Critical Care Study Guide Q & A
40. The health care provider orders IV infusion of epinephrine for an older adult patient who is not responding to the IM epinephrine that was administered for an allergic reaction to a bee sting. In conjunction with the epinephrine administration, which action does the nurse take? a. Place the patient on a cardiac monitor. b. Place the patient on continuous pulse oximetry. c. Obtain an order for an electrocardiogram (ECG). d. Obtain an order for an arterial blood gas.
ANSWER: a. Place the patient on a cardiac monitor.
56. What factor increases an older adult's risk for distributive (septic) shock? a. Reduced skin integrity b. Diuretic therapy c. Cardiomyopathy d. Musculoskeletal weakness
ANSWER: a. Reduced skin integrity
26. Which nurse activity would best help the hospital to meet the Joint Commission's mandate for emergency preparedness? a. Assist in planning drills that include patient simulations. b. Help other nurses make a personal emergency preparedness plan. c. Attend training classes to learn how to handle hazardous materials. d. Identify the credible threats to the safety of the community.
ANSWER: a. Assist in planning drills that include patient simulations
31. The nurse's next-door neighbor has sustained a deep laceration to the right upper arm & there is active bright-red bleeding. What does the nurse do to immediately control the bleeding? (SATA) a. Apply a tourniquet just above the laceration. b. Have the neighbor lie fat & elevate the arm. c. Apply direct pressure with a thick, dry towel. d. Apply sterile gauze & wrap the wound with an Ace bandage. e. Rinse the wound gently with tepid water & apply direct pressure with a towel.
ANSWERS: b. Have the neighbor lie fat & elevate the arm. c. Apply direct pressure with a thick, dry towel.
14. For which patients would the nurse advocate for a social services consult? (SATA) a. Toddler who bumped her head on a table; observation for 24 hours is required. b. Homeless woman who will be discharged with a splint to the lower leg & crutches. c. Woman who was punched & beaten by her husband & sustained a broken jaw. d. Man who drove himself to the ED for a dressing change of an infected wound on his back. e. Preteen admitted for vaginal bleeding & sexually transmitted infection.
ANSWERS: b. Homeless woman who will be discharged with a splint to the lower leg & crutches. c. Woman who was punched & beaten by her husband & sustained a broken jaw. e. Preteen admitted for vaginal bleeding & sexually transmitted infection
54. The nurse receives a phone call from a child who says, "Mommy was hit by lightning
She's outside. I'm afraid to touch her! I'll get shocked too!" How does the nurse advise the child? a. "There is no danger in touching your mom. You won't get hurt." b. "It will be okay, just quickly run outside & see if she is breathing." c. "Is there anybody at home with you? Let me speak to an adult." d. "You stay in the house & someone will come to help very soon." ! ANSWER: d. "You stay in the house & someone will come to help very soon."
2. Which event would be considered an internal disaster? a. A fire in a long-term care facility b. Gunfire in the hospital parking lot c. A tornado devastates the community d. Several people die from flulike symptoms
ANSWER: a. A fire in a long-term care facility
23. A gang-related incident has occurred involving major casualties from gunshot wounds to 11 victims. Which type of debriefing is utilized by the hospital after handling this event? a. Critical stress incident b. Posttraumatic stress c. Administrative stress d. Restoring normalcy
ANSWER: a. Critical stress incident
43. The nurse is caring for a PT with septic shock. Which therapy specific to the management of septic shock for this PT does the nurse anticipate will be used? a. Inotropics b. Antibiotics c. Colloids d. Anti-dysrhythmics
ANSWER: b. Antibiotics
21. A young trauma patient is at risk for hypovolemic shock related to occult hemorrhage. What baseline indicator allows the nurse to recognize the early signs of shock? a. Urine output b. Pulse rate c. Fluid intake d. Skin color
ANSWER: b. Pulse rate
30. A patient comes to the ED with severe injury & significant blood loss. The nurse anticipates that resuscitation will begin with which fluid? a. Whole blood b. 0.5% dextrose in water c. 0.9% sodium chloride d. Plasma protein fractions
ANSWER: c. 0.9% sodium chloride
41. The nurse is caring for a patient at risk for septic shock from a wound infection. In order to prevent systemic inflammatory response syndrome, the nurse's priority is to monitor which factor? a. Patient's pulse rate & quality b. Patient's electrolyte imbalance c. Localized infected area d. Patient's intake & output
ANSWER: c. Localized infected area
23. Which patient should be triaged as urgent (U)? a. 44-year-old man with a dislocated elbow b. 35-year-old man with chest pain & diaphoresis c. 85-year-old man with new onset of confusion; BP grossly elevated compared to his usual d. 65-year-old woman with redness & swelling on the forearm associated with a bee sting
ANSWER: a. 44-year-old man with a dislocated elbow
22. A patient sustained a coral snakebite on the forearm approximately 12 hours ago & he has been admitted for observation. He reported a mild transient pain, but was otherwise asymptomatic on admission. Which clinical manifestations are early signs of envenomation? a. Nausea, vomiting, & pallor b. Difficulty speaking & swallowing c. Total flaccid paralysis d. Severe pain & swelling at the site
ANSWER: a. Nausea, vomiting, & pallor
32. A patient is in hypovolemic shock related to hemorrhage from a large gunshot wound. Which order must the nurse question? a. Establish a large-bore peripheral IV & give crystalloid bolus. b. Give furosemide (Lasix) 20 mg slow IVP. c. Insert a Foley catheter & monitor intake & output. d. Give high-flow oxygen via mask at 10 L/ min.
ANSWER: b. Give furosemide (Lasix) 20 mg slow IVP.
46. A patient with which situation would best benefit from always carrying an epinephrine auto injector (EpiPen)? a. Frequently works outside in the yard b. Allergies to poison ivy, grass, & pollens c. Previous allergic reaction to a wasp sting d. History of severe pain with bee or wasp stings
ANSWER: c. Previous allergic reaction to a wasp sting
26. When administering anti-venom for pit viper bites, which signs/symptoms does the nurse observe for that would signal the most likely adverse reaction to the treatment? a. Elevated blood pressure b. Pain at the injection site c. Pruritus & hives d. Disorientation
ANSWER: c. Pruritus & hives
35. The nurse is caring for an older adult patient at risk for shock. What is an early sign of shock in this patient? a. Cool, clammy skin b. Decreased urinary output c. Restlessness d. Hypotension
ANSWER: c. Restlessness
9. An older couple on vacation comes to the ED. The man appears to be having a stroke & is unable to speak clearly or coherently. His wife is very distraught & states, "He has many allergies & takes many medications, but I can't remember anything right now
" What should the nurse do first to quickly obtain drug & allergy information? a. Call the patient's family health care provider for a phone report about his drugs & allergies. b. Remind the wife to keep a list of the patient's drugs & allergies in her purse. c. Call the pharmacy where the patient obtains his medications. d. Check for a medical alert bracelet & help the wife to look in the patient's suitcase. ! ANSWER: d. Check for a medical alert bracelet & help the wife to look in the patient's suitcase.
12. An older adult man in the ED has sustained a snakebite. What key questions does the nurse ask to assess the risk for envenomation? (SATA) a. "What color was the snake?" b. "Did the snake have a triangle-shaped head?" c. "Was the swelling localized or did it extend beyond the bite site?" d. "Did the bite leave any secretions on the skin?" e. "Was the fang mark immediately evident on the skin?"
ANSWER: b. "Did the snake have a triangle-shaped head?" c. "Was the swelling localized or did it extend beyond the bite site?"
84. The ED health care team is administering emergency treatment to a drowning victim. Which task can be delegated to a UAP? a. Insert the nasogastric tube. b. Advise the family about the patient's status. c. Take & report vital signs every 15 minutes. d. Assist with the bag-valve-mask during intubation.
ANSWER: C. Take & report vital signs every 15 minutes.
44. An elderly man is brought to the ED by the patient's son. The patient is alert, but is disoriented to person, place, & time, & is unable to follow simple instructions. Which question is the most important to ask the son? a. "Does your father have any health conditions?" b. "Are you the primary caregiver for your father?" c. "Do you think your father would consent to emergency care?" d. "Who is your father's primary care provider?"
ANSWER: a. "Does your father have any health conditions?"
48. The nurse is reviewing the laboratory results of a patient with a systemic infection. What is the significance of a "left shift" in the differential leukocyte count? a. Expected finding because the patient has a serious infection. b. Indication that the infection is progressing toward resolution. c. Indication that the infection is outpacing the white cell production. d. Important to watch for trends, but otherwise not urgently significant.
ANS: c. Indication that the infection is outpacing the white cell production.
11. The nurse serves on a committee that is tasked to develop tools & aids that the medical command physician could use during a disaster event. What is an appropriate project for this purpose? a. Make a current list, including contact information, of trauma & orthopedic surgeons. b. Make a telephone tree for contacting the nursing & ancillary staff. c. Design a triage algorithm that addresses different types of disaster events. d. Design an algorithm for contacting the Federal Emergency Management Agency.
ANSWER a. Make a current list, including contact information, of trauma & orthopedic surgeons.:
25. Because of the high risk for health care- acquired urinary tract infections, the nurse would question an order for a catheterized urine specimen for which patient? a. 78-year-old female transferred from a long-term care facility for urinary retention b. 25-year-old female with back pain & hematuria, currently menstruating c. 3-year-old with severe dehydration after prolonged diarrhea & vomiting d. 43-year-old multiple trauma patient with signs of hypovolemic shock
ANSWER: a. 78-year-old female transferred from a long-term care facility for urinary retention
10. The nurse is assigned to assist the hospital incident commander during a disaster drill. Which responsibility is appropriate for the nurse in this capacity? a. Call all nursing units to determine the number of patients who could potentially be discharged. b. Call the physical therapy department & direct therapists to assist in the operating room or the intensive care unit (ICU). c. Go to the emergency department (ED) & assist with the triage of disaster victims to appropriate clinical areas. d. Contact the security department & instruct them to control the number of people who attempt to enter the hospital.
ANSWER: a. Call all nursing units to determine the number of patients who could potentially be discharged.
16. Assessment findings of a patient with trauma injuries reveal cool, pale skin; reported thirst, urine output 100 mL/8 hr, blood pressure 122/78 mm Hg, pulse 102 beats/min, respirations 24/min with decreased breath sounds. This patient is in what phase of shock? a. Compensatory/non-progressive b. Progressive c. Refractory d. Multiple organ dysfunction
ANSWER: a. Compensatory/non-progressive
18. The nurse is assigned to assist the incident commander who is evaluating the feasibility of deactivating the emergency management plan. The commander directs the nurse to accomplish certain tasks. Which task is the priority? a. Contact all hospital departments & determine if needs have been met. b. Go to the ED & supervise the inventory & restocking of supplies. c. Arrange for temporary sleeping quarters for exhausted staff members. d. Assist in the preparations of the critical incident stress debriefing.
ANSWER: a. Contact all hospital depts & determine if needs have been met.
18. A parent brings her 2-year-old child to the ED, stating, "She fell & bumped her head & forearm." Which behavior by the child causes the nurse the least concern during the initial triage interview? a. Crying & reaching for the parent as the nurse approaches b. Alert & still, quietly watching as the nurse approaches c. Asleep, limp, with even & unlabored respirations d. Crying loudly & inconsolably since she was brought in
ANSWER: a. Crying & reaching for the parent as the nurse approaches
17. A patient is admitted for a poisonous snakebite. The nurse observes that the patient has hemorrhagic complications of hematuria, hemoptysis, petechiae, & extensive bruising. These clinical observations indicate to the nurse that the patient may be experiencing which complication associated with snakebite? a. Disseminated intravascular coagulation b. Agranulocytosis c. Thrombocytopenia d. Aplastic anemia
ANSWER: a. Disseminated intravascular coagulation
37. The nurse is caring for a patient with sepsis. What is a late clinical manifestation of shock? a. Drop in blood pressure b. MAP is decreased by less than 10 mm Hg c. Tachycardia with a bounding pulse d. Increased urine output
ANSWER: a. Drop in blood pressure
17. A patient comes to the ED worried that he has been exposed to an infectious bioterrorism agent that was sent to him through the mail. What is the priority action for the ED nurse take? a. Escort the patient to quarantined area. b. Take a history & assess for symptoms. c. Call local police & the Department of Public Health. d. Activate the emergency preparedness plan.
ANSWER: a. Escort the patient to quarantined area.
74. A patient is admitted to the ED for high-altitude sickness. In the morning, he appears apathetic & declines to perform basic activities of daily living (ADLs). Later in the shift, the patient is unable to move himself in bed or to independently sit upright. What condition does the nurse suspect? a. High-altitude cerebral edema (HACE) b. Severe hypoxemia c. Acute mountain sickness (AMS) d. Severe hypothermia
ANSWER: a. High-altitude cerebral edema (HACE)
11. A young migrant worker has been living in a garden shed for several months. He is brought to the emergency department (ED) & is alert & conversant, but appears fearful & confused. His skin is hot & dry & his lips are cracked & bleeding. His skin turgor is poor & he is malnourished. His blood pressure is 96/60 mm Hg, pulse is 120, respirations 30, temperature is 105° F. In addition to high-flow oxygen, what does the nurse anticipate the ED health care provider will initially order? a. IV normal saline & a Foley catheter b. IV Ringer's lactate & an NG tube c. IV 5% dextrose & acetaminophen (Tylenol) d. IV 45% saline & chlorpromazine (Torazine)
ANSWER: a. IV normal saline & a Foley catheter
85. Which combination of factors is likely to contribute to the highest survival rate for drowning victims? a. In very cold fresh water for 6 minutes; arrives in ED with pulse of 40 b. In warm salt water for 6 minutes; arrives in ED with pulse of 70 c. In very cold salt water for 10 minutes; arrives in ED with no pulse d. In warm contaminated water for 5 minutes; arrives in ED with no pulse
ANSWER: a. In very cold fresh water for 6 minutes; arrives in ED with pulse of 40
16. The nurse is making a personal emergency preparedness plan. What is the nurse sure to include in the plan? a. Make a disaster supply kit with clothing & basic survival supplies. b. Resolve the ethical conflicts of family & professional obligations. c. Stockpile antibiotics, first-aid supplies, & resuscitation equipment. d. Teach family members about radiation & HAZMAT safety issues.
ANSWER: a. Make a disaster supply kit with clothing & basic survival supplies.
46. The nurse is caring for a PT in septic shock. The nurse notes that the rate & depth of respirations is markedly increased. The nurse interprets this as a possible SIGN of the respiratory system compensating for which condition? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis
ANSWER: a. Metabolic acidosis
44. A 37-year-old woman was stung by a bee while gardening. What will cause her to develop a systemic effect? a. Multiple bee stings b. Immediate local reaction c. Desensitization to the venom d. No prior allergic reaction to bee stings
ANSWER: a. Multiple bee stings
8. It is the middle of summer & the weather has been hot & humid for several weeks. Which patient has the highest risk for severe heat related illness? a. Older adult woman who lives alone in an apartment with no air conditioning b. Well-conditioned athlete who is participating in a marathon c. Experienced construction worker who is working on an outdoor structure d. Young child who is participating in an organized team sport
ANSWER: a. Older adult woman who lives alone in an apartment with no air conditioning
31. Which change in the skin is an early indication of hypovolemic shock? a. Pallor or cyanosis in the mucous membranes b. Color changes in the trunk area c. Axilla & groin feel moist or clammy d. Generalized mottling of skin
ANSWER: a. Pallor or cyanosis in the mucous membranes
28. What is the fastest way for the nurse to estimate the systolic blood pressure in a patient with multiple injuries, who has just been moved from the transport stretcher to the ED resuscitation stretcher? a. Palpate for presence of a radial pulse. b. Use the automated blood pressure cuff. c. Place the patient on a cardiac monitor. d. Check for the presence of capillary refill.
ANSWER: a. Palpate for presence of a radial pulse.
34. Which patient is most likely to be treated with antivenin for a black widow spider bite? a. Patient in the second trimester of pregnancy b. Patient who relapsed 2 weeks after being bitten c. Patient who has severe pain & swelling at the site d. Patient who is asymptomatic with a cardiac history
ANSWER: a. Patient in the second trimester of pregnancy
22. Which patient is most likely to show elevated hemoglobin & hematocrit during shock? a. Patient with severe vomiting & large amounts of watery diarrheal stools b. Patient with a large wound with copious drainage c. Patient who was stable After surgery, but is now decompensating d. Patient with a hemothorax & chest tube
ANSWER: a. Patient with severe vomiting & large amounts of watery diarrheal stools
54. The nurse is interviewing a homeless patient in the triage area. The patient says, "I'm a nurse too. Flying pictures say God is me. I'm a god, taking noise away." The patient then stands up & kicks over the garbage can. What should the nurse do first? a. Remain calm & slowly step away from the patient. b. Run towards the panic button & immediately push it. c. Gently take the patient's arm & lead her to a quiet space. d. Call for help & instruct bystanders to get out of the way.
ANSWER: a. Remain calm & slowly step away from the patient.
60. The UAP working under supervision of an RN is checking vital signs on the patient at risk for hypovolemic shock. Which instruction must the nurse give the UAP? a. Report any increase in heart rate because it is an early sign of shock. b. Report any increased systolic pressure, which is an early sign of shock. c. Report any changes in body temperature, which may indicate sepsis. d. Report any increase in respiratory rate because of acid-base changes.
ANSWER: a. Report any increase in heart rate because it is an early sign of shock.
19. Which symptoms indicate that the patient may have the beginning of serum sickness? a. Skin rash with pruritus b. Nausea & vomiting c. Dizziness & lightheadedness d. Malaise & excessive fatigue
ANSWER: a. Skin rash with pruritus
24. A patient is at risk for hypovolemia secondary to large amounts of watery diarrhea & vomiting. The patient reports feeling a little thirsty & a slightly lightheaded. What does the nurse do next? a. Take the blood pressure & pulse & compare results to the patient's baseline. b. Obtain an order to start a sodium nitroprusside (Nipride) IV infusion. c. Have the patient rest in bed & take small frequent sips of water. d. Compare the patient's intake to the urinary output.
ANSWER: a. Take the blood pressure & pulse & compare results to the patient's baseline.
49. The nurse sees that the emergency provider has written an order to discharge an elderly patient to go home. The patient cannot walk independently & has no relatives. What should the nurse do first? a. Talk to the provider about the patient's self-care abilities. b. Ask the patient if a friend could come to the hospital. c. Obtain a taxicab voucher for the patient. d. Consult social services for nursing home placement.
ANSWER: a. Talk to the provider about the patient's self-care abilities.
29. A patient comes to the ED after falling of a roof. He displays absent breath sounds over the left chest, severe respiratory distress, hypotension, jugular vein distention, & tracheal deviation. Based on these assessment findings, for which condition does the nurse anticipate the patient must receive immediate treatment? a. Tension pneumothorax b. Cardiac arrest c. Airway obstruction d. Multiple fractured ribs
ANSWER: a. Tension pneumothorax
64. The health care provider orders core warming methods for a conscious patient with moderate hypothermia. What equipment would the nurse obtain in order to provide this therapy? a. Three-way Foley with warmed lavage fluid b. Axillary thermometer to monitor core temperature c. Bag-valve-mask with warmed humidified oxygen d. Several warm blankets & warming pads
ANSWER: a. Three-way Foley with warmed lavage fluid
30. A patient was bitten by a brown recluse spider 4 days ago. The nurse observes prolonged bleeding after venipunctures & notes that the patient has a low platelet count. What do these findings indicate? a. Thrombocytopenia b. Hemolytic anemia c. Aplastic anemia d. Agranulocytosis
ANSWER: a. Thrombocytopenia
63. A patient arrives at the ED after a prolonged cold exposure. The staff avoids rough & vigorous movements during the transfer from stretcher to bed to prevent which complication? a. Ventricular fibrillation related to rough handling b. Third-degree heart block related to cold auto transfusion c. After-drop due to cold blood moving to the central circulation d. Pulmonary emboli related to dislodgment of a clot
ANSWER: a. Ventricular fibrillation related to rough handling
69. The nurse is conducting a class about cold weather hiking. What are the early signs of frostbite, which hiking partners should frequently observe for? a. White, waxy, or pale gray appearance to ears, nose, & cheeks b. Edema & redness over the exposed skin c. Mottled coloring of the skin d. Small blisters that contain dark fluid & areas that do not blanch
ANSWER: a. White, waxy, or pale gray appearance to ears, nose, & cheeks
73. A patient reports having a throbbing headache with nausea & vomiting "like the worst hangover of my life" after recently returning from a hiking trip to the mountains. The nurse suspects high-altitude sickness. Which question helps the nurse gather relevant information about this condition? a. "Did you experience any episodes of hypothermia during your trip?" b. "How quickly did you ascend to the top of the mountain range?" c. "Did you go skiing or hiking in a high-altitude area?" d. "Did you have trouble sleeping while you were in the mountains?"
ANSWER: b. "How quickly did you ascend to the top of the mountain range?"
33. The nurse is performing a psychosocial assessment on a patient who is at risk for shock. Which statement made by the patient is of greatest concern to the nurse? a. "Do you have any idea when I might go home? No one is feeding my cat." b. "Something feels wrong, but I'm not sure what is causing me to feel this way." c. "I live alone in my house & my family lives in a different state." d. "I would usually go golfing with my friends today. I hope they're not worried about me."
ANSWER: b. "Something feels wrong, but I'm not sure what is causing me to feel this way."
4.What is the most important data to verify in order to determine potential for a multi-casualty event versus a mass casualty event? a. "How long ago did the event occur?" b. "What are the number & severity of the injuries?" c. "What are school officials saying about the incident?" d. "Have emergency medical services been notified?"
ANSWER: b. "What are the number & severity of the injuries?"
32. A patient who sustained multiple injuries in a job site accident has a BP of 100/60 mm Hg & pulse of 120/min. Two large-bore IVs are established & IV fluid resuscitation is initiated. After receiving IV fluid, repeat vital signs are BP 94/56 mm Hg, pulse 135/min; then BP 80/50 mm Hg, pulse 150/min. With these vital signs, the patient is likely to require blood products after how many liters of IV fluid? a. 1 b. 2 c. 4 d. 5
ANSWER: b. 2
22. Which patient should be triaged as emergent (E)? a. 56-year-old man with severe unilateral back pain & previous history of kidney stones b. 23-year-old woman with severe abdominal pain; positive home pregnancy test; BP 80/40 mm Hg c. 6-year-old with a temperature of 101° F & flulike symptoms d. 10-year-old girl with vomiting, diarrhea, & abdominal pain onset 4 hours after eating fish
ANSWER: b. 23-year-old woman with severe abdominal pain; positive home pregnancy test; BP 80/40 mm Hg
28. The nurse is caring for a postoperative patient who had major abdominal surgery. Which assessment finding is consistent with hypovolemic shock? a. Pulse pressure of 40 mm Hg b. A rapid, weak, thready pulse c. Warm, flushed skin d. Increased urinary output
ANSWER: b. A rapid, weak, thready pulse
32. The nurse is assessing a patient who reports being bitten by a black widow spider. The patient may have clinical signs & symptoms that mimic which disorder? a. Myocardial infarction b. Acute abdomen c. Small bowel obstruction d. Deep vein thrombosis
ANSWER: b. Acute abdomen
50. A patient treated for a severe allergic reaction to a bee sting tells the nurse, "The doctor told me that I had to be careful about getting bee stings in the future, because I could have another allergic reaction." Based on the patient's statement, what is the nurse's first action? a. Repeat the information that the health care provider gave her. b. Assess the patient's understanding of allergic reactions & first aid. c. Advise the patient to obtain a medical alert bracelet. d. Ensure that the patient has a prescription for an EpiPen.
ANSWER: b. Assess the PTs understanding of allergic reactions & first aid.
39. A patient has been admitted to the ED following a motor vehicle accident & has a history of substance abuse. What is a priority for the nurse to include in the assessment? a. Assess the time the patient last ate. b. Assess the patient's risk factors for suicide. c. Evaluate the patient's spiritual beliefs. d. Identify an individual who emotionally supports the patient.
ANSWER: b. Assess the patient's risk factors for suicide.
4. The nurse is interviewing a psychiatric patient who has been verbally aggressive for the past several hours according to the family. The family states, "He won't hurt anybody." However, the patient is pacing & appears suspicious & angry. Which strategy does the nurse use to conduct the interview? a. Sit at eye level with the patient in a quiet, secluded room. b. Conduct the interview standing near the door in a quiet room. c. Bring the entire family in & have everyone sit in comfortable chairs. d. Have the security guard stand by the patient during the interview.
ANSWER: b. Conduct the interview standing near the door in a quiet room.
25. After a major city-wide environmental crisis, which type of debriefing is most appropriate for hospital staff? a. Administrative debriefing b. Critical incident stress debriefing c. Discussion within small groups that can be shared with close family & friends d. Referrals for mental health counseling
ANSWER: b. Critical incident stress debriefing
26. A patient is showing early clinical manifestations of hypovolemic shock. The provider orders an arterial blood gas (ABG). Which ABG values does the nurse expect to see in hypovolemic shock? a. Increased pH with decreased Pao2 & increased Paco 2 b. Decreased pH with decreased Pao2 & increased Paco 2 c. Normal pH with decreased Pao2 & normal Paco 2 d. Normal pH with decreased Pao2 & decreased Paco 2
ANSWER: b. Decreased pH with decreased Pao2 & increased Paco 2
27. Which intervention would be addressed during the primary survey? a. Insert a urinary catheter. b. Establish patent airway. c. Stabilize a fracture. d. Insert a nasogastric tube.
ANSWER: b. Establish patent airway.
5. During a summer marathon, the temperature is over 100° F & the humidity is high. Suddenly a runner collapses after running in the race for 1 hour. The runner's body temperature is 105.2° F, she is confused & sweating. What is this patient suffering from? a. Classic heat stroke b. Exertional heat stroke c. Heat exhaustion d. Dehydration
ANSWER: b. Exertional heat stroke
38. A person is stung by a wasp at a picnic. The person has no difficulty breathing & no history of allergic reaction to bee or wasp stings. What is the priority first-aid action for this person? a. Place a tourniquet proximal to the sting. b. Gently scrape the stinger off with the edge of a credit card. c. Apply an ice pack to the area & elevate. d. Observe the area for signs of inflammation prior to taking any action.
ANSWER: b. Gently scrape the stinger off with the edge of a credit card.
48. The patient died in the ED despite resuscitation efforts. Homicide is suspected. Which nursing action would be incorrect, due to the likelihood of forensic investigation? a. Invites the family to spend time with the deceased patient b. Gives the patient's clothes & other belongings to the family c. Declines to give information to friends of the deceased d. Leaves intravenous lines & indwelling tubes in place
ANSWER: b. Gives the patient's clothes & other belongings to the family
47. Based on mechanism of injury, which patient is most likely to automatically require trauma team intervention? a. Stab wound to the leg b. Gunshot wound to the chest c. Possible drowning d. Unwitnessed cardiac arrest
ANSWER: b. Gunshot wound to the chest
43. A patient comes to the ED for gastric distress with vomiting large amounts of dark-brown emesis & passing small amounts of bright red blood. Which preexisting health condition is most likely to be a factor in determining triage classification? a. History of diabetes mellitus b. History of anticoagulant use c. History of high blood pressure d. History of childhood appendectomy
ANSWER: b. History of anticoagulant use
34. A patient has a systemic infection with a fever, increased respiratory rate, & change in mental status. Which laboratory values does the nurse seek out that are considered "hallmark" of sepsis? a. Increased white blood count & increased glucose level b. Increased serum lactate level & rising band neutrophils c. Increased oxygen saturation & decreased clotting times d. Decreased white blood count with increased hematocrit
ANSWER: b. Increased serum lactate level & rising band neutrophils
77. Which occurrence in the patient treated for AMS indicates that treatment with acetazolamide (Diamox) was effective? a. Decreased pulse rate & decreased urine output b. Increased urine output & an increased respiratory rate c. Periodic respirations during sleep & decreased pulse d. Decreased sleep disturbance & decreased respiratory rate
ANSWER: b. Increased urine output & an increased respiratory rate
55. The clinical manifestations in the first phase of sepsis-induced distributive shock results from the body's reaction to which factor? a. Leukocytes b. Infectious microorganisms c. Hemorrhage d. Hypovolemia
ANSWER: b. Infectious microorganisms
56. The patient was repeatedly kicked & punched in the abdomen. The initial assessment & diagnostic testing reveals no life threatening damage. The emergency provider tells the nurse that the patient should remain in the ED for observation. What is the most important action for the nurse to perform? a. Administer pain medication in a timely fashion. b. Initiate serial abdominal assessments. c. Instruct the UAP to take vital signs every 4 hours. d. Find a quiet space where the patient can rest
ANSWER: b. Initiate serial abdominal assessments.
27. The ED nurse is instructing a group of ED UAPs on how to use personal protective equipment (PPE) when caring for patients who may have been exposed to bioterrorism agents. One of the group is clowning around & making jokes. What should the nurse do first? a. Threaten to report him to the supervisor, if he doesn't settle down & pay attention. b. Instruct him to demonstrate use of PPE in the care of a patient with Ebola. c. Advise him that PPE is for his safety, but ignoring safety protocols is a personal choice. d. Ignore him & continue instructing because clowning around is a coping method for him.
ANSWER: b. Instruct him to demonstrate use of PPE /care of a PT with Ebola.
47. The nurse is administering a first dose of epinephrine to a patient with laryngeal edema after a bee sting. Which route of administration is recommended? a. Subcutaneous b. Intramuscular c. Intravenous d. Mucosal
ANSWER: b. Intramuscular
52. Which lightning-strike victim should receive attention first? a. Teenager who is motionless except for shallow respirations; he has a weak pulse b. Middle-aged man, unconscious, with no palpable pulse c. Confused older adult woman with apparent paralysis in lower extremities d. Child crying, bleeding from ears, mottled skin, & decreased pulses in left leg
ANSWER: b. Middle-aged man, unconscious, with no palpable pulse
21. A patient sustained a snakebite 2 hours ago & the health care provider orders CroFab. What is the priority nursing intervention in administering this medication to the patient? a. Monitor for symptom control after the first dose. b. Monitor the patient closely for hives, rash, or difficulty breathing. c. Give the bolus dose slowly over 10 minutes. d. Give the medication within 3 hours of the snakebite.
ANSWER: b. Monitor the patient closely for hives, rash, or difficulty breathing.
86. The nurse is teaching a class on water safety to a group of 5-year-old children. Which point is the nurse most likely to emphasize with this group? a. Take swimming lessons & learn how to use floatation devices. b. Never swim alone; a parent or other adult should always be with you. c. Always test the water depth before jumping in head-first. d. If your friends don't know how to swim, always watch out for them .
ANSWER: b. Never swim alone; a parent or other adult should always be with you.
67. The nurse is working in a mountain clinic where there is a high incidence of cold-related injuries. Which signs/symptoms indicate the most severe case of frostbite? a. Large fluid-filled blisters with partial thickness skin necrosis b. Numbness, coldness, & bloodlessness of affected area c. Small blisters that contain dark fluid; skin is cool d. Pain, numbness, & pallor of the affected area
ANSWER: b. Numbness, coldness, & bloodlessness of affected area
34. The ED clinical nurse specialist (CNS) is designing ways to teach newly graduated nurses about priority setting in the triage area. Which strategy is the CNS most likely to recommend? a. Assign new nurses to triage during low volume periods. b. Pair a new nurse with an experienced nurse in the triage area. c. Prepare handouts & tip sheets for the principles of triage. d. Have the new nurses observe the triage process for several days.
ANSWER: b. Pair a new nurse with an experienced nurse in the triage area.
1. Which emergency department (ED) patient represents an issue that has been addressed by the Core Measure Sets for the ED that are established by the Joint Commission? a. Patient has no health insurance & no steady source of income. b. Patient has waited 7 hours to be transferred to the medical-surgical unit. c. Patient has a history of falls & sustains a fall in the ED waiting room. d. Patient has respiratory arrest & requires emergency intubation.
ANSWER: b. Patient has waited 7 hours to be transferred to the medical-surgical unit.
6. The hospital committee is reviewing the emergency management plan of their small community hospital in a suburban area of a large city. What is a priority to include in this hospital's emergency management plan? a. Plan for evacuation routes out of the city. b. Plan for transporting patients to other hospitals. c. Method to contact the National Disaster Medical System. d. Stockpiling post-exposure prophylactic antibiotics.
ANSWER: b. Plan for transporting patients to other hospitals.
72. The nurse is reviewing the CBC results for a patient who lives in a high mountain town. The patient's red blood cell count (RBC) is 6.8 million/mm3. What does this lab value combined with the patient's environment indicate? a. Anemia related to a decreased production of erythropoietin b. Polycythemia related to chronic hypoxia c. Pernicious anemia related to a regional dietary deficiency d. Hemolytic anemia related to cold temperature
ANSWER: b. Polycythemia related to chronic hypoxia
24. The nurse is trying to prepare an intravenous antibiotic medication for a patient, but the ED is very busy, chaotic, & noisy & the nurse is continuously interrupted. What should the nurse do first? a. Ask the charge nurse to administer the antibiotic medication or send additional help. b. Prioritize the urgency of the medication in relation to the urgency of the interruptions. c. Shut the door & proceed through the six rights of medication administration. d. Prepare the medication, while fielding the interruptions & delegating appropriately.
ANSWER: b. Prioritize the urgency of the medication in relation to the urgency of the interruptions.
53. A postoperative hospitalized PT has a decrease in MAP of greater than 20 mm Hg from baseline value; elevated, thready pulse; decreased blood pressure; shallow respirations of 26/min; pale skin; moderate acidosis; and moderate hyperkalemia. The nurse recognizes that this PT is in what phase of shock? a. Compensatory/non-progressive b. Progressive c. Refractory d. Multiple organ dysfunction
ANSWER: b. Progressive
82. The pathophysiology of drowning involves a washing out of surfactant, which leads to decreased surface tension, increased lung compliance, & increased airway resistance. What disorder is a result of the pathophysiology? a. Pulmonary emboli b. Pulmonary edema c. Chemical pneumonitis d. Aspiration pneumonia
ANSWER: b. Pulmonary edema
43. At a park, the nurse observes a mother of a toddler attempting to remove the stinger of bee with tweezers. What should the nurse do? a. Instruct the mother to stop, because tweezing the stinger injects additional venom. b. Reinforce that the correct action is to immediately remove the stinger with tweezers or by scraping. c. Suggest applying an ice pack for local anesthesia before removing the stinger. d. Place a bandage over the stinger & suggest immediately going to the ED.
ANSWER: b. Reinforce that the correct action is to immediately remove the stinger with tweezers or by scraping.
70. The ED nurse receives a phone call from someone stating that he & his friend have been out in the cold weather & his friend's fingers 3 through 5 appear white & waxy. What does the nurse direct the caller to do? a. Seek shelter immediately & massage & briskly rub the fingers. b. Seek shelter immediately & place the hands under the armpits. c. Seek medical attention & place hands on car heating vents while en route. d. Seek medical attention & place fingers in cool water while en route.
ANSWER: b. Seek shelter immediately & place the hands under the armpits.
35. A patient comes to the ED with severe respiratory distress. He has a long history of chronic respiratory disease & now requires endotracheal intubation. How does the nurse assess this patient's lung compliance? a. Auscultate the lung fields, especially for coarse crackles. b. Sense the degree of difficulty in ventilating with a bag-valve-mask. c. Monitor the pulse oximeter for decreasing saturation levels. d. Count the respiratory rate & observe the respiratory effort.
ANSWER: b. Sense the degree of difficulty in ventilating with a bag-valve-mask.
6. The ED nurse is caring for a patient who was found in an alley with no identification & no known family. The nurse must give medication to the patient. What is the correct procedure? a. Emergent conditions prevent identification, so the nurse gives the medication as ordered. b. The patient is designated as John Doe & the nurse uses two unique identifiers. c. The nurse validates the order with another nurse & both verify that the patient is unidentified. d. The nurse gives the medication & identification is made as soon as possible.
ANSWER: b. The patient is designated as John Doe & the nurse uses two unique identifiers.
26. The nurse has administered pain medication to a patient who has a migraine headache. What instructions should be given to the UAP? a. Wait 45 minutes & then ask the patient how he feels & if the pain is relieved. b. When helping him to get out of bed, sit him up, dangle feet, then assist him to stand. c. Check the patient frequently to make sure he arouses & is not decompensating. d. Ask the patient if he has a ride home; if not, call a family member to make arrangements.
ANSWER: b. When helping him to get out of bed, sit him up, dangle feet, then assist him to stand.
42. A patient calls the health care provider's office asking for advice about whether to seek immediate medical attention for a bee sting. She has no shortness of breath or swelling to the face, throat, or lips. Which question will elicit information to assist the patient in making the decision? a. "Were you stung by an African 'killer bee'?" b. "Is the affected area red, painful, or swollen?" c. "Did you receive multiple stings?" d. "Were you able to remove the stinger?"
ANSWER: c. "Did you receive multiple stings?"
3. The ED nurse is attempting to transfer a patient to the medical-surgical unit. When the receiving nurse answers the phone, he says, "You people always dump these admissions on us during shift change." Which response by the ED nurse represents the best attempt at respectful negotiation & collaboration? a. "I am sorry. I realize you are busy, but we are busy too." b. "When would you be willing to take our patients?" c. "I apologize for the timing. I will call back in 30 minutes." d. "I apologize. We just received the bed assignment."
ANSWER: c. "I apologize for the timing. I will call back in 30 minutes."
51. The emergency physician & the nurse go together to tell the family that a patient died despite resuscitation efforts. What is the best way to inform the family? a. "We did everything that we could, but Mr. S. expired." b. "He never woke up, but we are sure that he passed on without discomfort." c. "We are sorry to inform you that Mr. S. died due to extensive injuries." d. "We want to extend our sympathies because Mr. S. is not with us anymore."
ANSWER: c. "We are sorry to inform you that Mr. S. died due to extensive injuries."
27. A patient calls the health care provider's office after sustaining a spider bite on the arm 3 hours ago asking for advice about whether to come into the office or hospital for evaluation. She denies any allergic reactions or shortness of breath. Which question would be the most relevant in helping the patient to make the decision? a. "Do you have diphenhydramine (Benadryl) at the house?" b. "Is your arm painful or swollen?" c. "Were you able to identify the spider?" d. "Was the spider hiding in a dark secluded area?"
ANSWER: c. "Were you able to identify the spider?"
38. A patient is brought to the ED by the paramedics. The patient is alert but disoriented, & the left lower leg has swelling & deformity. Which question is most essential to ask the paramedics? a. "Does the patient have insurance coverage?" b. "Are friends or family en route to the hospital?" c. "What was the mechanism of injury?" d. "Does the patient have a primary care provider?"
ANSWER: c. "What was the mechanism of injury?"
39. A teenager is brought to the ED with a reported bee sting. The nurse observes facial swelling, an audible wheeze, & labored rapid breathing. The teen's girlfriend reports he has been vomiting & having trouble speaking & breathing. What does the nurse anticipate the priority medication order will be? a. IV normal saline bolus of 400 mL b. 50 mg diphenhydramine (Benadryl) PO (by mouth) c. 0.5 mL of 1:1000 epinephrine IM d. 100 mg methylprednisolone sodium succinate (Solu-Medrol) IV infusion
ANSWER: c. 0.5 mL of 1:1000 epinephrine IM
49. The ICU nurse is caring for a patient with septic shock. Which IV infusion order for this patient does the nurse question? a. Antibiotics b. Insulin c. 10% dextrose in water d. Synthetic activated C protein
ANSWER: c. 10% dextrose in water
9. The nursing director of a long-term care facility is designated as the "incident commander" for the facility's emergency management plan. What is the priority action for the incident commander? a. Call all the of-duty staff & ask them to come into work. b. Take inventory of supplies according to the emergency management plan. c. Activate the disaster management process according to the plan. d. Call the National Guard to move all patients to other facilities.
ANSWER: c. Activate the disaster management process according to the plan.
24. A community hospital is reviewing the activation & implementation of its emergency preparedness plan after a recent mass-casualty event. What is the appropriate type of debriefing that will effectively evaluate these procedures? a. Hospital incident command b. Event resolution c. Administrative d. Critical incident
ANSWER: c. Administrative
29. Using disaster triage principles, which patient has been correctly triaged & marked with the appropriate color tag? a. A toddler who has died of his injuries: green tag b. An older woman with a fractured ankle: yellow tag c. An older man with shortness of breath & a hemothorax: red tag d. A teenager with profuse bleeding from a severe arm laceration: black tag
ANSWER: c. An older man with shortness of breath & a hemothorax: red tag
9. A patient has cardiac dysrhythmias & pulmonary problems as a result of receiving an IV antibiotic. What type of shock does the nurse recognize this represents? a. Hypovolemic b. Cardiogenic c. Anaphylactic d. Septic
ANSWER: c. Anaphylactic
28. A patient calls the ED for advice on immediate first aid for a brown recluse spider bite on his hand. He denies allergic response or shortness of breath & states that he plans to see his health care provider, but is currently about 2 to 3 hours away. What does the nurse advise the patient to do? a. Apply a warm pack & elevate the extremity. b. Wash the bite area several times with soap & water. c. Apply cold compresses & rest as much as possible. d. Apply a snug constricting band at the wrist level.
ANSWER: c. Apply cold compresses & rest as much as possible.
19. The unlicensed assistive personnel (UAP) reports repeatedly and unsuccessfully trying to take a patient's blood pressure with the electronic & manual devices. The nurse notes that the patient's apical pulse is elevated & the patient is at risk for hypovolemic shock. The patient begins to deteriorate. What is the best method for the nurse to determine the systolic blood pressure? a. Apply the electronic device to a lower extremity. b. Instruct the UAP to immediately get the Doppler. c. Apply the manual cuff & palpate for the systolic. d. Tell the UAP to try the electronic device on the other arm.
ANSWER: c. Apply the manual cuff & palpate for the systolic
23. A patient in hypovolemic shock is receiving sodium nitroprusside (Nitropress) to enhance myocardial perfusion. What is an important nursing implication for administering this drug? a. Assess the patient for headache because it is an early symptom of drug excess. b. Assess blood pressure at least every 15 minutes because hypertension is a symptom of overdose. c. Assess blood pressure at least every 15 minutes because systemic vasodilation can cause hypotension. d. Assess the patient every 30 minutes for extravasation because nitroprusside can cause severe vasoconstriction & tissue ischemia.
ANSWER: c. Assess blood pressure at least every 15 minutes because systemic vasodilation can cause hypotension.
31. Which disaster situation is most likely to increase the complexity of managing the green tagged patients who are more likely to self transport from the scene of the incident to the health care facility? a. Collapse of a church roof during Sunday services b. Human stampede at a poorly controlled music festival c. Breach of containment at a nuclear plant d. Demonstration with rioting on a college campus
ANSWER: c. Breach of containment at a nuclear plant
28. A long-term care facility formed a committee to review the facility's emergency preparedness plan. Which element needs to be resolved in order to meet the guidelines of the Life Safety Code, which is published by the National Fire Protection Association? a. Fire extinguishers are heavy & difficult to use. b. Fire safety training is difficult because of high staff turnover. c. Building has one main front door & side doors have sealed shut. d. Many residents are unwilling or incapable of participating in free drills.
ANSWER: c. Building has one main front door & side doors have sealed shut.
65. A man is found lying in an alley in cold weather for an unknown length of time. His hands, toes, & face show evidence of frostbite; otherwise there are no obvious injuries. He is severely obtunded with a pulse of 43 beats/min, respirations of 9/min, & a core temperature of 27° C. What is this patient's most immediate physiologic risk? a. Acute respiratory distress syndrome b. Pulmonary edema c. Cardiac arrest d. Acute renal failure
ANSWER: c. Cardiac arrest
53. A construction worker who was struck by lightning is brought to the ED. He was reported to be unconscious, but cardiopulmonary resuscitation (CPR) was started immediately & he awoke just before the arrival of emergency medical services (EMS) personnel. In the ED, he is alert but confused, & reports pain to his right hand & foot with fernlike marks. Which assessment tool is the priority for this patient? a. Glasgow coma scale b. Pulse oximeter c. Cardiac monitor d. Rule of nines chart
ANSWER: c. Cardiac monitor
44. A patient receives dopamine 20 mcg/kg/min IV for the treatment of shock. What does the nurse assess for while administering this drug? a. Decreased urine output & decreased blood pressure b. Increased respiratory rate & increased urine output c. Chest pain & hypertension d. Bradycardia & headache
ANSWER: c. Chest pain & hypertension
30. The nurse is helping the health care provider treat a patient with a tension pneumothorax. What type of equipment does the nurse obtain to immediately alleviate this life-threatening condition? a. Large adult endotracheal tube b. Transvenous pacemaker insertion c. Chest tube insertion tray d. Tracheostomy tray
ANSWER: c. Chest tube insertion tray
48. A man who was stung by a wasp is treated & observed for symptoms of urticaria, pruritus, & swelling of the lips & then discharged home with medication instructions. Which medication is most likely to be prescribed to prevent delayed allergic effects? a. EpiPen b. Acetaminophen (Tylenol) as needed c. Corticosteroids in tapered doses d. Albuterol (Proventil)
ANSWER: c. Corticosteroids in tapered doses
23. A patient sustained a coral snakebite & developed severe complications. Which diagnostic test results reveal the physiologic damage that occurs with envenomation? a. Complete blood count (CBC) b. Coagulation profile c. Creatine kinase d. Electrolytes
ANSWER: c. Creatine kinase
29. A patient sustained a brown recluse bite & has been admitted for IV antibiotics & wound management. Which laboratory value indicates that the patient may be developing severe systemic complications from the bite? a. Increased red blood count b. Increased glucose level c. Decreased platelet count d. Decreased blood urea nitrogen
ANSWER: c. Decreased platelet count
17. The nurse is evaluating the lower extremities of several patients. Which description represents the least serious physical presentation? a. Pain in calf; lower leg is swollen & red. b. Progressively increasing pain; distal portion is cool & bluish. c. Decreased sensation; lower leg has widespread brownish discoloration. d. Tight sensation in ankle; skin appears tight, shiny, & edematous.
ANSWER: c. Decreased sensation; lower leg has widespread brownish discoloration.
53. The nurse observes that a homeless woman frequently comes to the ED during the winter for symptoms of dizziness & generalized pain. The patient typically stays for several hours, undergoes diagnostic testing & is discharged with a referral to a primary care provider. What should the nurse do? a. Assess & treat the patient as if she were any other patient. b. Offer food & a blanket & encourage her to leave after she warms up. c. Develop an individual care plan using an interdisciplinary team approach. d. Talk to the patient & attempt to establish validity of symptoms.
ANSWER: c. Develop an individual care plan using an interdisciplinary team approach.
50. A patient died in the ED after sustaining multiple injuries that occurred during an aggravated assault. The family arrives after the patient is pronounced dead & they ask to see the body. What does the nurse do? a. Explain that viewing the body would be too traumatic because all the tubes must remain in place for the forensic exam. b. Remove any tubes or debris that are near the patient's face & then cover the rest of the body with a blanket. c. Explain what they will see; dim the lights; leave the patient's face exposed, but cover the rest of the body with a blanket. d. Suggest that the family could spend time with their loved one at the mortuary after the medical examiner is finished.
ANSWER: c. Explain what they will see; dim the lights; leave the patient's face exposed, but cover the rest of the body with a blanket.
51. Which person has the greatest risk for injury from lightning strike? a. Jogger in the park at mid-morning in December b. Deer hunter walking through the woods in the evening in October c. Golfer out on the green in the late afternoon in June d. Camper walking on the beach during the early morning in April
ANSWER: c. Golfer out on the green in the late afternoon in June
19. The ED trauma team is preparing to receive a motor vehicle crash victim with severe chest trauma with coughing of blood & a crush injury to the right leg. What type of personal protective equipment (PPE) does the nurse assigned to be the recorder put on? a. No PPE is necessary because the nurse is only recording & not giving direct care b. Gloves c. Gown, gloves, eye protection, face mask, a cap, & shoe covers d. The patient situation must first be assessed before determining what PPE to wear
ANSWER: c. Gown, gloves, eye protection, face mask, a cap, & shoe covers
3. A patient reports being outside when temperatures reached 110° F & he forgot to drink water. Now he reports weakness, a headache, & nausea with dizziness. His body temperature is 98.9° F. What is this patient suffering from? a. Classic heat stroke b. Exertional heatstroke c. Heat exhaustion d. Fluid overload
ANSWER: c. Heat exhaustion
58. The day camp nurse is with a group of children who have been participating in hiking, swimming, & crafts. The nurse sees a child who is soaking wet, stumbling, & taking of all of her clothes. What does the nurse suspect is wrong with this child? a. Snakebite b. High-altitude sickness c. Hypothermia d. Nearly drowned
ANSWER: c. Hypothermia
15. The nurse is on a backpacking trip. One of the hikers sustains a pit viper bite to the lower leg. Which first-aid measure will the nurse perform while waiting for transportation to the hospital? a. Elevate the leg & apply cool packs. b. Incise the fang marks with a pocket knife. c. Immobilize the leg with a splint in a functional position. d. Apply a constricting band proximal to the fang marks.
ANSWER: c. Immobilize the leg with a splint in a functional position.
12. For which circumstance would the use of Standard Precautions be adequate to ensure the safety of the nurse, staff, & other patients? a. Performing hygienic care for a patient with copious watery diarrhea b. Assisting with intubation of a patient with symptoms of tuberculosis c. Initiating a peripheral intravenous access attached to a saline lock d. Assessing a child with a fever & rash & known exposure to chickenpox
ANSWER: c. Initiating a peripheral intravenous access attached to a saline lock
55. The nurse is working at a level III trauma center. A patient involved in a chemical plant explosion arrives with burns, probable closed head injury, extremity fractures, & blunt trauma to the abdomen. What action is the nurse most likely to perform in the care of this patient? a. Preparing the patient for emergency surgery b. Debriding & cleansing the burned areas c. Initiating large-bore intravenous access for fluids d. Assisting with procedures to diagnose internal hemorrhage
ANSWER: c. Initiating large-bore intravenous access for fluids
15. Which function represents an appropriate referral to the case manager? a. Check with the admissions office to get a count of available intensive care beds. b. Contact the peripherally inserted central catheter (PICC) nurse, because the patient has bad veins. c. Investigate whether the patient is abusing & overusing ED services. d. Follow the patient into the community setting & evaluate the home environment.
ANSWER: c. Investigate whether the patient is abusing & overusing ED services.
16. A patient arrives in the ED after sustaining a cottonmouth snakebite. What is included in the immediate interventions for this patient? a. Assessing for cranial nerve deficits b. Applying a pressure bandage c. Monitoring blood pressure & cardiac function d. Administering antivenin
ANSWER: c. Monitoring blood pressure & cardiac function
37. A patient is being treated for a bark scorpion sting. He is currently alert, but somewhat confused. He complains of localized pain (5/10) at the site & requires frequent oral suction. Vital signs are temperature 102° F, pulse 95/min, respirations 12/min, & blood pressure 140/85 mm Hg. Which medication order does the nurse question? a. Acetaminophen 650 mg prn (as needed) for fever b. Tetanus toxoid 0.5 mL intramuscularly x 1 dose c. Morphine 20 mg intravenous push for severe pain d. Atropine 0.4 mg subcutaneously for hyper-salivation
ANSWER: c. Morphine 20 mg intravenous push for severe pain
42. Which factor is most likely to hinder the nurse's ability to objectively & accurately triage patients? a. Ambiguity about which triage model is the best for selected patients b. Several patients arrive simultaneously at the triage area c. Nurse is personally experiencing compassion fatigue and burnout d. Patient has a complex health history, and is a poor historian
ANSWER: c. Nurse is personally experiencing compassion fatigue and burnout
78. A rescue team is attempting to take the patient to the hospital for symptoms of HAPE. The descent to the hospital is delayed due to severe weather conditions. What is the most important treatment for this patient during the delay? a. Dexamethasone (Decadron) b. Furosemide (Lasix) c. Oxygen administration d. Avoidance of cold stress
ANSWER: c. Oxygen administration
8. Which patient is at risk for obstructive shock? a. Patient with a history of angina b. Patient with chronic atrial fibrillation c. Patient with a pulmonary embolus d. Patient with a history of heart failure
ANSWER: c. Patient with a pulmonary embolus
3. Which priority intervention would be more likely to occur during an internal disaster compared to an external disaster? a. Extra staff would be called in to assist. b. Emergency management plan would be activated. c. Patients & staff would be evacuated. d. Staff would don personal protective equipment. A nurse working at a small rural hospital gets a frantic phone call about a rumor of a student attacking other students at a local high school.
ANSWER: c. Patients & staff would be evacuated.
13. A patient at risk for shock has had some small, subtle changes in behavior within the past hour. How does the nurse evaluate the patient's mental status throughout the night? a. Assess the patient while he or she is awake, & then allow him or her to sleep until morning. b. Ask the patient & family to describe the patient's normal sleep & behavioral patterns. c. Periodically attempt to awaken the patient & document how easily he or she is aroused. d. Allow the patient to sleep, but assess respiratory effort & skin temperature.
ANSWER: c. Periodically attempt to awaken the patient & document how easily he or she is aroused.
83. A college student was drinking beer & dove from a 20-foot ledge into a lake. He was from the lake by a friend & given mouth-to-mouth. The patient is currently in the ED, awake, & receiving supplemental oxygen. What serial assessments is the nurse most likely to initiate for this patient? a. Cardiac monitoring for possible myocardial infarction b. Level of consciousness & orientation to monitor for stroke c. Peripheral sensation & movement related to spinal cord injury d. Frequent blood glucose checks to monitor for hypoglycemia
ANSWER: c. Peripheral sensation & movement related to spinal cord injury
13. A local news station calls the hospital seeking permission to verify the number of victims & details of a local disaster. What is the nurse's best response? a. "Please don't bother us now. We are swamped with victims." b. "We have a lot of stable victims & two people have died." c. "Please hold & I will connect you to the public information officer." d. "I will connect you with the emergency command center."
ANSWER: c. Please hold & I will connect you to the public information officer.
55. A patient was struck by lightning & sustained temporary paralysis of the lower limbs which resolved, with no physical effects, but the patient developed emotional problems. Which mental health disorder is the most likely complication? a. Generalized anxiety disorder b. Schizophrenia c. Posttraumatic stress disorder d. Acute-onset dementia
ANSWER: c. Posttraumatic stress disorder
8. The nurse based in Iowa is a volunteer member of the Medical Reserve Corps (MRC) & has been called to serve in Ohio where he does not hold an active nursing license. What should the nurse do? a. Determine if Ohio has reciprocity with Iowa before accepting deployment. b. Decline deployment because his nursing license will not allow him to practice in Ohio. c. Prepare for deployment because he will be considered a federal employee with valid licensure. d. Delay deployment until he has reviewed the nurse practice act that is specific to Ohio.
ANSWER: c. Prepare for deployment because he will be considered a federal employee with valid licensure.
38. The nurse is caring for a patient at risk for sepsis. Why does the nurse closely monitor the patient for early signs of shock? a. The patient is unable to self-identify or report these early signs. b. Distributive shock usually begins as a bacterial or fungal infection. c. Prevention of septic shock is easier to achieve in the early phase. d. There is widespread vasodilation & pooling of blood in some tissues.
ANSWER: c. Prevention of septic shock is easier to achieve in the early phase.
6. The nurse is participating in a local community sports day. The day is hot & humid & older adults are walking around. Prevention of heat-related injuries would include which intervention? a. Encouraging participants to eat high energy snacks, such as sports bars b. Advising that people with disabilities should not participate c. Setting up a shade tent with areas for rest & relaxed activity d. Limiting direct sun exposure to 2 hours during the hottest time of the day
ANSWER: c. Setting up a shade tent with areas for rest & relaxed activity
7. The nurse is volunteering at the first-aid station at a local community fair. The weather is predicted to be hot & humid. In planning care for people who may experience heat related illness in this setting, what should the nurse obtain? a. Supply of salt tablets & bottles of water b. Bags of IV normal saline & IV insertion equipment c. Several water spray bottles & a portable fan d. Supply of educational pamphlets & sunscreen samples
ANSWER: c. Several water spray bottles & a portable fan
24. The nurse is assisting a neighbor with a gardening project. The neighbor sustains a snakebite when reaching to move a rock. What is the best action to perform in order to identify the snake? a. Crush the body of the snake with a rock but preserve the head. b. Note the markings of the snake & seek pictures on the Internet. c. Stand at a distance & take a digital picture of the snake. d. Trap the snake using a long garden tool & bucket.
ANSWER: c. Stand at a distance & take a digital picture of the snake.
17. A patient with blunt trauma to the abdomen has been NPO for several hours in preparation for a procedure & now reports subjective thirst. What is the nurse's first priority action? a. Get the patient a few ice chips or a moistened swab. b. Obtain an order for a stat hematocrit & hemoglobin. c. Take the patient's vital signs & compare to baseline. d. Obtain an order to increase the IV rate.
ANSWER: c. Take the patient's vital signs & compare to baseline.
15. A city committee reviews possible scenarios related to a disaster event. Which is an example of the "greatest good for the greatest number of people"? a. The city's supply of antibiotics is sent to one hospital that has 25 victims with exposure to a bioterrorism agent. b. Twenty victims infected by a bioterrorism agent are placed on life support & mechanical ventilation. c. Thirty people with possible exposure to a bioterrorism agent are quarantined including five children who are asymptomatic. d. Elderly community members are treated with prophylactic antibiotics for a bioterrorism agent.
ANSWER: c. Thirty people with possible exposure to a bioterrorism agent are quarantined including five children who are asymptomatic.
58. The nurse is caring for a patient in septic shock with a serum glucose level of 280 mg/dL. What is the nurse's best interpretation of this finding? a. The patient is developing type 2 diabetes. b. The patient is developing type 1 diabetes. c. This finding is associated with a poor outcome. d. This finding is unexpected in septic shock.
ANSWER: c. This finding is associated with a poor outcome
25. A patient sustained a coral snakebite & calls the ED for instructions. Besides calling for an ambulance, what does the nurse instruct the patient to do? a. Apply ice to the wound. b. Incise the wound to allow the blood to flow freely. c. Use an elastic bandage to impede lymphatic flow & apply a splint. d. Place a tourniquet that is tight enough to reduce arterial flow of the venom.
ANSWER: c. Use an elastic bandage to impede lymphatic flow & apply a splint.
20. The nurse is working in the ED with an emergency health care provider, but the provider is currently involved in the care of several critical patients. The ED nurse must initiate care for patients under interdisciplinary & medical protocols. Which intervention is the least likely to be covered by a standing protocol? a. Give 50% dextrose IV push for low blood sugar. b. Obtain an arterial blood gas & start oxygen therapy. c. Ventilate with bag-valve-mask at 100% oxygen & intubate. d. Start a peripheral IV with normal saline at 125 mL/hour.
ANSWER: c. Ventilate with bag-valve-mask at 100% oxygen & intubate.
59. The nurse is conducting a community presentation on cold weather safety. Which point is the nurse sure to include in the presentation? a. Hydration & water intake are not an issue, so pack extra clothes, not extra water. b. Wear multiple layers of socks when participating in winter sports. c. When driving in cold winter weather, carry extra clothes, food, & fluids. d. Hypothermia occurs only in the winter months in the United States.
ANSWER: c. When driving in cold winter weather, carry extra clothes, food, & fluids.
36. The nurse is caring for a patient with sepsis. At the beginning of the shift, the patient is in a hypo-dynamic state. Several hours later, the patient's blood pressure is elevated & pulse is bounding. How does the nurse interpret this change? a. A positive response & a signal of recovery b. Temporary situation that is likely to normalize c. Worsening of the condition rather than improvement d. Expected response to standard therapies
ANSWER: c. Worsening of the condition rather than improvement
20. A patient is transported to the ED by a family member after sustaining a snakebite on a hiking trip. The patient may be a potential candidate for Crotalidae Polyvalent Immune Fab (CroFab). In order to safely administer therapy, which question would the nurse ask? a. "What type of snake inflicted the bite?" b. "How much time has passed since the snakebite occurred?" c. "Do you have a history of deep vein thrombosis (DVT) or do you take Coumadin?" d. "Do you have allergies to papaya or pineapple?"
ANSWER: d. "Do you have allergies to papaya or pineapple?"
79. Two teenagers bring their friend to the ED because "he was drowning." The patient is unconscious but shows spontaneous breathing, & he is immediately taken to the resuscitation area. Which question is most important for the nurse to ask the patient's friends in determining the outcomes for the patient? a. "Was this a fresh water or salt water drowning?" b. "Does he have any medical conditions, such as seizures?" c. "Was the water contaminated with chemicals or algae?" d. "How long was he under the water & not breathing?"
ANSWER: d. "How long was he under the water & not breathing?"
40. The student nurse is assessing a patient's mental status because of the patient's risk for decreased tissue perfusion. The supervising nurse intervenes when the student nurse asks the patient which question? a. "What is today's date?" b. "Who is the president of this country?" c. "Where are we right now?" d. "Is your name Mr. John Smith?"
ANSWER: d. "Is your name Mr. John Smith?"
7. The nurse is using the SBAR method to give a handoff report to the nurse who will assume care of the patient. What would the nurse say first? a. "CAT scan results are negative & neurology consult is pending." b. "Mr. S. has a history of high blood pressure, but stopped taking medication 3 months ago." c. "Current vital signs: temperature 98.6° F, pulse 80/min, respiratory rate 16/min & blood pressure 160/80." d. "Mr. S. is a 65-year-old male who came to the ED for a severe headache."
ANSWER: d. "Mr. S. is a 65-year-old male who came to the ED for a severe headache."
46. An experienced nurse is working in triage. For which circumstance is the nurse most likely to seek input from the emergency physician or advanced-practice nurse about acuity level of the patient? a. A 65-year-old man is having severe left anterior chest pain & shortness of breath. b. A 35-year-old man with history of kidney stones has severe back pain & hematuria. c. A 1-year-old child with history of frequent ear infections is screaming & pulling at his ear. d. A 23-year-old female with previous good health has sudden, severe flulike symptoms.
ANSWER: d. A 23-year-old female with previous good health has sudden, severe flulike symptoms.
32. Which scenario is most likely to require activation of the emergency preparedness plan? a. A private six-passenger plane crashes at a large urban airport on Wednesday morning b. There is an outbreak of food-borne illness at a long-term care center on Tuesday afternoon. c. An ice storm strikes a city on Monday night & causes falls & vehicular accidents. d. A multi-car accident occurs in front of a small rural hospital after midnight on Sunday.
ANSWER: d. A multi-car accident occurs in front of a small rural hospital after midnight on Sunday.
5. The nurse is working alone in triage. It is a busy night & the waiting room is full of people who are restless & unhappy about having to wait. Which situation warrants the nurse to activate the panic button under the triage desk? a. The line for patients waiting to be triaged becomes overwhelmingly long. b. EMS calls to announce they are en route with a patient in full arrest. c. Several patients in the waiting room start to complain very loudly. d. A person walks in & starts threatening the registration staff with a weapon.
ANSWER: d. A person walks in & starts threatening the registration staff with a weapon.
71. A patient has sustained severe frostbite to the toes & lower legs. He received rewarming therapy in the ED & arrives to the medical surgical unit with a splint on both legs. IV normal saline is infusing at 125 mL/hr. He reports severe pain in the lower extremities. Which HCP order does the nurse question? a. Morphine 1-2 mg IV push prn for pain in extremities b. Elevate bilateral lower extremities above the level of the heart c. Neurologic & circulation checks every 1 hour to bilateral lower extremities d. Apply compression bandage to bilateral lower extremities
ANSWER: d. Apply compression bandage to bilateral lower extremities
34. The nurse is working in the ED where several local gang members are being treated for gunshot & knife wounds. The nurse hears gunshots in the waiting room, followed by screaming & cries for help. What does the nurse do first? a. Grab the resuscitation box & run to the waiting room. b. Assist all the ambulatory patients to leave through a back entrance. c. Alert the ED health care provider that additional trauma victims need care. d. Assess the level of threat to self & others & call for help.
ANSWER: d. Assess the level of threat to self & others & call for help.
11. The nurse is performing a morning shift assessment on several patients. For which patient is the nurse immediately concerned about decreased tissue perfusion if the capillary refill time was delayed? a. Patient with diabetes mellitus b. Anemic patient c. Patient with peripheral vascular disease d. Asthmatic patient
ANSWER: d. Asthmatic patient
52. Which action would typically be performed by the ED bereavement committee? a. Assigns a staff nurse to sit with the family during resuscitation efforts of patient b. Advocates that one or two family members be allowed at bedside during resuscitation c. Provides grief counseling & group support for nurses who care for patients who code d. Attends funerals, sends sympathy cards, & makes follow-up calls to family
ANSWER: d. Attends funerals, sends sympathy cards, & makes follow-up calls to family
20. To prevent the development of posttraumatic stress disorder (PTSD) in hospital staff, what action is likely to be taken by the facility? a. Conducting administrative debriefings b. Providing employees with information on PTSD c. Offering employees psychological counseling d. Conducting critical incident stress debriefings
ANSWER: d. Conducting critical incident stress debriefings
47. The ICU nurse observes petechiae, ecchymoses, & blood oozing from gums and other mucous membranes of a patient with septic shock. How does the nurse interpret this finding? a. Pulmonary emboli (PE) b. Acute respiratory distress syndrome (ARDS) c. Systemic inflammatory response syndrome (SIRS) d. Disseminated intravascular coagulation (DIC)
ANSWER: d. Disseminated intravascular coagulation (DIC)
40. A patient was involved in a high-speed motor vehicle accident. The health care provider instructs the nurse to prepare for several urgent procedures because of severe injury & physical compromise. Which procedure does the nurse prepare for first? a. Central line insertion b. Peritoneal lavage c. Chest tube insertion d. Endotracheal intubation
ANSWER: d. Endotracheal intubation
10. A patient is brought to the ED by friends who report "he probably overdosed on downers." The patient has a decreased level of consciousness & a decreased gag reflex; his face & chest are covered with emesis; he demonstrates spontaneous sonorous respirations; & pulse oximetry is 87% on room air. What type of airway management does the nurse expect this patient to receive? a. Supplemental oxygen per nasal cannula at 4-6 L/min b. Bag-valve-mask & 100% oxygen to assist with ventilator effort c. Non-rebreather mask with high-flow oxygen d. Endotracheal intubation with initial high concentration oxygen
ANSWER: d. Endotracheal intubation with initial high concentration oxygen
21. Several patients have been waiting for more than 36 hours to be transferred to an inpatient room because the census is high during flu season. The ED staff is attempting to meet basic health needs in these difficult circumstances. Which need is the priority? a. Helping the patients with hygiene b. Making sure that patients are fed c. Informing patients about admission status d. Ensuring safety of environment & care
ANSWER: d. Ensuring safety of environment & care
56. The nurse is caring for a patient who had cardiac & respiratory arrest after being struck by lightning. The patient was resuscitated, & he is now alert & appears to be progressing toward recovery. The nurse observes tea colored urine in the Foley drainage bag. What does the nurse suspect? a. This is a normal finding associated with trauma & resuscitation b. Dehydration c. Urinary tract infection d. Excessive muscle damage affecting the kidneys
ANSWER: d. Excessive muscle damage affecting the kidneys
1. For which event would a large urban hospital's emergency management plan typically be activated? a. Three-car collision on the freeway b. Fight between two local street gangs c. School bus involved in an accident d. Explosion at a chemical factory
ANSWER: d. Explosion at a chemical factory
35. A patient reports a scorpion sting to the back of the hand. There is no obvious redness or inflammation at the suspected sting site. Which assessment technique does the nurse use to confirm a bark scorpion sting? a. Raise the arm & observe for blanching. b. Observe for the stinger embedded in the skin. c. Look for puncture marks surrounded by fine hairs. d. Gently tap at the suspected area to elicit pain.
ANSWER: d. Gently tap at the suspected area to elicit pain.
30. A committee is reviewing the hospital's emergency management plan. In the event of a large-scale multi-casualty event, which group is likely to require the largest amount of physical space to accommodate the number of victims? a. Black-tagged patients b. Red-tagged patients c. Yellow-tagged patients d. Green-tagged patients
ANSWER: d. Green-tagged patients
9. The nurse has received reports on several patients who were admitted for heat-related illnesses. The patient who has the most severe case of heat-related illness exhibits which signs/symptoms? a. Headache, heavy perspiration, temperature of 101° F b. Feeling of illness, nausea, & vomiting c. Significant sunburn to extremities, face, & neck; temperature of 102° F d. Hot & dry skin, alert & oriented to person, pulse of 120/min
ANSWER: d. Hot & dry skin, alert & oriented to person, pulse of 120/min
51. A patient is at risk for sepsis. Which assessment finding is most indicative of the hyper dynamic activity that occurs in septic shock? a. Crackles in lung bases b. Weak, rapid peripheral pulses c. Cool, clammy, cyanotic skin d. Increased pulse rate with warm, pink skin
ANSWER: d. Increased pulse rate with warm, pink skin
42. The nurse is evaluating the care & treatment for a patient in shock. Which finding indicates that the patient is having an appropriate response to the treatment? a. Blood pH of 7.28 b. Arterial Po 2 of 65 mm Hg c. Distended neck veins d. Increased urinary output
ANSWER: d. Increased urinary output
10. A patient with a head injury was treated for a cerebral hematoma. After surgery, this patient is at risk for what type of shock? a. Obstructive b. Cardiogenic c. Chemical-induced distributive d. Neural-induced distributive
ANSWER: d. Neural-induced distributive
7. The hospital staff is participating in a disaster drill & the nurse is assigned to organize personnel who are called in from home. Which task would be appropriate to delegate to a unlicensed assistive personnel (UAP) who usually works in the labor & delivery area? a. Stay with "black tag" patients in the holding area. b. Talk to the families of the "red tag" patients. c. Care for & support the "green tag" patients. d. Obtain vital signs of the "yellow tag" patients.
ANSWER: d. Obtain vital signs of the "yellow tag" patients.
29. Which IV therapy results in the greatest increase in oxygen-carrying capacity for a patient with hypovolemic shock? a. Lactated Ringer's solution b. Hetastarch c. Fresh frozen plasma (FFP) d. Packed red cells
ANSWER: d. Packed red cells
14. The emergency management plan is activated because a major earthquake has caused many serious & minor injuries. Which nurse reassignment is most likely to meet the needs of the patients, while best utilizing available personnel? a. Operating room nurse is reassigned to the ED to assist in triage. b. ED nurse is reassigned to care for patients on the medical-surgical unit. c. Critical care nurse is reassigned to the ED to care for "black tag" patients. d. Performance improvement nurse is reassigned to care for "green tag" patients..
ANSWER: d. Performance improvement nurse is reassigned to care for "green tag" patients..
33. The nurse is caring for a patient with a head injury whose Glasgow coma scale score is 3. This score indicates the patient is most likely to do what? a. Withdraw from painful stimuli b. Open eyes spontaneously c. Moan with incoherent speech d. Present as totally unresponsive
ANSWER: d. Present as totally unresponsive
37. Based on the nurse's knowledge of normal versus abnormal findings related to growth & development, which assessment finding concerns the nurse the most? a. Mottling of extremities in a newborn b. Dry skin with tenting in an elderly woman c. Anxiety & fearfulness in an 18-monthold child d. Rapid, shallow respirations in a 7-year-old child
ANSWER: d. Rapid, shallow respirations in a 7-year-old child
39. A patient has a localized infection. What assessment findings are considered evidence of a beneficial inflammatory response? a. Decreased urine output which normalizes after fluid bolus b. Pulse rate of 120 beats/min related to increased metabolic activity c. Decreased oxygen saturation which responds to supplemental O2 d. Redness & edema that appear but subside in several days
ANSWER: d. Redness & edema that appear but subside in several days
54. A 70-year-old man is admitted to the hospital with an infected finger of several days' duration. He is lethargic, confused, and has a temperature of 101.3° F. Other assessment findings include blood pressure of 94/50 mm Hg, pulse 105 beats/min, respirations 40, and shallow breathing. Pulmonary arterial wedge pressure (PAWP) is 4 mm Hg. These assessment findings indicate what type of shock? a. Hypovolemic b. Cardiogenic c. Anaphylactic d. Septic
ANSWER: d. Septic
4. Which statement about the systemic effects of shock is correct? a. The liver is essentially unaffected, but liver enzymes may be lower than normal. b. The current heart rate & blood pressure indicate cardiac system at baseline. c. The brain & neurologic system can withstand 10 to 15 minutes of severe hypoperfusion. d. The kidneys can tolerate hypoxia & anoxia up to 1 hour without permanent damage.
ANSWER: d. The kidneys can tolerate hypoxia & anoxia up to 1 hour without permanent damage.
2. The ED nurse is preparing a report on a patient being admitted for bacterial meningitis. Which points are included in the ED nurse's report to the medical-surgical nurse? (SATA) a. "Patient reports severe headache with high fever that started 4 days ago." b. "Patient currently alert & oriented x 2; speech clear, but rambling." c. "Patient is divorced & currently does not have any health insurance." d. "IV normal saline into left anterior forearm; received first dose of IV ceftriaxone (Rocephin) at 0700." e. "Lumbar puncture results are pending, but meningococcal meningitis is suspected." f. "Received 1000 mg acetaminophen (Tylenol) (for pain (9/10) & fever 103° F at 0400; pain continues (7/10), temperature now 100.9° F."
ANSWERS: a. "Patient reports severe headache with high fever that started 4 days ago." b. "Patient currently alert & oriented x 2; speech clear, but rambling." d. "IV normal saline into left anterior forearm; received first dose of IV ceftriaxone (Rocephin) at 0700." e. "Lumbar puncture results are pending, but meningococcal meningitis is suspected." f. "Received 1000 mg acetaminophen (Tylenol) (for pain (9/10) & fever 103° F at 0400; pain continues (7/10), temperature now 100.9° F."
12. At 3:00 am, the ED charge nurse of a large suburban hospital receives notification that a commercial plane has just crashed outside the city limits. What does the nurse do? (SATA) a. Collaborate with the medical command physician. b. Activate the hospital's emergency management plan. c. Initiate the staff telephone tree. d. Collaborate with the triage officer. e. Organize nursing & ancillary services.
ANSWERS: a. Collaborate with the medical command physician. c. Initiate the staff telephone tree d. Collaborate with the triage officer. e. Organize nursing & ancillary services.
3. The patient has decreased oxygenation & impaired tissue perfusion. Which clinical manifestations are evidence of onset of the non-progressive or compensatory stages of shock? (SATA) a. Decreased urine output b. Low-grade fever c. Narrowing pulse pressure d. Decreased heart rate e. Increased heart rate
ANSWERS: a. Decreased urine output c. Narrowing pulse pressure e. Increased heart rate
75. What are the most common signs/symptoms of high-altitude pulmonary edema (HAPE)? (SATA) a. Dyspnea at rest b. Persistent dry cough c. Abdominal pain & cramping d. Pale lips & nail beds e. Cyanotic lips & nail beds
ANSWERS: a. Dyspnea at rest b. Persistent dry cough e. Cyanotic lips & nail beds
20. The nurse identifies signs & symptoms of internal hemorrhage in a postoperative patient. What is included in the care of this patient for hypovolemic shock? (SATA) a. Elevate the feet with the head fat or elevated 30 degrees. b. Monitor vital signs every 5 minutes until they are stable. c. Administer clotting factors or plasma. d. Provide oxygen therapy. e. Ensure IV access. f. Notify the Rapid Response Team.
ANSWERS: a. Elevate the feet with the head fat or elevated 30 degrees. b. Monitor vital signs every 5 minutes until they are stable. d. Provide oxygen therapy. e. Ensure IV access. f. Notify the Rapid Response Team.
27. The nurse finds a patient on the bathroom floor. There is a large amount of blood on the floor & on the patient's hospital gown. Which actions must the nurse take? (SATA) a. Elevate the patient's legs. b. Establish large-bore IV access. c. Look for the source of the bleeding. d. Ensure a patent airway. e. Begin a nitroprusside (Nitropress) infusion.
ANSWERS: a. Elevate the patient's legs. b. Establish large-bore IV access. c. Look for the source of the bleeding. d. Ensure a patent airway.
45. When administering norepinephrine (Levophed), what does the nurse monitor for in the patient? (SATA) a. Extravasation b. Headache c. High-output renal failure d. Chest pain e. Hypertension
ANSWERS: a. Extravasation b. Headache d. Chest pain e. Hypertension
14. For which indications would the nurse be prepared to administer a colloid product? (SATA) a. Hemorrhagic shock b. Dehydration c. Peripheral tissue hypoxia d. Fluid replacement e. Restore osmotic pressure
ANSWERS: a. Hemorrhagic shock c. Peripheral tissue hypoxia e. Restore osmotic pressure
87. What might the nurse notice if the patient has impaired thermoregulation as a result of a cold-related injury? (SATA) a. Hyperemia & edema of fingers or toes b. Shivering c. Possible atrial fibrillation d. Numbness & pain of nose or ears e. Profuse diaphoresis
ANSWERS: a. Hyperemia & edema of fingers or toes b. Shivering d. Numbness & pain of nose or ears
66. The nurse has volunteered at a storm shelter to identify potential problems related to cold related injuries. Which conditions predispose people to a greater risk for cold injury? (SATA) a. Hypothyroidism b. Advanced age c. Crohn's disease d. Osteoarthritis e. Malnutrition
ANSWERS: a. Hypothyroidism b. Advanced age e. Malnutrition
90. On what should the nurse reflect in caring for the patient with impaired thermoregulation as a result of a cold-related injury? (SATA) a. Monitor the patient's response to pain medication & rewarming techniques. b. Monitor for further injury from rewarming techniques. c. Monitor for recurrence of cardiac dysrhythmias. d. Evaluate the patient & family's knowledge about the injury & treatment plans. e. Educate the patient & family on ways to prevent future cold-related injury.
ANSWERS: a. Monitor the patient's response to pain medication & rewarming techniques. b. Monitor for further injury from rewarming techniques. d. Evaluate the patient & family's knowledge about the injury & treatment plans. e. Educate the patient & family on ways to prevent future cold-related injury.
25. A patient with hypovolemia is restless & anxious. The skin is cool & pale, pulse is thready at a rate of 135 beats/min; blood pressure is 92/50 mm Hg; respirations are 32/min. What actions must the nurse take? (SATA) a. Obtain a stat order for an IV normal saline bolus. b. Administer supplemental oxygen. c. Notify the Rapid Response Team. d. Place the patient in a semi-Fowler's position. e. Call a "code blue."
ANSWERS: a. Obtain a stat order for an IV normal saline bolus. b. Administer supplemental oxygen. c. Notify the Rapid Response Team.
57. The nurse on a medical unit is presenting an in-service program on how to recognize sepsis. Which patients are at risk for distributive septic shock?(SATA) a. Older adult with urinary tract infection b. Patient with ruptured aortic aneurysm c. Patient with pneumonia d. Patient receiving heparin therapy e. Older adult with sacral pressure ulcers
ANSWERS: a. Older adult with urinary tract infection c. Patient with pneumonia e. Older adult with sacral pressure ulcers
18. Antivenin polyvalent is given to patients with caution when they exhibit which preexisting factors? (SATA) a. Previous allergic reaction to anti-venom therapy b. Older adults who were bitten several hours prior to arrival at the ED c. Sensitivity to mercury-containing products d. Pregnancy e. Hypersensitivity to bovine protein
ANSWERS: a. Previous allergic reaction to anti-venom therapy c. Sensitivity to mercury-containing products d. Pregnancy
6. A young woman comes to the emergency department (ED) with light-headedness & "a feeling of impending doom." Pulse is 110 beats/min; respirations 30/min; blood pressure 140/90 mm Hg. Which factors does the nurse ask about that could contribute to shock? (SATA) a. Recent accident or trauma b. Prolonged diarrhea or vomiting c. History of depression or anxiety d. Possibility of pregnancy e. Use of over-the-counter medications
ANSWERS: a. Recent accident or trauma b. Prolonged diarrhea or vomiting d. Possibility of pregnancy e. Use of over-the-counter medications
61. A patient involved in a boating accident has extensive injuries & comes to the ED in wet clothes. The nurse identifies a risk for hypothermia. Which interventions does the nurse implement? (SATA) a. Remove wet clothing. b. Infuse warm IV solutions. c. Set the room temperature at 90° F. d. Give sips of warm fluid. e. Use a heating blanket.
ANSWERS: a. Remove wet clothing. b. Infuse warm IV solutions e. Use a heating blanket.
12. The nursing student takes the morning blood pressure of a postoperative patient & the reading is 90/50 mm Hg. What does the student do next? (SATA) a. Report the reading to the primary nurse as a possible sign of hypovolemia. b. Assess the patient for subjective feelings of dizziness or shortness of breath. c. Check the patient's chart for trends of morning vital sign readings. d. Notify the instructor to verify the significance of the finding. e. Call a "code blue."
ANSWERS: a. Report the reading to the primary nurse as a possible sign of hypovolemia. b. Assess the patient for subjective feelings of dizziness or shortness of breath. c. Check the patient's chart for trends of morning vital sign readings. d. Notify the instructor to verify the significance of the finding.
1. Which statements about shock are true? (SATA) a. Shock is a whole-body response to tissues not receiving enough oxygen. b. Shock is widespread abnormal cellular metabolism. c. Shock only occurs in the acute care setting. d. Shock may occur in older adults in response to urinary tract infections. e. Shock is mostly classified as a disease.
ANSWERS: a. Shock is a whole-body response to tissues not receiving enough oxygen. b. Shock is widespread abnormal cellular metabolism. d. Shock may occur in older adults in response to urinary tract infections.
62. Several people on a cross-country ski trip return to the ski lodge with mild hypothermia. Which items does the nurse offer or obtain for the hypothermia victims? (SATA) a. Synthetic-fiber hats b. Cups of warm broth c. Caffeinated beverages d. Polyester fleece shirts e. Dry socks & gloves
ANSWERS: a. Synthetic-fiber hats b. Cups of warm broth d. Polyester fleece shirts e. Dry socks & gloves
88. What should the nurse interpret for the patient with impaired thermoregulation as a result of a cold-related injury? (SATA) a. Temperature b. Cardiac assessment c. Neurologic assessment d. Gastrointestinal assessment e. Fluid status
ANSWERS: a. Temperature b. Cardiac assessment c. Neurologic assessment e. Fluid status
89. How should the nurse respond to the patient with impaired thermoregulation as a result of a cold-related injury? (SATA) a. Thaw frozen body parts in a warm-water bath & handle gently. b. Provide pain control measures. c. Apply compression dressings. d. Administer tetanus prophylaxis & possible antibiotics for open wounds. e. Initiate passive external rewarming by covering with blankets.
ANSWERS: a. Thaw frozen body parts in a warm-water bath & handle gently. b. Provide pain control measures. d. Administer tetanus prophylaxis & possible antibiotics for open wounds. e. Initiate passive external rewarming by covering with blankets.
50. The nurse is preparing a teaching session for a patient at risk for septic shock. Which topics does the nurse include in this teaching? (SATA) a. Wash hands frequently using antimicrobial soap. b. Avoid aspirin & aspirin-containing products. c. Avoid large crowds or gatherings where people might be ill. d. Do not share utensils; wash toothbrushes in a dishwasher. e. Take temperature once a week. f. Do not change pet litter boxes.
ANSWERS: a. Wash hands frequently using antimicrobial soap. c. Avoid large crowds or gatherings where people might be ill. d. Do not share utensils; wash toothbrushes in a dishwasher f. Do not change pet litter boxes.
49. The nurse is instructing a patient who has a history of allergic reaction to bee stings on what to do if he or she experiences a bee sting in the future. What information does the nurse relay to the patient? (SATA) a. Wear a medical alert bracelet. b. Take an antihistamine before administering an EpiPen injection. c. Administer epinephrine immediately. d. Call 911 to be transported to a medical facility. e. Take an aspirin immediately.
ANSWERS: a. Wear a medical alert bracelet. c. Administer epinephrine immediately. d. Call 911 to be transported to a medical facility.
60. Which signs/symptoms indicate the most severe case of hypothermia? (SATA) a. Tachycardia b. Depressed respiratory rate c. Decreased pain response d. Acid-base imbalance e. Dysarthria
ANSWERS: b. Depressed respiratory rate c. Decreased pain response d. Acid-base imbalance
76. A Foreign Service employee normally lives in a coastal area, but he must take an emergency trip to a high-mountain area. He asks the nurse what he can do if AMS occurs when he is at a high altitude. The nurse ADVISES: (SATA) a. Stay at a higher altitude if a throbbing headache occurs. b. If available, administer oxygen. c. Take the oral form of furosemide (Lasix). d. Descend to a lower altitude. e. Get a prescription for sildenafil (Viagra).
ANSWERS: b. If available, administer oxygen. d. Descend to a lower altitude.
18. A patient is brought to the ED with a gunshot wound. For which early signs of hypovolemic shock does the nurse monitor? (SATA) a. Elevated serum potassium level b. Increase in heart rate c. Decrease in oxygen saturation d. Marked decrease in blood pressure e. Increase in respiratory rate
ANSWERS: b. Increase in heart rate e. Increase in respiratory rate
8. An older adult is in the ED for over 48 hours awaiting transfer to an inpatient bed. The charge nurse delegates turning the patient every 2 hours to the unlicensed assistive personnel (UAP) for Risk for impaired skin integrity. The ED is busy; the patient is not turned & begins to develop a pressure ulcer. What does the charge nurse do to prevent a recurrence of this type of problem for future patients? (SATA) a. Nothing; in the overall priorities of the ED, the situation is inevitable. b. Make anecdotal notes & counsel all the involved UAPs. c. Delegate the duty of turning & repositioning to the physical therapist. d. File an incident report & seek resolution at the systems level. e. Reeducate staff on the need to turn patients at risk for skin breakdown.
ANSWERS: b. Make anecdotal notes & counsel all the involved UAPs. d. File an incident report & seek resolution at the systems level. e. Reeducate staff on the need to turn patients at risk for skin breakdown.
7. Which are specific causes or risk factors for cardiogenic shock? (SATA) a. Anesthesia b. Myocardial infarction c. Cardiac tamponade d. Ventricular dysrhythmias e. Constrictive pericarditis
ANSWERS: b. Myocardial infarction d. Ventricular dysrhythmias
68. Which measures are correct when rewarming a victim of deep frostbite? (SATA) a. Rubbing the area helps speed the warming process. b. Rapid rewarming in a 40° C to 42° C water bath will be required. c. Rapid rewarming is avoided because of increased tissue damage. d. After rewarming, the extremity should be elevated above the heart level. e. An opioid analgesic may be given because of the pain associated with rewarming. f. Immunization for tetanus prophylaxis will be needed.
ANSWERS: b. Rapid rewarming in a 40° C to 42° C water bath will be required. d. After rewarming, the extremity should be elevated above the heart level. e. An opioid analgesic may be given because of the pain associated with rewarming. f. Immunization for tetanus prophylaxis will be needed.
45. An anaphylactic reaction to a wasp or bee sting manifests as which conditions? (SATA) a. Hypertension b. Respiratory distress c. Hypoglycemia d. Laryngeal edema e. Deterioration in mental status
ANSWERS: b. Respiratory distress d. Laryngeal edema e. Deterioration in mental status
5. Which patients are at risk for shock related to fluid shifts? (SATA) a. Hypoglycemic patient b. Severely malnourished patient c. Patient with paralytic ileus d. Patient with kidney disease e. Patient with minor burns f. Patient with large wounds
ANSWERS: b. Severely malnourished patient c. Patient with paralytic ileus d. Patient with kidney disease f. Patient with large wounds
80. What responses does the "diving reflex" cause in the body? (SATA) a. Tachycardia b. Metabolic alkalosis c. Bradycardia d. Increased cardiac output e. Vasoconstriction of vessels in the intestines & kidneys
ANSWERS: c. Bradycardia e. Vasoconstriction of vessels in the intestines & kidneys
15. The nurse is caring for a patient at risk for hypovolemic shock. For which indicators of shock does the nurse monitor? (SATA) a. Elevated body temperature b. Increased peristalsis c. Decreasing urine output d. Vasodilation e. Increasing heart rate
ANSWERS: c. Decreasing urine output e. Increasing heart rate
41. The school nurse is preparing for an outside field trip to a farm with middle school-aged children. What instructions does the nurse provide to the children for bee & wasp sting prevention? (SATA) a. Place all jackets or sweaters in a pile on the ground. b. Do not try to outrun bees if attacked by a swarm. c. Keep garbage or leftover food in covered containers. d. Inspect clothes & shoes for insects before putting on. e. Do not swat at bees or wasps close to you.
ANSWERS: c. Keep garbage or leftover food in covered containers. d. Inspect clothes & shoes for insects before putting on. e. Do not swat at bees or wasps close to you.
33. The triage method for multi-casualty or mass response utilizes what sorting methods? (SATA) a. Patients are alphabetized by name. b. Health care providers triage most critical patients. c. Patients are labeled by number. d. Patients are ranked by assessment scores. e. Patients are ranked using colored labels.
ANSWERS: c. Patients are labeled by number. e. Patients are ranked using colored labels.
4. Which prehospital interventions are appropriate for a patient with heat exhaustion? (SATA) a. Provide salted snacks for him to eat. b. Call for emergency medical services. c. Provide oral hydration such as a sports drink. d. Fan or spray water on his skin. e. Avoid giving him salt tablets.
ANSWERS: c. Provide oral hydration such as a sports drink. d. Fan or spray water on his skin. e. Avoid giving him salt tablets.
19. A multiple-car accident with mass casualties has occurred near an urban hospital. The hospital's emergency preparedness plan is activated. For what purposes is the post plan administrative review conducted? (Select all that apply.) a. To identify only the things that went wrong during the plan b. To identify employees who need financial assistance or reimbursement c. To establish a social networking system for the employees d. To provide all employees the opportunity to express positive & negative comments e. To solicit written critique forms for additional information
ANSWERS: d. To provide 4 the opportunity to express positive & negative comments e. To solicit written critique forms for additional information
36. Each patient listed below has entered the ED's waiting area. Place them in order of priority, with 1 being the highest priority & 4 being the lowest priority. _____ a. 3-year-old child with inconsolable high-pitched crying, high fever, headache, & nuchal rigidity _____ b. 65-year-old man having diaphoresis with left anterior crushing chest pain _____ c. 32-year-old woman reporting upper abdominal pain & vomiting green bile emesis _____ d. 16-year-old boy with a broken arm from skateboarding, pulse & sensation intact
ANSWERS: 1 b. 65-year-old man having diaphoresis with left anterior crushing chest pain 2 a. 3-year-old child with inconsolable high-pitched crying, high fever, headache, & nuchal rigidity 3 c. 32-year-old woman reporting upper abdominal pain & vomiting green bile emesis 4 d. 16-year-old boy with a broken arm from skateboarding, pulse & sensation intact
33. A patient who has been bitten by a black widow spider requires the following interventions in which priority order? (Select in order of priority.) _____ a. Administration of antivenin for severe reaction (respiratory arrest & uncontrolled hypertension) _____ b. Application of an ice pack to the site _____ c. Monitoring of vital signs _____ d. Administration of diazepam (Valium) for seizures
ANSWERS: 1 b. Application of an ice pack to the site 2 c. Monitoring of vital signs 3 d. Administration of diazepam (Valium) for seizures 4 a. Administration of antivenin for severe reaction (respiratory arrest & uncontrolled hypertension)
81. Several people are looking out across a lake & pointing to a swimmer in the distance who appears to be struggling to stay afloat. What is the correct sequence of emergency steps to take? (Select in order of priority.) _____ a. Stabilize the spine with a board. _____ b. Safely rescue the victim. _____ c. Begin immediate CPR. _____ d. Assess neurologic status. _____ e. Assess airway patency.
ANSWERS: 1 b. Safely rescue the victim. 2 e. Assess airway patency. 3 c. Begin immediate CPR. 4 a. Stabilize the spine with a board. 5 d. Assess neurologic status.
41. A patient in the ED has sustained a closed fracture after falling 50 feet while rock climbing. What are the assessments & interventions the nurse would perform for this patient in priority order? (Select in order of priority, with 1 being the highest priority.) _____ a. Evaluate the neuromuscular status of the left lower extremity. _____ b. Assess the head, chest, & abdomen for injuries. _____ c. Assess airway, breathing, & circulation. _____ d. Immobilize the injured extremity. _____ e. Monitor the degree of pain or discomfort.
ANSWERS: 1 c. Assess airway, breathing, & circulation. 2 b. Assess the head, chest, & abdomen for injuries. 3 a. Evaluate the neuromuscular status of the left lower extremity. 4 d. Immobilize the injured extremity. 5 e. Monitor the degree of pain or discomfort.
5. The hospital in a small mountain town is updating their emergency management plan to incorporate the "all hazards approach" & to address all credible threats to the area. Which disaster events are the likely priorities in this community's emergency management plan? (SATA) a. Avalanches b. Floods c. Burns d. Car accidents e. Tornadoes f. Bioterrorism
ANSWERS: a. Avalanches c. Burns d. Car accidents f. Bioterrorism
21. To protect hospital staff from experiencing posttraumatic stress disorder (PTSD), what are appropriate recommendations by the facility to its employees? (SATA) a. Drink plenty of water. b. Limit verbalizing feelings to family & friends. c. Use available counseling. d. Encourage & support coworkers. e. Do not work more than 14 hours per day.
ANSWERS: a. Drink plenty of water. c. Use available counseling d. Encourage & support coworkers.
36. A patient is admitted for observation following a bark scorpion sting. The nurse monitors the patient for which type of systemic complications? (SATA) a. Gastrointestinal disorders b. Tachycardia c. Hypotension d. Temperature of 100.7° F (38.2° C) e. Pulmonary edema
ANSWERS: a. Gastrointestinal disorders b. Tachycardia e. Pulmonary edema
1. Which predisposing factors are associated with heat-related illness? (SATA) a. High humidity b. Beta-adrenergic blockers c. Obesity d. Anemia e. Seizures f. Dehydration
ANSWERS: a. High humidity b. Beta-adrenergic blockers c. Obesity e. Seizures f. Dehydration
22. To promote effective coping for survivors of a mass-casualty event, the nurse practices which principles while interacting with patients in crisis? (SATA) a. Listening to patients b. Encouraging patients to have solitude c. Promoting relaxation d. Allowing unstructured routines e. Offer choices whenever possible to increase feelings of control
ANSWERS: a. Listening to patients c. Promoting relaxation e. Offer choices whenever possible to increase feelings of control
13. A patient sustained a bite from a pit viper & is admitted for observation. Which potential complications does the nurse observe for? (SATA) a. Local tissue necrosis b. Diarrhea c. Massive tissue swelling d. Renal failure e. Hypovolemic shock f. Increased intracranial pressure
ANSWERS: a. Local tissue necrosis c. Massive tissue swelling d. Renal failure e. Hypovolemic shock
31. Which complications are related to a black widow spider bite? (SATA) a. Muscle rigidity & spasms of large muscles b. Severe dizziness & tinnitus c. Severe abdominal pain d. Latrodectism e. Hypertension
ANSWERS: a. Muscle rigidity & spasms of large muscles c. Severe abdominal pain d. Latrodectism e. Hypertension
59. The patient has been diagnosed with sepsis. Following the sepsis resuscitation bundle, which interventions should the nurse expect within the first 3 hours? (SATA) a. Obtain serum lactate level. b. Begin administering vasopressor drugs. c. Draw blood cultures. d. Administer broad-spectrum antibiotics. e. Assist with insertion of a central venous pressure line.
ANSWERS: a. Obtain serum lactate level. c. Draw blood cultures. d. Administer broad-spectrum antibiotics.
13. A patient is brought to the ED by the family because he has verbally threatened others & attempted to stab the neighbor's dog. What does the nurse do in order to ensure the safety of the patient & others? (SATA) a. Search the patient's belongings & secure personal effects. b. Instruct the patient's family to stay with him & call for help as necessary. c. Remove dangerous equipment from the room, such as sharps containers or portable instruments. d. Escort the patient to the waiting area where he can readily be observed by the triage nurse. e. Use a metal detector to search for objects that could be used as weapons. f. Instruct nursing students to avoid wearing a stethoscope around their necks.
ANSWERS: a. Search the patient's belongings & secure personal effects. c. Remove dangerous equipment from the room, such as sharps containers or portable instruments. e. Use a metal detector to search for objects that could be used as weapons. f. Instruct nursing students to avoid wearing a stethoscope around their necks.
52. The home health nurse is visiting a frail older adult PT at risk for sepsis because of failure to thrive & immunosuppression. What does the nurse assess this patient for? (SATA) a. Signs of skin breakdown & presence of redness or swelling b. Cough or any other symptoms of a cold or the flu c. Appearance & odor of urine, & pain or burning during urination d. Patient's & family's understanding of isolation precautions e. Availability & type of facilities for hand washing
ANSWERS: a. Signs of skin breakdown & presence of redness or swelling b. Cough or any other symptoms of a cold or the flu c. Appearance & odor of urine, & pain or burning during urination e. Availability & type of facilities for hand washing
57. The nurse is advising parents who are organizing a winter cross-country skiing trip. In assisting the parents to develop an appropriate winter clothing list, which articles should be taken on the trip? (SATA) a. Synthetic socks b. Cotton underwear c. Polyester fleece shirt d. Windproof outer jacket e. Hat made from Gore-Tex f. Sunglasses
ANSWERS: a. Synthetic socks c. Polyester fleece shirt d. Windproof outer jacket e. Hat made from Gore-Tex f. Sunglasses
2. The nurse is providing patient education about the prevention of heat-related illness. Which statements are correct? (SATA) a. "Wear lightweight, dark-colored clothing when working outside." b. "Plan to limit activities at the hottest time of day." c. "Avoid fluids with electrolytes before, during, & after exercise." d. "Wear loose-fitting clothing." e. "Rest frequently when working in a hot environment."
ANSWERS: b. "Plan to limit activities at the hottest time of day." d. "Wear loose-fitting clothing." e. "Rest frequently when working in a hot environment."
16. Three people who came to the ED with a patient have become verbally argumentative & threatening towards each other. Which actions does the ED nurse take to ensure staff safety? (SATA) a. Ask the individuals to sit down & offer them coffee. b. Follow the hospital's security plan. c. Attempt to deescalate the situation. d. Quietly ask the individuals to leave. e. Identify potential escape routes.
ANSWERS: b. Follow the hospital's security plan. c. Attempt to deescalate the situation. e. Identify potential escape routes.
11. The ED nurse is caring for several patients, all of whom are currently lying on stretchers either pending discharge or awaiting transfer to a hospital bed. Which patients have the greatest risk for falls? (SATA) a. Patient with chronic pain who received 10 mg PO oxycodone for myalgia b. Opioid-naive teenager with a fracture who received 3 mg IV morphine for pain c. Middle-aged woman with severe vomiting & frequent watery stools for 3 days d. Child with a fever of 102° F, crying, with an ear infection e. Older adult patient with acute dementia secondary to infection
ANSWERS: b. Opioid-naive teenager with a fracture who received 3 mg IV morphine for pain c. Middle-aged woman with severe vomiting & frequent watery stools for 3 days e. Older adult patient with acute dementia secondary to infection
2. Which hormones are released in response to decreased mean arterial pressure (MAP)? (SATA) a. Insulin b. Renin c. Antidiuretic hormone (ADH) d. Epinephrine e. Aldosterone f. Serotonin
ANSWERS: b. Renin c. Antidiuretic hormone (ADH) d. Epinephrine e. Aldosterone
10. A homeless man is found lying in a vacant lot in the middle of July. He is lethargic & confused & he has sustained severe sunburns on the exposed areas of his skin. His core temperature is 106° F. What do prehospital emergency cooling measures include for this patient? (SATA) a. Administering cold IV fluid b. Stripping of all clothing c. Packing the axilla & groin with ice d. Encouraging sips of cool water e. Sponging with cool water & fanning
ANSWERS: b. Stripping of all clothing c. Packing the axilla & groin with ice e. Sponging with cool water & fanning
14. The nurse is participating in a summer hike with a group of children. Suddenly the children start screaming, "Snake
Snake!" One little girl is sitting in a tall grassy area, clutching her ankle & crying. What is the first priority in the field care of this child? a. Remove any constricting clothing. b. Maintain the extremity below the level of the heart. c. Move the child to a safe area & encourage rest. d. Keep the child warm & provide calm reassurance. ! ANSWER: c. Move the child to a safe area & encourage rest.
35. Following a tornado disaster, a charge nurse is assigned to be the group co-leader of a critical incident stress debriefing session. During the session, a nurse says, "We weren't prepared for this
The administration at this hospital is a joke." What is the best response? a. "Tis session is not about pointing fingers or fixing blame." b. "Tell us about what you experienced while you were caring for victims." c. "Improving the emergency plan will be discussed at the administrative review." d. "We are all pretty stressed out. Let's take a deep breath & calm down." ! ANSWER: b. "Tell us about what you experienced while you were caring for victims."
45. A patient with a sprained ankle says, "I have been here for 4 hours & other people who came after me have been taken back to see the doctor. My ankle hurts
Why am I being ignored?" What is the best response? a. "Sir, other patients have problems that are more serious than yours." b. "Tis is a system fault, if you would like to complain, I'll call a supervisor." c. "We have to attend to life-threatening or unstable conditions first." d. "Sir, I see that you are frustrated, but please sit down & wait your turn." ! ANSWER: c. "We have to attend to life-threatening or unstable conditions first."
