MEDICAL EMERGENCIES

Question 18 A patient visits a health clinic because of urticaria and shortness of breath after being stung by several wasps. The nurse practitioner immediately administers which medication to reduce bronchospasm?

Correct Response: • Epinephrine Explanation: Epinephrine is given for its vasoconstrictive actions, as well as for its rapid effect of reducing bronchospasm. Benadryl and Proventil (nebulized) are given to reverse the effects of histamine. Prednisone is given to reduce inflammation, if necessary.

Question 15 A nurse is monitoring a client with PROM who is in labor and observes meconium in the amniotic fluid. What does the observation of meconium indicate?

Correct Response: • fetal distress related to hypoxia Explanation: When meconium is present in the amniotic fluid, it typically indicates fetal distress related to hypoxia. Meconium stains the fluid yellow to greenish brown, depending on the amount present. A decreased amount of amniotic fluid reduces the cushioning effect, thereby making cord compression a possibility. A foul odor of amniotic fluid indicates infection. Meconium in the amniotic fluid does not indicate CNS involvement.

Question 20 A client weighing 132 lb is brought to the emergency department in status epilepticus. The physician asks the nurse to prepare diazepam 0.25 mg/kg. How many milligrams will be given to this client?

Correct Response: • 15 Explanation: Step 1: 2.2 lb / 1 kg = 132 lb / X kg 132 lb = 2.2 X 60 kg = X Step 2: 1 kg / 0.25 mg = 60 kg / X mg 15 mg = X

Question 1 A few minutes after beginning a blood transfusion, a nurse notes that a client has chills, dyspnea, and urticaria. The nurse reports this to the health care provider immediately because the client probably is experiencing which problem?

Correct Response: • A hemolytic allergic reaction caused by an antigen reaction Explanation: Hemolytic allergic reactions are fairly common and may cause chills, fever, urticaria, tachycardia, dyspnoea, chest pain, hypotension, and other signs of anaphylaxis a few minutes after blood transfusion begins. Although rare, a hemolytic reaction to mismatched blood can occur, triggering a more severe reaction and, possibly, leading to disseminated intravascular coagulation. A hemolytic reaction to Rh-incompatible blood is less severe and occurs several days to 2 weeks after the transfusion. Bacterial contamination of donor blood causes a high fever, nausea, vomiting, diarrhoea, abdominal cramps and, possibly, shock.

Question 10 The nurse caring for a 2-year-old near-drowning victim monitors for what possible complication?

Correct Response: • Acute respiratory distress syndrome Explanation: Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. Options A, C, and D are incorrect.

Question 7 A 13-year-old adolescent has had a near-drowning experience. The nurse notices the client has labored breathing and a cough. What is the priority intervention?

Correct Response: • Administer 100% oxygen by mask. Explanation: Management of the near-drowning victim focuses on assessing the client's airway, breathing, and circulation (ABCs) and correcting hypoxemia. Administering oxygen is the primary intervention to assist breathing. It is best to let the adolescent assume the most comfortable position for him or her. Checking capillary refill time helps determine ineffective tissue perfusion, but it does not provide an intervention for the labored breathing. Providing sedation is an intervention for pain. Pain is assessed after the ABCs and neuro assessments are completed.

Question 2 A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to his back. Which intervention takes priority for this client?

Correct Response: • Administering morphine I.V. as ordered Explanation: The nurse should address the client's pain issues first by administering morphine I.V. as ordered. Placing the client in a Semi-Fowler's position, maintaining NPO status, and providing mouth care don't take priority over addressing the client's pain issues.

Question 12 The nurse is caring for a client admitted to the emergency room with suspected meningitis. The nurse prepares to perform which nursing intervention upon physician orders, while diagnostic testing is being completed?

Correct Response: • Administration of antibiotics Explanation: The nurse should prepare to administer antibiotics as ordered by the physician while the diagnostic tests are being completed. Delay in initiation of antimicrobial therapy, most frequently due to medical imaging prior to lumbar puncture or transfer to another medical facility, can result in poor client outcomes.

Question 8 A child has fallen off of a swing at the playground and her father states that she became groggy. After assessing a child's airway, breathing, and circulation (ABCs), what would the nurse do next?

Correct Response: • Assess level of consciousness. Explanation: Once the ABCs are completed, the nurse's next step is to assess the child's level of consciousness or disability. This would be followed by removing the child's clothing and diaper (exposure) to assess for underlying signs of illness or injury. Next, full vital signs are taken while facilitating the family presence, followed by giving comfort by managing pain and providing emotional support. The acronym ABCDEFG is a useful reminder of the order of assessment: airway, breathing, circulation, disability, exposure, full vital signs and facilitating family, and giving comfort.

Question 18 The nurse is working in collaboration with a nurse anesthetist to assess a preoperative client. When addressing the client's risk for malignant hyperthermia as a result of neuromuscular junction blockers, what assessment should be prioritized?

Correct Response: • Assessing for a family history of malignant hyperthermia Explanation: Family history is the most salient risk factor for malignant hyperthermia. This adverse effect is physiologically unrelated to childhood febrile seizures and does not result from cytochrome P450 dysfunction. Malignant hyperthermia is not a hypersensitivity response.

Question 13 A female client presents to the emergency department with nausea, vomiting, and a heart rate of 45 beats per minute. Her husband states that she takes digoxin, Lasix, and nitroglycerin for chest pain. Laboratory results confirm digoxin toxicity. The nurse would expect the health care provider to order what medication to treat the bradycardia?

Correct Response: • Atropine Explanation: Atropine or isoproterenol, used in the management of bradycardia or conduction defects, may be administered to clients with digoxin toxicity.

Question 6 A patient is admitted to the emergency room after a car accident. Based on the experience of the emergency room nurse, what system will affect a response to the emergency?

Correct Response: • Autonomic nervous system Explanation: The functions of the autonomic nervous system can be described broadly as activities designed to maintain a constant internal environment (homeostasis), to respond to stress or emergencies, and to repair body tissues. The central nervous system regulates respiration or circulation. The endocrine system regulates hormone balance. The cardiovascular system regulates heart function.

Question 13 The nurse is planning care for a school-aged child recovering from being hit by a motor vehicle while riding a bicycle. For what will the nurse assess to determine the onset of disseminated intravascular coagulation in this child?

Correct Response: • Bleeding from intravenous sites Explanation: Disseminated intravascular coagulation is an acquired disorder of blood clotting that results from excessive trauma. The child begins to develop petechiae or have uncontrolled bleeding from puncture sites from injections or intravenous therapy. Blurred vision, nausea, vomiting, and a sudden onset of knee pain are not manifestations associated with disseminated intravascular coagulation.

Question 4 A 21-year-old man experienced massive trauma and blood loss during a motorcycle accident and has been started on a dopamine infusion upon his arrival at the hospital. In light of this drug treatment, what assessment should the care team prioritize?

Correct Response: • Cardiac monitoring Explanation: The high potential for adverse effects that is associated with the use of dopamine necessitates vigilant cardiac monitoring. Respiratory assessment, ABGs, and monitoring of ICP are likely indicated by the patient's injuries, but these are not directly related to the use of dopamine.

Question 17 A 24-year-old patient was admitted to the emergency room after a water skiing accident. The X-rays revealed two fractured vertebrae, T-12 and L1. Based on this information, the nurse would know to perform which of the following actions?

Correct Response: • Check the patient's urine for hematuria. Explanation: The kidneys are located from the 12th thoracic vertebrae to the third lumbar vertebrae. Therefore, the accident may have caused blunt force trauma damage to the kidneys. Ice is always applied for the first 24 hours, then heat, if not contraindicated. Activity will be restricted but bed rest is not necessary.

Question 18 The nurse in the ED is triaging patients during the shift. What does the nurse know is the first priority in treating any patient in the ED?

Correct Response: • Establishing an airway. Explanation: The primary survey focuses on stabilizing life-threatening conditions. The ED staff work collaboratively and follow the ABCDE (airway, breathing, circulation, disability, exposure) method. The first priority is always to establish a patent airway.

Question 1 After a car accident, a client is admitted to an acute care facility with multiple traumatic injuries, including a fractured pelvis. For 24 to 48 hours after the accident, the nurse must monitor the client closely for which potential complication of a fractured pelvis?

Correct Response: • Fat embolism Explanation: Fat embolism is a relatively rare but life-threatening complication of pelvis and long-bone fractures, arising 24 to 48 hours after the injury. It occurs when fat droplets released at the fracture site enter the circulation, become lodged in pulmonary capillaries, and break down into fatty acids. Because these acids are toxic to the lung parenchyma, capillary endothelium, and surfactant, the client may develop pulmonary hypertension. Signs and symptoms of fat embolism include an altered mental status, fever, tachypnea, tachycardia, hypoxemia, and petechiae. Compartment syndrome and infection may complicate any fracture and aren't specific to a pelvis fracture. Volkmann's ischemic contracture is a potential complication of a hand or forearm fracture.

Question 6 A victim of a motor vehicle accident has been brought to the emergency room. The patient is exhibiting paradoxical chest expansion and respiratory distress. Which of the following chest disorders should be suspected?

Correct Response: • Flail chest Explanation: When a flail chest exists, during inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. On expiration, because the intrathoracic pressure exceed atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. Cardiac tamponade is compression of the heart resulting from fluid or blood within the pericardial sac. A pulmonary contusion is damage to the lung tissues resulting in hemorrhage and localized edema. A simple pneumothorax occurs when air enters the pleural space through the rupture of a bleb or a bronchopleural fistula.

Question 20 The nurse educator is preparing a presentation about the indicators of chemical terrorism. The nurse educator would include which indicators in the presentation. Select all that apply.

Correct Response: • Fog-like or low-lying cloud in the atmosphere • Numerous dead animals and birds • Unexplained odor atypical for the location Explanation: The indicators that the nurse educator would include in the presentation are fog-like or low-lying cloud in the atmosphere, numerous dead animals and birds, and unexplained odor atypical for the location. The temperature in the area would not increase after a chemical event. There would be no wind associated with a chemical event

Question 5 An elderly patient with a history of congestive heart failure has been admitted to hospital with failure to thrive and admission blood work reveals a hemoglobin level of 6.9 g/dL. The care team has consequently administered two units of packed red blood cells, but auscultation of the client's lungs now reveals diffuse crackles. Administration of what drug is likely to resolve the patient's pulmonary edema?

Correct Response: • Furosemide Explanation: Furosemide can be given intravenously to provide rapid relief from pulmonary edema. Mannitol is not normally used to treat pulmonary edema and neither HCTZ nor triamterene is used in the acute treatment of pulmonary edema.

Question 16 A client with malignant hypertension is at risk for a hypertensive crisis, including the cerebral vascular system often causing cerebral edema. The nurse would assess this client for which signs and symptoms?

Correct Response: • Headache and confusion Explanation: Cerebral vasoconstriction probably is an exaggerated homeostatic response designed to protect the brain from excesses of blood pressure and flow. The regulatory mechanisms often are insufficient to protect the capillaries, and cerebral edema frequently develops. As it advances, papilledema (i.e., swelling of the optic nerve at its point of entrance into the eye) ensues, giving evidence of the effects of pressure on the optic nerve and retinal vessels. The client may have headache, restlessness, confusion, stupor, motor and sensory deficits, and visual disturbances. In severe cases, convulsions and coma follow. Lethargy, nervousness, and hyperreflexia are not signs or symptoms of cerebral edema in malignant hypertension.

Question 17 A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with?

Correct Response: • Intubation and mechanical ventilation Explanation: Decompensation of the lungs increases the likelihood that mechanical ventilation will be needed. Administration of oxygen via a mask would be appropriate in the compensatory stage but insufficient in the event of lung decompensation. Periocardiocentesis or thoracotomy with chest tube insertion would not be necessary or appropriate.

Question 9 What is the most important goal of nursing care for a client who is in shock?

Correct Response: • Manage inadequate tissue perfusion. Explanation: Nursing interventions and collaborative management are focused on correcting and maintaining adequate tissue perfusion. Inadequate tissue perfusion may be caused by hemorrhage, as in hypovolemic shock; by decreased cardiac output, as in cardiogenic shock; or by massive vasodilation of the vascular bed, as in neurogenic, anaphylactic, and septic shock. Fluid deficit, not fluid overload, occurs in shock.

Question 6 During a disaster, the nurse sees a victim with a green triage tag. The nurse knows that the person has which type of injury?

Correct Response: • Minor; treatment can be delayed hours to days Explanation: A green triage tag (priority 3, or minimal) indicates injuries that are minor; treatment can be delayed hours to days. A red triage tag (priority 1, or immediate) indicates injuries that are life threatening but survivable with minimal intervention. A yellow triage tag (priority 2, or delayed) indicates injuries that are significant and require medical care but can wait hours without threat to life or limb. A black triage tag (priority 4, or expectant) indicates injuries that are extensive; chances of survival are unlikely even with definitive care.

Question 5 A client with suspected inhalation anthrax is admitted to the emergency department. Which action by the nurse takes the highest priority?

Correct Response: • Monitor vital signs and oxygen saturation every 15 to 30 minutes. Explanation: Monitoring vital signs and oxygen saturation every 15 to 30 minutes takes priority. Suctioning the client as needed to obtain a sputum specimen may be necessary, but assessing the client for changes in his respiratory status takes priority. Assessing intake and output and providing adequate hydration are important steps for liquefying secretions; however, they don't take priority. Reassuring the client that intubation and mechanical ventilation is temporary is inappropriate. The client may not require intubation and mechanical ventilation; however, if he does, the nurse can't predict the length of time it may be necessary.

Question 16 A patient with a history of hypothyroidism is admitted to the intensive care unit unconscious and with a temperature of 95.2ºF. A family member informs the nurse that the patient has not taken thyroid medication in over 2 months. What does the nurse suspect that these findings indicate?

Correct Response: • Myxedema coma Explanation: Myxedema coma is a rare life-threatening condition. It is the decompensated state of severe hypothyroidism in which the patient is hypothermic and unconscious (Ross, 2012a). This condition may develop with undiagnosed hypothyroidism and may be precipitated by infection or other systemic disease or by use of sedatives or opioid analgesic agents. Patients may also experience myxedema coma if they forget to take their thyroid replacement medication.

Question 20 The nurse is caring for a client who is developing hypovolemic shock from a duodenal ulcer bleed. What is the first intervention the nurse can provide to facilitate blood flow to the brain?

Correct Response: • Place the client in a modified Trendelenburg position. Explanation: The first action by the nurse would be to place the client in a modified Trendelenburg position to facilitate blood flow to the brain. Administering a crystalloid solution and testing the client for blood in the stool may be later action but is not relevant in facilitating blood flow to the brain. Preparing the client for an endoscopy would be important after the physician obtains the informed consent but would not facilitate blood flow to the brain.

Question 10 Which treatment should take place immediately in a client experiencing autonomic dysreflexia?

Correct Response: • Position the client in upright position, and correct the initiating stimulus. Explanation: Autonomic dysreflexia is a clinical emergency, and requires monitoring of blood pressure while correcting the initiating stimulus (e.g., full bladder, pain). The nurse should place the client in an upright position and remove all support hose binders to promote venous pooling to help decrease an extremely elevated blood pressure. Intravenous fluids are not an immediate intervention for this condition.

Question 19 The emergency department nurse is caring for clients involved in a chlorine exposure accident at a local chemical plant. The nurse is aware that permanent damage can occur to which body systems?

Correct Response: • Respiratory Explanation: The consequences of exposure to chlorine and other respiratory toxins are related to the amount, route, and length of chemical exposure. Death occurs as fluid infiltrates the pulmonary air spaces and terminal bronchioles interfering with gas exchange. Following recovery from an acute event, victims may develop chronic bronchitis and emphysema.

Question 3 A nurse is performing triage at the scene of a building collapse and is using a five-level triage system. Place the categories below in the proper order from most to least immediate.

Correct Response: • Resuscitation • Emergent • Urgent • Nonurgent • Minor Explanation: The five-level system of triage classifies patients as follows: resuscitation (need immediate treatment to prevent death); emergent (may deteriorate rapidly and develop a major life-threatening situation or require time-sensitive treatment); urgent(need two or more resources to provide care and conditions are not life-threatening); nonurgent (need only one resource for needs and condition is not life-threatening); and minor (require no resources for care with no life-threatening condition).

Question 9 A client has a burn that involves the entire epidermis and various degrees of the dermis. It is painful, moist, and blistered. The nurse recognizes the burn as:

Correct Response: • Second-degree partial thickness Explanation: Second-degree partial-thickness burns involve the epidermis and parts of the dermis. First-degree partial-thickness burns involve only the outer layers of the epidermis. Third-degree full-thickness burns extend into the subcutaneous tissue and may involve bone and muscle. Second-degree full-thickness burns involve the entire epidermis and dermis.

Question 20 A client is receiving a secondary infusion of a new antibiotic. After 5 minutes of administration, the client reports itching and appears flushed. What is the first nursing intervention?

Correct Response: • Stop the infusion. Explanation: The client may be experiencing a reaction to the antibiotic. Because intravenous administration occurs quickly, life-threatening reactions can also occur quickly. The first nursing action is to stop the infusion. Slowing the rate is inappropriate, as this will not solve the problem if the client is having a reaction. Assessing the itching and contacting the health care provider can occur after the infusion is stopped.

Question 12 A 29-year-old female client in labor has just received epidural anesthesia. Before the procedure her blood pressure was 120/78 and her pulse was 60 bpm. Now her blood pressure is 100/60 and her pulse is 80 bpm. She reports a metallic taste in her mouth, hears a ringing in her ears, and appears confused. What is this client most likely experiencing?

Correct Response: • Systemic toxicity from local anesthesia Explanation: CNS (central nervous system) symptoms (such as tinnitus and disorientation) are commonly present before hemodynamic changes are evidenced when a client has systemic toxicity. Systemic toxicity in this case is from a local anesthetic being injected into a blood vessel.

Question 5 A surgical client has developed malignant hyperthermia. Which medication can be used to treat this health emergency?

Correct Response: • dantrolene Explanation: Dantrolene acts directly on skeletal muscle to inhibit muscle contraction. It is used to relieve spasticity in neurologic disorders (e.g., MS, spinal cord injury) and to prevent or treat malignant hyperthermia, a rare but life-threatening complication of anesthesia characterized by hypercarbia, metabolic acidosis, skeletal muscle rigidity, fever, and cyanosis. None of the other medications are prescribed for this emergency.

Question 11 A woman is admitted with a diagnosis of ectopic pregnancy. For which procedure should the nurse prepare?

Correct Response: • immediate surgery Explanation: Ectopic pregnancy means an embryo has implanted outside the uterus, usually in the fallopian tube. Surgery is usually necessary to remove the growing structure before the tube ruptures or to repair the tube if rupture has occurred already.

Question 14 A client is brought to the emergency department and immediately diagnosed with a tension pneumothorax. The priority intervention would be:

Correct Response: • insertion of a large-bore needle or chest tube. Explanation: Emergency treatment of tension pneumothorax involves the prompt insertion of a large-bore needle or chest tube into the affected side of the chest along with one-way valve drainage or continuous chest suction to aid in lung reexpansion. Other listed options may be implemented after the emergency measure.

Question 7 On the 2nd day after surgery, the nurse assesses an older adult client. The nurse finds: • blood pressure is 148/92 mm Hg. • heart rate is 98 bpm. • respirations are 32 breaths/min. • O2 saturation is 88% on 4 L/min of oxygen administered by nasal cannula. • breath sounds are coarse and wet bilaterally with a loose, productive cough. • The client has voided 100 mL very dark, concentrated urine during the last 4 hours. • bilateral pitting pedal edema. Using the SBAR (Situation-Background-Assessment-Recommendation) method to notify the health care provider of current assessment findings, the nurse should recommend which prescription?

Correct Response: • diuretic medication Explanation: The client is experiencing a fluid overload and has vital signs that are outside of normal limits. The provider must be notified of the client's current status. It would be appropriate to recommend the provider administer a diuretic to correct the fluid overload. It is not appropriate to administer an antihypertensive medication or administer more fluids. It may be appropriate to administer additional oxygen, but because of the fluid volume excess the client exhibits, diuretic administration is most important.

Question 12 A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the:

Correct Response: • ductus arteriosus remains open. Explanation: Excess pressure in the alveoli stimulates the ductus arteriosus to remain open, compromising efficient cardiovascular function.

Question 10 The nurse is providing support to the parents of a 10-year-old boy receiving emergency care. The boy is their foster child. Which comment will be most effective?

Correct Response: • "Hold your child's hand while this is going on." Explanation: The atmosphere during an emergency can be chaotic and overstimulating. Keep the parents or other family with the child whenever possible. Involve the parents in the child's care; tell the parents in concrete terms what they can do to support the child (e.g., hold the child's hand and talk quietly to him or her). Attempt to talk quietly and soothingly and provide comfort measures. Involving parents in the care helps them to cope. Tell them in concrete terms what they can do to help. Talking about hypovolemia may be too technical. When in doubt, simplify. Many professional organizations, such as the Emergency Nurses Association and the American Heart Association, support giving parents the option to be present during resuscitation efforts. Any caregiver with a parental role should remain with the child when possible.

Question 14 The nurse is caring for a client with severe hypothyroidism and knows to contact the health care provider if which symptoms of myxedema coma occur? (Select all that apply.)

Correct Response: • Decreased level of consciousness • Decreased respirations • Decreased blood pressure Explanation: Symptoms of myxedema coma include coma, hypothermia, cardiovascular collapse, hypoventilation, hypoglycemia, and lactic acidosis.

Question 2 A nurse is reviewing the dietary history of a client who has experienced anaphylaxis. What would the nurse identify as a common cause of anaphylaxis? Select all that apply.

Correct Response: • Milk • Eggs • Shrimp Explanation: Common food causes of anaphylaxis include peanuts, tree nuts, shelfish, fish, milk, eggs, soy, and wheat. Beef and chicken are not common causes.

Question 2 A client is admitted to the unit with diabetic ketoacidosis (DKA). Which insulin would the nurse expect to administer intravenously?

Correct Response: • Regular Explanation: Regular insulin is administered intravenously to treat DKA. It is added to an IV solution and infused continuously. Glargine, NPH, and Lente are only administered subcutaneously.

Question 18 A 6-year-old child has been brought to the emergency department in apparent status asthmaticus. The care team recognizes the need to intubate the client, who is inconsolably agitated. The nurse should anticipate a STAT prescription for what medication?

Correct Response: • Succinylcholine Explanation: The very rapid onset and short duration of succinylcholine make it appropriate for facilitating intubation in a distraught child. None of the nondepolarizing neuromuscular junction blockers has such a rapid onset or short duration.

Question 8 Which patient should not receive mitotane as ordered?

Correct Response: • The patient experiencing shock Explanation: The patient experiencing shock should not receive mitotane as ordered and should receive steroid supplementation. A heart rate of 100 beats per minute is not a contraindication to receiving this medication. Because the medication is given to treat adrenocarcinoma, this is not a contraindication. Dizziness may be caused by this medication, but it is not a dose-limiting side effect.

Question 8 When developing a teaching plan for parents of toddlers about poisonous substances, the nurse should emphasize which safety points? Select all that apply.

Correct Response: • Toddlers should be adequately supervised at all times. • All poisonous substances should be kept out of the reach of children and stored in a locked cabinet if necessary. • The difference between pediatric and adult dosages of medicines is significant, and adult dosages given to children can have serious, harmful effects. • Following any poisoning, the parents should call the Poison Control Center for instructions for appropriate treatment. Explanation: Safety measures for poisonous substances include close supervision of children, safely storing toxic substances, teaching proper dosages and differences between adult and child doses, and the proper way to contact the Poison Control Center for instructions. Poison Control should be notified as soon as the poisoning has occurred and airway and circulation have been assessed. Poison Control will direct any further treatment. Syrup of ipecac is rarely used today in the treatment of ingested substances due to the potential for aspiration. It is contraindicated in cases of arsenic poisoning, seizures, and the ingestion of petroleum or corrosive substances.

Question 11 A client presents to the ED with serious health problems that are not immediately life threatening. The nurse will correctly triage the client into which category?

Correct Response: • Urgent Explanation: Clients triaged as urgent have serious health problems that are not immediately life threatening. They must be seen within 1 hour. The emergent category is for clients who have the highest priority conditions that are life-threatening and they must be seen immediately. Nonurgent is for clients who have episodic illness that can be addressed within 24 hours without increased morbidity. Clients in the less urgent category must be reassessed at least every 60 minutes and do not have serious health problems.

Question 4 A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:

Correct Response: • raccoon's eyes and Battle sign. Explanation: A basilar skull fracture commonly causes only periorbital ecchymosis (raccoon's eyes) and postmastoid ecchymosis (Battle sign); however, it sometimes also causes otorrhea, rhinorrhea, and loss of cranial nerve I (olfactory nerve) function. Nuchal rigidity and Kernig's sign are associated with meningitis. Motor loss in the legs that exceeds that in the arms suggests central cord syndrome. Pupillary changes are common in skull fractures with associated meningeal artery bleeding and uncal herniation.

Question 7 The nurse is preparing an in-service program on pediatric cardiopulmonary resuscitation. The nurse would include a discussion that cardiopulmonary arrest in infants and children is most likely the result of:

Correct Response: • respiratory failure. Explanation: Cardiopulmonary arrest in infants and children typically results from disorders that lead to respiratory failure and shock. In adults, the most common causes of cardiopulmonary arrest are lethal arrhythmias secondary to heart disease. Although neurologic trauma can lead to respiratory failure, it alone is not the most likely factor.

Question 19 A client has had a central venous pressure line inserted. The nurse should immediately report which sign to the health care provider?

Correct Response: • sharp pain on the affected side Explanation: Sudden, sharp pain with breathing or coughing on the affected side, tachypnea, dyspnea, diminished or absent breath sounds on the affected side, tachycardia, anxiety, and restlessness indicate a pneumothorax, which can be a complication of inserting a central venous pressure line. The other findings are within normal limits.

Question 4 What type of seizure activity is characterized by generalized tonic-clonic convulsions lasting for several minutes during which the client does not regain consciousness?

Correct Response: • status epilepticus Explanation: Status epilepticus is a life-threatening emergency characterized by generalized tonic-clonic convulsions lasting for several minutes or occurring at close intervals during which the client does not regain consciousness. None of the other options present with this described experience.

Question 16 The nurse assesses a dark-skinned patient who has cherry-red nail beds, lips, and oral mucosa. What does this assessment data indicate the patient may be experiencing?

Correct Response: • Carbon monoxide poisoning Explanation: Cherry red nail beds, lips, and oral mucosa in a dark-skinned person are signs of carbon monoxide poisoning.

Question 15 A client is diagnosed with atropine toxicity that resulted from the ingestion of herbal therapies. What would be done first?

Correct Response: • Gastric lavage Explanation: If atropine toxicity is due to ingestion, immediate gastric lavage is performed to limit absorption of the drug. Physostigmine would then be given as an antidote. Diazepam may be used if the client experiences seizures. Cool sponge baths would be used as additional support measure to relieve fever and hot skin.

Question 3 A nurse notices a client lying on the floor at the bottom of the stairs. The client is alert and oriented and denies pain other than in the arm, which is swollen and appears deformed. After calling for help, what should the nurse do?

Correct Response: • Immobilize the client's arm. Explanation: Signs of a fracture in an extremity include pain, deformity, swelling, discoloration, and loss of function. When a nurse suspects a fracture, the extremity should be immobilized before moving the body part. It isn't appropriate for the nurse to move the client into a sitting position without further assessment. The client shouldn't walk to the nurses' station; the client should wait for help to arrive.

Question 2 The nurse is caring for a client with a stage IV leg ulcer. The nurse is closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that the nurse should notify the physician of immediately?

Correct Response: • The client's heart rate is greater than 90 beats per minute. Explanation: A heart rate greater than 90 beats per minute or a respiratory rate greater than 20 breaths per minute will indicate that sepsis has occurred. Sepsis does not increase the client's appetite or affect the client's urinary output.

Question 17 A nurse is providing care for client who experienced a stroke. Which nursing intervention reflects the tertiary level of prevention?

Correct Response: • provide care transition at discharge for speech therapy Explanation: Tertiary prevention minimizes the consequences of a disorder through aggressive rehabilitation or appropriate management of the disease. An example is speech therapy to help restore ability. Blood pressure and mental status exams are examples of secondary prevention associated with the acute stroke. Discussing family history is also secondary prevention in terms of assessing for further risk factors.

Question 3 Your hospital has had an influx of clients who are in respiratory distress and require ventilator assistance. What might this indicate?

Correct Response: • A bioterrorism attack Explanation: If large numbers of people were to become acutely ill simultaneously as a consequence of bioterrorism, the numbers of ventilators available in any particular agency would likely become exhausted quickly. This scenario does not indicate a natural disaster. Options B and C are distractors to the

Question 17 A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?

Correct Response: • An intracerebral hematoma Explanation: Intracerebral hemorrhage (hematoma) is bleeding within the brain, into the parenchyma of the brain. It is commonly seen in head injuries when force is exerted to the head over a small area (e.g., missile injuries, bullet wounds, stab injuries). A subdural hematoma (SDH) is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of cerebrospinal fluid. After a head injury, blood may collect in the epidural (extradural) space between the skull and the dura.

Question 10 A client has a sucking stab wound to the chest. Which action should the nurse take first?

Correct Response: • Apply a dressing over the wound and tape it on three sides. Explanation: The nurse should immediately apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.

Question 9 A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client?

Correct Response: • Assess fetal heart sounds. Explanation: To rule out cord prolapse, always assess fetal heart sounds immediately after rupture of the membranes whether this occurs spontaneously or by amniotomy, as the fetal heart rate will be unusually slow or a variable deceleration pattern will become apparent when cord prolapse has occurred. The other answers refer to therapeutic interventions to implement once cord prolapse has been confirmed.

Question 15 Atelectasis is the term used to designate an incomplete expansion of a portion of the lung. Depending on the size of the collapsed area and the type of atelectasis occurring, the nurse may see a shift of the mediastinum and trachea. Which way does the mediastinum and trachea shift in compression atelectasis?

Correct Response: • Away from the affected lung Explanation: If the collapsed area is large, the mediastinum and trachea shift to the affected side. In compression atelectasis, the mediastinum shifts away from the affected lung.

Question 12 A postpartum client develops uncontrolled postpartum bleeding, oozing from IV sites, a blood pressure of 82/40, and respiratory distress. Which complication does the nurse suspect is occurring?

Correct Response: • Disseminated intravascular coagulation (DIC) Explanation: With DIC, bleeding may be present as petechiae, purpura, oozing from puncture sites, or severe hemorrhage. Uncontrolled postpartum bleeding may indicate DIC. Microemboli may obstruct blood vessels and cause tissue hypoxia and necrotic damage to organ structures, such as the kidneys, heart, lungs, and brain. As a result, common clinical signs may be due to renal, circulatory, or respiratory failure, acute bleeding ulcers, or convulsions and coma.

Question 14 A 12-year-old boy has broken his arm and is showing signs and symptoms of shock. Which of the following would the nurse do first?

Correct Response: • Establish a suitable IV site. Explanation: The goal of treating shock is to restore circulating blood volume. This requires that vascular access be obtained to administer fluids and vasoactive drugs. Hyperventilation is reserved for temporary treatment of severe intracranial pressure. Analgesics should not be administered prior to neurologic and cardiovascular examination being performed. Drawing blood for type and cross match would be once vascular access is obtained and fluid and drug therapy has been initiated.

Question 19 A client has had a stroke and computed tomography reveals infarcts in multiple brain regions. An infarct in which region is most likely to affect the function of the client's autonomic nervous system?

Correct Response: • Hypothalamus Explanation: The hypothalamus plays a major role in the coordination of autonomic nervous system function. The parietal cortex primarily regulates touch and sensation. The amygdala contributes to memory and decision making. The ventricular system contributes to the production and distribution of cerebrospinal fluid.

Question 11 The nurse is assisting a client who had a myocardial infarction 2 days ago during a bath. The client suddenly lost consciousness and the nurse was unable to feel a pulse. Cardiopulmonary resuscitation was begun and the client was connected to the monitor with a gross disorganization without identifiable waveforms or intervals observed. What is a priority intervention at this time?

Correct Response: • Immediate defibrillation Explanation: The classic electrocardiographic pattern of ventricular fibrillation is that of gross distortion without identifiable waveforms or or intervals. When the ventricles do not contract, there is no cardiac output, and there are no palpable or audible pulses. Immediate defibrillation using a nonsynchronized, direct-current electrical shock is mandatory for ventricular fibrillation and for ventricular flutter that has caused loss of consciousness.

Question 3 What is a true statement regarding status epilepticus?

Correct Response: • It is a common neurologic emergency in children. Explanation: Status epilepticus is a common neurological emergency in children. Children younger than 3 years of age are most likely to develop status epilepticus. The most common cause of status epilepticus in children is febrile seizures. Status epilepticus occurs when seizures last longer than 30 minutes or recur without return of consciousness between seizures.

Question 16 The nurse prepares to assess the circulation status of a toddler in the emergency room following a near-drowning. What would the nurse specifically assess? Select all that apply.

Correct Response: • Level of consciousness • Apical and femoral pulse • Skin color and temperature Explanation: Circulation is evaluated with the heart rate (via apical or palpation of a central pulse, not a cardiac monitor), skin color and temperature, cardiac rhythm and level of consciousness. The nurse would assess the child's temperature but this would not indicate circulation status.

Question 11 A client is brought to the emergency department after taking an overdose of levothyroxine. When assessing this client, what adverse effects would the nurse expect to find?

Correct Response: • Nervousness and tachycardia Explanation: Excessive doses of levothyroxine, a thyroid drug, can cause the same signs and symptoms that occur with hyperthyroidism. These include nervousness and tachycardia.

Question 6 A nurse suspects a child is experiencing cardiac tamponade after heart surgery. What would be the priority nursing intervention?

Correct Response: • Notify the doctor immediately. Explanation: The nurse would notify the doctor immediately. Cardiac tamponade is a medical emergency and should be addressed. The child can die if intervention is postponed. It would not be appropriate to perform any interventions until confirming that this is the actual diagnosis.

Question 14 The nurse is caring for a patient with hyperthyroidism who suddenly develops symptoms related to thyroid storm. What symptoms does the nurse recognize that are indicative of this emergency?

Correct Response: • Temperature of 102ºF Explanation: Thyroid storm is characterized by the following: 1) high fever (hyperpyrexia), >38.5°C (>101.3°F); 2) extreme tachycardia (>130 bpm); 3) exaggerated symptoms of hyperthyroidism with disturbances of a major system—for example, gastrointestinal (weight loss, diarrhea, abdominal pain) or cardiovascular (edema, chest pain, dyspnea, palpitations); and 4) altered neurologic or mental state, which frequently appears as delirium psychosis, somnolence, or coma.

Question 1 A nurse is preparing a continuous insulin infusion for a child with diabetic ketoacidosis and a blood glucose level of 800 mg/dl. Which solution is the most appropriate at the beginning of therapy?

Correct Response: • 100 units of regular insulin in normal saline solution Explanation: Continuous insulin infusions use only short-acting regular insulin. Insulin is added to normal saline solution and administered until the client's blood glucose level falls. Further along in the therapy, a dextrose solution is administered to prevent hypoglycemia.

Question 19 The nurse is caring for a child experiencing a cardiac arrest. The nurse has administered IV epinephrine at 1315. At what time can the nurse administer another dose of epinephrine?

Correct Response: • 1320. Explanation: Epinephrine may be administered IV, intraosseous (IO) or via and ET tube. During CPR, it may be repeated every 3 to 5 minutes.

Question 7 A nurse is administering a chemotherapeutic medication to a client, who reports generalized itching and then chest tightness and shortness of breath. The nurse immediately

Correct Response: • Stops the chemotherapeutic infusion Explanation: The client may be experiencing a type I hypersensitivity reaction, which may progress to systemic anaphylaxis. The most immediate action of the nurse is to discontinue the medication followed by initiating emergency protocols.

Question 15 A nurse is monitoring a client closely for malignant hyperthermia because the client received which NMJ blocker?

Correct Response: • Succinylcholine Explanation: Succinylcholine is associated with the development of malignant hyperthermia in susceptible clients. Pancuronium, vecuronium, and atracurium are not associated with the development of this condition.

Question 5 In a person being treated for a diagnosed seizure disorder, what is the most common cause of status epilepticus?

Correct Response: • abruptly stopping the antiseizure medications Explanation: In a person taking medications for a diagnosed seizure disorder, the most common cause of status epilepticus is abruptly stopping AEDs. In other clients, regardless of whether they have a diagnosed seizure disorder, causes of status epilepticus include brain trauma or tumors, systemic or central nervous system (CNS) infections, alcohol withdrawal, and overdoses of drugs (e.g., cocaine, theophylline).

Question 8 A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to:

Correct Response: • administer oxygen by mask. Explanation: An amniotic embolism quickly becomes a pulmonary embolism. The woman needs oxygen to compensate for the sudden blockage of blood flow through her lungs.

Question 1 A parent brings a preschool child to the emergency department after the child ingested an unknown quantity of acetaminophen. Which treatment does the nurse anticipate?

Correct Response: • gastric lavage and administration of activated charcoal Explanation: The healthcare provider will probably order gastric lavage or activated charcoal administration. Ipecac syrup is no longer recommended, and an antacid is not an effective treatment for poisoning. Infusing normal saline solution I.V. may be helpful in treating dehydration caused by vomiting, but in itself is not effective in eliminating the poisonous substance.

Question 9 The nurse is preparing a teaching plan for a pregnant woman about the signs and symptoms to be reported immediately to her health care provider. Which signs and symptoms would the nurse include? Select all that apply.

Correct Response: • headache with visual changes in the third trimester • sudden leakage of fluid during the second trimester • lower abdominal pain with shoulder pain in the first trimester Explanation: Danger signs and symptoms that need to be reported immediately include headache with visual changes and sudden leakage of fluid in the second trimester and lower abdominal pain accompanied by shoulder pain in the first trimester. Urinary frequency in the third trimester, nausea and vomiting during the first trimester, and backache during the second trimester are common discomforts of pregnancy.

Question 13 A nurse manager attempts to achieve performance improvement in the emergency department of a busy inner-city hospital. Which nursing actions follow Haase and Miller's recommended steps in performance improvement? Select all that apply.

Correct Response: • The nurse discovers that there is a problem with the triage system that is in place in the emergency department. • The nurse calls a meeting of the emergency department interdisciplinary team to effect change in the triage process. • The nurse organizes a task force to implement change in the triage process of a busy emergency department. • The nurse meets with the emergency department staff to assess changes made to the triage process. Explanation: Nurses committed to healthier clients, quality care, reduced costs, and the personal satisfaction of knowing that they are actually making a difference (versus merely wishing things were different) value performance improvement. The four steps, according to Haase & Miller, that are crucial in improving performance include: 1. Discover a problem. 2. Plan a strategy using indicators. 3. Implement a change. 4. Assess the change; if the outcome is not met, plan a new strategy.

Question 13 A child is brought to the emergency department with a full-thickness burn involving the epidermis, dermis, and underlying subcutaneous tissue, but does not report pain at this time. Which statements by the nurse are correct about this type of burn? Select all that apply.

Correct Response: • This is a severe burn and nerve endings have been destroyed. • The child must be monitored for signs of fluid shift. • Rehabilitation and skin grafting will be necessary. Explanation: This is an example of a third-degree burn, which is very serious. This child must be carefully monitored for complications. The fact that there is no pain is due to the destruction of the nerve endings. Fluid shift can occur and result in shock. A burn of this degree will also require a long rehabilitation with skin grafting. Oral pain medication would not be administered as the child would be NPO and oral medication would not be effective. This burn is not superficial.

Question 4 The client sustained an open fracture of the femur from an automobile accident. The nurse should assess the client for which type of shock?

Correct Response: • hypovolemic Explanation: A fractured femur, especially an open fracture, can cause much soft tissue damage and lead to significant blood loss. Hypovolemic shock can develop. Cardiogenic shock occurs when cardiac output is decreased as a result of ineffective pumping. Neurogenic shock occurs as a result of an impaired autonomic nervous system function. Anaphylactic shock is the result of an allergic reaction.