NP4 Review for Final/Exit/NCLEX
What nursing intervention is appropriate for a patient who is the victim of domestic violence and is afraid to return to his or her partner?
Develop a safety plan that will help the victim escape the violent relationship.
Which drug should be prescribed for increased intracranial pressure in a patient?
Dexamethasone
Which health problem increases the incidence of Bell's palsy?
Diabetes
A patient with a history of patent airways who is stung by a scorpion is brought to the hospital. Following drug therapy, the patient has shortness of breath and air hunger. Which medication is the reason for these symptoms?
Diazepam (Valium)
A patient with heat stroke has arrived at the hospital for medical intervention. The patient develops chills during the cooling process. What is the drug of choice to prevent chills in this patient?
Diazepam (Valium)
Which symptom indicates tube obstruction in a patient with tracheostomy?
Difficulty in breathing.
In a patient with a tracheostomy, the nurse notes that the cuff requires increasing amounts of air in order to maintain the seal and observes food particles in the tracheal secretions. Which tracheal complication does the nurse suspect occurred in this patient?
Dilation
What are the responsibilities of the emergency medicine physician?
Direct overall care in the department.
The forensic nurse examiner is assessing a patient who is a victim of intimate partner violence (IPV). What interventions does the nurse perform for this patient?
Document injuries and collect photographic evidence.
A nurse is discharging a patient diagnosed with Bell palsy who is experiencing muscle weakness on the left side of the mouth. What information does the nurse include in the discharge education for management of Bell palsy?
Drink using the right side of the mouth.
Why do blisters not form in deep partial-thickness wounds?
Due to the thick dead tissue layer which sticks to the underlying dermis.
A patient with respiratory failure has been intubated and placed on a ventilator and is requiring 100% oxygen delivery to maintain adequate oxygenation. Twenty-four hours later, the nurse notes new-onset crackles and decreased breath sounds, and the most recent arterial blood gases (ABGs) show a PaO 2 level of 95 mm Hg. The ventilator is not set to provide positive end-expiratory pressure (PEEP). Why is the nurse concerned?
Lung sounds may indicate absorption atelectasis.
Who greets patients with chest pain?
MONA (morphine, oxygen, nitro, aspirin)
Which level of trauma center offers advanced life support care in rural or remote settings?
Level IV
Which diagnostic test is done to detect subtle changes in brain tissue and show more specific details of a brain injury?
Magnetic resonance imaging (MRI) scan
Which drug will be most effective for the treatment of cerebral edema and increased intracranial pressure?
Mannitol
Which medication is used to treat cerebral edema by pulling water out of the extracellular space of the edematous brain tissue?
Mannitol
The emergency department charge nurse is making patient assignments and delegating care after a mass casualty event. Which of these patients could be delegated to a nursing assistant?
Patient who is unconscious with massive aortic bleeding from the chest.
Which patient does the triage nurse treat with highest priority?
Patient with a stab wound to the stomach.
Which statement is true about surgical procedures for a patient with cystic fibrosis?
Patients remain in the intensive care unit for a few days after transplantation.
Which statement is true about a patient with flail chest?
Patients with flail chest are stabilized by using positive-pressure ventilation.
A patient with a cardiopulmonary disorder is admitted into the emergency department (ED). Which action can a nurse who is certified in basic life support (BLS) training perform?
Perform cardiopulmonary resuscitation.
The nurse has an order to wean a patient from a tracheostomy. Several hours after capping the tube, the nurse assesses the patient and observes a heart rate of 90 beats/min, respirations of 22 breaths/min, and an oxygen saturation of 94%. The patient has a productive cough and expresses anxiety about weaning. Which action by the nurse is correct?
Reassure the patient that everything is normal.
What are the classical manifestations in patients with class one primary pulmonary arterial hypertension (PAH)?
Shortness of breath is not observed during any physical activity.
Which statement explains the mechanisms of action of Sinemet in the treatment of Parkinson's disease?
Sinemet is converted to dopamine and provides an exogenous form of dopamine replacement.
Which interventions may worsen the outcome in a patient who has suffered from a pit viper's bite?
Sucking the wound, applying ice to the wound, and using tourniquet at the wound.
A nurse is administering dopamine to a patient who is in shock. After the therapy, the patient's mean arterial pressure is 22 mm Hg from the baseline value. Which intervention should the nurse perform to prevent severe vasoconstriction and tissue necrosis?
The patient's IV site should be assessed every 30 minutes.
Which statement is true regarding the stationary chest tube drainage system?
The tubes from the patient are connected to the first chamber.
When caring for a patient with hypothermia, why does the nurse administer intravenous (IV) drugs only after the core temperature is above 86° F (30° C)?
There is a potential for drug toxicity.
A patient has developed subcutaneous emphysema after surgery for a tracheostomy. Why must the nurse notify the health care provider immediately?
There is an opening or tear in the trachea, allowing air leakage into the tissues.
Which action is taken for critically ill or injured patients in the military form of the triage process?
They are triaged into the expectant category.
What is the major concern when "green-tagged" patients evacuate themselves and go to a hospital for treatment on their own?
They may unknowingly carry contaminants from the disaster site to the hospital.
Which instruction would the nurse give to a patient who has had an allergic reaction to environmental airborne allergens?
Thoroughly clean cloth drapes, carpeting, and upholstered furniture.
A patient arrives in the emergency department with burns as a result of spilling boiling water while cooking. Which assessment finding of the burned areas on the tops of both hands and chest does the nurse use as a basis to document a probable full-thickness injury?
Thrombosed blood vessels are visible beneath the skin surface.
The patient is a burn victim who is noted to have increasing edema and decreased urine output as a result of the inflammatory compensation response. What does the nurse do first?
Titrate fluid replacement.
What is the purpose of the Glasgow Coma Scale used by health care personnel?
To assess level of consciousness.
What is one of the purposes of oxygen therapy?
To have an acceptable blood oxygen level.
What is the rationale for the nurse to assess a patient's sleeping habits?
To identify changes in pattern, duration, and intensity.
What is the rationale behind prescribing digoxin and diuretics to a patient with pulmonary arterial hypertension?
To improve cardiac function.
A patient with a brain tumor is prescribed lansoprazole (Prevacid). What is the purpose of lansoprazole for this patient?
To prevent development of stress ulcers.
Which drug used to treat migraines reportedly causes suicidal tendencies in a patient with bipolar disorder if taken in large doses above 400 mg?
Topiramate
Which medical emergency can lead to a life-threatening situation?
Trachea-innominate artery fistula
Which condition causes subcutaneous emphysema in a patient with a new tracheostomy?
Trapping of air escaped into the tissues.
A patient with pulmonary arterial hypertension is prescribed treprostinil. The nurse finds a high drug error rate for administration of this drug. What is the cause for this high drug error rate?
Treprostinil requires continuous infusion.
A patient who is admitted to the emergency department (ED) is assigned an emergency severity index (ESI) level 4. Which nursing action is appropriate?
Understand that the patient will tolerate waiting for a brief period before receiving treatment.
What rewarming technique does the nurse use for partial-thickness to full-thickness frostbite injury?
Use a water bath set to 104° F to 108° F.
An older patient admitted to the emergency department is on a stretcher awaiting bed availability. What intervention does the nurse perform to protect the skin integrity of this patient?
Use mobility techniques that reduce shearing force when moving the patient.
A patient is receiving oxygen therapy. What are potential sources of infection the nurse should address?
Use of a heated humidifier or nebulizer, and use of an oral suction catheter in the endotracheal tube.
A patient with a traumatic brain injury underwent monitoring of the intracranial pressure. Suddenly, it resulted in leakage of the cerebrospinal fluid. What would be the possible reason for the leakage?
Use of intraventricular catheter.
The nurse is educating a patient about oral hygiene. Which is the best oral hygiene practice to help keep the airway patent in a patient with a tracheostomy?
Use of normal saline for rinsing.
A nurse is caring for a non-English-speaking adult patient who is the victim of domestic abuse and will not speak. What is the appropriate nursing action to take with this patient?
Use telephone language lines and arrange for interpreters.
What is a common side effect of betablockers for men?
erectile dysfunction
For a normal patient, if you instill cold water in their right ear, you would expect...?
eye movement to the right
The nurse is caring for a patient with facial burns from a house fire. Which mode of oxygen delivery is recommended for this patient?
face tent
The nurse is assessing a patient who is admitted with an arthropod bite. Which findings indicate that the patient is suffering from a black widow spider bite?
facial edema
What are the most common causes of traumatic brain injuries (TBIs) in the United States?
falls and motor vehicle accidents
True or false. If during post mortem care, the body expels gas- you should stop as the patient is still alive.
false
What type of burn injury may require the nurse to remove smoldering clothing and metal objects that are close to the patient's body?
flame burns
A patient develops syndrome of inappropriate antidiuretic hormone (SIADH) following a craniotomy with brain tumor removal. What medical management should the nurse expect?
fluid restriction
After a bio valve replacement how long does a patient need to be on Warfarin?
for a few months
A patient is admitted to the emergency department after reporting being raped. Who is the best team member for the admitting nurse to locate to provide care for this patient?
forensic nurse examiner
The nurse is caring for a patient who is the victim of domestic violence. To which health care professional who counsels victims of domestic violence will the nurse refer this patient?
forensic nurse examiner
A patient received a burn due to contact with hydrochloric acid. The burn is brown in color with severe edema and absence of blisters. Which category of burn does the patient have?
full-thickness burn
Which type of factors most likely explains the variance in lung cancer development among adults with similar smoking histories?
genetic factors
What is the sequence for doffing PPE?
gloves, face shield or goggles, gown, and then mask or respirator
What differentiates cerebrospinal fluid leakage from normal nasal secretions?
glucose content
What is the sequence for donning PPE?
gown first, mask or respirator, goggles or face shield, then gloves
The nurse should apply which color tag to nonurgent patients during a mass casualty event?
green tag
What is the most common complication of endocarditis?
heart failure
What is the most FATAL form of stroke?
hemorrhagic stroke
Which type of chest trauma produces a dull sound on percussion of the affected side?
hemothorax
The nurse is teaching a group of school-aged children about different insect bites and stings. The nurse teaches the students that which arthropod has a stinger that becomes lodged in the victim?
honey bee
Which finding would be associated with a scorpion sting?
hyperactivity
The nurse finds that the patient with burns has developed a low-grade fever. Which patient condition could be the reason for developing a low-grade fever?
hypermetabolic condition
Which complication may occur when the brain tumor compresses the pituitary gland, causing syndrome of inappropriate antidiuretic hormone (SIADH) or diabetes insipidus (DI)?
pituitary dysfunction
Which blood product is mostly preferred in patients with septic shock?
platelets
Your patient asks why murmurs may be heard with endocarditis. You tell them it's due to...?
platelets & vegetative deposits on the valves
What is a possible reason for the development of bronchopleural fistula in a patient with lung cancer?
pneumonectomy
In which condition does the primary health care provider advocate the use of a single chest tube in a patient with chest trauma?
pneumothorax
Your patient has a weird rythm. What labs will you pull?
potassium and magnesium
Which member of the emergency care team reports a patient's mechanism of injury (MOI)?
prehospital care provider
What may happen if a black widow spider bites a pregnant patient?
premature delivery
What condition related to prolonged immobility in the emergency department (ED) does the nurse seek to prevent in a patient?
pressure ulcers
Which class of drugs provides the best specific dilation of pulmonary blood vessels in a patient with pulmonary hypertension?
prostacyclin agents
A patient is receiving heparin sodium therapy for a pulmonary embolism. Which antidote does the nurse confirm is available on the unit?
protamine sulfate
What is the first priority in a disaster?
protect yourself
Which clinical sign demonstrates the neurotoxic effects of both a coral snakebite and a black widow spider bite?
ptosis
What is the gold standard to diagnose PE?
pulmonary angiogram
Which phase of Guillain-Barré syndrome (GBS) coincides with axonal regeneration?
recovery phase
The nurse assesses a patient with pneumonia and notes a productive cough, dyspnea with ambulation, and increased work of breathing. The patient's oxygen saturation is 96%, and an arterial blood gas reveals a PaO 2 of 93%. The nurse contacts the provider to report which condition based on these findings?
respiratory distress
The patient is assessed and a blood glucose level and vital signs are obtained upon arrival on the unit. Results are as follows: BG—239 mg/dL BP—138/88 mm Hg HR—128 RR—36 breaths/min O2 saturation—88% (room air) Temperature—101.6º F Which vital sign or test result requires the nurse's immediate attention?
respiratory rate
A mechanical ventilator in the emergency department (ED) has stopped functioning properly. Who should the nurse contact to troubleshoot the problem with the mechanical ventilator?
respiratory therapist
What type of shunting is cyanotic?
right to left shunting
Which medication is an example of a long-acting beta 2 agonist (LABA) used in asthma management?
salmeterol
Which clinical manifestation is indicative of wound healing for a patient in the acute phase of burn injury?
scar tissue formation
A patient presents with fever, arthralgia, rash, malaise, lymphadenopathy, nephritis, and polyarthritis. The patient has been admitted to the hospital several times in the past month and was last discharged one week ago. What does the nurse suspect this patient is experiencing?
serum sickness
The patient is a marathon runner who has asthma. Which category of medication is used as a rescue inhaler?
short-acting beta agonists
Low-flow oxygen delivery systems typically include which types of components?
simple facemask and nonrebreather mask
After valve repair a patient should wait how long before getting dental work?
six months
Which complication does the nurse expect when finding puffiness or crackling at the site of chest tube insertion in a patient with lung cancer?
subcutaneous emphysema
Which type of burn injury has a moist, pink wound bed and blanches when gentle pressure is applied?
superficial partial-thickness
What is inserted to drain cerebrospinal fluid to another area of the body when there is a long-term treatment required for chronic hydrocephalus?
surgical shunt
Which is a common exclusion criterion for a patient with cystic fibrosis preparing for lung transplantation?
systemic infection
Occupational exposure to which materials increases an individual's risk for lung cancer?
tar, iron oxide, nickel, cobalt, beryllium, coal, chromium, and asbestos
What is the treatment of choice for non-small cell lung cancer?
targeted therapy
Which nonsurgical treatment for lung cancer involves inhibiting the tumor cell growth factors?
targeted therapy
A patient recovering from an open reduction of the femur suddenly feels lightheaded, with increased anxiety and agitation. Which key vital sign differentiates a pulmonary embolism from early sepsis?
temperature
Door to 12 lead time should be...?
ten minutes
Which condition may manifest in a patient with a completely collapsed lung due to entry of air into the chest cavity?
tension pneumothorax
Which is a serious side effect associated with positive end-expiratory pressure (PEEP)?
tension pneumothorax
Which type of chest trauma produces a hyperresonance sound on percussion of the affected area?
tension pneumothorax
In which case can the nurse clean and prepare the body of a deceased patient for viewing by the family.
terminal illness
Deliberate release of virus, bacteria or other germs is...?
terrorism
What are the four T's? (HINT: They're cyanotic defects!)
tetralogy of fallot, truncus arteriosus, transposition of the great vessels, and tricuspid atresia
The three areas of damage after an MI are...?
the area of infarction, area of injury, and area of ischemia
Your patient has had a right-sided CVA. On which side do you expect weakness?
the left side
Your patient has had a left-sided CVA. On which side do you expect weakness?
the right side
What happens during S1?
the tricuspid and mitral valve are closing
What are the three triage categories you start with? (HINT: it's the Sort.)
those not moving and have obvious life-threatening injuries; people who can wave or have purposeful movement; and those who can walk
Which surgery of neck cancer leads to absence of a natural voice?
total laryngectomy
The nurse is caring for a patient with a cuffed tracheostomy and is aware the patient is at risk for developing which complication?
tracheomalacia
Which field encompasses the continuum of care from injury prevention and prehospital services to acute care, rehabilitation, and, ultimately, community reintegration?
trauma nursing
True or false. You can groom the hair on a dead body, but do not shave it.
true
Between PCI and TPA, which is preferred?
typically PCI
What is the difference between stable and unstable angina?
unstable angina can happen at rest
Which physiological action of carbon-monoxide manifests as "cherry red" coloration of skin in a patient with carbon-monoxide poisoning?
vasodilating effect
What two EKG patterns would you defibrilliate?
ventricular fibrilliation and pulseless ventricular tachcardia
Which type of stroke syndrome would most likely cause a coma in a patient?
vertebrobasilar artery strokes
What is preload?
volume of blood in ventricles at end of diastole
What passive external rewarming method is typically applied to treat mild hypothermia?
warm clothing
At what point does an item wet with body fluids need to go in a biobag?
when it is saturated
At what point post-precedure should you allow a patient to eat?
when the gag reflex returns
When can a cardiac patient resume having sex?
when they can walk two flights of stairs easily
At what point do you treat sinus bradycardia or sinus tachycardia?
when your patient is symptomatic
How do you treat torsade de pointes?
with magnesium
What is the difference between the ST elevation with pericarditis and with a MI?
with pericarditis the elevation will be in ALL leads, not just 2 or 3
A nurse is caring for patients who were brought to the emergency department following an earthquake. Which tag will the nurse use for patients who have an open fracture with large wound?
yellow tag
The nurse is assisting with triage in the field after a large airplane crash. She is assessing a victim who has an open tibial fracture and a large laceration to his head, but is otherwise stable. What is the appropriate color tag for the victim?
yellow tag
The nurse is caring for a patient with burns. Which question does the nurse ask the patient and family to assess their coping strategies?
"How have you handled similar situations before?"
A patient with COPD presents for a routine follow up. The patient smokes 1 PPD. Which statement by the patient causes the nurse to suspect an increase in dyspnea?
"I bought a new pillow so I could prop myself up at night to sleep."
The nurse is caring for a patient with burns to the face. Which statement by the patient requires further evaluation by the nurse?
"I don't know what I will do when people stare at me."
When the nurse begins taking the patient's history, the patient asks, "Did you know that I have throat cancer and may not survive?" What is the appropriate nursing response?
"I know you have been diagnosed with cancer. Are you concerned about what the future may hold?"
A patient is being discharged to home on warfarin (Coumadin) therapy to manage an acute pulmonary embolism. Which patient response indicates a need for further teaching by the nurse?
"I should eat more green leafy vegetables like spinach."
The nurse is teaching a patient with a tracheostomy who is to be discharged about home tracheostomy management. Which statement by the patient indicates that further instruction may be needed?
"I should sleep in a room with a dehumidifier."
A patient with Grade 3 meningiomas has to undergo surgery. The nurse is teaching the patient about the precautions to take before surgery. Which statement made by the patient shows a need for further learning?
"I will not drink alcohol for at least 8 hours before the surgery."
A patient has been diagnosed with Huntington's disease (HD). The nurse is teaching the patient and her parents about the genetic aspects of the disease. Which statement made by the parents demonstrates a good understanding of the nurse's teaching?
"If she has children, she'll pass the gene on to her kids."
The nurse is assisting the triage team at an earthquake site. Which patient does the nurse refer to as the "walking wounded?"
Patient with several bruises and a closed fracture of the elbow.
Which statement best describes the symptoms of a transient ischemic attack (TIA)?
They resolve within 60 minutes.
What is the function of the cerebral cortex?
To translate impulses into understandable feelings.
Which factors are implicated in the greatest number of injuries associated with traumatic brain injuries (TBIs)?
Weekends, alcohol use, and evenings and nights.
What can the nurse anticipate will be the initial management for a tension pneumothorax?
needle thoracostomy
The nurse provides care to an intubated adult patient with hypocarbia. Which finding does the nurse report immediately to the health care provider?
nonreactive, dilated pupils
Rubeola/Rubella is airborne.
rubeola
A patient in the allergy clinic develops all of these clinical manifestations after receiving an intradermal injection of an allergen. Which symptom requires the most immediate action by the nurse?
stridor
What are signs of oxygen toxicity?
sub-sternal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty
What happens during S2?
the pulmonic and aortic valve closing
The camp nurse is providing snakebite prevention tips. Which statement by a camper indicates a need for additional education?
"A dead snake is a safe snake."
A patient presents to the ED and is diagnosed with an acute MI. The patient's spouse asks what type of damage has been caused by the "heart attack." What is the appropriate nursing response?
"A heart attack evolves over several hours. We won't know the extent of the damage immediately."
A nurse is assessing pain in a patient with trigeminal neuralgia. Which patient response describes classic pain with trigeminal neuralgia?
"The pain is excruciating, sharp, and shooting."
What is the therapeutic dig level?
1-2
A patient sustained deep partial-thickness burns to the anterior and posterior surface of bilateral lower extremities. Using the rule of nines, which percentage of body surface area does the nurse estimate the patient's burn to be?
36%
What is a normal PCWP/PAWP pressure?
4-12 mm/hg
Door to balloon time should be how long?
90 minutes
Which patient would be diagnosed with epilepsy?
A patient who has had two or more seizures.
A patient with a history of asthma is having shortness of breath. The nurse discovers that the peak flowmeter indicates a peak expiratory flow (PEF) reading that is in the red zone. What is the priority nursing action?
Administer the rescue drugs.
Which treatment modality is the focus during the management of an uncomplicated rib fracture?
Administering analgesics.
The nurse is caring for a patient who presents to the hospital with profuse sweating and a temperature of 104° F (40° C). Assessment findings include a patent airway, tachycardia, acute confusion, and anxiety. What is the priority intervention?
Applying ice packs.
The nurse is caring for a post-operative patient who underwent supratentorial surgery. Which treatment should be avoided if the patient's fluid loss is 8 L/hr?
Aqueous vasopressin should be administered to the patient.
Define hemianopia.
Blindness over half the field of vision, on one or both eyes.
Define homonymous hemianopia.
Blindness over half the field of vision, same half each eye.
Define rhinorrhea.
CSF leakage through NOSE.
Define otorrhea.
CSF through EAR.
A patient with trigeminal neuralgia (TN) has excruciating pain. What is the first choice for drug therapy in TN?
Carbamazepine
Hypotension, fluid retention, and the valsalva maneuver are all...?
Cardiac complications associated with mechanical ventilation.
Which body systems are most profoundly affected by lightning injuries?
Cardiopulmonary and central nervous systems.
Function of brain depends on...?
Continuous blood flow with 02 & glucose.
What is the final component of the primary survey in the care of a patient who is admitted to the health care facility in critical condition after a sexual assault?
Cutting away the clothing with scissors to preserve any evidence.
A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen with a Venturi mask at a rate of 3 L/min. Prior to initiating oxygen therapy, the patient appeared anxious with gray skin, a respiratory rate of 24 breaths/min, and an oxygen saturation of 87%. After 15 minutes of oxygen therapy, the nurse observes the patient resting with closed eyes, pink coloration, a respiratory rate of 12 breaths/min, and an oxygen saturation of 95%. Which action by the nurse is correct?
Decrease the oxygen to 2 L/min to improve respiratory rate.
Which characteristic feature may be associated with the patient in stage I of Alzheimer's disease?
Decreased sense of smell.
What kind of reflex is displayed with an abnormal Babinski's sign?
Dorsiflexion of the great toe.
What information is used to determine the stage of lung cancer at time of diagnosis?
Extent of disease identified.
What does the FAST acronym stand for?
Face, Arm, Speech, Time
What finding is consistent with a status migrainous?
Headache lasting longer than 72 hours.
Which are physical findings of a patient who has a mild traumatic brain injury (TBI)?
Headache, dizziness, and fatigue.
Which is a risk factor for Bell's palsy?
Herpes Simplex Virus (HSV)
After assessing a patient with high altitude illness, the nurse anticipates that a phosphodiesterase inhibitor will be prescribed to treat what condition?
High altitude pulmonary edema.
Which part of the brain plays a major role in controlling the autonomic nervous system (ANS)?
Hypothalamus
A nurse is assessing a patient diagnosed with Bell palsy. Bell palsy is believed to be the result of inflammation triggered by a formerly dormant herpes simplex virus type 1. What is an expected finding in a patient with Bell palsy?
Inability to close the eye.
Define aphasia.
Inability to use or understand language.
The health care provider has ordered a blood transfusion for a female patient with serious electrical burns. What hematocrit level reflects the need for transfusion when symptoms of hypoxia are present?
Less than 20-25%.
How long do status migraines typically last?
More than 72 hours.
What methods can the nurse use to determine if the drainage is CSF?
Observe for a "halo" around a spot of drainage, and check the liquid for glucose.
Define hemiplegia.
Paralysis of one side of the body.
What is an important clinical indication of high altitude pulmonary edema (HAPE)?
Persistent dry cough.
What is the first collaborative intervention that should be performed on a patient with heat stroke?
Provide high-concentration oxygen therapy.
What must the nurse anticipate from a patient in the emergency department (ED) who is a Jehovah's Witness?
Refusal of blood transfusions.
The lunch tray is served to a patient wearing a Venturi mask. What does the nurse do to facilitate eating?
Request a prescription for a nasal cannula to only be used during mealtime.
Pramipexole and Ropinirole are dopamine agonists used extensively in...?
Restless Leg Syndrome (RLS).
A female patient is admitted into the emergency department (ED) with bruises around her breasts and genitals. Her clothes are also torn and stained with blood. Which nursing team should be assigned to the patient?
Sexual Assault Nurse Examiners (SANEs)
Which factors precipitate myasthenia gravis (MG)?
Stress, alcohol use, infection, and hormonal changes.
To check for Babinski's sign you...?
Stroke the plantar surface of the foot.
Agina s/s are...?
Substernal CP Radiating LT Arm Precipitated by stress or exertion Relieved by NTG or Rest Lasting < 15 Fewer assoc Sx
What is the main characteristic of fourth-degree frostbite?
The affected part is numb, cold, and bloodless.
A patient's laboratory report shows an intracranial pressure of 12 mmHg. Which events will occur in the patient's body?
The body will function normally.
Following a mass casualty event, a nurse who treated victims is referred to a critical incidence stress debriefing team, where a co-leader begins addressing the emotional needs of the health care team. Which statement is true about the co-leader?
The co-leader is a nurse.
In a mass casualty event, who has the role of facilitating patient movement through the system?
The hospital incident commander.
Which team member is responsible for "standing down" or deactivating the emergency response plan?
The hospital incident commander.
Which health care personnel within the institution's emergency response plan decides the number, acuity, and resource needs of patients in a mass casualty event or disaster?
The medical command physician.
Which statement is accurate regarding the management of a family in a crisis involving death?
The nurse should provide concrete terms such as "the patient died" while communicating with family.
Which team member of the emergency department, other than the hospital incident commander, plays a leadership role in emergency situations?
The nursing supervisor.
What signs/symptoms are characteristic of a patient who is described as lethargic?
The patient is drowsy but easily awakened.
Which rationale best supports the intravenous (IV) administration of fentanyl to a burn patient?
The risk of overdose from rapid absorption of drug from the interstitial space is reduced.
Which characteristic accurately describes the occurrence of status epilepticus?
The seizure lasts longer than 5 minutes.
During a mass casualty, staff roles are defined. If the triage officer is incapacitated, who is the best choice for replacement?
The triage nurse.
A rape victim's report includes interventions taken, family history, assessment, and diagnostic findings. Which vital piece of information should have also been included considering the fact that the victim has been raped?
Transmission-based precautions taken.
A patient with a penetrating trauma is admitted to the emergency department with cervical trauma, impaired consciousness, and respiratory depression. The nurse should intervene when what action is performed during resuscitative efforts?
Use of a non-rebreather mask.
How does the nurse determine accurate calorie requirements for a patient with burns?
Using indirect calorimetry.
The nurse is caring for a patient who has anxiety resulting from a pulmonary embolism. When might the nurse expect the health care provider to prescribe a sedative to the patient?
When the patient is mechanically ventilated.
When managing the care of a patient with a major full-thickness burn, when would the nurse begin to see fluid shifts resulting in edema?
Within 12 hours.
During which time frame does an acute subdural hematoma (SDH) present?
Within 48 hours after impact.
What is considered a late postoperative complication following craniotomy?
Wound infection or abscess.
The nurse in the triage area of an emergency unit is preparing identification tags for patients. What information is used to identify a patient brought in from a disaster site?
a digital photo
A patient has been admitted to the health care facility after an electrical burn to the lower extremity, exposing the muscles and bone. On diagnosis, infection is found in the lower extremity. What is the most appropriate treatment method for the patient?
amputation
Before doing care of the body on a patient who has recently died, the nurse should find out if what is needed?
an autopsy
Which ectopic hormone is associated with weight gain?
antidiuretic hormone
Which patient condition may be treated by oxygen therapy?
anxiety
A patient comes into the emergency department (ED) clutching the chest. Which core competency for ED nurses is the first one used in this situation?
assessment
What is the foundation of an emergency nurse's skill base?
assessment
Vagal stimulation during suctioning can contribute to which conditions?
asystole, heart block, and bradycardia
A patient has developed a type II hypersensitivity reaction. Which condition is associated with this type of hypersensitivity?
autoimmune hemolytic anemia
Which arthropod bite is associated with a wheal-and-flare skin reaction?
bee
A patient with burns has pulmonary edema. Which drug will likely be administered to the patient?
beta blockers
Your patient has a dysrythmia with a pulse that calls for a shock. As a prudent nurse, you know that this is called...?
cardioversion
Your patient has vtach with a pulse. You?
cardiovert and give an antirythmic
A patient is frequently seen in the emergency department for severe headaches that typically involve unilateral, pulsating pain accompanied by nausea and sensitivity to light. These symptoms begin when the patient has stress persisting for 2-3 days. Which type of headache does the nurse suspect in this patient?
common migraine
What type of hypersensitivity occurs when a patient receives the wrong blood type during a transfusion, leading to a hemolytic transfusion reaction?
cytotoxic reaction
What intervention needs to be done with a patient with cardiomypathy?
daily weights
A patient has just been admitted to the emergency department and requires high-flow oxygen therapy after suffering facial burns and smoke inhalation. Which oxygen delivery device should the nurse use initially?
face tent
What is diffferent about the lead placements for a one time EKG and continous monitoring?
for continous, the limb leads will be placed on the trunk to eliminate artifact
What term describes increased vibrations felt on the chest wall that indicate areas of the lung where air spaces are replaced with tumor or fluid in patients with lung cancer?
fremitus
On a patient with pericarditis what will you hear?
friction rub
Which factor has been shown to delay stroke intervention?
gender
Which condition can be managed by the administration of hypertonic saline?
head trauma
A 58-year-old woman who has been diagnosed with throat cancer 1 week ago comes to the clinic today to discuss surgical options with her health care provider. She is very tearful and appears sad when the nurse calls her back to the examination room. Based on her diagnosis, which clinical manifestation will the nurse likely observe in the patient?
hoarseness
Which potential disorder should be ruled out before a patient's level of consciousness is attributed to stroke?
hypoglycemia
Which clinical manifestation would the nurse observe in a patient with cystic fibrosis associated with infection?
intercostal retractions
What would be the first intervention performed by the nurse to prevent airway obstruction for a patient who suffered smoke inhalation injury during a fire accident?
intubation
What type of shunting is acyanotic?
left to right shunting
Which chemical is responsible for a prolonged inflammatory response, leading to airway obstruction?
leukotriene
Eyes, skin and bone harvesting do not require ____ _______.
life support
Which level of brain injury is present in a patient with a Glasgow Coma Scale score ranging from 9 to 12?
moderate traumatic brain injury
What oxygen delivery system is known to deliver low-flow fraction of inspired oxygen (FiO 2,) up to 6L?
nasal cannula
Discharge planning begins when...?
on admission
Which type of seizure is mostly seen in adults and is less responsive to medical treatments in comparison to other seizures?
partial seizure
What is the reversing agent for heparin?
promatine sulfate
Xerostomia is a condition associated with which of the following types of treatment?
radiation therapy
Define hydrocephalus.
↑ in volume of CSF within the ventricular system.
What is the radiation absorbed dose given to patients with small cancers in specific locations while treating them with standard radiation therapy?
5000 to 7500 rad
What is door to needle time?
60 minutes or the "Golden Hour"
What is the duration of mild traumatic brain injury symptoms?
72 hours
A patient has developed a type II hypersensitivity. Which mechanism is involved in this type of allergic reaction?
phagocytosis of self cells
What are s/s of lidocaine toxicity?
slurred or difficult speech, altered CNS, muscle twitching, and seizures
Which patient teaching point could conceivably prevent the majority of all lung cancers?
smoking cessation
Where does the nurse know "Africanized" or "killer" bees are found in the United States?
southwest
The nurse is about to administer a contrast medium to the patient undergoing diagnostic testing. Which question does the nurse first ask the patient?
"Are you taking ibuprofen daily?"
Which question would be appropriate for the nurse to ask to assist in determining the cause of the patient's seizure?
"Have you had a high fever?"
Which statement made by the student nurse indicates understanding of neurogenic pulmonary edema?
"Most patients with neurogenic pulmonary edema do not survive."
Which medical assistant statement regarding tiers of a triage system indicates a need for further teaching by the nurse?
"Patients in the emergent tier need quick treatment, but they are not in a life-threatening situation."
Which statement made by a nursing student regarding vulnerable populations is accurate?
"They have unique health care problems."
A patient is intubated and cannot talk. What is the best possible Glasgow Coma score for this patient?
11t
Which ethnic group has the highest prevalence of stroke?
American Indians and Alaskan Natives
Heparin needs labs taken how often?
Q6hours
Why would a patient with Bell's palsy benefit from psychosocial support?
Body image is affected.
The nurse correctly identifies the speech area of the brain as being located in which region of the cerebrum?
Broca's area
Slurred speech indicates that...?
Broca's motor speech area of the brain is affected.
The nurse assesses a patient who is receiving oxygen using a partial rebreather facemask at a flow rate of 12 L/min. The nurse notes the patient's oxygen saturation level is 90%. Which action would the nurse take next?
Change the mask to a non-rebreather mask.
A patient with a traumatic brain injury from a motor vehicle crash is monitored for signs of increased intracranial pressure (ICP). Which sign does the nurse monitor for?
Changes in breathing pattern.
A disoriented patient involved in a motor vehicle crash is admitted to the emergency department (ED). What action must the nurse take first when assessing this patient?
Check for a medical alert necklace or bracelet.
Define flaccidity.
Complete loss of muscle tone.
What is a manifestation of post-traumatic stress disorder (PTSD)?
Feeling "numb" 2 weeks or more after a disaster.
What happens when salt water is aspirated into the lungs of a drowning person?
Fluid from vascular spaces moves into the alveoli.
Which phase of a migraine includes the symptom of mood changes?
Prodromal
A patient with heat stroke arrives at the hospital, undergoes treatment, and is stabilized. What parameters are assessed to prevent further complications?
Serum sodium, serum bilirubin, and serum creatinine.
A patient with myasthenia gravis (MG) has been hospitalized after a myasthenic crisis. Once the patient is free from respiratory symptoms, which diet does the nurse anticipate the provider to order for this patient?
Soft
A patient has a fenestrated tracheostomy tube in place. Which multidisciplinary team would be involved in the discharge planning process, specific to the tracheostomy?
Speech therapy
While assessing a trauma patient, the nurse is unable to obtain the radial pulse. What does the nurse infer from this finding?
The blood pressure is less than 80 mm Hg systolic.
The nurse is caring for a patient with encephalitis who is currently immobile and stuporous. Of the nursing interventions that must be implemented for the patient, which one can the nurse delegate to unlicensed assistive personnel (UAP)?
Turning, coughing, and deep-breathing.
Which type of hypersensitivity may be associated with rhinorrhea?
Type I hypersensitivity.
What methods can be used to prevent hypothermia in a patient?
Use heat lamps and warming blankets.
A patient has continuous seizures for more than 6 minutes. Which term best describes this condition?
status epilepticus
Which arthropod bite results in a dark and necrotic wound (eschar)?
brown recluse spider
What are the two major categories of asthma medications?
control and reliever
What are the signs and symptoms of pulmonary embolism (PE)?
crackles, diaphoresis, and low-grade fever
Which type of burn injury is caused by an open flame?
dry heat
What is a late manifestation of lung cancer?
dysphagia
Which non-pulmonary manifestation of cystic fibrosis is commonly seen in this patient population?
excessive fat in stools
The nurse is obtaining a history on a patient who has had several transient ischemic attacks. Which risk factor in this patient's history cannot be changed with appropriate management of care?
head trauma
Which condition is a medical emergency in which the body temperature may exceed 104°F (40°C)?
heat stroke
What term describes bleeding into the chest cavity?
hemothorax
Which assessment finding is commonly seen in a patient with a tension pneumothorax?
hyperresonance on percussion
Decreased tissue oxygenation is..?
hypoxia
The nurse is assisting a patient who has severe emphysema with meal and snack choices for the next day. Which selection is appropriate for this patient?
ice cream with fudge topping
Hypoxemia can trigger anxiety and sense of ____________ ____?
impending doom
Which type of ventilator is suitable for patients who have severe lung disease?
microprocessor ventilator
What term describes air in the pleural space?
pneumothorax
Which essential item is added to a personal-readiness supplies "go bag?"
potable water
If you have a patient with a u wave what labs would you look at?
potassium
What labs do you check before giving a direutic?
potassium and magnesium
Which condition can be prevented by maintaining quite environment for better sleep?
psychosis
A nurse is listening to family members discuss feelings of guilt and anger over a patient's traumatic brain injury. How does the nurse document this type of assessment?
psychosocial
Rubeola/Rubella is droplet.
rubella
Which is considered a late complication of burn injuries?
scarring
What is the clinical sign of a bite from a pit viper?
seizure
Which surgical procedure involves the removal of the entire larynx in patients with laryngeal cancer?
total laryngectomy
Who is said to be the gatekeeper in the emergency care system?
triage nurse
What is a normal magnesium?
1.5-2.5
How long do you hold metformin pre- cardiac cath?
24 hours
A patient planning an expedition to the mountains is prescribed acetazolamide (Diamox). When must the patient take the first dose of this medication so that it is effective?
24 hours before ascent.
Which patient is at greatest risk of developing acute respiratory distress syndrome (ARDS)?
24-year-old male admitted with blunt chest trauma and aspiration.
Which score on the Glasgow Coma Scale (GCS) would the nurse give to an unresponsive patient with no verbal or motor response?
3
How long do you hold metformin post- cardiac cath?
48 hours
Which assessment finding is most indicative of Guillain-Barré syndrome (GBS)?
A sudden onset of muscle weakness and pain.
Which drug is considered an antithrombotic?
Clopidogrel
The nurse is performing a rapid neurologic assessment on a trauma patient. Which assessment finding is normal?
Constriction of pupils.
A patient brought to the trauma center dies following a suicide attempt. What action does the nurse take to prepare the body for family viewing?
Cover the body and only expose the face.
What does it mean if the patient has an indirect traumatic brain injury (TBI)?
Force was applied to another body part, but the brain was still affected.
Which factor is a manifestation of tracheoesophageal fistula (TEF)?
Increased cough and choking while eating.
What is the leading cause of death from head trauma in patients who reach the hospital alive?
Increased intracranial pressure (ICP)
Which is associated with "paradoxical chest wall movement"?
Inward movement of the thorax during inspiration with an outward movement during expiration.
What is the feature of the Emergency Severity Index (ESI) triage system?
It categorizes patients into five groups.
Which characteristics are associated with migraine headaches?
Nausea, photophobia, and phonophobia.
Define thrombotic CVA.
Occlusion of large cerebral vessel by thrombus.
Which describes secondary brain injuries?
Occur after the initial injury.
Which intervention is beneficial in the management of anoxia when it occurs as a result of a witnessed cardiac arrest in a patient?
Performing therapeutic hypothermia.
The triage nurse is a member of the medical relief team who has been delegated to a hurricane-hit area. What supplies does the nurse take along in the "go bag," assuming they have already packed potable water?
Personal ID with emergency contacts in a waterproof bag.
The older adult patient with degenerative arthritis is admitted for tracheostomy surgery. What is the best communication method for this patient during the postoperative period?
Picture board
_________ _____ ____, an abnormal response, occurs when the eyes constantly look upward, regardless of which way the head is turned .
Positive Doll's Eyes
Define ICP.
Pressure within cranial cavity measured within lateral ventricles.
The nurse is caring for a patient who has renal failure and who has received a prescription for propranolol therapy. Which instruction should the nurse give to the patient?
"Do not sit up or stand up too fast."
A patient who is concerned about getting a tracheostomy says, "I will be ugly with a hole in my neck." What is the nurse's best response?
"Do you have a scarf or a large loose collar that you could place over it?"
The student nurse is discussing postoperative care with the nurse. Which statement made by the student requires correction?
"Elevate the head of the bed (HOB) 90 degrees to promote venous drainage."
The nurse's friend fears that his mother is getting old, saying that she is becoming extremely forgetful and disoriented and is beginning to wander. What is the nurse's best response?
"Have you taken her for a check-up?"
The nursing instructor asks the student nurse caring for a patient with Alzheimer's disease, who has been prescribed donepezil, how the drug works. Which response by the nursing student best explains the action of donepezil?
"It delays the destruction of acetylcholine by acetylcholinesterase."
After losing her home to a hurricane several years ago, the patient says, "I get very nervous during a thunderstorm and want to hide under the bed." What is the nurse's best response?
"What do you do when you feel this way?"
A patient who smokes is being discharged home on oxygen. The patient states, "My lungs are already damaged, so I'm not going to quit smoking." What is the discharge nurse's best response?
"You are right, the damage has been done. But let's talk about why smoking around oxygen is dangerous."
A Glasgow Coma Scale (GCS) score of __ is normal and suggests that the brain is fully functioning. It indicates that a person's eyes open spontaneously, he is alert and oriented, and is able to physically respond appropriately to verbal commands.
15
Which age group has the highest rate of meningococcal infections?
16-21
Which victim of intimate partner violence requires an endotracheal tube?
A rape victim who has been strangled and is unconscious.
A nurse is caring for a patient with myasthenia gravis. What nursing intervention should be implemented to promote mobility and prevent fatigue in the patient?
Assist the patient in planning periods of rest.
The nurse is caring for a patient with orthostatic hypotension. What is the correct intervention for this patient?
Assist the patient to move slowly from a supine to an upright position.
How long must a patient with burns wear pressure garments after undergoing biological dressing?
At least 23 hours per day.
The nurse is caring for a patient who is on mechanical ventilation because of severe burns. Which medication is appropriate for this patient?
Atracurium
A patient is diagnosed with an acoustic neuroma. Which cranial nerve (CN) is affected by an acoustic neuroma?
Auditory (Cranial Nerve VIII)
The nurse is providing information about preventing respiratory infections to a patient diagnosed with idiopathic pulmonary fibrosis. What instruction should the nurse include?
Avoid crowded areas.
Which of the following findings would indicate a major burn?
Electrical injury, inhalation injury, and injury of eyes, ears, face.
A patient who experienced an anaphylactic reaction is hypotensive and has a rapid, weak, and irregular pulse. What is the priority nursing intervention?
Elevate the legs and feet.
The nurse is preparing to administer an intravenous (IV) solution to a critically ill patient who is in a state of shock. The nurse finds it difficult to access the patient's veins. Which nursing action will benefit the patient?
Establish intraosseous vascular access.
Which may be the largest cistern of the spinal cord?
From the level of the second lumbar vertebra to the second sacral vertebra (L2-S2).
An older patient injured in an accidental fire shows burn injuries on more than 10% of the total body surface area (TBSA). The skin has turned a black color with severe edema and eschar that is hard and inelastic. What should the nurse infer about the degree of burns?
Full-thickness wounds at a major level.
A patient is undergoing a magnetic resonance imaging (MRI) test. Which contrast medium is used in this procedure?
Gadolinium
Which is the most effective way for a college student to minimize the risk for bacterial meningitis?
Get the meningococcal vaccine.
Which intervention can lead to complications in a patient who is suspected of having heat exhaustion?
Giving salt tablets.
A patient who was successfully fluid resuscitated following a burn injury begins diuresis 3 days after admission. Once diuresis begins, which complications would the nurse monitor for?
Hypotension, hyponatremia, and metabolic acidosis.
A patient is diagnosed with a type I hypersensitivity. Which antibody level increases during this type of allergy?
IgE
A patient who underwent treatment for severe burns complains to the primary health care provider of respiratory discomfort. Which physiological change may be causing this discomfort?
Leakage of capillaries.
After prescribing an endothelin-receptor agonist to a female patient with pulmonary arterial hypertension, the primary health care provider advises the patient to use at least two reliable methods of contraception. Which medication is prescribed by the primary health care provider?
Macitentan
The nurse suspects a patient has a brain tumor. What noninvasive test is most likely to be ordered to validate the presence of a brain tumor?
Magnetic resonance imaging (MRI) scan
Which is the most common benign tumor that arises from the coverings of the brain (the meninges)?
Meningiomas
The nurse is extubating a patient who has been receiving mechanical ventilation for several days. Which action is correct immediately after removal of the endotracheal (ET) tube?
Monitoring vital signs.
Which vector is responsible for the transmission of West Nile virus?
Mosquito
Which finding in the incidence of bacterial meningitis is the most common?
Most cases have occurred in densely populated areas..
While at a soccer match, a player drops to the ground with heat exhaustion and a diminished level of consciousness. What does the team nurse do first?
Move the player to the shade.
What is absorption atelectasis?
Not enough nitrogen to keep open.
Define hemorrhagic stroke.
Occurs when cerebral blood vessels rupture.
Which statement is true regarding neurologic changes in older adults?
Older adults may need more time to retrieve information.
Which principle should guide the nurse's decision regarding oral care for a patient with a tracheostomy during the first 24 hours postoperative?
Oral care is indicated to decrease the accumulation of organisms.
While in the treatment room, the patient says she needs to use the bathroom. The nurse delegates this task to the unlicensed assistive personnel (UAP). What is the best approach for the nursing assistant to take?
Place the patient on a bedpan and stay with her until she is finished.
What signs/symptoms classify the severity of a pit viper bite as "moderate?"
Presence of swelling beyond the site of bite, presence of nausea and hypotension.
The nurse enters a patient room in the emergency department and finds the patient is hostile, screaming, and making threats. What should be the nurse's first intervention?
Press the panic button in the room.
The home nurse is caring for an older patient with mild hypothermia at home. What first aid care does the nurse provide to the patient?
Provide warm high-carbohydrate liquids.
A patient calls the ER and tells you that he cut his finger off and is holding it in his hand. You tell him to...?
Put it in a sealed bag with one part ice and three parts water and come to the ER immediately.
What is the drug of choice for Myasthenia Gravis (MG)
Pyridostigmine
Nitrates can be given how often?
Q 5 minutes X 3
Which physiologic outcome describes the goal of topical sulfadiazine in the care of a patient with a burn injury?
Reduction of bacterial growth in the wound and prevention of sepsis.
Which physiological change in cystic fibrosis (CF) may cause airway obstruction?
Secretion of thick and sticky mucus.
While assessing a patient, the nurse notes that the patient's vagina and buccal and nasal mucous membranes are dry. The laboratory reports indicate the presence of elevated levels of IgM rheumatoid factor. The nurse suspects what syndrome?
Sjögren's Syndrome
A patient presents to the emergency department with facial trauma after a motor vehicle accident. The nurse notes extensive bruising behind the ears and suspects which of the following conditions?
Skull fracture and brain trauma
The nurse is assessing the wound of a patient who was burned while burning leaves in the yard. Which assessment finding of the burned areas on the patient's feet, legs, and hands suggests a deep partial-thickness injury?
The area is red and dry and blanches slowly when firm pressure is applied.
A patient is brought to the emergency department following a painful bite. A clinical test reveals myoglobinuria. What does the health care provider conclude?
The bite is from a coral snake.
When providing care to a patient with a recently placed tracheostomy who is on a mechanical ventilator, which principle guides nursing care?
The pilot balloon should be inflated.
A patient is scheduled to undergo a cerebral angiography. What is the purpose of this diagnostic test?
To detect a blockage in the arteries or veins of the brain.
Which cranial nerve (CN) is affected by trigeminal neuralgia?
Trigeminal (Cranial Nerve 5)
Which cranial nerve is located in the midbrain?
Trochlear (Cranial Nerve IV)
Which cranial nerve is responsible for eye movement via the superior oblique muscles?
Trochlear (Cranial Nerve IV)
Where does the BP need to be kept post CABG?
a certain range
Which ectopic hormone is involved in Cushing syndrome and may cause small cell lung cancer?
adrenocorticotropic hormone
At what point is someone considered "clear" of TB?
after 3 negative sputum smears
A patient is being treated for myasthenia gravis with bulbar involvement with a cholinesterase (ChE) inhibitor. The nurse instructs the patient to eat at least 45 minutes after the drug is given. What complication is the nurse helping to prevent?
aspiration
The nurse should use which color tags for patients who need priority emergency treatment during a disaster?
red tag
What are the duties of the nurse case manager in the emergency department (ED)?
Arrange appropriate referrals for the patient.
Which category of burn injury reflects deep partial-thickness burns affecting 20% of the total body surface area (TBSA)?
moderate burn
What is the role of decongestants in the treatment of a type I hypersensitivity?
reduce edema
For extubation, when do you remove the ET tube?
remove tube at peak inspiration
RACE
rescue, alarm, confine, extinguish
The nurse is caring for a patient experiencing an anaphylactic reaction to an intravenous (IV) infusion. Which action would the nurse take immediately after stopping the infusion?
Apply oxygen using a high-flow non-rebreather mask.
What is a true statement about the Prevnar vaccine?
it produces antibodies
Which of the following skin grafts are obtained from human cadavers?
allograft
PASS
pull, aim, squeeze, sweep
Which common restrictive lung disease is an example of excessive wound healing with loss of cellular regulation?
pulmonary fibrosis
Which does the nurse teach the patient is a modifiable risk factor for stroke?
obesity
As a direct result of overcrowding in emergency department (ED) environments, for whom must the emergency department nurse expect to provide care?
"Boarding" or holding inpatient patients.
Which statement made by the student nurse indicates a need for further teaching about the important factors of standard wound dressing and the number of gauze layers to be used?
"The number of gauze layers depends on the cause of the injury."
Elevate head of bed for at least __ minutes after eating to prevent aspiration during swallowing
30 minutes
What is the initial bolus dose of morphine through patient-controlled analgesia (PCA)?
5 to 10 mg of morphine
Lack of oxygen in the brain for _ to __ minutes results in permanent brain damage.
5-10 minutes
Which people are considered at higher risk for inheriting pulmonary arterial hypertension (PAH)?
A person whose sibling is affected.
A patient who is a Jehovah's Witness is admitted into the emergency department (ED) suffering from blood loss. Which nursing action is appropriate?
Administering volume expanders.
Which systemic signs of infection can be seen in the patient with burn injuries?
Altered level of consciousness.
Which best describes hydrocephalus?
An abnormal increase in cerebrospinal fluid.
The Osmitrol (mannitol) is in an IV solution of 15%. Which action should the nurse take when administering the Osmitrol (mannitol)?
An inline filter must be used when Osmitrol (mannitol) is prepared.
The triage nurse is assessing the acuity level of patients rushed to the emergency department. What sign or symptom reported by the patient prompts the nurse to classify the patient as emergent?
Chest pain with diaphoresis.
After surgical placement of a tracheostomy tube, what is the recommended method to verify placement?
Chest x-ray
Which food is commonly thought to be a trigger for migraine headaches?
Chocolate
What is the cause of classic heat stroke?
Chronic exposure to a hot, humid environment.
Areas of PPE that have or are likely to have been in contact with body sites, materials, or environmental surfaces where the infectious organism may reside.
Contaminated - outside front.
Which statement should the nurse use to describe cystic fibrosis when teaching a patient about the disease?
Cystic fibrosis is associated with the formation of thick mucus.
Which medication would the nurse administer for treatment of any type of seizures?
Divalproex (Depakote)
Which is the priority nursing intervention for maintaining mobility in a patient with burns to the head and neck?
Do not allow the use of pillows under the head or neck.
What nursing assessments are necessary prior to the discharge of an older adult patient from the emergency department (ED) to his or her home?
Evaluate for the risk for falls, perform a functional assessment, and screen the patient for depression.
Which drug should be prescribed to patients with dementia who experience hallucinations?
Haloperidol
Which virus is believed to be the cause of Bell's palsy?
Herpes Simplex Virus (HSV)
Osmitrol (mannitol) is administered. In response to the administration of Osmitrol (mannitol), you expect...?
Intracranial pressure (ICP) to decrease, cerebral edema to decrease, and urine output to increase.
Which device is most invasive for monitoring intracranial pressure?
Intraventricular catheter.
Which drug is given to a patient as an option to prevent early-onset seizure activity that may occur with some types of specific brain injuries?
Phenytoin
What brain injury is confined to a specific area of the brain?
focal injury
Which electrolyte abnormality does the nurse anticipate during the resuscitation phase in a patient with burn injury?
hyperkalemia
What two electrolytes disorders can lead to Dig toxicity?
hypokalemia and hypomagnesemia
For cardiac patients the preferred way to give meds is?
iv push
What surgery is a big risk for DVTs/PEs?
orthopedic, especially hip and knee
Which type of burns result in a reduction in the activation of vitamin D when exposed to sunlight?
partial-thickness burns
A patient with a burn injury due to a house fire is admitted to the burn unit. The patient's family asks the nurse why the patient received a tetanus toxoid injection on admission. What is the nurse's best response to the patient's family member?
"Burn wound conditions promote the growth of Clostridium tetani."
The nurse is teaching a patient who underwent surgery for mandibular fracture with inner maxillary fixation about self-care upon discharge. Which statement regarding self-management made by the patient indicates effective learning?
"I will cut the wires if I vomit."
The nursing instructor asks the student nurse to explain a type IV hypersensitivity reaction. Which statement by the student best describes type IV hypersensitivity?
"The reaction of sensitized T-cells with antigen and release of lymphokines activate macrophages and induce inflammation."
How many hours after death can a dead or decapitated snake inflict venom?
1
Artificial airway used usually no longer than __-_ days. A tracheostomy is considered at that time.
10-14 days
What is normal ICP?
10-15 mm HG
You can suction for how long?
10-15 seconds
At what core body temperature does the nurse stop cooling interventions for a patient with heat stroke?
102° F (39° C)
How many categories are on the National Institutes of Health Stroke Scale (NIHSS)?
11
If over 60, your patient should keep their BP below...?
150/90
Which nursing intervention should be initiated to prevent increased intracranial pressure (ICP)?
Administer a prescribed stool softener as needed (PRN).
To position a patient's burned upper extremities appropriately, how does the nurse position the patient's elbow?
In a neutral position.
Which statement is not applicable for Huntington's disease?
It is associated with an increased amount of dopamine levels.
Which description of minor burn wound care defines open technique?
The medication is applied on the burn without the dressing.
After a bomb blast, the injured patients were brought to the emergency department. Which health care team member will be responsible to assign order of priority to patients for providing care?
The triage officer.
What medications and treatments can be given for Aflutter?
antiarythmics, beta blocker, calcium channel blocker and treat with cardioversion and ablation
What medications and treatments can be given for Afib?
anticoagulants, antirythmics, beta blockers and treat with cardioversion
What are the three steps to stroke recognition?
ask the person to smile and stick out their tongue, ask the person to make a complete sentence, and ask the person to raise both arms
The nurse is educating a patient on safety regarding lightning strikes. Which patient statement requires further teaching?
"I should use a computer to warn my friends about lightning."
The nurse is working with a group of patients after an emergency event in the community regarding the potential for post-traumatic stress disorder (PTSD). Which statement of a patient indicates a need for further instruction?
"I will avoid talking about this event with others who also experienced it."
The nurse is teaching preventive measures to prevent drowning incidents. Which statement made by the patient indicates ineffective learning?
"I will make sure I swim alone."
What is the most appropriate response by the nurse when a patient's family asks about the time needed for the patient's deep partial-thickness burns to heal?
"It may take 2 to 6 weeks for the wound to heal."
A patient who will undergo a laryngofissure to remove a laryngeal tumor asks the nurse how the surgery will affect the ability to speak. What does the nurse tell this patient?
"People who have laser surgery will have a normal voice."
A patient who has severe migraine headaches will begin taking a triptan medication to treat this disorder. What does the nurse include when teaching the patient about this medication?
"Take it when symptoms first develop or during an aura."
The nurse is explaining desired outcomes of tumor management to a patient undergoing chemotherapy and radiation for a brain tumor. Which statement made by the patient indicates teaching was successful?
"The goal of chemotherapy and radiation for my cancer is to decrease tumor size, improve my quality of life, and to improve my survival time."
The registered nurse is teaching a student nurse about post-surgery management of a patient who underwent supratentorial surgery. Which statement made by the student nurse indicates ineffective learning?
"The patient should be placed in a supine position."
What is a regular BNP?
0-100
What is a normal INR?
0.8-1.2
Which value of the expiratory volume signifies a poor prognosis in patients with deep chest trauma?
10 mL/kg
What is door to EKG time?
10 minutes
What is a normal PT?
10-12 seconds
If under 60, your patient should keep their BP below...?
140/90
An expiratory volume of less than __ __/__ is considered to be a sign of poor prognosis. The chances of survival are very bleak.
15 mL/kg
The nurse is assessing the verbal response of a patient on a Glasgow scale. What score does the nurse determine when the patient makes incomprehensible sounds?
2
What is the only type of heart block that can be treated with atropine?
2 degree, type 1
What is a normal CVP pressure?
2-6 mm/hg
Patients who have been admitted to the emergency department (ED) are assessed by the ED triage nurse for an oncoming shift. Which patient is most appropriately assigned to an LPN/LVN?
24-year-old with heat exhaustion, receiving an IV of normal saline, with normal chemistry laboratory results and a temperature of 37° C
A patient spilled a large open frying pan of hot cooking grease and received burns to the entire anterior chest and abdomen, the entire anterior section of the left arm, and the anterior portion of the left leg from the groin to the knee. At what percentage of total body surface area does the nurse calculate the injury using the rule of nines?
25% to 27%
What is a normal PTT?
25-45 seconds
Which patient has the highest risk for developing a pulmonary embolism (PE)?
25-year-old woman who frequently flies internationally.
When a patient has a mechanical heart valve, their INR should be kept at...?
3-4
Alteplase should be given within how many hours from the onset of symptoms of stroke?
4.5
A minimum flow rate of _ L/min is needed for patients receiving oxygen via facemask to prevent the rebreathing of exhaled air.
5 L/min
After extubation, monitor patient every _ minutes; assess ventilatory pattern for respiratory distress.
5 minutes
C.Diff spores can persist on environmental surfaces for up to _ months
5 months
What is a normal GFR?
90-120 mL/min
During a CABG the patient should be kept at what temperature?
95-98 degrees F
What is a normal troponin?
< 0.5 mg/dl
What will the PCWP/PAWP pressure be in cardiogenic shock?
> 18 mm/hg
How long should an intubation attempt take?
>30 seconds
Which statement by the nurse leader best describes Parkinson's disease?
A chemical imbalance in the brain leads to movement and coordination problems.
Accredited health care institutions are required to take an "all hazards approach" to disaster planning. Which disaster drill uses this approach?
A hospital in North Carolina plans a response to a hurricane.
When caring for the patient with hypercarbia who is receiving supplemental oxygen, why must the nurse use caution with the rate of administration?
A lower arterial oxygen level provides the stimulus to breathe.
The nurse is caring for four patients. Which patient does the nurse anticipate might receive fibrinolytic therapy within a 3- to 4.5-hour window as recommended by the American Stroke Association?
A patient who is 60 years old.
Which assessment scale should a nurse use to record the responsiveness and consciousness of a victim who had been violently raped?
AVPU scale
Which seizure type is characterized as a generalized seizure?
Absence
A patient admitted to the emergency department following a snakebite tells the nurse that he did not see the snake. How does the nurse identify that the patient may have been bitten by a coral snake?
Absence of clear fang marks.
Which medication does the nurse expect to be ordered for the patient experiencing a mild migraine?
Acetaminophen or ibuprofen.
Which medical complication increases the risk for developing a seizure?
Acute alcohol withdrawal
A woman who is breastfeeding is diagnosed with rheumatoid arthritis. She does not want to stop breastfeeding. Which medication is safest for her to take?
Adalibumab (Humira)
The spouse of a patient who is scheduled for a tracheostomy is expressing concern regarding the surgery's impact on their quality of life. What should the focus of the nurse be at this time?
Addressing approaches for the patient to communicate with the tracheostomy.
Which patient outcome is the priority during the initial phase of treatment for a pulmonary embolism?
Adequate gas exchange and oxygenation.
Which action does the nurse take if a patient develops bradycardia during nasopharyngeal suctioning?
Administer 100% oxygen by bag-valve-mask.
A patient with a history of chronic obstructive pulmonary disease is admitted with shortness of breath. Which nursing intervention is most appropriate?
Administer oxygen via Venturi mask.
The nurse is coordinating care for a patient who was bitten by a black widow spider. Which nursing action is assigned to the LPN/LVN?
Administering tetanus toxoid vaccine intramuscularly.
Which factors contraindicate administering alteplase more than three hours after stroke onset?
Age older than 80 years, history of both diabetes and stroke, use of warfarin or other anticoagulants, or imaging evidence of middle cerebral artery involvement.
Which substance is prevented from crossing the blood brain barrier (BBB)?
Antibiotic
A patient is postoperative for craniotomy surgery to remove a tumor in the brain. The nurse notes periorbital edema and ecchymoses of both eyes. Which action is correct?
Apply cold compresses to both eyes.
The nurse is directing the care of a newly admitted patient who is severely hypothermic, but breathing on their own. What does the nurse advise the rapid assessment team to do first?
Apply electrocardiographic (ECG) monitor leads to monitor cardiac activity.
What first aid measure is appropriate for a brown recluse spider bite?
Apply ice packs.
What is the first intervention to be performed for a patient bitten by a black widow spider?
Apply ice packs.
Which nursing action would cause an "after-drop" in a patient with moderate hypothermia?
Applying a heating blanket.
A patient who needs oxygen therapy wants the cost to be reimbursed by Medicare. What criteria does Medicare use to cover the cost of home oxygen therapy for the patient?
Arterial oxygen saturation of less than 88% on room air, and/or artial pressure of arterial oxygen level of less than 55 mm Hg.
What is the best nursing intervention when talking with the family members of a patient who died suddenly in the emergency room?
Ask the family members if they would like to have a clergy member present.
How can the nurse ensure that an older patient, admitted to the emergency department (ED) after a fall, does not return to the ED with a similar incident?
Ask the patient to provide adequate lighting at home, and to avoid throw rugs.
What practice does a nurse follow to preserve evidence when treating a rape victim?
Asking the patient not to take a bath until after a physical exam.
Which assessment strategy does the nurse use to assess the function of cranial nerve VII?
Asks the patient to raise the eyebrows and grimace or puff the cheeks.
Which assessment intervention will the nurse implement specifically for the diagnosis or Guillain-Barre syndrome?
Assess deep tendon reflexes.
A patient with 32% total body surface area burns has a hematocrit of 54% 10 hours after a burn injury and 8 hours after fluid resuscitation was started. Which action would the nurse take?
Assess the patient's blood pressure and urine output.
What is the priority nursing intervention when caring for a patient who is a victim of interpersonal violence who is breathing and talking?
Assessing any threats to the patient's life with the standard ABCDE mnemonic.
Using a blunt object, the nurse gently scrapes the sole of the patient's foot from the heel to the toe. Which reflex is the nurse assessing?
Babinski's reflex
The nurse is assessing a patient with a chest tube following a pneumonectomy. Which assessment finding requires intervention?
Bandage around the posterior tube is loose.
A patient presents with severe angioedema of the lips, face, and tongue. Which medication is most likely to have caused this hypersensitivity reaction?
Benanzepril (Lotensin)
The nurse is caring for a patient with impending respiratory failure who refuses intubation and mechanical ventilation. Which method provides an alternative to mechanical ventilation?
Bilevel positive airway pressure (BiPAP)
Which method is used in assessing the measurement of burns in a patient whose weight and height are in proportion?
Body area is divided into multiples of 9%.
Which are expected findings in a patient experiencing a cholinergic crisis? Select all that apply.
Bronchospasms, excessive sweating, and abdominal cramping.
Women older than 50 with histories of migraines are at an increased risk for which type of disease?
Cardiovascular
Which test used for assessing the neurologic system involves the use of a contrast agent?
Cerebral Angiography
A patient with an artificial airway is receiving oxygen at a rate of 4 L/min. The nurse notes that a humidifier bottle between the oxygen source and the patient is half-full of sterile water and that the water is bubbling. Which action by the nurse is correct?
Change the humidification device to a heated nebulizer.
The patient with a tracheostomy who is using a T-piece mask reports a feeling of suffocation to the nurse. What is the first intervention that the nurse adopts in order to provide relief to the patient?
Check that the exhalation port is open and uncovered.
Which finding indicates a need for low-flow oxygen delivery for a patient?
Chronic hypercarbia
A patient is admitted to the emergency department with frontal-temporal pain, preceded by a visual disturbance. The patient is upset and believes it is a stroke. What does the nurse suspect may be occurring?
Classic migraine
The nurse is caring for a conscious patient with a fractured elbow following a fall at home. What does the nurse do to ensure a patent airway for the patient?
Clear the airway of secretion or debris.
While reviewing a patient's chart from the previous shift, the nurse reads the phrase, "The patient continues to demonstrate decorticate posturing." From this entry, what does the nurse expect the patient to exhibit?
Clenched fists and arms bent in toward the body, with wrists and fingers held on the chest.
A patient with a newly diagnosed brain tumor complains of a headache. What medication is likely to be prescribed for this patient?
Codeine and acetaminophen (Tylenol, ACE-Tabs)
Which topical agent is typically used on a burn wound for rapid debridement?
Collagenase
The nurse is providing reminders to a Red Cross class about safety procedures to prevent drowning or submersion. In which situation does this present the greatest risk?
College students going to a fraternity party at a boat house.
Assessment findings reveal that a patient admitted to the hospital has a contact type I hypersensitivity to latex. Which preventive nursing intervention is best in planning care for this patient?
Communicate the need for avoidance therapy to the health care team.
The provider is planning to discharge a patient home. The nurse suspects domestic violence as the cause of injury, although the patient denies this. What is the best course of action for the nurse to take?
Consult with Social Services.
The nurse assesses a patient with pneumonia who has been receiving oxygen 45% via Venturi mask for 2 days and notes dyspnea when getting to a chair and a nonproductive cough. The patient reports chest pain below the sternum and gastrointestinal (GI) upset. Which initial action by the nurse is correct?
Contact the provider to report these findings, since these are signs of oxygen toxicity.
Where do most PE's come from?
DVTs in lower extremities, but above the knee
What describes traumatic brain injury (TBI)?
Damage to the brain from an external mechanical force.
Neurologic changes associated with aging and vision include the need for additional light. What is the pathophysiology underlying this change?
Decrease in pupil size.
Which assessment finding for an older adult patient does the nurse ascribe to the natural aging process?
Decrease in respiratory muscle strength
What is the main focus with a patient with a rib fracture?
Decrease pain so that adequate ventilation is maintained.
Which physiologic effect may indicate mild carbon monoxide poisoning?
Decreased visual acuity.
A patient with a cuffed fenestrated tracheostomy tube has been speaking well when the decannulation cap is in place. While visiting, the family alerts the nurse that the patient is having difficulty breathing. Which action by the nurse has the highest priority?
Deflating the cuff
Which drug is usually administered to control cerebral edema?
Dexamethasone
A trauma patient has been brought in to the emergency department after sustaining severe injuries during a violent rape. What is the priority nursing intervention?
Establishing a patent airway by positioning, suctioning, and giving oxygen as required.
What is the nurse's first step when caring for any patient in an emergency?
Establishing a patent airway.
The nurse is reviewing the orders for a patient admitted with 25% body surface area burns. Which order does the nurse clarify with the health care provider?
Hold omeprazole.
Which part of the brain controls the functions of the "master gland"?
Hypothalamus
A patient with Alzheimer's disease is independent in activities of daily living (ADLs), has no social or employment problems, forgets names and misplaces items, and experiences short-term memory loss. The nurse documents that the patient is in which stage of the disease?
I
Which condition manifests as delirium in patients on mechanical ventilation in the intensive care unit (ICU)?
ICU psychosis
A patient with Alzheimer's disease is completely bedridden; has lost all motor and verbal skills; and cannot recognize family members. The nurse documents that the patient is in which stage of the disease?
III
A patient is scheduled to undergo desensitization therapy during which a very dilute solution of allergen (1:100,000) is injected. This process induces the formation of antibodies against the allergen. Which antibody is produced during this process?
IgG
The nurse is caring for a patient transported to the emergency room after sustaining burns to the arms from a fire. The nurse is unable to secure an intravenous access. What is the most appropriate nursing intervention?
Implementing an intraosseous normal saline infusion.
Define apraxia.
Inability to perform a previously learned set of coordinated movements, not related to paralysis or lack of comprehension.
Which alteration observed in a patient rescued from a fire indicates pulmonary injury?
Inability to swallow fluids.
Which are characteristics of a myasthenia crisis?
Incontinence, hypertension, and decreased urine output.
While the Rapid Response Team is at the bedside, the patient's healthcare provider arrives. The provider writes several orders. Which order is most important for the nurse to implement immediately?
Increase O2 to 3 L per nasal cannula.
What causes polycythemia in some people who remain in a high-altitude environment?
Increase in hemoglobin.
A patient receiving oxygen via a simple facemask has a pulse oximetry level of 96% and a respiratory rate of 14 breaths per minute. Oxygen is being delivered at a flow rate of 4 L/min. What is the correct action by the nurse?
Increase the oxygen flow rate to 5 L/min and review the provider's orders.
Which laboratory result is consistent with the diagnosis of Guillain-Barré syndrome (GBS)?
Increased protein in the cerebrospinal fluid.
A patient with burns who was admitted to the hospital 3 days ago develops paralytic ileus. Which pathophysiological phenomenon may be the cause of the patient's condition?
Increased secretion of epinephrine.
What is thrombophlebitis?
Inflammation of a vein with formation of a clot
A 2-year-old child falls into the community swimming pool and does not resurface. A lifeguard dives in to save the child. What does the lifeguard do first after the rescue?
Initiates rescue breathing on the child.
A patient with cardiovascular problems was admitted to the emergency department (ED). Which nursing action is appropriate?
Initiating drug therapy.
Which statement of the student nurse indicates inadequate understanding about precautionary measures to take while treating a patient with a history of allergic reaction during an emergency situation?
Intravenous fluid administration is avoided in the patient.
How does chest physiotherapy benefit a patient with cystic fibrosis (CF) through relieving symptoms?
It creates mini-coughs to dislodge the mucus from the lungs.
How does a hospital in the United States test its disaster preparedness according to mandates set by The Joint Commission in 2017?
It involves community-wide resources in at least two drills per year.
Which statement is true about primary pulmonary arterial hypertension?
It is also known as idiopathic pulmonary hypertension.
Which statement about trigeminal neuralgia (TN) is correct?
It is also known as tic douloureux.
Which statement best describes the pathophysiologic changes associated with Guillain-Barré syndrome (GBS)?
It is an immune disorder in which the immune system destroys the myelin sheath of peripheral nerves.
Which statement accurately describes the rationale for an Out-of Hospital Do-Not-Resuscitate Order?
It is an order that will prevent paramedics from starting cardiopulmonary resuscitation.
An emergency room nurse is working when she hears about a 60-car pileup on the expressway. The nurse knows that a military form of triage may be instituted. What is the rationale for using a military form of triage?
It is based on doing the greatest good for the greatest number of people.
What is the purpose for using magnetic resonance spectroscopy (MRS)?
It is used to detect abnormalities in the brain's biochemical processes.
What is the best time to perform a closed reduction of a nasal fracture?
Just after injury and within 24 hours.
A 70-year-old male patient who underwent an open reduction internal fixation (ORIF) surgery experiences a seizure after 24 hours. Which drug can cause seizures related to its toxic metabolites?
Meperidine
Which clinical manifestation of the patient brought to the hospital following a snake bite would indicate that the patient is suffering from a pit viper's bite?
Metallic taste in mouth.
Which drug increases cardiac output by improving myocardial contractility?
Milrinone
What tool is ideal to test cognitive changes related to Alzheimer's disease?
Mini-Mental State Examination
Which Fowler's position is ideally recommended for a patient with pulmonary contusion?
Moderate Fowler's
A patient with a history of migraines will begin therapy with beta-adrenergic blocking drugs. Which information does the nurse identify as the priority?
Monitor pulse rate with this therapy.
Which region of the cerebrum controls voluntary function?
Motor cortex
Why might narcotics be avoided in a patient where you need to frequently assess neurological status?
Narcotics can mask signs and symptoms that are important indicators of neurological status.
Which organization offers training in disaster management to all levels of health care professionals?
National Disaster Life Support Foundation (NDLSF)
The nurse is caring for a patient whose medical record indicates moderate grade pit viper envenomation. What can the nurse expect to find in this patient?
Nausea and vomiting.
Which would be the initial radiographic findings in a patient with pulmonary contusion?
No opacity in the lobes or parenchyma.
A new nurse is learning about the nurse's role in a disaster as part of her orientation. Which statement about the nurse's role in a mass casualty incident is accurate?
Nurses may have to assume roles in making decisions for the most appropriate treatment of casualties.
The normal balance of the body's oxygen intake and delivery system can be disrupted when there is a problem with normal oxygen delivery. Which statement is true in these situations?
Oxygen administration will decrease the work of the heart to improve the delivery of oxygen to vital organs.
After consulting with the provider, the following orders are received: Full liquid diabetic diet IV fluids 1000 mL .9 NS at 60 mL/hr Oxygen at 2 L per nasal cannula Blood cultures × 3 and urinalysis Tylenol grain × every 4 hour for temperature above 101º F Cefazolin (Ancef) 1 g IVP every 8 hour
Oxygen at 2 L per nasal cannula
When the ED physician is notified of the patient's manifestations, and she is moved immediately to a treatment room. The physician writes the following orders: O2 at 2 L per nasal cannula Stat CBC, BMP, d-dimer, aPTT, INR Stat CT of the chest Start a saline lock Which order takes priority at this time?
Oxygen at 2 L per nasal cannula
What should be available in the home for patients susceptible to a myasthenia crisis?
Oxygen, suctioning equipment, and a manual resuscitation bag.
While suctioning a patient, vagal stimulation occurs. What is the appropriate nursing action?
Oxygenate the patient with 100% oxygen.
The nurse assists with the intubation of an 80-kg patient who will receive mechanical ventilation with positive end-expiratory pressure (PEEP) ventilation. When monitoring the patient, the nurse ensures that which settings are maintained?
PEEP pressure between 5 and 15 cm H 2O
Which value indicates clinical hypoxemia and the need to increase oxygen delivery?
PaO 2 of 65 mm Hg
A golfer who is caught in a thunderstorm is struck by lightning. A fellow golfer, who is a nurse, runs to the victim's aid. What does the nurse do initially?
Palpate to check for the presence of a pulse.
What are the ABGs for Acute Respiratory Failure?
Pao2 <60 mm Hg Sao2 <90%; or Paco2 >50 mm Hg with pH <7.30
When assessing the adequacy of a patient's oxygenation, which information is important for the nurse to note?
Partial pressure of arterial oxygen (PaO 2)
A patient has sustained a burn injury affecting 15% of the total body surface area (TBSA). The entire epidermis is affected, but there is no damage to the eyes, ears, feet, hands, or perineum. Which description accurately defines the severity of the burns?
Partial-thickness wounds at a moderate level.
Define expressive aphasia.
Patient understands what is said but difficulty responding—use of small phrases
A patient calls the nurse to report a nosebleed that started with a sneeze. What does the nurse do first?
Position the patient upright and leaning forward over an emesis basin.
The nurse assesses a patient who is suffering from dementia and metabolic disorders. Which diagnostic test will be most beneficial to assess the patient's condition?
Positron Emission Tomography (PET)
Which protective gear is most important when caring for patients with tuberculosis or other airborne pathogens?
Powered air-purifying respirator (PAPR)
What is the most essential intervention performed by the nurse to prevent complications when administering mafenide acetate topically for a patient with burn wounds?
Premedicating for pain before application of the drug.
What is the role of the second chamber in a chest tube drainage system?
Prevents air from reentering the patient's pleural space.
When a patient is on a ventilator and wakes up and is attempting to breathe at a rate other than what the ventilator is set to, which drug is administered?
Propofol
Which is the emergency department nurse's priority action when caring for a patient with head, neck, and facial trauma resulting from domestic violence that has already been established a patent airway?
Protecting the cervical spine in positioning the patient.
A patient with heat stroke is admitted to the emergency department with a body temperature of 106° F. While using the rapid cooling method to reduce the body temperature in the patient, the nurse notices that the patient is shivering. What action should the nurse take?
Provide a parenteral benzodiazepine.
How does the nurse ensure a patent airway for a patient with significantly impaired consciousness?
Provide an endotracheal tube and mechanical ventilation.
A patient who has been in a car accident is unconscious and is admitted to the emergency department (ED). What is the priority nursing intervention after an airway has been established?
Provide special identification to the patient.
What is the role of a forensic nurse examiner?
Recognize evidence of physical abuse.
What does the nurse understand about scorpion stings?
Scorpion stings have neurotoxic effects.
A patient with Alzheimer's disease is exhibiting signs of depression for the first time. Which type of drug does the nurse anticipate will be prescribed?
Selective serotonin reuptake inhibitor
Define receptive aphasia.
Sensory speech problem. Patient can't understand spoken or written. May talk but inappropriate context.
Which factor differentiates full-thickness wounds from deep full-thickness wounds?
Severity of edema.
A patient is exhibiting shivering, slurred speech, and clumsiness. The nurse suspects the patient has hypothermia. What steps should the nurse take according to the American Heart Association (AHA)?
Space administration of medications at longer intervals, keep in mind that drug toxicity may occur when giving medication, and initiate cardiopulmonary resuscitation (CPR) if circulation is impaired.
The nurse is providing care for a patient diagnosed with Parkinson Disease (PD). Which stage of PD is characterized by bilateral limb involvement with a masklike face and a slow, shuffling gait?
Stage 2
MI s/s are...?
Substernal CP Radiating Lt Arm, back or Jaw Occurring without cause usually in AM Relieved only by opioids or intervention Last > 30 min N/V, diaphoresis, fear, anxiety, dysrhythmias, fatigue, epigastric distress, SOB
As the assessment is completed, the nurse observes that the patient has a large amount of thick secretions visible in the trach. What is the priority nursing action?
Suction the artificial airway and remove the secretions.
An older adult patient is being discharged home with a tracheostomy. Which nursing action is an acceptable assignment for an experienced LPN/LVN?
Suction the tracheostomy using sterile technique.
The nurse documents that a patient with a brain tumor has developed papilledema. What is papilledema?
Swelling of the optic disk.
Which division of the nervous system activates the mechanism of "fight or flight" response?
Sympathetic Nervous System
A patient's brain tumor has increased in size and is placing pressure on the pituitary gland. The nurse is alert for which manifestation indicative of pituitary gland dysfunction?
Syndrome of inappropriate antidiuretic hormone.
A patient has developed a type IV hypersensitivity reaction. Which immune cells or components are involved in this type of reaction?
T-cells
A patient is getting ready to go on vacation in the Colorado mountains. What education does the nurse provide to the patient about the use of acetazolamide?
Take the drug to acclimatize faster to high altitudes.
A patient comes to the emergency department covered with coagulated blood and a white powder. The patient is hysterical and fears that it is anthrax. What does the nurse do first?
Takes the patient to the decontamination room.
Which drug can be used to differentiate whether a patient is experiencing a myasthenic crisis as opposed to a cholinergic crisis?
Tensilon
A 3-year-old child was injured when placed in extremely hot bath water. The water was more than 50 °C. The child's skin was yellow at the injury site with severe edema and pain. What should the nurse infer?
The child has full-thickness wounds.
Who is responsible for determining the number of staff needed to care for the anticipated victims of a mass casualty situation?
The medical command physician.
If a patient has a traumatic brain injury (TBI) with ataxia, what does that mean?
The patient has a loss of balance.
Which dietary guideline must be followed for a patient with a large burn area?
The patient who can eat solid foods should be encouraged to ingest as many calories as possible.
When the inner cannula is removed from a fenestrated tracheostomy tube, what is an expected patient function?
The patient will be able to speak.
The nurse reads the patient's health record and sees that the patient's brain is contused. What does the nurse infer from this?
The patient's brain is bruised.
A patient was involved in a car crash and sustained an injury to the left side of the head. The patient is experiencing a severe headache, nausea, and vomiting. The Glasgow Coma Score of the patient is 10. The patient underwent neurological assessments and tests which revealed diplopia, decrease in level of consciousness, and ovoid pupil. What would the nurse infer from the patient's condition?
The patient's optic chiasma or optic tract is damaged.
A patient with a tracheostomy has been weaned off of the mechanical ventilator and now has a decannulation cap over the end of the tracheostomy tube. What additional finding does the nurse note when assessing the patient?
The pilot balloon is flat.
Which cells stimulate the fight or flight response?
The sympathetic nervous system (SNS) cells originating in gray matter from T1 through L2 or L3.
Which nursing student statement regarding the role of the psychiatric crisis nurse team indicates a need for further teaching?
The team collects forensic evidence.
In the military form of triage, why are "expectant" patients attended to after others receive care?
They are highly critical with little chance of survival.
What is Raynaud's Syndrome?
Vascular vasospasm brought on by exposure to cold or stress. Vasoconstriction results in coldness, pallor pain.
What are the three components measured by the GCS?
Verbal response, motor response, and eye opening.
What neurological changes are associated with the prodromal phase of a migraine headache?
Vertigo, aphasia, and an acute confusional state.
Which symptoms can be present with a transient ischemic attack (TIA)?
Vertigo, aphasia, and blurred vision.
Define hemiparesis
Weakness on one side of the body.
The nurse is assigned to a patient who has just arrived in the emergency department (ED). The patient is diagnosed with tuberculosis (TB). What action should the nurse take?
Wear a powder air-purifying respirator (PAPR).
What is the greatest priority while providing care to a patient with a tracheostomy?
When changing the ties, having someone assist by holding the tube until it is securely stable.
When does the acute period of Guillain-Barré syndrome end?
When no further deterioration occurs.
What is actually used first to diagnose PE?
a CT scan
What medication can be given to decrease heart rate in Sinus Tachycardia?
a beta blocker
Your patient has a positive stress test. What's next?
a cardiac cath
What is the appropriate intervention for a 3rd degree heart block?
a pacemaker
You are working in the ER when a man walks in. During admission he tells you that he recently had a long flight from CA a week ago, and when driving today had a "bad feeling," and knew he needed to come in. Based on this information alone, you suspect?
a pulmonary embolism from a DVT
Two hours later, the patient is admitted to the medical unit where she is started on a continuous IV heparin weight-based protocol. Which finding indicates that the heparin infusion is therapeutic?
aPTT is 1.5 to 2.5 times the control
A patient with a history of seizure activity experiences a few seconds of loss of consciousness with blank staring. During the brief episode, the patient also exhibits lip-smacking. The nurse correctly classifies this as which seizure type?
absence
A patient is receiving plasmapheresis through a shunt in the right arm for Guillain-Barré syndrome. The nurse should notify the physician of which abnormal finding?
absence of a bruit
What teaching is essential when you have a patient on calcium channel blockers?
absolutely no grapefruit or grapefruit juice
A patient has developed serum sickness. What is the most likely cause?
antibiotic therapy
With cardiac hypertrophic myopathy you need to tell your patient to report?
any dizziness
Which is a clinical manifestation of a cerebral tumor?
aphasia
Which motor manifestations occur that affect mobility in the patient with Guillain-Barré syndrome?
ataxia
The nurse is preparing to discharge a patient with myasthenia gravis. What self-management activities should the nurse include in the discharge education to prevent exacerbations of myasthenia gravis?
avoid heat and plan rest periods
A patient presents to the primary healthcare provider's office with fever, ear pressure, sore throat, nasal congestion, and poor response to decongestants. What condition does the nurse suspect?
bacterial rhinosinusitis
Which assessment finding is associated with obstructive lung disease and not with interstitial lung disease?
barrel chest
The nurse is providing care to a patient with a skull fracture. The nurse notes leakage of fluid from the patient's nose and ears. The magnetic resonance imaging report indicates hemorrhage and damage to the anterior and middle fossal regions of the brain. Which type of fracture does the nurse suspect?
basilar skull fracture
Which class of drugs would be administered to a patient experiencing a constant, dull, and burning phantom limb pain (PLP)?
beta blockers
The nurse is caring for a young patient who was bitten by a spider after playing in a pile of rocks outside. The child described the spider as having a red spot on its back. Which kind of spider most likely bit the child?
black widow
Which arthropod bite is associated with latrodectism?
black widow spider
To some degree, most patients with chronic obstructive pulmonary disease (COPD) have which pathologic processes present?
bronchitis and emphysema
The patient with myasthenia gravis is undergoing Tensilon testing. The nurse is alert for the possibility of which complication?
cardiac dysrhythmias
The nurse is caring for a patient who is experiencing tachypnea followed by periods of apnea. Assessment findings include nonreactive pupils and an abnormal protrusion of the brainstem into other brain tissue. The nurse identifies that the patient is experiencing what complication?
central herniation
Which complication results from changes in capillary endothelial tissue permeability, allowing the plasma to seep into the extracellular spaces?
cerebral edema
If you get a reading of asystole the first thing you should do is...?
check your patient
Dispersal of toxic chemical agent into the environment is...?
chemical exposure
What is often the treatment of choice for small cell lung cancer?
chemotherapy
Which procedure would be beneficial in confirming a hemothorax in a patient who suffered blunt chest trauma?
chest x-ray
What do you teach your patient to do for new onset angina at home?
chew 325mg of aspirin (81mg x 4) and call 911
You receive a patient with orders for both heparin and lovenox. You...?
clarify the order with the physician
Which brain injury is caused by blunt force?
closed traumatic brain injury
Abuse of which substance is most likely to result in a hemorrhagic stroke?
cocaine
A patient is admitted to the emergency department after prolonged exposure to extreme cold. Both feet are numb, cold, and nonblanchable. The skin over the feet is red and blue. Both feet are swollen. The nurse recognizes that the patient is experiencing what complication?
compartment syndrome
What type of seizure has symptoms similar to those of psychosis?
complex partial seizure
Which seizure is known as psychomotor seizure?
complex partial seizure
The nurse understands that which of the following is the most common symptom of pneumonia in the older adult patient?
confusion
In people over 80 the major s/s of a MI is...?
confusion or disorientation
Which assessment finding does the nurse interpret that is associated most closely with lung disease?
cough
Which therapy must be performed to open the skull and remove the tumor?
craniotomy
A patient reports a cough and limited exercise tolerance. Which disease does the nurse suspect in this patient when the diagnostic reports indicate the presence of Burkholderia cepacia?
cystic fibrosis
What is the most reliable indictor of fluid gain and loss?
daily weights
What is a symptom of moderate hypothermia?
decreased clotting
Your patient has a dysrythmia without a pulse that calls for a shock. As a prudent nurse, you know that this is called...?
defibrillation
Your patient has vtach without a pulse. You?
defibrilliate
Your patient is in vfib. You?
defibrilliate and give an antiarymthic
Which type of hypersensitivity is a cell-mediated immunity with T-lymphocyte as the reactive cell?
delayed hypersensitivity
The nurse is caring for a patient with a poison ivy skin rash. What type of hypersensitive reaction is the patient experiencing?
delayed reaction
The nurse is assessing a patient admitted with a stroke. What assessment finding would indicate that the patient experienced a stroke to the right hemisphere?
denial of the illness
What should be considered if the patient voids large amounts of very dilute urine with an increasing serum osmolarity and electrolyte concentration?
diabetes insipidus
What brain injury will be initially at a microscopic level and not detectable by computerized tomography (CT) scan?
diffuse injury
After a mechanical valve replacement how long does a patient need to be on Warfarin?
for the rest of their life
A patient gradually becomes weak, lethargic, and confused following a craniotomy. What electrolyte alteration may be causing the patient's status change?
hyponatremia
Which condition may occur as a result of fluid volume overload, syndrome of inappropriate antidiuretic hormone (SIADH), or steroid administration?
hyponatremia
The patient with a pulmonary embolism who is experiencing anxiety asks the nurse for a sedative. The nurse teaches that sedatives increase the risk for which complication?
hypoventilation
Low levels of oxygen in the blood is...?
hypoxemia
Which condition damages a patient's brain tissue and contributes to cerebral vasodilation and increased intracranial pressure (ICP)?
hypoxemia
Cancer and cancer treatments increase/decrease the risk for clots.
increase
Necrosis or cell death that occurs when severe ischemia is prolonged and decreased perfusion causes irreversible damage to tissue is...?
infarction
Leads II, III, and aVF portray the...?
inferior wall
If balloon is _______, it can interfere with passage of food through the esophagus
inflated
Which tumors produce ataxia, autonomic nervous system dysfunction, vomiting, drooling, hearing loss, and vision impairment?
infratentorial
Insufficient oxygen supply to meet requirements of myocardium is...?
ischemia
A positive D Dimer means...?
it can be indicative of a clot, but could also be caused by inflammation, etc.
How should nitro feel under the tongue?
it should tingle
While doing post mortem care, you are unable to get the patient's dentures in their mouth. You...?
label them accordingly and send them with the patient
Which surgical treatment has a high cure rate with a normal resulting voice quality?
laryngofissure
What position should your patient be in for an upper GI endoscopy?
left lateral Sim's
What position should your patient be in for an lower GI endoscopy?
left lateral decubitus position (drape pt for privacy)
To insure early recognition of increased intracranial pressure (ICP), which of the following assessments is MOST IMPORTANT?
level of consciousness
Vital organ donation (heart/lungs/liver): patient must remain on ____ _______ until harvesting.
life support
A patient's burn injury was caused by an exposure to pool chemicals. Which laboratory result does the nurse monitor closely for possible signs of organ injury?
liver function tests
What is the characteristic feature of minimal envenomation?
local swelling
What is the most important reason a patient with lung cancer should be handled carefully while the nurse repositions and ambulates him or her?
low bone density
A patient in acute respiratory failure is classified as having ventilatory failure. The nurse understands that which finding is a potential cause of ventilatory failure?
opioid analgesic overdose
Your patient in heart failure has some frothy pink-tinged sputum. As a prudent nurse you know that is a sign of...?
pulmonary edema
Which diagnostic test is used to determine the diffusion capacity in a patient with pulmonary arterial hypertension?
pulmonary function tests
In patients with lung cancer, what quality of sputum may occur if infection or necrosis is present?
purulent
What intervention needs to be done for a right sided EKG?
push fluids
Which type of hypersensitivity is anaphylaxis?
rapid hypersensitivity
A patient is receiving almotriptan for treatment of severe migraines. What is one of the potential side effects of this drug?
rebound headache
A patient with myasthenia gravis (MG) has undergone a thymectomy. For what complication will the nurse assess the patient?
respiratory distress
The inferior wall is supplied by the...?
right coronary artery in most of the population
Define cerebral edema.
↑in volume of brain tissue due to abnormal accumulation of fluid.
Why are agonist and beta-adrenergic drugs ineffective in treating asthma in older adults?
Because of decreased sensitivity of receptors.
Areas of PPE that are not likely to have been in contact with the infectious organism.
Clean - inside, outside back, ties on head and back.
The school nurse is educating children about preventing injury from lightning strikes. What does the nurse teach them?
Leave water when there is thunder.
Which level of trauma center is capable of providing total collaborative care?
Level I
In a mass casualty incident, a patient is given a black tag with the "expectant" category during disaster triage. How would this patient be classified in civilian triage?
emergent
Which rewarming method is used to treat severe hypothermia?
performing hemodialysis
What is afterload?
peripheral resistance against which the left ventricle must pump
What are the three phases of cardiac rehab?
phase 1 which is inpatient, phase 2 which is outpatient, and phase 3 which is independent
Which team member is authorized to decide where a patient will be sent after discharge?
physician
In patients with lung cancer, what quality of sputum may occur if bleeding from the tumor is present?
pink-tinged
A patient has developed a pulmonary embolism. The nurse anticipates orders for which lab values before beginning heparin therapy for this condition?
Partial thromboplastin time (PTT)
What is the regular dosing for Tamiflu?
Q12Hours x 5 days for anyone over 2 weeks of age. Dosing is weight based.
Which term is used to refer to the damage to the alveoli by an inflammatory response?
biotrauma
What tests are run to diagnose endocarditis?
blood cultures, echocardiography, and TEE
Which diagnostic test is not necessary for a patient presenting with a brain abscess?
bone scan
Which is a clinical sign of severe hypothermia?
bradycardia
Which arthropod bite is associated with "red, white, and blue sign"?
brown recluse spider
What is the most common type of cardiac myopathy?
dilated
What information does the nurse use on the identification band of a patient brought to the triage area of the hospital?
disaster number
Which is a clinical manifestation of brainstem tumors?
dysphagia
The older patient with coronary artery disease (CAD) is more likely to have what symptom if experiencing cardiac ischemia?
dyspnea
What is a normal potassium?
3.5-5
Door to needle time should be how long?
30 minutes
The nurse knows that under normal physiologic conditions of tissue perfusion, a patient will have what percent of oxygen dissociate from the hemoglobin molecule?
50%
A 70-year-old patient has an infected tibial fracture. What is the estimated healing time?
90 days
Autonomic dysreflexia (hyperreflexia) can be a life-threatening complication of spinal cord injury. The most common precipitating cause is...?
A distended bladder or rectum.
Which patient should the nurse refer to a social worker before discharge from the emergency department?
A patient who was treated for bruises and cuts after being attacked by a spouse.
Four patients who sustained injuries during mob violence are admitted to the emergency department. Which will require an endotracheal tube and mechanical ventilation for breathing?
A patient with a Glasgow Coma Scale (GCS) score of 7.
Which patient condition would necessitate the nurse to wear latex-free gloves when providing care?
A patient with spina bifida.
Which member may be designated as the team leader of a critical incident stress debriefing (CISD) team during a mass casualty incident?
A person who has a background in a mental health or behavioral health field.
The nurse is caring for a patient admitted to the ED after experiencing a fall while rock climbing. The patient has several facial fractures. Which objective assessment finding requires immediate intervention?
Clear glucose positive fluid draining from nares.
What is the goal of abortive therapy in migraine headaches?
Alleviating pain during the aura phase.
Which drug may induce idiopathic pulmonary fibrosis?
Amiodarone
Which drug is contraindicated in older adult patients with Alzheimer's disease (AD) who develop depression?
Amitriptyline
Which statement about brain abscesses is correct?
An electroencephalogram (EEG) shows electro-cerebral silence in the area of abscess.
A registered nurse is providing care for a patient admitted with status epilepticus who has a recent history of craniotomy. What is a craniotomy?
An incision into the cranium.
An escharotomy must be performed in a patient admitted for burns. Which statement accurately describes this procedure?
An incision is made through the burn eschar.
What is the best explanation of an open traumatic brain injury (TBI)?
An injury in which the skull is fractured.
Which statement best describes an aura?
An unusual sensation before the seizure occurs.
A comatose patient is receiving oxygen via a simple facemask. Which nursing action is a priority for this patient?
Assessing the oropharynx for secretions and vomitus.
The nurse is recording the output from a Hemovac drain of a patient one-day postoperative following infratentorial craniotomy. For the past eight hours, the total amount of drainage is 45 mL. What action should the nurse take?
Continue to monitor the output.
A patient with COPD who has been receiving oxygen via nasal cannula is becoming increasingly dyspneic with increased use of accessory muscles to breathe. The nurse auscultates markedly diminished breath sounds in all lung fields. The nurse correctly notifies the provider and discusses which oxygen delivery method for this patient?
Continuous positive airway pressure (CPAP)
What is the purpose of vagal nerve stimulation (VNS) in the treatment of seizures?
Controls the occurrence of simple or complex partial seizures.
Which environmental injury can cause elevations in creatinine kinase (CK) levels from muscle breakdown and myoglobinuria?
Coral snake bite.
A patient receiving antibiotic therapy for 2 months reports high fever, arthralgia, and rashes. Diagnostic reports of the patient indicate polyarthritis and enlarged lymph nodes. What is the best explanation for these clinical manifestations?
Deposition of immune complexes in blood vessel walls.
When caring for a patient with septic shock who has disseminated intravascular coagulation (DIC), the nurse anticipates which finding?
Elevated d-dimer levels.
What does the nurse teach the community about human waste management if toilets do not flush?
Emphasize the importance of using a hand sanitizer.
The nurse is caring for a patient admitted for treatment of neck and throat cancer. Which intervention should the nurse perform?
Encourage the patient to sit in a chair for meals.
The registered nurse teaches a student nurse about ways to reduce the risk of falls in a geriatric patient. The registered nurse should intervene when the student nurse performs what action when caring for an older adult with orthostatic hypotension?
Encourages the patient to ambulate.
A chest x-ray is ordered for an ambulatory patient receiving nasal oxygen. What does the nurse do when transport personnel come to get the patient?
Ensure portable oxygen is in place before transport to radiology.
What is recommended as safe nursing practice when caring for a patient with a tracheostomy and T-piece?
Ensure that aerosol continuously comes out of the exhalation side of the T-piece.
When administering oxygen to a patient at 5 L/min per nasal cannula, which intervention does the nurse include in the patient's plan of care?
Ensure that oxygen bubbles through the water in the humidifier.
A "do not resuscitate" (DNR) patient has a nonrebreather oxygen mask, and breathing appears to be labored. What does the nurse do first?
Ensure that the tubing is patent and that oxygen flow is high.
The nurse is reviewing the diagnostic results of a patient with a suspected brain tumor. Which tumor type indicates it is malignant?
Ependymoma
A patient is admitted with an electrical burn injury. Which nursing intervention is a priority for this patient?
Evaluate the urine volume and color.
An RN is designated as a triage officer in a hospital. What action does the nurse take as triage officer?
Evaluates each patient to determine priorities for treatment.
Damage to which cranial nerve (CN) would lead to facial paralysis in the patient?
Facial (Cranial Nerve VII)
A patient sustained chemical burns and is admitted to the emergency room. The patient shows black coloring to the skin with severe edema and no damage to the eyes or face. Eight percent of the total body surface area (TBSA) is injured. What should the nurse infer about the degree of burn?
Full-thickness wounds at a moderate level.
Which types of burn injuries require grafting as a part of treatment plan?
Full-thickness wounds, and deep full-thickness wounds.
A patient with a burn injury is receiving treatment in the hospital. There is redness of the skin with moderate edema and pain. The symptoms do not decrease even after proper treatment for 6 weeks. Which type of burn injury uses grafting as a part of the treatment plan to reduce the healing time of the injury?
Full-thickness wounds, deep full-thickness wounds, and deep partial-thickness wounds.
Which drug is often used as adjunctive therapy to reduce the incidence of rebound from mannitol?
Furosemide
Which drug wafers may be placed directly into the cavity created during surgical brain tumor removal?
Gliadel
A nurse is assessing an adult patient in an inpatient unit. The patient states, "I came into the emergency department because I was experiencing numbness in my feet. On the way to the hospital, it got worse and went up my legs and I couldn't move them." What disease of the peripheral nervous system is the patient experiencing?
Guillain-Barré syndrome
Which question should the nurse ask to support the diagnosis of Guillain-Barre syndrome?
Have you had any type of cold or stomach flu in the last month?
What is the characteristic of a burn caused by brief contact with a hot plate?
Heals in about 2 weeks.
The nurse is using auditory-evoked potentials to assess a patient. What is this technique meant to detect?
High-frequency hearing loss.
On the EKG what is the difference between 2nd degree type 1 and 2nd degree type 2?
In type 1 the PR interval gets longer until it drops the beat and in type 2 the PR interval remains the same until it drops
What training does an Advanced Cardiac Life Support (ACLS) certification offer?
Invasive airway management skills and electrical therapies.
What is the desired outcome of a disease management program for patients with chronic conditions?
Keep the patient out of the hospital for as long as possible.
The nurse is assessing a patient with severe pet-induced allergy. The patient has two pet dogs. What action is the most beneficial for this patient?
Keep the pets out of the house.
What is an important assessment post cardiac cath?
LOC and mental status
A school bus overturns in a small, rural community that is served by a critical access hospital and one volunteer fire department. How is the incident of the overturned school bus categorized?
May be a mass casualty.
A mountain climber developed fatigue and weakness on the second day of the climb. On the fourth day, the client then developed a dry cough, cyanosis of the lips and nail beds, a heart rate of 90 beats/min, and a respiratory rate of 30 breaths/min. When the patient arrives at the hospital, which medication should the nurse anticipate being prescribed by the primary health care provider?
Nifedipine (Procardia)
Which principles are important for the nurse to remember about oxygen administration?
Nitrogen helps prevent alveolar collapse, as it doesn't cross over capillary membranes, and high levels of oxygen dilute the nitrogen in the lungs leading to alveolar collapse.
A patient presents with fang marks from a rattlesnake but no local systemic reactions. Which envenomation grade does the nurse assign this patient?
None
Which method must be employed during hydrotherapy for the debridement of a wound in the patient with acid burns?
Nonviable tissue must be removed by forceps.
When the patient arrives to the unit, she is assessed and is in acute respiratory distress. Her respirations are labored and her respiratory rate is 34. She states that she is severely short of breath. Her oxygen saturation is 82% on O2 at 2 L via nasal cannula. Based on these findings, what should the nurse do next?
Notfiy the Rapid Response Team, and stay with the patient.
The nurse is caring for a patient the day after tracheostomy placement and notes new swelling around the tube. When gently palpating the area, the nurse feels a crackling sensation. What is the appropriate response?
Notify the health care provider immediately.
A patient arrives at the emergency department after a motor vehicle accident and indirect injury to the head. Upon assessment, it is discovered that the patient's increased intracranial pressure (ICP) is 18 mm Hg. What is the priority nursing action?
Notify the health care provider.
A patient who sustained a head injury in a motor vehicle crash several days ago has been active and talkative, and headaches have been well controlled with acetaminophen. When performing the daily assessment, the nurse observes increased dilation of the patient's pupils and notes a sluggish response to light. Which action is correct?
Notify the provider immediately.
Define embolic CVA.
Occurs when blood clot or clump lodges in vessel.
The next morning, the patient is taken to the cardiac catheterization laboratory. The cardiologist finds that there is an 80% blockage in the proximal LAD coronary artery. Which procedure is most likely to be performed to correct this condition?
PTCA with coronary artery stent placement
The nurse is discharging a patient with a prescription for continuous oxygen therapy via nasal cannula at home. What does the nurse include in the discharge teaching?
Pad the tubing behind the ears.
The nurse is caring for a patient with chronic renal impairment who presents with acute confusion, delirium, and bizarre thinking. Which intervention is appropriate to include in the patient's plan of care?
Placing a clock and calendar at the patient's bedside.
The nurse is giving discharge instructions to a patient who is Mexican-American. Which nursing action is appropriate?
Printing the instructions in Spanish.
Why might a patient's laboratory report show dilution of serum electrolytes?
Production of antidiuretic hormone from a different tissue.
While monitoring a patient with a burn injury the nurse observes that the cardiac output is 3.5 liters/minute. Which nursing intervention is done to prevent further complications?
Providing fluid replacement for the patient.
The risk for aspiration with a tracheostomy tube in place is related to which factor?
Proximity of the tracheostomy tube to the epiglottis.
The nurse is caring for a patient who was stung by a honeybee, and is sitting up and talking. What will the nurse do first?
Pull out the stinger and sac left in the patient.
Which action by the forensic nurse examiner is appropriate when a victim refuses to answer questions regarding domestic violence?
Respect the victim's response.
Which complication does the nurse suspect in a patient with cystic fibrosis?
Respiratory failure
Which are clinical manifestations of Guillain-Barré syndrome?
Respiratory failure and ascending paralysis.
A patient recently admitted to the hospital is to receive an antibiotic intravenously for the first time for a urinary tract infection. Before checking the five rights prior to administration, what is the nurse's first action?
Review the clinical records and ask the patient about any known allergies.
Which medication for the treatment of migraine headache would be avoided by a patient diagnosed with Prinzmetal's angina?
Rizatriptan
The nurse is evaluating a patient's equilibrium. When the patient stands with eyes closed, the patient begins to sway back and forth; with the eyes open, the patient remains erect. How does the nurse identify this assessment?
Romberg sign
Airborne precautions are for what 4 diseases?
SARS (Severe Acute Respiratory Syndrome), TB, Measles and Varicella
Which method of communication system would be beneficial when the nurse communicates the patient's status to the nurse working the next shift?
SBAR (situation, background, assessment, response)
Which condition occurs when the posterior pituitary gland releases too much antidiuretic hormone, causing water retention?
Syndrome of inappropriate antidiuretic hormone.
The nurse is caring for a patient who came to the hospital after being stung by a honey bee. The stinger is still in the patient's forearm. There are no objective signs of hypersensitivity related to the bee sting. What first aid measures does the nurse teach the patient to perform, should this event reoccur?
Use tweezers to pull out the stinger, but scraping it out with a credit card is preferred to avoid squeezing it.
While on the school playground, a child is stung by a bee, resulting in redness and swelling. The school nurse is nearby when it happens. What does the nurse do first?
Use tweezers to pull out the stinger, but scraping it out with a credit card is preferred to avoid squeezing it.
How do health care workers identify people of position in the chaotic work environment during an emergency situation?
Using brightly colored vests with large lettering.
Which cranial nerves are included in the assessment for dysphagia in a patient diagnosed with Guillain-Barré syndrome?
V (Trigeminal), VII (Facial), X (Vagus), XI (Spinal Accessory), and XII (Hypoglossal Nerve)
When is grafting required in the treatment of burn injuries?
When there is absence of skin cells.
An injury that is caused by an external force contacting the head, placing the head in sudden motion, is known as what?
acceleration injury
Which tumor arises from the sheath of Schwann cells in the peripheral portion of cranial nerve VIII?
acoustic neuromas
A patient who has thick, sticky respiratory secretions requires high-flow, humidified oxygen delivery. Which oxygen delivery equipment does the nurse use for this patient?
aerosol mask
The first emergency approach to all chest injuries is "ABC." What is the first part of this approach?
airway
Inhaled corticosteroids are typically used to treat which symptom of asthma?
airway inflammation
What meds is sodium bicarb not compatible with?
all of them
Which antidote is used for blocking fibrinolytic therapy?
aminocaproic acid
Which is an example of a type I hypersensitivity reaction?
angioedema
Which stroke syndrome includes personality and behavior changes?
anterior cerebral artery
Which abnormality occurs during embryonic development?
arteriovenous malformation
Which patient complication is most commonly associated with dysphagia?
aspiration
Which term is used to describe loss of balance in a patient with a brainstem or cerebellar injury?
ataxia
What causes aneurysms?
atherosclerosis, congenital defect, trauma to head, aging, and HTN1Q
What medication can be given to increase heart rate in Sinus Bradycardia?
atropine
What is the antidote for Tensilon?
atropine sulfate
Which type of grafting method is preferred in regards to reducing the risk of infection?
autograft
The nurse is assisting a patient who is learning to use the supraglottic method of swallowing after a partial laryngectomy. What does the nurse instruct the patient to do immediately after placing food in the mouth?
bear down
A patient is in the resuscitation phase of burn injury. Which route does the nurse use to administer pain medication to the patient?
intravenous
Among other findings, the physician determines that pupil response to light is not normal in one of your patient's eyes. Pupil changes that happen as a result of brain injury occur ______________ to the site of brain injury.
ipsilateral
What enzymes should you check on a patient recieving a statin?
liver enzymes
A hiker begins to feel ill within 48 hours after arriving at a resort in Colorado. Symptoms include poor activity tolerance, tachycardia, tachypnea, and a dry cough. Which treatment provides the most effective relief for this hiker?
lower altitude
What is the hallmark s/s of bleeding, especially after a cardiac cath?
lower back pain that radiates
Which is the leading cause of cancer-related deaths in North America?
lung cancer
Which diagnostic study is used to differentiate normal tissue from diseased tissue?
magnetic resonance imaging
A patient has intensive care unit (ICU) psychosis. What procedure is the most probable cause?
mechanical ventilation
A patient with Parkinson's disease (PD) has bilateral limb involvement, masklike face, and slow, shuffling gait. Which stage of Parkinson's disease does the nurse suspect in this patient?
mild stage
A patient reports feeling disoriented after having been hit in the head with heavy material from a construction site. Although the patient's MRI results do not show evidence of brain damage and the patient did not lose consciousness, the patient is unable to remember events immediately following the accident, including how the patient ended up at the hospital. The nurse understands that the patient most likely has which condition?
mild traumatic brain injury
What are the 4 categories you assess patients into for triage? (HINT: it's the Assess.)
minimally injured; those that will survive with delayed treatment; those that need immediate intervention, and dead or expected to die
A patient sustains severe burn injuries from contact with a hot liquid. Which type of burn injury would the nurse anticipate?
moist heat injury
A nurse administers endrophonium chloride (Tensilon) to a patient with myasthenia gravis to help determine definitive treatment for the patient. What finding indicates to the nurse that the patient is experiencing a cholinergic crisis?
muscle twitching
What is important to keep in mind when cardioverting an atrial dysrythmia?
must reach a theurapeutic level on the anticoagulants
Which is an example of a low-flow oxygen delivery system used for long-term therapy?
nasal cannula
What clinical manifestation related to respiratory difficulty does the nurse expect to observe in a patient who has experienced laryngeal trauma?
nasal flaring
The nurse is administering azathioprine to a patient diagnosed with idiopathic pulmonary fibrosis. What common side effect should the nurse assess for?
nausea
A patient is being admitted with severe respiratory distress and will require an Fio 2 greater than 80%. Prior to possible intubation and mechanical ventilation, the nurse anticipates using which oxygen delivery equipment?
nonrebreather mask
N95 masks should be fitted how often?
once a year
You suspect your patient has a DVT on their left calf. When applying SCDs you...?
only apply to the right leg, if at all
Which treatment strategy would be most beneficial to the patient with a hemothorax who has severe blood loss from the chest?
open thoracotomy
What is the priority care for the patient experiencing a migraine?
pain management
What is the priority of care for a patient with trigeminal neuralgia?
pain management
The nurse is assessing a patient who underwent a rewarming procedure following frostbite. What primary observation is indicative of compartment syndrome?
painful tingling
Which may be a typical clinical feature of a black widow spider bite?
papule
While observing your new admit, you notice "sucking inward" of loose chest area during inspiration, "puffing out" of same area during expiration. Being an attractive and prudent nurse, you know that this is...?
paradoxical chest movement
What is, arguably, the most important part of discharge?
patient (and family) teaching
What is the only contraindictation for an EKG?
patient refusal
