Exam 4 AH3 Questions
The following clients come at the emergency department complaining of acute abdominal pain. Prioritize them for care in order of the severity of the conditions. 1. A 27-year-old woman complaining of lightheadedness and severe sharp left lower quadrant pain who reports she is possibly pregnant. 2. A 43-year-old woman with moderate right upper quadrant pain who has vomited small amounts of yellow bile and whose symptoms have worsened over the week. 3. A 15-year-old boy with a low-grade fever, right lower quadrant pain, vomiting, nausea, and loss of appetite for the past few days. 4. A 57-year-old woman who complains of a sore throat and gnawing midepigastric pain that is worse between meals and during the night. 5. A 59-year-old man with a pulsating abdominal mass and sudden onset of persistent abdominal or back pain, which can be described as a tearing sensation within the past hour.
5,1,3,2,4
Your patient is receiving aggressive treatment for septic shock. Which findings demonstrate treatment is NOT being successful? (SATA) A. MAP (mean arterial pressure) 40 mmHg B. Urinary output of 10 mL over 2 hours C. Serum Lactate 15 mmol/L D. Blood glucose 120 mg/dL E. CVP (central venous pressure) less than 2 mmHg
A. MAP (mean arterial pressure) 40 mmHg B. Urinary output of 10 mL over 2 hours C. Serum Lactate 15 mmol/L E. CVP (central venous pressure) less than 2 mmHg
Nurse Ejay is assigned to a telephone triage. A client called who was stung by a honeybee and is asking for help. The client reports of pain and localized swelling but has no respiratory distress or other symptoms of anaphylactic shock. What is the appropriate initial action that the nurse should direct the client to perform? A. Removing the stinger by scraping it. B. Applying a cold compress. C. Taking an oral antihistamine. D. Calling the 911.
A. Removing the stinger by scraping it.
The physician orders a patient in septic shock to receive a large IV fluid bolus. How would the nurse know if this treatment was successful for this patient? A. The patient's blood pressure changes from 75/48 to 110/82. B. Patient's CVP 2 mmHg C. Patient's skin is warm and flushed. D. Patient's urinary output is 20 mL/hr.
A. The patient's blood pressure changes from 75/48 to 110/82.
A nurse is providing discharge instruction to a woman who has been treated for contusions and bruises due to a domestic violence. What is the priority intervention for this client? A. Making a referral to a counselor. B. Making an appointment to follow up on the injuries. C. Advising the client about contacting the police. D. Arranging transportation to a safe house.
D. Arranging transportation to a safe house.
A patient is at risk for septic shock when a microorganism invades the body. Which microorganism is the MOST common cause of sepsis? A. Fungus B. Virus C. Parasite D. Bacteria
D. Bacteria
A client was brought to the emergency department after suffering a closed head injury and lacerations around the face due to a hit-run accident. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessment findings if observed after few hours, should be reported to the physician immediately? A. Bleeding around the lacerations. B. Withdrawal of the client in response to painful stimuli. C. Bruises and minimal edema of the eyelids. D. Drainage of a clear fluid from the client's nose.
D. Drainage of a clear fluid from the client's nose.
An anxious female client complains of chest tightness, tingling sensations, and palpitations. Deep, rapid breathing, and carpal spasms are noted. Which of the following priority action should the nurse do first? A. Provide oxygen therapy. B. Notify the physician immediately. C. Administer anxiolytic medication as ordered. D. Have the client breathe into a brown paper bag.
D. Have the client breathe into a brown paper bag.
True or False: Septic shock causes system wide vasodilation which leads to an increase in systemic vascular resistance. In addition, septic shock causes increased capillary permeability and clot formation in the microcirculation throughout the body.
False
A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. Which of the following assessment should take the highest priority to take? A. Irregular pulse. B. Ecchymosis in the flank area. C. A deviated trachea. D. Unequal pupils.
C. A deviated trachea.
The following clients are presented with signs and symptoms of heat-related illness. Which of them needs to be attended first? A. A relatively healthy homemaker who reports that the air conditioner has been broken for days and who manifest fatigue, hypotension, tachypnea, and profuse sweating. B. An elderly person who complains of dizziness and syncope after standing in the sun for several hours to view a parade. C. A homeless person who is a poor historian; has altered mental status, poor muscle coordination, and hot, dry ashen skin; and whose duration of heat exposure is unknown. D. A marathon runner who complains of severe leg cramps and nausea, and manifests weakness, pallor, diaphoresis, and tachycardia.
C. A homeless person who is a poor historian; has altered mental status, poor muscle coordination, and hot, dry ashen skin; and whose duration of heat exposure is unknown.
The physician has ordered cooling measures for a child with a fever who is likely to be discharged when the temperature comes down. Which task would be appropriate to delegate to a nursing assistant? A. Prepare and administer a tepid sponge bath. B. Explain the need for giving cool fluids. C. Assist the child in removing outer clothing. D. Advise the parent to use acetaminophen (Tylenol) instead of aspirin.
C. Assist the child in removing outer clothing.
In the work setting, what is the primary responsibility of the nurse in preparation for disaster management, that includes natural disasters and bioterrorism incidents? A. Being aware of the signs and symptoms of potential agents of bioterrorism. B. Making ethical decisions regarding exposing self to potentially lethal substances. C. Being aware of the agency's emergency response plan. D. Being aware of what and how to report to the Centers for Disease Control and Prevention.
C. Being aware of the agency's emergency response plan.
The emergency medical service has transported a client with severe chest pain. As the client is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and unpalpable pulse. Which of the following task is appropriate to delegate to the nursing assistant? A. Assisting with the intubation. B. Placing the defibrillator pads. C. Doing chest compressions. D. Initiating bag valve mask ventilation.
C. Doing chest compressions.
Which problem places a client at highest risk for sepsis? A. Pernicious anemia B. Pericarditis C. Post kidney transplant D. Client owns an iguana
C. Post kidney transplant
How does the nurse caring for a client with septic shock recognize that severe tissue hypoxia is present? a. PaCo2 58 mmHg b. Lactate 9.0 mmol/L c. Partial thromboplastin time 64 seconds d. Potassium 2.8 mEq/L
b. Lactate 9.0 mmol/L
Which clinical symptoms in a PostOp client indicate early sepsis with an excellent recovery rate if treated? a. Localized erythema and edema b. Low-grade fever and mild hypotension c. Low O2 Sat rate and decreased cognition d. Reduced urinary output & increased RR
b. Low-grade fever and mild hypotension
You're providing care to four patients. Select all the patients who are at risk for developing sepsis: (SATA) A. A 35-year-old female who is hospitalized with renal insufficiency and has a Foley catheter and central line in place. B. A 55-year-old male who is a recent kidney transplant recipient. C. A 78-year-old female with diabetes mellitus who is recovering from colon surgery. D. A 65-year-old male recovering from right lobectomy for treatment of lung cancer.
A. A 35-year-old female who is hospitalized with renal insufficiency and has a Foley catheter and central line in place. B. A 55-year-old male who is a recent kidney transplant recipient. C. A 78-year-old female with diabetes mellitus who is recovering from colon surgery. D. A 65-year-old male recovering from right lobectomy for treatment of lung cancer.
An intoxicated client comes into the emergency unit with an uncooperative behavior, mild confusion, and with slurred speech. The client is unable to provide a good history but he verbalizes that he has been drinking a lot. Which of the following is a priority action of the nurse? A. Administer IV fluid incorporated with Vitamin B1 as ordered. B. Administer Naloxone (Narcan) 4 mg as ordered. C. Contact the family to get information of the client. D. Obtain an order for the determination of blood alcohol level.
A. Administer IV fluid incorporated with Vitamin B1 as ordered.
Your patient, who is post-op from a gastrointestinal surgery, is presenting with a temperature of 103.6 'F, heart rate 120, blood pressure 72/42, increased white blood cell count, and respirations of 21. An IV fluid bolus is ordered STAT. Which findings below indicate that the patient is progressing to septic shock? Select all that apply: A. Blood pressure of 70/34 after the fluid bolus B. Serum lactate less than 2 mmol/L C. Patient needs Norepinephrine to maintain a mean arterial pressure (MAP) greater than 65 mmHg despite fluid replacement D. Central venous pressure (CVP) of 18
A. Blood pressure of 70/34 after the fluid bolus C. Patient needs Norepinephrine to maintain a mean arterial pressure (MAP) greater than 65 mmHg despite fluid replacement Rationale: To know if the patient is progressing to septic shock, you need to think about the hallmark findings associated with this condition. Septic shock is characterized by major persistent hypotension (<90 SBP) that doesn't respond to IV fluids (refractory hypotension), and the patient needs vasopressors (ex: Norepinephrine) to maintain a mean arterial pressure greater than 65 and their serum lactate is greater than 2 mmol/L. A serum lactate greater than 2 indicates the cell's tissue/organs are not functioning properly due to low oxygen; hence tissue perfusion is poor due to the low blood pressure and mean arterial pressure.
A group of people arrived at the emergency unit by a private car with complaints of periorbital swelling, cough, and tightness in the throat. There is a strong odor emanating from their clothes. They report exposure to a "gas bomb" that was set off in the house. What is the priority action? A. Direct the clients to the decontamination area. B. Direct the clients to the cold or clean zone for immediate treatment. C. Measure vital signs and auscultate lung sounds. D. Immediately remove other clients and visitors from the area. E. Instruct personnel to don personal protective equipment.
A. Direct the clients to the decontamination area.
Your patient's blood pressure is 72/56, heart rate 126, and respiration 24. The patient has a fungal infection in the lungs. The patient also has a fever, warm/flushed skin, and is restless. You notify the physician who suspects septic shock. You anticipate that the physician will order what treatment FIRST? A. Low-dose corticosteroids B. Crystalloids IV fluid bolus C. Norepinephrine D. 2 units of Packed Red Blood Cells
B. Crystalloids IV fluid bolus
A client arrives in the emergency unit and reports that a concentrated household cleaner was splashed in both eyes. Which of the following nursing actions is a priority? A. Use Restasis (Allergan) drops in the eye. B. Flush the eye repeatedly using sterile normal saline. C. Examine the client's visual acuity. D. Patch the eye
B. Flush the eye repeatedly using sterile normal saline.
Your patient, who is post-op from a kidney transplant, has developed septic shock. Which statement below best reflects the interventions you will perform for this patient? A. Administer Norepinephrine before attempting a fluid resuscitation. B. Collect cultures and then administer IV antibiotics. C. Check blood glucose levels before starting any other treatments. D. Administer Drotrecogin Alpha within 48-72 hours.
B. Collect cultures and then administer IV antibiotics.
A patient is on IV Norepinephrine for treatment of septic shock. Which statement is FALSE about this medication? A. "The nurse should titrate this medication to maintain a MAP of 65 mmHg or greater." B. "This medication causes vasodilation and decreases systemic vascular resistance." C. "It is used when fluid replacement is not unsuccessful." D. "It is considered a vasopressor."
B. "This medication causes vasodilation and decreases systemic vascular resistance."
Nurse Anna is an experienced travel nurse who was recently employed and is assigned in the emergency unit. In her first week of the job, which of the following area is the most appropriate assignment for her? A. Triage. B. Ambulatory section. C. Trauma team. D. Psychiatric care
B. Ambulatory section.
When an unexpected death occurs in the emergency department, which task is the most appropriate to delegate to a nursing assistant? A. Help the family to collect belongings. B. Assisting with postmortem care. C. Facilitate meeting between the family and the organ donor specialist. D. Escorting the family to a place of privacy.
B. Assisting with postmortem care.
The nursing manager decides to form a committee to address the issue of violence against ED personnel. Which combination of employees would be best suited to fulfill this assignment? A. RNs, LPNs, and nursing assistants. B. At least one representative from each group of ED personnel. C. Experienced RNs and experienced paramedics. D. ED physicians and charge nurses.
B. At least one representative from each group of ED personnel.
A 5-year-old client was admitted to the emergency unit due to ingestion of unknown amount of chewable vitamins for children at an unknown time. Upon assessment, the child is alert and with no symptoms. Which of the following information should be reported to the physician immediately? A. The child has been treated multiple times for injuries caused by accidents. B. The vitamin that was ingested contains iron. C. The child was nauseated and vomited once at home. D. The child has been treated several times for toxic substance ingestion.
B. The vitamin that was ingested contains iron.
A patient with a severe infection has developed septic shock. The patient's blood pressure is 72/44, heart rate 130, respiration 22, oxygen saturation 96% on high-flow oxygen, and temperature 103.6 'F. The patient's mean arterial pressure (MAP) is 53 mmHg. Based on these findings, you know this patient is experiencing diminished tissue perfusion and needs treatment to improve tissue perfusion to prevent organ dysfunction. In regards to the pathophysiology of septic shock, what is occurring in the body that is leading to this decrease in tissue perfusion? (SATA) A. Absolute hypovolemia B. Vasodilation C. Increased capillary permeability D. Increased systemic vascular resistance E. Clot formation in microcirculation F. A significantly decreased cardiac output
B. Vasodilation C. Increased capillary permeability E. Clot formation in microcirculation
A patient with a fever is lethargic and has a blood pressure of 89/56. The patient's white blood cell count is elevated. The physician suspects the patient is developing septic shock. What other findings indicate this patient is in the "early" or "compensated" stage of septic shock? (SATA) A. Urinary output of 60 mL over 4 hours B. Warm and flushed skin C. Tachycardia D. Bradypnea
B. Warm and flushed skin C. Tachycardia
A patient is diagnosed with septic shock. As the nurse you know this is a __________ form of shock. In addition, you're aware that __________ and _________ are also this form of shock. A. obstructive; hypovolemic and anaphylactic B. distributive; anaphylactic and neurogenic C. obstructive; cardiogenic and neurogenic D. distributive; anaphylactic and cardiogenic
B. distributive; anaphylactic and neurogenic
Nurse Kelly, a triage nurse encountered a client who complaints of mid-sternal chest pain, dizziness, and diaphoresis. Which of the following nursing action should take priority? A. Complete history taking. B. Put the client on ECG monitoring. C. Notify the physician. D. Administer oxygen therapy via nasal cannula.
D. Administer oxygen therapy via nasal cannula.
Which problem places a person at highest risk for septic shock? A. Kidney failure B. Cirrhosis C. Lung cancer D. 40% burn injury
D. 40% burn injury
A patient in septic shock is experiencing hyperglycemia. The patient is started on an insulin drip. A blood glucose goal for this patient would be: A. <110 mg/dL B. <80 mg/dL C. >200 mg/dL D. <180 mg/dL
D. <180 mg/dL
A patient in septic shock receives large amounts of IV fluids. However, this was unsuccessful in maintaining tissue perfusion. As the nurse, you would anticipate the physician to order what NEXT? A. IV corticosteroids B. Colloids C. Dobutamine D. Norepinephrine
D. Norepinephrine
You are preparing a child for IV conscious sedation before the repair of a facial laceration. What information should you report immediately to the physician? A. The parent wants information about the IV conscious sedation. B. The parent is not sure regarding the child's tetanus immunization status. C. The child suddenly pulls out the IV. D. The parent's refusal of the administration of the IV sedation.
D. The parent's refusal of the administration of the IV sedation.
A client suffered an amputation of the first and second digits in a chainsaw accident. Which task should be delegated to an LPN/LVN? A. Cleansing the amputated digits and placing them directly into an ice slurry. B. Cleansing the digits with sterile normal saline and placing in a sterile cup with sterile normal saline. C. Gently cleansing the amputated digits and the hand with povidone-iodine. D. Wrapping the cleansed digits in saline-moistened gauze, sealing in a plastic container, and placing it in an ice.
D. Wrapping the cleansed digits in saline-moistened gauze, sealing in a plastic container, and placing it in an ice.
A client comes into the ED clutching the chest. Which core competency for ED nurses is the first one used in this situation? a. Assessment b. Communication c. Priority setting d. Technical and Procedural skills
a. Assessment
A client with a gunshot wound is admitted to the ED. Which minimum Standard Precaution activity does the nurse require for staff safety? a. Blood and body fluid precautions b. Metal detector screening of the client c. Placement of a security guard d. Use of a positive air-purifying respirator (PAPR)
a. Blood and body fluid precautions
A client is admitted to the hospital with two of the systemic inflammatory response syndrome variables: temperature of 95 and high WBCs. Which intervention from the sepsis resuscitation bundle does the nurse imitate? a. Broad-spectrum antibiotics b. Blood transfusion c. Cooling baths d. NPO status
a. Broad-spectrum antibiotics
A client is admitted to the ED after reporting being raped. Who is the best team member for the admitting nurse to locate to provide care for this client? a. Forensic nurse examiner b. Physician or HCP c. Psychiatric Crisis Nurse d. Police officer
a. Forensic nurse examiner
An air medical helicopter arrives on the scene of a high-speed motorcycle collision with a train. The client was not wearing a helmet and is very confused, with a GCS score of 13. There is an apparent partial amputation of both hands. Vital signs are stable and the airway is secure. Which level of trauma center would be the most appropriate destination for this client? a. Level I b. Level II c. Level III d. Level IV
a. Level I
The client is admitted into the ED with diaphoresis, pale clammy skin, and BP of 90/70. Which intervention should the nurse implement first? a. Start an IV with an 18 gauge catheter b. Administer dopamine IV infusion c. Obtain ABGs d. insert an indwelling urinary catheter
a. Start an IV with an 18 gauge catheter
The nurse and an unlicensed assistive personnel are caring for a group of clients on a medical floor. Which action by the UAP warrants intervention by the nurse? a. The UAP places a urine specimens in a biohazard bag in the hallway b. The UAP uses the alcohol foam hand cleanser after removing gloves c. the UAP puts solid linen in a plastic bag in the client's room d. The UAP obtains a disposable stethoscope for a client in an isolation room
a. The UAP places a urine specimens in a biohazard bag in the hallway
As a direct result of overcrowding in ED environments, for whom must the ED nurse expect to provide care? a. A variety of age groups and cultures b. "Boarding" or holding inpatient clients c. Clients with a broad spectrum of issues, illnesses, and injuries d. Uninsured and underinsured clients
b. "Boarding" or holding inpatient clients
A client with septic shock has been started on dopamine (intrepid) at 23 mcg/kg/min. Which response indicates a positive outcome? a. Hourly urine output 10 to 12 mL/hr b. BP 90/60 and mean arterial pressure 70 mmHg c. Blood glucose 245 mg/dL d. Serum creatinine 3.6 mg/dL
b. BP 90/60 and mean arterial pressure 70 mmHg
The provider is planning to discharge a client home. The nurse suspects domestic violence as the cause of injury, although the client denies this. What is the best action for the nurse to take? a. Call the police b. Consult with Social Services c. Discharge the client as instructed d. Instruct t the client to go to a safe place
b. Consult with Social Services
The nurse plans to administer an antibiotic to a client newly admitted with septic shock. What action does the nurse take first? a. Administer the antibiotic immediately b. Ensure that blood cultures were drawn c. Obtain signature for informed consent d. Take the client's vital signs
b. Ensure that blood cultures were drawn
The client diagnosed with septicemia has the following HCP orders. Which HCP order has the highest priority? a. Provide clear liquid diet b. Initiate IV antibiotic therapy c. Obtain a STAT chest xray d. Perform hourly glucometer checks
b. Initiate IV antibiotic therapy
A client from a local care facility has sustained a cardiac arrest in the ED, and resuscitation was unsuccessful. The client's family wishes to view the body. What steps should the ED nurse take? (SATA) a. remove all lines and indwelling tubes b. cover the client with a sheet, leaving the face exposed c. Call a chaplain or social worker to accompany the family d. Tell the family that the client "is in a better place now." e. Dim the light in the client's room
b. cover the client with a sheet, leaving the face exposed e. Dim the light in the client's room
Which lab result is seen in late sepsis? a. decreased serum lactate b. decreased segmented neutrophil count c. Increased numbers of monocytes d. Increased platelet counts
b. decreased segmented neutrophil count
EMS arrives at the scene of an automobile crash. On primary assessment, the driver is found to be unresponsive, not breathing, and bleeding profusely. What is the first resuscitation intervention to be performed? a. Apply pressure to the bleeding b. Carry out artificial respirations c. Clear the airway d. Place a cervical collar
c. Clear the airway
What typical s/s indicates the early stage of septic shock? a. Pallor and cool skin b. BP 84/50 mmHg c. Tachypnea and Tachycardia d. Respiratory Acidosis
c. Tachypnea and Tachycardia
The nurse is caring a client diagnosed with septic shock. Which assessment data warrant immediate intervention by the nurse? a. Vital signs: T 100.4, P 104, RR 26, and BP 102/60 b. A WBC of 18,000 c. a urinary output of 90 mL in the last 4 hours d. the client complains of being thirsty
c. a urinary output of 90 mL in the last 4 hours
A client is admitted to the ED after being in a MVC. The client was wearing a seat belt and airbag deployed. There are no apparent injuries besides an abrasion from the shoulder harness across the clavicle and anterior chest. First vital signs are BP 110/70, HR 98, RR 18, SaO2 98% on RA. The client's GCS score is 15. What does the nurse do next? a. Allows the client to go home b. Checks blood alcohol levels c. Prepares the client for surgery d. Monitors the client
d. Monitors the client
There has been an explosion at a local refinery. Numerous serious and life-threatening injuries have occurred. The following clients arrive from the scene by private vehicle. Which client is considered a priority for treatment? a. Child with an open fracture of the arm b. Man with contusion on the head c. Teenager with a closed fracture of the leg d. Woman bleeding heavily
d. Woman bleeding heavily
The nurse caring for a patient with sepsis writes the client diagnosis of "alteration in comfort R/T chills and fever". Which intervention should be included in the plan of care? a. Ambulate the client in the hallway every shift b. Monitor urinalysis, creatinine, and BUN level c. apply sequential compression devices to the lower extremities d. administer an antipyretic medication every 4 hours PRN
d. administer an antipyretic medication every 4 hours PRN