains an amputation of the first and second digits in a chainsaw accident. Which task should be delegated to the LPN/LVN?
A. Gently cleanse the amputated digits with Betadine solution.
B. Place the amputated digits directly into ice slurry.
C. Wrap the amputated digits in sterile gauze moistened with saline.
D. Store the amputated digits in a solution of sterile normal saline - correct answer C. The only correct intervention is C. the digits should be gently cleansed with normal saline, wrapped in sterile gauze moistened with saline, and placed in a plastic bag or container. The container is then placed on ice.
A 36-year-old patient with a history of seizures and medication compliance of phenytoin (Dilantin) and carbamazepine (Tegretol) is brought to the ED by the MS personnel for repetitive seizure activity that started 45 minutes prior to arrival. You anticipate that the physician will order which drug for status epilepticus?
A. PO phenytoin and carbamazepine
B. IV lorazepam (Ativan)
C. IV carbamazepine
D. IV magnesium sulfate - correct answer B. IV Lorazepam (Ativan) is the drug of choice for status epilepticus. Tegretol is used in the management of generalized tonic-clonic, absence or mixed type seizures, but it does not come in an IV form. PO (per os) medications are inappropriate for this emergency situation. Magnesium sulfate is given to control seizures in toxemia of pregnancy.
You are preparing a child for IV conscious sedation prior to repair of a facial laceration. What information should you immediately report to the physician?
A. The parent is unsure about the child's tetanus immunization status.
B. The child is upset and pulls out the IV.
C. The parent declines the IV conscious sedation.
D. The parent wants information about the IV conscious sedation. - correct answer C. Parent refusal is an absolute contraindication; therefore, the physician must be notified. Tetanus status can be addressed later. The RN can restart the IV and provide information about conscious sedation; if the parent still not satisfied, the physician can give more information.
An intoxicated patient presents with slurred speech, mild confusion, and uncooperative behavior. The patient is a poor historian but admits to "drinking a few on the weekend." What is the priority nursing action for this patient?
A. Obtain an order for a blood alcohol level.
B. Contact the family to obtain additional history and baseline information.
C. Administer naloxone (Narcan) 2 - 4 mg as ordered.
D. Administer IV fluid support with supplemental thiamine as ordered - correct answer D. The patient presents with symptoms of alcohol abuse and there is a risk for Wernicke's syndrome, which is caused by a thiamine deficiency. Multiples drug abuse is not uncommon; however, there is nothing in the question that suggests an opiate overdose that requires naloxone. Additional information or the results of the blood alcohol level are part of the total treatment plan but should not delay the immediate treatment.
When an unexpected death occurs in the ED, which of the following tasks is most appropriate to delegate to the nursing assistant?
A. Escort the family to a place of privacy.
B. Go with the organ donor specialist to talk to the family.
C. Assist with postmortem care.
D. Assist the family to collect belongings - correct answer C. Postmortem care requires some turning, cleaning, lifting, etc., and the nursing assistant is able to assist with these duties. The RN should take responsibility for the other tasks to help the family begin the grieving process. In cases of questionable death, belongings may be retained for evidence, so the chain of custody would have to be maintained.
Following emergency endotracheal intubation, you must verify tube placement and secure the tube. List in order the steps that are required to perform this function?
a. Obtain an order for a chest x-ray to document tube placement.
b. Secure the tube in place.
c. Auscultate the chest during assisted ventilation.
d. Confirm that the breath sounds are equal and bilateral. - correct answer C D B A
Auscultating and confirming equal bilateral breath sounds should be performed in rapid succession. If the sounds are not equal or if the sounds are heard over the mid-epigastric area, tube placement must be corrected immediately. Securing the tube is appropriate while waiting for the x-ray study.
A teenager arrives by private car. He is alert and ambulatory, but this shirt and pants are covered with blood. He and his hysterical friends are yelling and trying to explain that that they were goofing around and he got poked in the abdomen with a stick. Which of the following comments should be given first consideration?
A. "There was a lot of blood and we used three bandages."
B. "He pulled the stick out, just now, because it was hurting him."
C. "The stick was really dirty and covered with mud."
D. "He's a diabetic, so he needs attention right away - correct answer B. An impaled object may be providing a tamponade effect, and removal can precipitate sudden hemodynamic decompensation. Additional history including a more definitive description of the blood loss, depth of penetration, and medical history should be obtained. Other information, such as the dirt on the stick or history of diabetes, is important in the overall treatment plan, but can be addressed later.
You are assigned to telephone triage. A patient who was stung by a common honey bee calls for advice, reports pain and localized swelling, but denies any respiratory distress or other systemic signs of anaphylaxis. What is the action that you should direct the caller to perform?
A. Call 911.
B. Remove the stinger by scraping.
C. Apply a cool compress.
D. Take an oral antihistamine - correct answer B. The stinger will continue to release venom into the skin, so prompt removal of the stinger is advised. Cool compresses and antihistamines can follow. The caller should be further advised about symptoms that require 911 assistance.
These patients present to the ED complaining of acute abdominal pain. Prioritize them in order of severity.
a. A 35-year-old male complaining of severe, intermittent cramps with three episodes of watery diarrhea, 2 hours after eating
b. A 11-year-old boy with a low-grade fever, left lower quadrant tenderness, nausea, and anorexia for the past 2 days
c. A 40-year-old female with moderate left upper quadrant pain, vomiting small amounts of yellow bile, and worsening symptoms over the past week
d. A 56-year-old male with a pulsating abdominal mass and sudden onset of pressure-like pain in the abdomen and flank within the past hour - correct answer D B C A
The patient with a pulsating mass has an abdominal aneurysm that may rupture and he may decompensate suddenly. The 11-year-old boy needs evaluation to rule out appendicitis. The woman needs evaluation for gallbladder problems that appear to be worsening. The 35-year-old man has food poisoning, which is usually self-limiting
The nursing manager decides to form a committee to address the issue of violence against ED personnel. Which combination of employees is best suited to fulfill this assignment?
A. ED physicians and charge nurses
B. Experienced RNs and experienced paramedics
C. RNs, LPN/LVNs, and nursing assistants
D. At least one representative from each group of ED personnel - correct answer D. At least one representative from each group should be included because all employees are potential targets fro [Show Less]