CEN Exam 5

88. A pt is brought to the ED by law enforcement after attempting to kill their brother with a knife. Presently the pt is calm, cooperative and following directions. While preforming the patients intial assessment, which of the following would be the highest priority for the ED nurse?: A. Offer the pt food or drink as soon as possible B. Approach the pt early with a display of a power attitude C. Have the pt undress completely D. Physically restrain the pt with soft restraints

C. Have the pt undress completely It is most important for all psych pts to undress completely and have their clothing checked, undergo a safety check kfor any items that could be used to harm oneself or others

70. A woman who is 39 weeks pregnant presents to the ED. Which of the following findings would alert the ED nurse that a vaginal delivery is imminent?: A. The pt states that her contractions are 3 mins apart and lasting a long time B. The pt reports an urge to push C. The pt reports feeling a "gush of water" 1 hour ago D. A pulsating ubilical cord is felt in the vagina

B. The pt reports an urge to push The urge to push is associated with the second stage of labor. The mothers desire to bear down usually indicates that delivery is imminent

69. While treating a pt with postpartum hemorrhage, the nurse adminsters 20 units of oxytocin per 1000ml of lactated ringers. The nurse recognizes that the desired effect of this medication has occured when: A. The pts blood pressure has decreased B. There is decreased vaginal bleeding C. The pt experiences a decrease in abdominal discomfort D. There is softening of the uterus

B. There is decreased vaginal bleeding Postpartum hemorrhage most commonly occurs as a result of uterine atony. Oxytocin is a vasoconstrictor that stimulates uterine contractions, improves uterine tone and reduces postpartum bleeding

54. When assessing a pt who presents to the ED complaining of bright red rectal bleeding, what question regarding the pts history is most important for the nurse to ask the pt?: A. " Are you diabetic?" B. " Do you have A-fib?" C. " Do you take NSAIDs?" D. " Do you take iron supplements?"

C. " Do you take NSAIDs?" Chronic ingestion of NSAID's is associated with a risk for GI bleed

23. A pt is recieving an enteral feeding. Which of the following statements indicates that the nurse understands the importance of keeping the head of the bed elevated?: A. " The head of the bed is elevated to increase pt comfort when sitting up in bed and eating" B. " The head of the bed is elevated to facilitate the tube feeding formula getting to the pt faster, thereby helping to reduce a negative nitrogen balance from lack of nutrients" C. " Keeping the head of the bed elevated helps to prevent aspiration pneumonia" D. " Keeping the head of the bed elevated prevents the feeding tube from becoming occluded as the tube feeding flows into the stomach"

C. " Keeping the head of the bed elevated helps to prevent aspiration pneumonia" Maintaining the pt in a supine position during enteral feedings can result in reflux and subsequent aspiration, leading the pneumonia . Pts recieving enteral feedings should be in a semi-fowlers position

44. The ED nurse is preparping to administer tissue plasminogen activator to a stroke pt. What percentage of the total dose should the nurse first administer to this pt as a bolus dose?: A. 1% B. 5% C. 10% D. 15%

C. 10% 10% of the 0.9mg/kg total dose is administered as a bolus over 1 min. The remaining 90% of the 0.9mg/kg is then administered over 60 mins

91. Which lab test would indicate that a pts psychotic symptoms may be related to a medical conditon and not a psychiatric condition?: A. A sodium level of 145 B. A potassium level of 4.0 C. A blood glucose level of 20 D. A calcium level of 10

C. A blood glucose level of 20 - Symptoms of severe hypoglycemia include pale skin, diaphoresis and an alterered mental status, which may cause severe confusion and hallucinations

42. A pt has been recieving an IV infusion of norepinephrine (Levophed) for the treatment of hypotension related to the presence of spinal shock following a fracture of throacic vertebrae 4 and accompanying spinal cord injury. Which of the following clinical signs would suggest that this intervention has had the desired effect?: A. The pt becoming less responsive B. Capillary refill of 4 seconds C. A systolic BP of 100 D. Urine output of 20ml/hr and 25 ml/hr over each of the past 2 hours

C. A systolic BP of 100 Hypotension and bradycardia are suggestive or spinal shock. Pts who have sustained a spinal cord injury resulting in sympathetic input experience no motor function, no sensation and a loss of reflexes below the level of the spinal cord injury. A systolic BP greater than 90mmHg is a recognized end point of shock resuscitation

41. Assessment of a pt who was thrown from a horse 1 hour before arrival to the ED reveals the pt is able to move their R leg but cannot feel pain or touch. They are unable to move their left leg but can feel pain and touch. The ED nurse is aware that this assessment finding is consistent with the following spinal cord syndrome?: A. Central cord syndrome B. Cauda equina syndrome C. Brown-Sequard syndrome D. Anterior cord syndrome

C. Brown-Sequard syndrome Brown-Sequard syndrome is characterized by the pt experiencing ipsilateral (same side) paralysis and loss of pressure, touch, and vibration sensation and a contralateral (Opposite side) loss of pain and temperature sensation

19. A pt recently discharged from the hospital following a 3 week hospitalization for a right femur fracture with internal fixator repair returns to the ED with a sudden onset of right calf pain. The nurse notes swelling and redness to the right calf. The nurse realizes that the pt is exhibiting signs and symptoms of what disorder?: A. Phlebitis of the right leg B. Postoperative infection C. DVT D. Compartment syndrome

C. DVT Swelling, pain and redness as well as a recent fracture with an extended period of immobilization, indicate that the pt is most likely exhibiting signs of a DVT

57. A pt is being treated in the ED for chonic liver diease related to cirrhosis. The ED nurse knows that the most common cause of cirrhosis is: A. Nonalcoholic or fatty liver disease B. Chronic Hep B C. Excessive alcohol consumption D. End-stage cardiac disease

C. Excessive alcohol consumption Alcohol consumption is a common cause of cirrhosis, Alcohol is absorbed in the small intestine, and blood transports it directly to the liver where it is then converted into a toxic chemical

51. Following a motor vehicle collision, an unresponsive male pt is recieved in the ED. On pt assessment, priapism is noted. Based on this finding, what intervention should the ED nurse preform first?: A. Ensure full spinal immobilization B. Insert a urinary drainage catheter C. Prepare the pt for an abdominal ultrasound D. Obtain IV access and begin fluid resuscitation

A. Ensure full spinal immobilization Priapism is a urological emergency that can occur as result of a spinal cord injury, tumor, sickle cell disease or the ingestion of phosphodiesterase inhibitors. The mechanism of injury and their inability to respond to commands would lead the nurse to suspect spinal cord injury

90. Which of the following statements made by a pt being treated for DKA would increase the nurses suspiscion that an untoward effect was occuring during the treatment phase?: A. " I seem to have developed a pretty serious headache in the past hour" B. " I feel like I need to urinate very badly" C. " Can I have something for this back pain that has been getting worse?" D. " I feel like I am aching all over"

A. " I seem to have developed a pretty serious headache in the past hour" A too rapid decrease in blood glucose level can cause cerebral edema, which could be indicated by the headache. The nurse should be on alert for any manifestations of increased ICP ( dizziness, visual disturbances, N/V, changes in speech)

46. On arrival to triage, a pt states they have experienced facial numbness and slurred speech, although the symptoms dissapeared just before arrival. The pt states that they no longer wish to be seen by the ED provider. In formulating a response to the pts wish to leave the dept, the ED nurse should state the following to the pt: A. " You have likley experienced a transient ischemic attack and therefore should be evaluated by the provider for appropriate care and follow up" B. " You should be evaluated by the provider since your symptoms will return in less than 24 hours" C. " You are experiencing a lacunar stroke and should immediately be evaluated by the provider" D. " A hemorrhagic stroke is the likely cause of your symptoms and you will deteriorate rapidly"

A. " You have likley experienced a transient ischemic attack and therefore should be evaluated by the provider for appropriate care and follow up" The pts symptoms have disappeared, including the possible presence of a TIA. The pt should be examined by the provider to evaluate the presence of associated risk factors and recommend appropriate follow up care

77. A young child presents to the ED with signs and symptoms of diabetic ketoacidosis. The ED nurse anticipates the need to correct the childs dehydration by administering which of the following IV fluids?: A. 10-20ml/kg sodium chloride IV over 1-2 hours B. 20ml/kg of 0.9% sodium chloride rapid IV push ober 15 mins C. 30ml/kg bolus of 0.9 sodium chloride IV administered over 1 hour D. 10-20ml/kg dextrose 5% with sodium chloride IV over 2 hours

A. 10-20ml/kg sodium chloride IV over 1-2 hours Isotonic IV fluid should be administered slowly over 1-2 hours to avoid cerebral edema

72. Following a precipitious delivery of a full-term infant in the ED, the infant is successfully intubated and adequately ventilated. The ED nurse would begin chest compressions if the infants HR is below which of the following?: A. 60-80 bpm B. 90-100 bpm C. 110-120 bpm D. 130-150 bpm

A. 60-80 bpm AHA guidelines are CPR is initiated if the infants HR is below 60 bpm

45. Which of the following assessment findings best describes the presence of a Le forte II fracture?: A. A pyramidall maxillary bone fracture involving the midface B. A transverese maxillary bone fracture occuring above the level of the teeth C. A complete craniofacial separation, including the maxilla, zygoma and orbits D. A fracture of the base of the skull, resulting in CSF leakage

A. A pyramidall maxillary bone fracture involving the midface A Le forte II fracture is a pyramidal maxillary bone fracture involving the mid face that traverses above the bridge of the nose

13. A 5 y/o weighing 33lbs (15kg) presents to the ED in cardiac arrest. The child remains in Ventricular tachycardia despite having been defibrilated 3 times, having recieved epinephrine 0.15mg IO and recieved good quality CPR. Which drug should be administered next?: A. Amiodarone (Cordarone) 75 mg IO B. Atropine 0.3mg IO C. Calcium chloride 1.0mL IV D. Lidocaine (Xylocaine) 50mg IV

A. Amiodarone (Cordarone) 75 mg IO Amio is the next drug used in a pt with pulseless V-tach. The pt should also recieve good quality CPR, be re-evaluated every 2 mins and be defibrilated as indicated

37. A young adult presents to triage with a fever, severe headache, and stiff neck. The ED provider diagnosis the pt with meningitis. The ED nurse is aware that the priority for this pt is the administration of: A. Antibiotics B. Acetaminophen (Tylenol) C. Morphine sulfate D. Osmitrol (Mannitol)

A. Antibiotics The priority medication management for a pt with meningitis, or any infection, is the prompt administration of antibiotics

63. Following the insertion of a large caliber gastric tube, which of the following nursing measures would best assist the nurse in intially determining that the gasttric tube has been properly positioned in the GI system?: A. Assessment of the pH of the gastric aspirate B. Auscultation of instilled air over the epigastrum C. Determination of the carbon dioxide level within the gastric tube D. Assessing the pt for signs or respiratory distress

A. Assessment of the pH of the gastric aspirate Current research supports the validity of gastric aspirate pH measurement to lead the nurse to initially determine that the gastric tube is most likely in the right spot

39. Which assessment parameter should be preformed on a 26 week pregnant female who presents with a tonic-clonic seizure?: A. Continuous electronic fetal heart monitoring B. Measurement of abdominal girth C. Pelvic ultrasound D. Measurement of fundal height

A. Continuous electronic fetal heart monitoring Continuous electronic fetal heart monitoring provides an overall view of maternal-fetal well being. The ED nurse is aware that the maternal patient must maintain compensated respiratory alkalosis for the placenta to carry O2 to the fetus. The mother may have experienced an episode of respiratory acidosis during the seizure, which could result in decreased oxygenation to the developing fetus

92. Which of the following lab trends does the ED nurse expect to be present in a pt diagnosed with disseminated intravascular coagulation?: A. Decreased platelet count, elevated d-dimer, prolonged prothrombin time B. Increased platelet count, elevated d-dimer and prolonged prothrombin time C. Decreased platelet count, increased fibrinogen and decreased d-dimer D. Increased platelet count, decreased d-dimer, prolonged prothrombin time

A. Decreased platelet count, elevated d-dimer, prolonged prothrombin time DIC results in a depletion of clotting factors due to diffuse microvascular clot formation. These clots are triggered by hemorrhage and dilution, often related to resusctiation after hemorrhage or the presence of a specific disease state

59. A pt presents with left-sided abdominal pain and is diagnosed with diverticulitis. The ED nurse would anticipate administering which medication to manage the pts symptoms?: A. A PPI B. An anticholinergic medication C. An antiemetic medication D. An antidiarrheal agent

B. An anticholinergic medication Anticholinergic meds reduce intestinal spasms and relieve the pain experienced by the pt with diverticulitis

30. A toddler presents to the ED triage with their parents. The child is sitting in a tripod position, drooling with stridorous respirations, and diaphoretic. The pt states that the child was playing when they suddenly heard the child coughing. The parent denies recent illness or ill contacts, past medical history is negative for similar episodes or chronic illnesses, and immunizations are up to date. The ED nurse recognizes that the child is most likely experiencing: A. Foreign body aspiration B. Acute asthma aspiration C. Acute epiglottitis D. Acute laryngotracheobronchitis (Croup)

A. Foreign body aspiration The parent does not report any illness or ill contacts. The history of events and assessment findings are consistent with a foreign body aspiration. Patients who have ingested a foreign body will present with a variety of symptoms that include coughing, apnea, wheezing, drooling and stridor. Airway management is priority assessment for this pt

40. What is the least important information for the ED nurse to obtain from a pt who has experienced a tonic-clonic seizure?: A. History of febrile seizures as a child B. History of current medications, alcohol use and illicit drug use C. Pregnancy status D. Family history of seizure

A. History of febrile seizures as a child The presence of febrile seizures as a child does not increase the risk for an adult to develop seizures, and most adults may not be able to recall this information

96. The pt presents to triage complaining of nausea, weakness and fatigue. The pt appears anorexic and has a hyperpigmentation to the knuckles and creases of the hands. The pts medical history includes the presence of Addisons disease, and the provider orders a dose of hydrocortisone to be administered. The ED nurse anticipates which of the following outcomes as a result of this medication?: A. Increase in BP B. Decrease in sodium C. Decrease in glucose D. Weight gain

A. Increase in BP This pt is displaying symptoms of adrenal crisis which can occur after cessation of prednisone. S/S: hypotension, tachycardia, fatigue, nausea, hyperpigmentation of knuckles, creases in hands, hyponatremia, hypoglycemia, hyperkalemia

4. Which of the following is a form of distributive shock?: A. Neurogenic B. Metabolic C. Respiratory D. Obstructive

A. Neurogenic

5. A pt presents following an acute onset of chest pain, dyspnea and severe diaphoresis, with near syncope. Assessment shows a pt in severe distress, with HR 110, BP 60/40 and RR 36 with bilateral rales. An EKG reveals ST segment elevation across the precordial leads. A diagnosis of acute MI with cardiogenic shock is made, and the pt is being prepared for transfer to the cardiac cath lab. The vasopressor of choice, based on this pts degree of hypotension is: A. Norepineprhine (Levophed) B. Dopamine (Inotropin) C. Dobutamine (Dobutrex) D. Vasopressin (Pitressin)

A. Norepineprhine (Levophed) The intial use of norepinephrine for marked hypotension, <70mmHg systolic is the current recommendation from the AHA

32. A tension pneumothorax leading to inadequate tissue perfusion is considered to be which type of shock?: A. Obstructive B. Hypovolemic C. Distributive D. Cardiogenic

A. Obstructive The increasing intrathoracic pressure of a tension pneumothorax results in compression of the lungs, heart and great vessels. Venous return decreases and cardiac output becomes inadequate, resulting in obstructive shock

29. A pt arrives by ambulance unresponsive after falling off a bicycle. The pt was not wearing a helmet at the time of the injury. Cervical spine immobilization is in place. During the primary assessment, the ED nurse observes loose teeth and vomitus in the mouth. To properly suction the pt, the ED nurse should: A. Open the airway using the jaw thrust maneuver B. Open the airway using the head tilt chin lift maneuver C. Insert an appropriately sized nasopharyngeal airway D. Place the pt in the "sniffing position" with the neck and chin extended

A. Open the airway using the jaw thrust maneuver When a cervical spine injury is suspected, the jaw thrust maneuver is the safest method to use in order to maintain cervical spine protection while a second person is suctioning the airway

49. A young male presents to the ED triage stating that he felt a "pop" in his head after lifting heavy weights. The pt now complains of a right-sided headache that he rates as a 10/10. The ED nurse notes that the pts right pupil is oval and sluggishly reactive to light. The ED triage nurse will next: A. Proceed with immediate bedding B. Place the pt in fast track C. Place the pt in the waiting room until a room becomes available D. Complete the medical screening exam in triage

A. Proceed with immediate bedding Subarachnoid hemorrhages typically occur in younger males and may be associated with a strenuous act. Pupillary changes are typically ipsilateral in the presence of a subarachnoid hemorrhage and result from compression of cranial nerve III

16. Which condition places the pt ar the highest risk for infective endocarditis due to a dental procedure?: A. Prosthetic cardiac valve B. Diabetes C. Congestive heart failure D. Rheumatoid arthritis

A. Prosthetic cardiac valve To reduce the incidence of infective endocarditis, it is recommended that pts with prosthetic valves, a previous history of infective endocarditis or congenitial heart disease receive antibiotic prophylaxis before dental procedures.

35. Which disease process is characterized by the presence of foreign material occluding one or more pulmonary blood vessels?: A. Pulmonary embolism B. Pulmonary edema C. Pneumothorax D. Pulmonary effusion

A. Pulmonary embolism PE is defined as the presence of foriegn material occluding one or more pulmonary blood vessels. The symptoms and signs of a PE include dyspnea, hypoxia, feelings of anxiety, and chest pain.

53. When assessing a pt with suspected appendicitis, the ED nurse would expect the pt to demonstrate rebound tenderness in which area of the abdomen?: A. RLQ B. LLQ C. RUQ D. Periumbilical area

A. RLQ Rebound tenderness in the right lower quadrent is most commonly associated with appendacitis

15. A female pt presents to the ED complaining of numb fingers and throbbing pain. The fingertips of both hands are noted to be light blue in color and pale to the touch. The pt denies both trauma and recent exposure to the cold. The pt is a 2 pack per day smoker and has a history of hypertension. Based on the assessment findings, the ED nurse should suspect the pt has which condition?: A. Raynauds disease B. Buergers disease C. Thrombocytopenia D. Inflammatory arthritis

A. Raynauds disease Raynauds disease is a blood vessel disease affecting the skin. Symptoms include numbness and pallor to the fingertips, nose and ears. Light bluish color discoloration can also be present. Smoking, being female and having hypertension are noted to be predisposing factors

6. A pt presents with complaints of chest pain that radiates to the jaw, stating the pain is a 6/10. Other symptoms include nausea, dizziness, shortness of breath with clear lung sounds, and a sense of impending doom. The pain started 40 mins before arrival. Vitals: BP 116/58, HR 98, RR 20, SpO2 94%, T 98.6F. The 12 lead EKG shows inferior wall myocardial injury pattern. Which clinical presentations indicate the need to complete a right sided 12 lead EKG?: A. Shortness of breath with clear lung sounds B. Nausea and dizziness C. Chest pain with radiation to the jaw D. Sense of impending doom

A. Shortness of breath with clear lung sounds Classic right ventricular infarcts are associated with the absence of pulmonary congestion Think: RIGHT to my foot

17. A clevidipine (Cleviprex) infusion is ordered for a symptomatic pt with severe hypertension. The nurse is aware that this medication would be contraindicated in a pt with which history?: A. Soybean or egg allergy B. Asthma C. Sinus Bradycardia D. Recent use of Sildenafil (Viagra)

A. Soybean or egg allergy Clevidipne is a calcium channel blocker used for blood pressure reduction. It is a lipid emulsion and is contraindicated in pts with allergies to soybean, soy products and eggs. Strict aseptic technique should be followed, and unused medication should be discarded within 12 hours of puncturing the stopper

22. To limit the recurrence of COPD exacerbations, it is important that patients should preform which intervention?: A. Stop smoking B. Exercise C. Take all medications as directed D. Get immunized against penumonia

A. Stop smoking Smoking irrritates the lung tissue, causing pulmonary inflammation and damages the alveoli. Continuous irritation decreases the lungs ability to function normally. Not smoking is the most important way to prevent further lung damage and limit the recurrence of COPD exacerbations

9. A pt presents with complaints of lightheadedness, weakness and near syncope. The pts 12 lead EKG reveals the presence of 2:1 arterial flutter. The most appropriate intervention for this presentation with arterial flutter rhythm is to preform: A. Synchronized cardioversion at 50 joules B. Unsynchronized cardioversion at 120 joules C. Unsynchronized cardioversion at 50 joules D. Synchronized cardioversion at 120 joules

A. Synchronized cardioversion at 50 joules Synchronized cardioversion is reccomended for rhythms with a normal width QRS complex. A pt with new onset atrial flutter, who is experiencing chest pain, shortness of breath or other symptoms of instability should be considered for cardioversion. A-flutter requires less energy to cardiovert than other dysrhythmias

78. A pt with myxedema coma is most likely to seek care in the ED in which season of the year?: A. Winter B. Fall C. Spring D. Summer

A. Winter Pts with hypothyroidism have an intolerance for cooler or cold temperatures, which is related to their decreaesed metabolism. Myedema coma is more commonly seen in winter because of exposure to cold temperatures or a cold environment

74. An adolescent is being evaluated for abdominal pain. When the mother leaves to make a phone call, the pt reveals to the nurse that they are being sexually fondled at school by a teacher. The priority nursing intervention for this pt is to: A. notify the appropriate child protective services or law enforcement B. Obtain consent from the mother to report the abuse to the appropriate agency C. Report the name of the alleged abuser to law enforcement immediately D. Discuss birth control and STI prevention with the pt

A. notify the appropriate child protective services or law enforcement Sexual abuse of children is a crime in all states. As a mandated reporter, the nurse has legal responsibiltiy to report alleged sexual assault to the appropriate local agency

97. The ED nurse is assessing a pt with a history of sickle cell disease. The pt tells the nurse that he is experiencing wheezing, fever, and shortness of breath. Which high morbidity complication of SCD would the nurse suspect this pt is experiencing?: A. Priapism B. Acute chest sydrome C. Cholecystitis D. Splenic sequestration

B. Acute chest sydrome Acute chest syndrome occurs when sickled-shaped RBC attach to the lung endothelium that is already inflamed and the failure of the lung tissue to be reoxygenated leads to additional inflammation and lung infarction. Symptoms include chest pain, dyspnea, fever, cough, wheezing, hypoxemia and pulmonary infiltrates

86. Which of the following interventions would the ED nurse expect to implement first in the pt who has developed signs of neuroleptic malignant syndrome?: A. Application of a cooling blanket B. Administration of a benzodiazepine C. Administration of a dopamine agonist D. Insertion of a urinary catheter

B. Administration of a benzodiazepine Pts who develop neuroleptic malignant syndrome should recieve immediate IV benzos. Pts with neuroleptic malignant syndrome will exhibit fever, muscle rigidity and altered mental status and dysfunction of autonomic nervous system

84. A pt from a skilled nursing facility is transported to the ED after sustaining a minor hand laceration; the bleeding has been controlled. The pt has recently been recieving high-dose chemotherapy for treatmemt of non-hodgkin's lymphoma. The most appropriate area in the ED for the pt to recieve treatment is in which of the following?: A. The waiting room B. An ED room with reverse isolation precaution C. Any available ED room D. A quick care or rapid care minor treatment area

B. An ED room with reverse isolation precaution The high dose chemo used to treat non-hodgkins and hodgekins lymphoma results in profound neutropenia. Protection from infections is of vital importance

3. An unrestrained driver is brought to the ED following a motor vehicle collision. The pt reports hitting their chest on the steering wheel and is complaining of chest pain across the front of their chest. There are no vital sign abnormalities and no other complaints of pain. The diagnosis of blunt cardiac injury is considered. The nurse anticipates an order for which of the following?: A. EKG B. Cardiac marker evaluation (CK or Troponin) C. Cardiac monitoring D. Chest radiograph

B. Cardiac marker evaluation (CK or Troponin) Not all trauma pts with blunt cardiac injury will have acute alterations in cardiac markers, and other organ injury may cause release of creatinine kinase and confound the diagnosis of blunt cardiac injury

20. The definition of preload is: A. End systolic volume B. End diastolic volume C. Systolic blood pressure D. Mean arterial pressure

B. End diastolic volume Preload is the amount of blood within the left ventricle at the end of diastole, or left ventricular diastolic pressure.

80. A pt is brought to the ED from an outpatient clinic following increasing agitation and the verbal and physical abuse of a staff member after being denied narcotics. The pt is speaking loudly and threatening to "blow up the place" if narcotics are not ordered to be given to him. The nurse has called the rapid response team. Which of the following indicates an initial desired patient response to the rapid response team intervention? The pt: A. Requests removal from physical restraints B. Follows verbal instruction C. Requires IM injection of an antianxiolytic medication D. Tolerates being placed in seclusion

B. Follows verbal instruction According to ENA, "workplace violence" in health care is 3.8 times higher than all private industry, with the ED being a highly vulnerable area

43. The emergency nurse is caring for a pt with a subdural hematoma. Which of the following assessment findings would indicate the presence of an early increase in intracranial pressure?: A. Dilated, nonreactive pupils B. Headache C. Bradycardia D. Decreased respiratory effort

B. Headache Early assessment findings of increased ICP include headache, nausea, vomiting, amnesia, behavioral changes and an altered level of consciousness

75. When caring for a pt who has recently been diagnosed with leukemia, the ED nurse should consider which assessment variation in this pt?: A. The sudden onset of initial symptoms is related to thrombocytopenia B. Hepatomegaly and splenomegaly are common assessment findings in a pt with leukemia C. Leukemia is a nonmalignant neoplasm D. Early symptoms of fatigue may be related to the presence of thrombocytopenia

B. Hepatomegaly and splenomegaly are common assessment findings in a pt with leukemia Leukemia cells may invade the liver and spleen, resulting in organ enlargement of both

1. A pt presents to the ED experiencing an anterior ST segment elevation MI. The pts vital signs are normal. The hospital is not equipped with a cardaic catheterization lab. The pt can be transferred to a cardaic catheterization lab within 60 mins. Which of the following would you anticipate for this pt?: A. A bolus of tissue plasminogen activator, followed by an infusion for fibrinolytic therapy B. Immediate transfer to the hospital with a cardiac catheterization lab for percutaneous coronary intervention C. A single bolus of tenecteplase (Tnkase) for fibrinolytic therapy D. A bolus of reteplase (Retavase), followed by a second bolus of reteplase 30 mins later for fibrinolytic therapy

B. Immediate transfer to the hospital with a cardiac catheterization lab for percutaneous coronary intervention In adult pts presenting with a STEMI of a hospital that does not have PCI capability, it is recommended that the pt be transferred immediately without fibrinolytics to a PCI center, instead of immediate fibrinolysis at the intial hospital with transfer onlu for ischemia driven PCI

65. The ED nurse would anticipate hospital admission for a pt newly diagnosed with renal calculi (renal stones) if the pt demonstrated which of the following?: A. Renal calculi size greater than 3mm B. Inability to tolerate oral fluids C. Pain D. Hematuria

B. Inability to tolerate oral fluids An increased intake of oral fluids is necessary to facilitate the passage of renal calculi. Pts who are unable to tolerate oral fluids will need to be hospitalized for IV fluids

98. Which of the following condititions is a rare, life-threatening and serious complication of hypothyroidism?: A. Adrenal crisis B. Myxedema coma C. Thyroid storm D. Cushings syndrome

B. Myxedema coma Pts complain of fatigue, SOB, weight gain and may expereince tongue swelling

71. The most characterisitic clinical finding in a pt with placenta previa is: A. Elevated BP B. Painless bright red vaginal bleeding C. Vaginal discharge of blood-tinged mucus D. Vaginal passing of tissue

B. Painless bright red vaginal bleeding Painless bright red vaginal bleeding is the msot characteristic clinical finding of placenta previa. In this condition, the placenta has implanted, either totally or partially, over the cervical os. The uterus is not contracting, so the bleeding is painless

94. An emergency pt has been diagnosed with thrombocytopenia. The ED nurse is aware the following lab value has been confirmed in this diagnosis?: A. WBC count of 8000 uL B. Platelet count of 5000 uL C. Platelet count of 900,000 uL D. WBC count of 26,000 uL

B. Platelet count of 5000 uL Thrombocytopenia is a very low platelet count (normal is 150,000-400,000)

67. Following the incision and drainage of a Bartholin's gland abscess, the pts discharge teaching instructions should include which of the following?: A. Your sexual partner will not need to be treated for this infection B. Take a sitz bath or soak in a bathtub with warm water several times a day C. You should follow up with your provider to have the drainage catheter removed in 24 hours D. Having an IUD puts you at greater risk for developing a Bartholin's gland abscess

B. Take a sitz bath or soak in a bathtub with warm water several times a day The pt should be instructed to use a sitz bath or soak in a warm tub for 10-15 mins 3-4 times a day

28. A pt presents to triage with complaints of throat pain, hoarseness and difficulty swallowing after sustaining a "clothesline" injury. The pt is having difficulty speaking and tolerating oral secretions and there is ecchymosis to the anterior neck. The ED nurse suspects that the pt may have a fractured larynx and provides appropriate instructions. The pt demonstrates understanding when: A. The pt requests ice chips for comfort B. The pt communicates by writing on a peice of paper C. The pt opens their mouth wide and sticks their tongue out for the nurse to inspect D. The pt states a detailed description of the injury

B. The pt communicates by writing on a peice of paper Resting the voice will increase the pts comfort and reduce swelling and inflammation to the airway

58. The ED nurse has administered lactulose to a pt with hepatic encephalopathy. The nurse is able to determine that the medication has been effective if the pt exhibits which of the following?: A. Decreased pain B. Increased urine output C. Improved mental status D. Diminished deep tendon reflexes

C. Improved mental status Hepatic encephalopathy occurs as a result of the livers inability to remove ammonia from circulation. Symptoms include personality changes, memory loss, irritability, agititation, decreased level of consciousnes. Lactulose works to lower the pH in the colon and inhibit the diffusion of ammonia into the bloodstream

2. An anxious pt arrives by ambulance following an acute onset of difficulty breathing. The pt is diaphoretic and denies chest pain. High-flow O2 by non-rebreather mask has been applied. Vitals: BP 210/140, HR 130, RR 32, SpO2 88%. In addition to initiating noninvasive ventilation to treat the pts difficulty breathing, the nurse anticipates the administration of which medication to further treat the pts symptoms?: A. Morphine (Morphine sulfate) B. Furosemide (Lasix) C. Initation of a continuous nitroglycerin infusion D. Acetylsalicylic acid (Aspirin)

C. Initation of a continuous nitroglycerin infusion Pts who present with acute pulmonary edema are typically markedly hypertensive and in acute respiratory distress. Rapid initiation of appropriate treatment is vital to reversing the neurohormonal surge and rescuing pts from respiratory and complete cardiac failure. Nitroglycerin is the most important first line medication in treatment of acute pulmonary edema and respiratory distress. The initation of continuous NTG infusion at low doses acts as a vasodilator, leading to decreased preload: at higher doses ( >100mcg/min) acts as a potent afterload reducer

8. During transcutaneous pacing for a pt in third-degree heart block, there is a loss of ventricular capture. Which is a significant physiological reason for loss of a pacemaker capture?: A. Metabolic alkalosis B. Hypomagnesemia C. Lactic acidosis D. Hypokalemia

C. Lactic acidosis Lactic acidosis alters the contractility of the myocardium, leading to decreased abilty to gain ventricular capture, this results in lack of tissue perfusion

21. A pt with a history of asthma has audible wheezing, tachypnea and pale, cool skin that persists following the administration of an albuterol nebulizer breathing treatment. What medication would the ED nurse anticipate giving next to this pt?: A. Etomidate via IV push B. Oral prednisone C. Magnesium sulfate via IV infusion D. Oral ibuprofen

C. Magnesium sulfate via IV infusion Magnesium sulfate inhibits calcium influx into airway smooth muscle cells, thus allowing for bronchodilation. Magnesium sulfate is used in the treatment of severe asthma exacerbations for pts who are not responsive to conventional treatments

68. A female presents to the ED with complaints of right lower abdominal pain and is diagnosed as having a unruptured ectopic pregnancy to the right Fallopian tube. The pts vitals are stable, and the ectopic pregnancy is estimated to be 3.0cm in size. A nonsurgical treatment to terminiate the pregnancy is recommended. The nurse anticipates that the pt will recieve which medication?: A. Rh immune globin B. Oxytocin (Pitocin) C. Methotrexate D. Medroxyprogesterone (Provera)

C. Methotrexate Methotrexate is an antimetabolite that prevents further duplication of the fetal cells. It is administered IM and reh pt is then followed with quantitative HGC levels

12. Initial interventions for a pt diagnosed with acute aortic dissection include 2 large caliber IV's, O2 and aortic wall pressure control with beta blocker administration. Maintaining which assessment finding is a priority for determining end organ perfusion?: A. HR below 60 B. Systolic BP above 120mmHg C. Normal mental status D. Urinary output above 30ml/hr

C. Normal mental status Determining the pts mental status is an important finding in determining adequate end organ perfusion. Clinically, the pt must be assessed frequently for hemodynamic compromise, mental status change, neurologic or peripheral vascular changes and developement or progression of carotid, brachial and femoral bruits to establish the presence of continued adequate organ perfusion

14. The ED nurse is caring for a pt with a permanent pacemaker and observes that the pt has a paced rhythm with an occasional normal beat (pts own intrinsic beat) without the presence of a pacemaker spike. The ED nurse would interpret this rhythm as: A. Paced rhythm with capture B. Paced rhythm with failure to sense C. Paced rhythm with sensing D. Malfunctioning pacemaker

C. Paced rhythm with sensing A pacemaker can have the capability of sensing an intrinsic beat or intrinsic rhythm and cease to fire. This is a safety feature to prevent a demand pacemaker from firing during a cardiac cycle, possibly causing a lethal dyshrhythmia

85. Which of the following assessment findings would the ED nurse be most concerned about in a hemophiliac pt with hemarthrosis?: A. Skin breakdown B. Severe pain C. Paresthesias D. Impaired range of motion

C. Paresthesias Paresthesia can be an indicator of compartment syndrome. The collection of blood and edema can compress nerves and vasculature, reducing distal circulation and leading to tissue damage

18. A pt is brought into the ED by EMS with chest pain, a low grade fever of 100.2F, cough, SOB and a 1-3mm ST segment elevation on their EKG in all leads except aVR and V1. The nurse recognizes that the pts symptoms are associated with the presence of: A. Congestive heart failure B. ST segment elevation MI C. Pericarditis D. Acute coronary syndrome

C. Pericarditis Fever, chest pain, shortness of breath and ST segment elevation in all leads except aVR and V1 are indicative of pericarditis

31. A pt with end stage renal failure is complaining of increasng shortness of breath and exercise intolerance. The ED nurse auscultates muffled breath sounds on assessment and anticipates that the pt is at risk for developing which respiratory complication?: A. Unstable airway B. Pulmonary embolism C. Pleural effusion D. Pulmonary edema

C. Pleural effusion End-stage renal failure causes hypoalbuminemia due to a reduced synthesis of albumin. Albumin is necessary in maintaining oncotic pressure, which pulls water into the circulatory system. As albumin levels decrease, so does the oncotic pressure, allowing intravascular fluid to move out of capillaries and into the pleural space

34. A 34 week pregnant female arrives to triage complaining of dyspnea with exertion and right-sided chest pain since the previous evening. She admits to smoking a half-pack of cigarettes per day. Vitals: BP 135/90, HR 125, RR 32, SpO2 85% on RA, T 99.5F. The ED nurse knows that these signs and symptoms are consistent with which of the following?: A. Pneumonia B. HELLP syndrome C. Pulmonary embolism D. Asthma exacerbation

C. Pulmonary embolism The signs and symptoms of a PE include dyspnea, hypoxia, feelings of anxiety, and chest pain. Risk factors include venous stasis, recent trauma, obesity, pregnancy, use of oral contraceptives and a history of thrombosis

60. Which of the following is a priority intervention for a pt with bleeding esophageal varies?: A. Administer 2 units of whole blood B. Establish IV access with 2 large bore IVs C. Secure the pts airway D. Administer high flow O2

C. Secure the pts airway Bleeding esophageal varices present an immediate threat to the pts airway. The priority is to determine the airway is secure and open

38. A young adult presents to triage with dry mouth, blurred vision, profound fatigue and constipation . The pt was recently diagnosed with multiple sclerosis and has begun taking selective serotonin reuptake inhibitors (SSRI's). The ED nurse anticipates that the most likely cause of this pts symptoms is: A. New onset diabetes B. Progression of MS C. Side effects related to SSRI's D. A hemorrhagic stroke

C. Side effects related to SSRI's SSRI's have side effects such as dry mouth, constipation, urinary retention, and profound fatiguem which may indicate high serum levels of this medication and potential toxicity

52. An elderly female presents to the ED for evaluation of headache and vomiting. The family reports that the pt sustained a fall 2 days ago, during which she struck her head. The pts medications include lisinopril, atorvastatin and warfarin. The ED nurse anticipates this pt may have experienced which of the following?: A. Intraparenchymal hemorrhage B. Epidural hematoma C. Subdural hematoma D. Subarachnoid hemmorhage

C. Subdural hematoma Subdural hematomas result from injury to the bridging veins. This injury occurs in pts on anticoagulation therapy. Symptom onset is usualluy slow and progressive but can also happen spontanously if the pt recieves a blow to the head or falls

89. A pt who has sustained a 4 inch laceration to the left anterior thigh arrives via EMS. The wound had previously been bleeding profusely, however, direct pressure to the wound has reduced the blood flow. The pt is anxious and continually states " I am a bleeder! I know I will need some factor VIII! Get it quick!". The ED nurse is aware that this pt most likely has which of the following coagulopathies?: A. Hemophilia B B. Hemophilia A C. Von Willebrand disease D. Christmas disease

C. Von Willebrand disease This is a genetically inhereted bleeding disorder. The disease is manifested in both males and females. Von willebrand disease is caused by defects in the adherence of platelets, a low level of factor VII and decreased levels of von willebrand factor

87. The ED nurse has provided discharge instructions to the parents of a child who experienced a febrile seizure. Which of the following statements made by the parents indicates to the ED nurse that the teaching has been effective?: A. " Axillary temperature measurement is the preferred route for temperature measurement because it is the most accurate" B. " Aspirin and acetaminophen (Tylenol) are the preferred medications for reducing a fever" C. " Febrile seizures occur most often in children over the age of 2" D. " Febrile seizures most often occur because of a rapid rise in the body's temp"

D. " Febrile seizures most often occur because of a rapid rise in the body's temp" A rapid rise in the bodys temp, not the actual degree of the temp, is often the cause of a febrile seizure. The rapid rise irritates the immature nervous system and often causes the seizure activity

62. A 65 y/o pt has been diagnosed with Hepatitis C. After recieving education regarding this diagnosis, which of the following statements made by the pt indicates their correct understanding of the disease?: A. " I'll separate my eating and drinking utensils from those used by other family members" B. " I never used IV drugs or had unprotected sex with multiple partners, even when I was much younger " C. " My partner will need to be vaccinated so they dont become infected too" D. " I know I can be infected even though I dont have any symptoms"

D. " I know I can be infected even though I dont have any symptoms" Individuals who are infected with Hep C may be asymptomatic for a long period of time before they develop symptoms that would lead them to seek medical care

10. In preparing to discharge a pt who has been given a prescription for nitroglycerin tablets 0.4mg SL PRN, the ED nurse acknowledges that the pt teaching has been effective when the pt states: A. " I am to take the tablets at least every 2-3 mins when I experience chest pain" B. " I will call my doctor every time I need to take a tablet for my chest pain" C. " I should keep the tablets on my window sill in the kitchen so I can find them easily" D. " If my chest pain has not gone away after I have taken 2 tablets, I will come to the hospital"

D. " If my chest pain has not gone away after I have taken 2 tablets, I will come to the hospital" Nitro should result in vasodilation of the coronary arteries, leading to improved blood flow and a decrease in the pts chest discomfort. Pts are instructed to seek medical care if their chest pain has not subsided after taking 2-3 NTG 5 mins apart

48. A pt arrives to the ED accompained by her husband. The husband states that the pt has a history of Alzheimers disease, and he is concerned that she has experienced a stroke. While evaluating his understanding of his wifes disease, the ED nurse suspects he requires additional education when he states: A. " She forgot the word 'oven' but remembered it in the car" B. " I know she cant die from Alzheimers disease, but I got worried that she was having a stroke" C. " She takes her medication everyday and has always been able to take care of herself" D. " She wasnt able to make a cake today because she couldnt follow the recipe"

D. " She wasnt able to make a cake today because she couldnt follow the recipe" Alzhiemers is a progressive diseases whose symptoms worsen over time. Individuals lose the ability to preform previous routine skills

66. A bicyclist is brought to the ED after crashing into a wall and flying over the handlebars. The pt is awake and alert and is complaining of left sided abdominal pain with nausea. Vitals: 124/60 BP, 80 HR, 16 RR, 98% SpO2 and temp 97.6F. The ED nurse would anticipate which diagnostic test to asses for possible intra-abdominal injury?: A. Diagnostic peritoneal lavage B. Exploratory laparotomy C. CT scan with contrast of the abdomen and pelvic area D. A focused assessment with sonograpy for trauma

D. A focused assessment with sonograpy for trauma This pts mechanism of injury and complaints of abdominal pain are highly suspiscious for intra-abdominal injury due to blunt abdominal trauma. A bedside FAST is indicated

100. When caring for a variety of pts, the ED nurse is knowledgeable that the pt with the least risk for developing compartment syndrome would be a pt with which of the following injuries?: A. A pt with a venomous snake bite to the forearm B. A crush injury to the shaft of the femur C. A pt with circumferential full thickness burn to the calf D. A nondisplaced fracture to the medial malleolus

D. A nondisplaced fracture to the medial malleolus Most malleolus fractures are associated with inversion or eversion injuries related to ankle sprains. This fracture is nondisplaced and the pt most likely will only need a splint/cast applied

36. The ED nurse is caring for a pt with apparent ligature marks on the neck. The pt is experiencing dyspnea, hoarseness and subcutaneous emphysema in the neck and face. The priority intervention for this pt is to: A. Prepare for laryngoscopy B. Prepare for intubation C. Prepare for bronchoscopy D. Administer oxygen via mask with an oxygen reservior (nonrebreather)

D. Administer oxygen via mask with an oxygen reservior (nonrebreather) Tracheobronchial injury commonly occurs as a result of penetrating trauma but could result from blunt trauma such as a direct blow, strangulation, or clothesline type injury. Assesssment findings include dyspnea, tachypnea, hoarseness, subcutaneous emphysema, hemoptysis ans signs of airway obstruction

50. The ED nurse is caring for a pt with increased ICP due to a subarachnoid hemorrhage. The provider has ordered a bolus administration of IV mannitol. Which of the following would indicate that this medication has had the desired effect?: A. A decrease in the level of consciousness B. A partial pressure of carbon dioxide between 35 and 40 mmHg C. An increase in serum sodium level above 145mEq D. An increase in urinary output

D. An increase in urinary output The osmotic diuretic mannitol pulls fluid from normal brain tissue, reducing intracranial pressure, This can cause an increase in urine output

7. Following the successful resuscitation of a pt in a cardiac arrest, which of the following findings is the best indicator high-quality CPR?: A. A compression depth of 1 1/2 inches B. Palpable pulses with the preformance of chest compressions during CPR C. A decrease of skin and mucus membrane cyanosis D. An increasing end tital Co2 level

D. An increasing end tital Co2 level An increasing end-tidal carbon dioxide level indicates increasing cellular perfusion with effective CPR or ROSC

24. Pts with COPD should recieve the influenza and pneumonoccal vaccines: A. So they will not get sick during the flu season B. Because these vaccines prevent the need for long-acting beta agonists C. Because these vaccines will prevent them from acquiring pneumonia D. Because viral and bacterial infections play a major role in COPD exacerbations

D. Because viral and bacterial infections play a major role in COPD exacerbations This is a preventative measure to help reduce morbidity and mortality in pts with COPD

82. A pt who was diagnosed with terminal cancer 2 days previously presents to the ED. Since recieving their diagnosis, the pt has repeatedly verbalized a desire to commit suicide, making such statements as " I will just get my shotgun when things get bad", and " You cant stop me from driving my pickup into a tree". They are angry that their family has brought them to the ED and is continually yelling at their family members. What is the priority intervention the ED nurse should take in this situation?: A. Explain to the family that the pt is experiencing the normal reaction of anger B. Reassure the pt that they will be provided with resources such as hospice care C. Recommend that the pt follow up with their PCP for antidepressants D. Call for extra staff to assist

D. Call for extra staff to assist - The pt has verbally expressed anger and is yelling at their family. They are facing a difficult time and having a hard time coping. The priority is to get the pt to a safe place so they can recieve treatment, help and reassurance

55. A 28 y/o female presents to the ED with a sudden onset of epigastric pain that radiates to the RUQ. The pt is nauseated and has vomited. While obtaining the pts medical history, the nurse also notes that teh pt is 3 months postpartum. Which of the following conditions is most consistent with the pts presenting symptoms?: A. Pancreatitis B. Esophagitis C. Acute Gastroenteritis D. Cholyecystitis

D. Cholyecystitis One of the most common symptoms of cholecystitis is the sudden onset of epigastric pain that radiates to the right upper quadrent (especially after ingesting greasy foods) and it is associated with the presence of nausea and vomting. Pregnancy and postpartum period predispose women to cholecystitis because of the elevation of estrogen and progesterone. Those hormones cause the gallbladder to contract less and empty more slowly. The bile in the gallbladder becomes more concentrated, creating stones

95. A pt presents to the ED with a swollen abdomen. The pt's arms and legs are very thin, their face is round and their skin is very thin and there is a buffalo hump between their shoulders. Pink stretch marks are noted on the abdomen. The pt has a history of long-term dexamethasone (Prednisone) use for urticaria. Vitals: 200/100 BP. The ED nurse suspects that this pt has which of the following?: A. Hashimoto disease B. Thyrotoxicosis C. Syndrome of inappropriate antidiuretic hormone D. Cushings syndrome

D. Cushings syndrome Cushings is a collection of symptoms which can be attributed to prolonged exposure to cortisone. Signs/symptoms: buffalo hump, hypertension, abdominal swelling, thin extremities, round moon face, adrenal gland tumor can also cause cushings

26. A pt has just been intubated and placed on mechanical ventilation. What measure can the ED nurse initiate to reduce the risk of ventilator assisted pneumonia?: A. Only suction the pt once a shift to allow for oral secretions to pool in the oral cavity and prevent irritation to the oral mucosa from frequent suctioning B. Keep the pt supine C. Verify that the endotracheal tube cuff is deflated D. Elevate the head of the bed

D. Elevate the head of the bed Elevation of the head of the bed and oral care with chlorahexadine are measures to assist in preventing VAP

33. A pt presents to the ED complaining of a sudden onset of wheezing and difficulty breathing. The pt states that they sustained an acute myocardial infarction 1 month ago On auscultation of bilateral lung fields, scattered wheezing and bibasilar crackles are heard. As the ED nurse, which order from the provider would you question?: A. Give the pt 125mg of methylprednisolone (Sou-medrol) IV B. Place the pt on O2 via a nonrebreather mask C. Give the pt 2.5mg albuterol via nebulizer D. Give the pt 1000ml 0.9% sodium chloride bolus over 30 mins

D. Give the pt 1000ml 0.9% sodium chloride bolus over 30 mins The pt has findings consistent with congestive heart failure or pulmonary edema. Administering IV fliuids may further impair the pts cardaic and respiratory status anf lead to further fluid overload

56. A pt presents to the ED with restlessness, severe right flank pain, nausea and diaphoresis. The ED nurse should anticipate preparing the pt for which diagnostic test?: A. Kidney, ureter and bladder radiograph B. Intravenous pyelogram C. Renal ultrasound D. Helical CT scan

D. Helical CT scan This pt is most likely experiencing kidney stones. The helical CT scan is the most accurate tool for diagnosis of kidney stones

11. Which of the following findings would the ED nurse to anticipate in a pt experiencing signs and symptoms of cardiac tamponade following successful aspiration of fluid from the pericardial sac?: A. Presence of electrical alternans B. Increase in the pts heart rate C. Decrease in the pts BP D. Increase in the pts BP

D. Increase in the pts BP Following removal of fluid from the pericardial sac, the pts central venous pressure should decrease, allowing for increased preload and an increase in the pts blood pressure

83. A pt presents to the ED with severe swelling around their eyes and lips (angioedema). They deny and known allergies and states they are currently taking one one medication for a recent diagnosis of hypertension. The ED nurse recognizes that the most likely cause of the pts angioedema is related to which of the following?: A. Midodrine (ProAmatine) B. Losartan (Cozaar) C. Diltiazem (Cardizem) D. Lisinopril (Zesteril)

D. Lisinopril (Zesteril) - Lisinopril is an ACE, angioedema is a rare side effect of ACE inhibitors, more common in african americans

61. A pt presents to the ED with a 72 hour history of vomiting and diarrhea. The pts HR is elevated, skin is pale and the pt is hard to arouse. The ED nurse is aware that the primary management for this pt is to preform which of the following?: A. Obtain a stool sample B. Establish IV access for administration of crystalloid fluids C. Administer antiemetics D. Maintain airway, breathing and circulation

D. Maintain airway, breathing and circulation Because of continued vomiting and difficulty arousing the pt, the pts airway may become compromised

73. A 25 y/o female presents to the ED 4 days postpartum. She has a high fever and rigors following a vaginal delivery with an episiotomy and left sulcus laceration. On examination, the vaginal area is edematous and tender to the touch, with a purpuric discoloration from the left labia that extends to the buttocks unilaterally and the presence of a "foul smelling" liquid discharge from the episotomy site. The pt is tachycardic and tachypneic. The ED nurse suspects this pt may have: A. Septic thrombophlebitis B. Endometriosis C. Pelvic abscess D. Necrotizing fascitis

D. Necrotizing fascitis Necrotizing fascitis is a severe wound infection involving superfical and deep fascia. It is frequently associated with episotimy or other perineal trauma during delivery. It can present with purport and swelling

81. A pt was involved in a severe motor vehicle collision 2 months ago. Although the pts injuries are healing appropriately, the pt has been treated in the ED 6 times for a variety of complaints since the incident. The pt reports trouble sleeping because of nightmares, fear when driving or riding in cars and freuquent thoughts of the incident. What mental health disorder should the nurse consider when assessing this pt?: A. Agoraphobia B. Depression C. Bipolar disorder D. PTSD

D. PTSD - pts who return often to the ED following a serious trauma should be questioned regarding ongoing pain, coping skills and general wellbeing. Symptoms of PTSD include fear, intrusive recollections, dreams of the event and avoidance of stimuli associated with trauma

64. A pt presents to the ED with complaints of upper left quadrent pain radiating to the back for the past week. The pts serum amylase level is normal, but the serum lipase is elevated. The nurse suspects that the pt may have which of the following disease processes?: A. Peptic ulcer B. Pyelonephritis C. Cholecystitis D. Pancreatitis

D. Pancreatitis In acute pancreatitis, the serum amylase level will rise quickly but return to normal within 72 hours. Serum lipase will typically rise at a slower rate but remain elevated for up to 2 weeks

25. A pt with no past medical history arrives to triage with the complaint of fever, malaise, cough and crackles that do not clear with coughing. The ED nurse anticipates that the pt will most likely be treated for which of the following?: A. COPD exacerbation B. Acute bronchitis C. Acute asthma exacerbation D. Pneumonia

D. Pneumonia This pt meets clinical diagnostic criteria for pneumonia with fever, malaise, cough, and crackles that do not clear with coughing

76. A pt presents to triage extremely tearful and visibly trembling. The pt states " I cant take it anymore... this new medication the doctor gave me is not working! I have been taking this medication for 5 days and I feel even more depressed than I did before!". The nurse begins the pt assessment by completing the medication reconcilliation and identifies that the new medication the pt has been prescribed is fluoxetine (Prozac). What intervention by the nurse would have the greatest impact for this pt?: A. Provide the pt with a benzodiazepine such as Ativan to calm the pts nerves B. Inform the pt that the provider will likely change the medication given that the symptoms are worsening C. Instruct the pt to stop the medication immediately D. Reassure the pt that fluoxitine requires at least 1-4 weeks before a noticable improvement in depression symptoms is evident

D. Reassure the pt that fluoxitine requires at least 1-4 weeks before a noticable improvement in depression symptoms is evident SSRI's are used in treatment of major depressive disorders. It may take up to 4 weeks to reach therapeutic levels and see improvement. Frequent follow up with the prescribing provider is required, and dosage may need to be adjusted if no improvement is evident within 4 weeks

79. During the assessment of a young, nonambulatory child, the ED nurse identifies the presence of a possible spiral leg fracture. The pts states that the child rolled off the bed onto the floor. Based on this assessment, the ED nurse prepares for which of the following?: A. Separate the parents and ask each what event led to the childs leg injury B. Do not permit the parents to hold the child C. Record all verbal interactions between the parent and the ED providers D. Report suspicion of child maltreatment to the child protective services

D. Report suspicion of child maltreatment to the child protective services

27. A pt is admitted to the ED via EMS following the detection of carbon monoxide in their home. The pt is alert to verbal stimuli but is demonstrating intermittent snoring-type respirations. After opening the pts airway and administering supplemental O2 via nonrebreather, what assessment finding would indicate that the pt is recieving adequate oxygenation?: A. A pCO2 level of 70mmHg B. A continuous pulse ox reading of 100% C. Alertness to verbal stimuli D. The pts level of consciousness returning to their normal level of alertness

D. The pts level of consciousness returning to their normal level of alertness A pt who is at their normal level of consciousness and level of alertness is the correct finding for adequate oxygenation and ventilation of a pt with a patent airway

47. A pt with cerebral edema has recieved 1g/kg mannitol IV. Which of the following clinical signs would indicate that this intervention has had the desired effect?: A. Systolic BP of 80 B. Intracranial pressure of 60 C. A cerebral perfusion pressure decreased to 30 D. Urinary output of 500ml in the last hour

D. Urinary output of 500ml in the last hour Mannitol, an osmotic diuretic, decreases cerebral edema by pulling fluid into the vasculature for elimination by the kidneys. Increased urinary elimination means there is a decreased fluid in the intracranial cavity and a potential decrease in ICP because blood, brain volume and cerebrospinal fluid are components that contribute to ICP

93. After recieving fluid resuscitation with an isotonic crystalloid solution, an ED pt diagnosed with septic shock remains hypotensive. Which of the following would be initiated to assist in maintaining pts blood pressure?: A. Transfuse hydroxyethyl starches to maintain a MAP of 65 or higher B. Addition of albumin to the current crystalloid solution to maintain a MAP of 65 or higher C. Transfuse packed red blood cells to maintan a MAP of 65 or higher D. Vasopressor to maintain a MAP of 65 or higher

D. Vasopressor to maintain a MAP of 65 or higher If crystalloids do not resuscitate the pts BP, then a vasopressor needs to be started to maintain a MAP of 65

99. Parents arrive to triage with their toddler, whose hand was caught in the car door, resulting in amputation of the index finger. The amputated part has been wrapped in gauze, which is presented to the triage nurse. The ED nurse is aware that the proper way to care for the amputated part is to: A. Wrap the amputated part with sterile gauze soaked in tap water, placed in a sealed bag, place the bag in another bag and place in tepid water B. Wrap the amputated part in sterile soaked with hibiclens and saline, place the part in a sealed bag, put the bag in another bag and place in ice water C. Wrap the amputated part in dry sterile gauze, place in a sealed bag, place the sealed bag in another bag and place in tepid water D. Wrap the amputated part in sterile gauze moistened by saline, place in a sealed bag, place in another bag and place in ice water

D. Wrap the amputated part in sterile gauze moistened by saline, place in a sealed bag, place in another bag and place in ice water