CEN practice exam questions

Question 1

1-1 A patient presents to ED with chest pain and diaphoresis and denies dyspnea. Vitals are BP 148/70, HR 72, RR 18, SpO2 98%RA. Breath sounds are clear and equal. The EKG shows inferior wall ST segment elevation. You anticipate the following oxygen order:
A) No supplemental O2
B) Nasal cannula at 6L/min
C) Partial rebreather mask at 10L/min
D) Nonrebreather mask at 15L/min

Answer 1

A) No supplemental O2

Supplemental O2 has been shown to increase the size of the MI when patient has normoxia

Question 2

1-2 A pt complains of chest pain, dyspnea, and diaphoresis. Which of the following assessment factors would indicate a possible dx of ACS?
A) Pleuritic chest pain
B) Positional chest pain
C) Chest pain that radiates to the shoulders with pain in the rt shoulder worse than pain in the left shoulder
D) Pain reproducible with chest wall palpation

Answer 2

C) Chest pain that radiates to the shoulders with pain in the rt shoulder worse than pain in the left shoulder

Question 3

1-3 Which of the following human compensatory mechanisms to the presence of shock triggers glycogenolysis?
A) Chemoreceptor activation
B) Clotting cascade activation
C) Cerebral autoregulation stimulation
D) Adrenal gland stimulation

Answer 3

D) Adrenal gland stimulation

Adrenal gland stimulation causes adrenals to release two catecholamines: epinephrine and norepinephrine. Epinephrine increases HR and peripheral vasoconstriction and triggers glycogenolysis. Chemoreceptors are activated by changes in blood oxygen, carbon dioxide, and pH. Activation of clotting cascade is associated with trauma triad of death. Cerebral autoregulation maintains constant cerebral blood flow.

Question 4

1-4 A pt presents to the ED with abdominal pain and “ripping” back pain. Which condition places the pt at risk for abdominal aortic dissection?
A) Down syndrome
B) Romano-Ward syndrome
C) Jervell and Lange-Nielsen syndrome
D) Ehler-Danlos syndrome

Answer 4

D) Ehler-Danlos syndrome

Ehler-Danlos syndrome is a connective tissue disorder that causes hypermobile joints and skin that is hyper-extensible, soft, velvety-like appearance, is fragile, and tears or bruises easily. Pts with down syndrome are at increased risk for heart defects, digestive problems, hearing loss, and sometimes hypothyroidism. Romano-Ward syndrome causes long QT syndrome that often causes sudden death from a dysrhythmia. Jervell and Lange-Nielsen syndrome causes hearing loss from birth along with long QT syndrome, often resulting in sudden death.

Question 5

1-5 A pt arrives to ED via EMS in cardiac arrest, following 15 mins of CPR. Which of the following findings would indicate that termination of resuscitation efforts should be considered?
A) Decreased compliance while preforming bag-mask ventilation
B) An end-tidal carbon dioxide level reading less than 10% after 20 minutes of high-quality CPR
C) An initial rhythm of PEA
D) An initial presentation of a shockable rhythm

Answer 5

B) An end-tidal carbon dioxide level reading less than 10% after 20 minutes of high-quality CPR.

A low end-tidal carbon dioxide level indicates a lack of both end cellular perfusion and adenosine triphosphate production resulting in cellular death. Changes in bag-mask compliance indicates a pneumothorax. With initial rhythm of PEA, there should be a review of potential underlying causes before discontinuing CPR.

Question 6

1-6 A 7 year old develops v-fib. The child weighs 66lbs (30kg). CPR is started. What is the correct initial defib shock dose?
A) 60 joules
B) 30 joules
C) 120 joules
D) 90 joules

Answer 6

A) 60 joules

The correct first dose is 2joules/kg. A second dose would be 4 joules/kg.

Question 7

1-7 The ER is caring for an obtunded patient presumed to have taken an overdose of tricyclic antidepressant. The patient has a palpable pulse and an ECG is obtained. The nurse would anticipate the presence of which ECG finding?
A) Sinus bradycardia with normal QRS and QT intervals
B) Ventricular fibrillation
C) Narrow complex supraventricular tachycardia
D) Sinus tachycardia with both a widened QRS interval and prolonged QT interval

Answer 7

D) Sinus tachycardia with both a widened QRS interval and prolonged QT interval

Dysrhythmias from cyclic antidepressant toxicity typical are wide complex tachycardias. Sinus tachycardias occur frequently from the anticholinergic effects of tricyclic antidepressant toxicity. QRS complex widening occurs as a result of sodium channel blockade and this delayed conduction may be seen more commonly involving the right side of the heart manifesting as a right bundle branch block.

Question 8

1-8 During triage, the patient states the pacemaker only fires when the patient’s heart rate slows below a certain number of beats/minute. The nurse anticipates that the patient has a(n):
A) Asynchronous pacemaker
B) Demand pacemaker
C) Dual-chamber pacemaker
D) Fixed-rate pacemaker

Answer 8

B) Demand pacemaker

A demand pacemaker is able to sense the patient’s intrinsic heart rhythm and only delivers an impulse to “fire” when the pt’s intrinsic HR falls below a given rate. Asynchronous is another name for fixed-rate pacemaker which will continue to deliver an impulse to “fire” regardless of the patient’s intrinsic HR. Dual-chamber pacemakers provide electrical stimulation to both atrial and ventricular chambers, based on the patient’s intrinsic heart rate.

Question 9

1-9 A pt is noted to have Janeway lesions, Roth spots, and Osler’s nodes along with an elevated body temp and elevated WBC’s. Pt assessment reveals presence of several recent body piercings. The ER nurse suspects that the pt has:
A) endocarditis
B) pericarditis
C) myocarditis
D) leukemia

Answer 9

A) endocarditis

Endocarditis - Janeway lesions, Roth spots, Osler’s nodes, elevated temp, increased WBC’s

Pericarditis is characterized by increased WBC, pericardial friction rub, and ST changes.

Myocarditis typically a viral infection that presents with fevers and elevated WBC count, chest pain, cardiac rhythm abnormalities, poor nutrition, and fatigue.

Leukemia, a cancer of the blood system, is diagnosed by abnormalities in WBC counts. A rash may also be present with certain types of leukemia.

Question 10

1-10 A conscious pulseless patient with a continuous-flow left ventricular assist device and a history of end-stage heart failure presents to the ED because of “low-flow” alarm. The nurse anticipates preforming which intervention first?
A) Obtain a bp using doppler and a bp cuff
B) Auscultate over the pump to ascertain if the device is working
C) Administer IV fluids
D) Begin chest compressions

Answer 10

A) Obtain a bp using a doppler and bp cuff

The “low-flow” alarm may be because of decreased preload from hypotension, obstruction of inflow or outflow (which would cause an increase in afterload) cannula, or disconnection of percutaneous leads. Left ventricular assist device (LVAD) patients should have MAP’s between 70-80 mmHg. Auscultation of the pump is prudent to determine if the pump is functioning properly. Device failure is 2nd most common cause of death in LVAD pts. Signs of pump failure include the absence of a power light on the controller, undetectable blood pressure while using doppler, and an inability to auscultate the motor.

Question 11

1-11 A heart failure patient with profound dyspnea, lung crackles, and pink frothy sputum presents to the ER. The Dr orders the pt to be placed on bilevel positive airway pressure at an end-expiratory pressure of 10cmH2O and an inspiratory pressure of 5cmH2O. Which of the following findings demonstrates that the pt’s symptoms and work of breathing have been reduced?
A) Increasing the blood returned to the right side of the heart
B) Decreasing the cardiac output
C) Decreasing the preload
D) Increasing the afterload

Answer 11

C) Decreasing the preload

NIPPV includes both continuous positive airway pressure and bilevel positive airway pressure (BiPAP) devices. By increasing the pressure within the thoracic cavity through NIPPV, blood flow into the right heart is reduced: this results in a decreased preload, which helps to improve pulmonary congestion in the acute heart failure patient.

Question 12

1-12 Intravenous nitroprusside (Nipride) has been ordered for blood pressure reduction in a patient with a hypertensive emergency. The patient’s bp is 280/124 with MAP of 176. When titrating the nitroprusside for this patient, which order has the safest parameter to follow?
A) Titrate to a MAP of 124mmgHg over the next hour
B) Titrate to a MAP of 106mmHg over the next hour
C) Titrate to MAP of 158mmHg over the next hour
D) Titrate to a MAP of 132mmHg over the next hour

Answer 12

D) Titrate nitroprusside to a MAP of 132mmHg over the next hour

Hypertensive emergency is defined as severe hypertension with signs or symptoms of end organ dysfunction. It is recommended that the patient’s MAP be reduced by about 20-25% within the first hour of treatment, and rapid reduction of blood pressure should be avoided to prevent organ hypoperfusion.

Question 13

1-13 The assessment of a patient involved in a motor vehicle collision reveals muffled heart sounds and distended neck veins. The nurse understands that the treatment for this life-threatening situation is to:
A) Minimize the administration of intravenous fluids
B) Prepare for a 3-to-4-cm incision to the left of the xyphoid process
C) Prepare for insertion of a 14 G needle into the midclavicular line at the second intercostal space.
D) Prepare for chest tube insertion at the 5th intercostal space

Answer 13

B) Prepare for a 3-to4-cm incision to the left of the xyphoid process

Muffled heart sounds and distended neck veins are classic signs of pericardial tamponade. A 3-to4-cm incision to the left of the xiphoid process allows for pericardial decompression or release of pericardial tamponade, which is the treatment for this life-threatening situation. Insertion of a 14G needle into the midclavicular line at the second intercostal space is the treatment for decompression of a tension pneumothorax. Chest tube insertion at the 5th intercostal space at the anterior or midaxillary line is the treatment for a hemothorax. Minimizing the administration of intravenous fluids in addition to possible intubation and ventilation support is the treatment for cardiac contusion but is not the immediate treatment for pericardial tamponade.

Question 14

1-14 What is the best position to place a patient, in order to assess for the presence of a cardiac friction rub?
A) Ask the patient to stand up and then squat, then place the stethoscope at the left sternal border and listen at mid-systole
B) Ask the patient to lie or sit quietly, then place the stethoscope at the right sternal border and listen for radiation to the neck.
C) Ask the patient to lean forward, then place the stethoscope at the left sternal border and listen at end-expiration
D) Aks the patient to lie or sit quietly, then place the stethoscope at the apex of the heart and listen for radiation to the axilla.

Answer 14

C) Ask the patient to lean forward, then place the stethoscope at the left sternal border and listen at end-expiration

It has been reported that up to 85% of patients with pericarditis will have a friction rub. Although the presence of a friction rub during the initial evaluation of a patient with pericarditis is unreliable, when present, it is best heard as listed above. The murmur in a patient with hypertrophic cardiomyopathy will decrease with a change from a standing to squatting and peaks at mid-systole, and an S4 gallop may also be present. The harsh crescendo-decrescendo murmur in a patient with aortic stenosis is best heard at the right sternal border with radiation to the neck. The pansystolic blowing murmur in a patient with mitral regurgitation is best heard tat the apex and radiates to the axilla.

Question 15

1-15 Raynaud’s disease is characterized by which assessment finding?
A) Severe leg cramps and redness
B) Carpopedal spasms and intense heat
C) Intense vasospasms and pallor of the digits
D) Numbness and tingling of the wrist and elbow

Answer 15

C) Intense vasospasms and pallor of the digits

Intense vasospasms are noted in digits, tip of nose or ears. The disease may also affect motor function.

Question 16

1-16 Which of the following statements made by a patient recently diagnosed with peripheral vascular disease indicates that the patient has an accurate understanding of the disease?
A) “When my leg starts to cramp, I should stop walking and rest.”
B) “When pain develops in my leg, I should apply an ice pack.”
C) “When my leg starts to cramp, I should elevate it on two pillows.”
D) “I will limit my cigarette smoking to half-pack a day.”

Answer 16

A) “When my leg starts to cramp, I should stop walking and rest.”

Pain from PVD can develop while exercising, experiencing stress, and being in a cold environment.

Question 17

1-17 Which of the follow patients would demonstrate the presence of delayed venous return resulting from increased intra-abdominal pressure, creating a high risk for DVT and PE?
A) 57 year old hypertensive male
B) 48 year old diabetic female
C) 26 year old bariatric female
D) 32 year old with peripheral vascular disease

Answer 17

C) 26 year old bariatric female

Question 18

1-18 A patient has sustained a stab wound to the left parasternal anterior chest. Emergency medical services treatment has included intubation and intravenous therapy with crystalloid solution. The patient exhibited vital signs during transport; however, as the patient is being wheeled into the trauma room pulses are no longer detected. CPR is initiated. Breath sounds are present bilaterally. The nurse anticipates the follow procedure to be immediately performed.
A) POC ultrasound
B) Chest radiograph
C) Open thoracotomy
D) Needle pericardiocentesis

Answer 18

C) Open thoracotomy

Patients with low velocity penetrating chest trauma with loss of signs of life on or just before arrival to the ER have the best chance of survival with an open EDT (Emergency Department Thoracotomy). Other options listed may be helpful to do, but if done first would simply delay the EDT.

Question 19

1-19 Emergency medical servies arrives with an unrestrained driver who was involved in a multivehicle collision. The patient is diagnosed with a pelvic fracture and left tibial fracture. Which classification of hypovolemic shock would most likely occur as the result of these injuries?
A) Class IV
B) Class III
C) Class II
D) Class I

Answer 19

A) Class IV

Estimated blood loss from a pelvic fracture is 3000mL and from a tibial fracture is approximately 650mL.
Class IV = blood loss greater than 2000mL.
Class III = blood loss of 1500 to 2000mL
Class II = blood loss of 750 to 1500mL
Class I = blood loss of less than 750mL

Question 20

1-20 Following the insertion of an IO, which of the following findings by the emergency nurse would indicate that the IO has been properly placed?
A) The needle has slight movement after insertion
B) Bright red blood is noted in the cannula after insertion
C) The fluid will only infuse with the use of positive pressure
D) A reddish frothy aspirate is noted after insertion

Answer 20

D) A reddish frothy aspirate is noted after insertion

The reddish frothy aspirate is bone marrow being aspirated and indicates proper placement. In some emergent situations, the bone marrow may be used for some laboratory testing. The IO should not move. Bright red blood indicates that the IO is in a vein. Following an initial isotonic crystalloid solution bolus to clear the cannula and open any connective tissue, fluid or medications administered through the IO need should flow freely without the use of positive pressure. the fluid will only flow as accommodated by the diameter of the marrow cavity. The marrow cavity does not expand with the use of pressure to infuse medications or fluids.

Question 21

1-21 When caring for a child who has been treated for an asthma exacerbation, the emergency nurse identifies that the patient is ready for discharge when:
A) The patient is awake and alert
B) The patient can demonstrate proper use of a rescue inhaler without assistance
C) The patient’s peak expiratory flow is greater than 70% and response is sustained for 60 minutes following the last bronchodilator treatment.
D) The patient demonstrates SpO2 of 93% on room air (21%O2)

Answer 21

C) The patient’s peak expiratory flow is greater than 70% and response is sustained for 60 minutes following the last bronchodilator treatment.

Oxygenation is not the only indicator of respiratory improvement and HR may remain elevated for several hours after bronchodilator therapy. An improved peak expiratory flow of greater than 70% associated with no respiratory distress is a better indicator of the patient’s success at home.

Question 22

1-22 An adult patient with a history of asthma presents to triage stating they are experiencing an acute asthma exacerbation. The emergency care provider orders an ECG. The patient asks the nurse why this procedure is necessary. The explains to the patient:
A) “In adults, underlying cardiac conditions can often present as, or exist with, respiratory complaints.”
B) “It is part of our order set for patients with respiratory complaints.”
C) “ECGs can show us how well you are breathing.”
D) “I don’t know. I just do what the provider orders.”

Answer 22

A) “In adults, underlying cardiac conditions can often present as, or exist with, respiratory complaints.”

Cardiac conditions, such as STEMI and dysrhythmias can cause respiratory distress. Respiratory inefficacies can lead to myocardial irritation.

Question 23

1-23 A patient is being discharged after being treated for the presence of a cough for 3 months and increasing SOB with excretion. The patient has been diagnosed with COPD. The ER nurse knows that the only proven medical therapy shown to reduce the progression and mortality of COPD is:
A) Smoking cessation
B) Short-acting inhaled bronchodilator
C) Inhaled corticosteroids
D) Pulmonary rehabilitation

Answer 23

A) Smoking cessation

Other treatments only have the capability of possibly decreasing the number of exacerbations and/or improving quality of life. These treatments, however, do no slow down the progression of the disease.

Question 24

1-24 The emergency nurse would anticipate arterial blood gas values from a patient in a severe chronic obstructive pulmonary disease exacerbation to illustrate:
A) Metabolic acidosis
B) Respiratory alkalosis
C) Respiratory acidosis
D) Metabolic alkalosis

Answer 24

C) Respiratory acidosis

Question 25

1-25 The nurse ensures that the mechanically ventilated patient is placed in a semirecumbent position to:
A) Prevent the develop of a decubitus pressure ulcer
B) Make the patient more comfortable
C) Allow for oral care to be more easily preformed
D) Prevent aspiration

Answer 25

D) Prevent aspiration

Semirecumbent position increases the risk of the patient developing a decubitus pressure ulcer. Lying supine increases chances of gastric reflux of stomach contents.

Question 26

1-26 A patient arrives via emergency medical services following a house fire. The pt has a GCS of 15. The emergency nurse understands that the patient’s airway is patent because:
A) The pulse oximetry reads at 100%
B) The patient is able to state their name clearly.
C) The patient’s respiratory rate is 20.
D) The patient is not able to cough.

Answer 26

B) The patient is able to state their name clearly.

Pulse oximetry only detects saturated hemoglobin and does not differentiate between oxygen and carbon monoxide hemoglobin saturation, so the pulse oximetry reading will usually appear to be within normal limits. A carboxyhemoglobin level will be necessary to determine the presence of carbon monoxide in the patient’s blood. Signs of inhalation injury include hoarse voice, stridor, wheezing, cough, and presence of carbonaceous sputum. An absence of the patient’s ability to cough is usually indicative of airway obstruction.

Question 27

1-27 A patient with severe respiratory distress has been intubated, and mechanical ventilation has been initiated. The ventilator is alarming, indicating high airway pressures. As the emergency nurse, you are aware that this alarm indicates the importance to assess for the:
A) Signs of a pneumothorax
B) Need for additional sedation
C) Change in the patient’s oxygen saturation level
D) Presence of secretions

Answer 27

D) Presence of secretions

High pressure alarms can be caused by secretions, coughing, gagging, secretions, ventilator asynchrony, kinked tubing, pneumothorax, and tubing condensation. The priority to assess is the patient’s airway which may become blocked by secretions. If secretions are clear and alarm continues, then the nurse should assess for signs of pneumothorax (subcutaneous emphysema, absent/decreased breath sounds over affected side, asymmetrical chest movement, tracheal deviation). The patient may also need additional sedation if patient is fighting the ET tube causing the high-pressure alarm to go off.

Question 28

1-28 A patient presents to triage with a complaint of difficulty breathing, presence of a nonproductive cough, and “stabbing” chest pain. The patient reports a history of congestive heart failure. On assessment, the ER nurse auscultates diminished breath sounds, bilaterally. What additional information would be the most pertinent to obtain from the paint?
A) Recent sick contacts
B) Medications prescribed and compliance
C) Vaccination history
D) Recent travel history

Answer 28

B) Medications prescribed and compliance

Dyspnea, cough, and chest pain are symptoms caused by numerous respiratory conditions. However, lung sounds that are decreased may indicated fluid or air around the lungs. Congestive heart failure causes increased hydrostatic pressure in the pulmonary vasculature, which leads to excess fluid collecting in the pleural space, known as a pleural effusion. In this scenario, it is most pertinent to assess a patient’s compliance related to managing their congestive heart failure because unmanaged heart failure is the leading cause of pleural effusions.

Question 29

1- 29 Which assessment finding would best indicate that chest tube insertion has been successful in relieving a tension pneumothorax?
A) Presence of blood draining in the chest tube
B) Decrease in discomfort
C) Improvement in hemodynamics
D) Improved ability to deep breathe

Answer 29

C) Improvement in hemodynamics

The increasing intrathoracic pressure compresses the lungs, heart, and great vessels, resulting in markedly decreased cardiac output.

Question 30

1-30 A tube thoracostomy has been placed for a patient with a hemothorax. Initially after placement, what output amount would alert the nurse to anticipate that the patient would be taken to the operating room for an emergency thoracotomy?
A) 1000 mL
B) 750 mL
C) 500 mL
D) 200 mL

Answer 30

A) 1000 mL

If there is at least 1000mL of blood in the chest initially or blood drainage greater than 200mL per hour for 3-4 hours, then an emergency thoracotomy may be considered to identify and repair the bleeding source.

Question 31

1-31 A patient presents to the ER pale and diaphoretic with VS; BP 130/85, HR 135, RR 40, SpO2 48% room air, temp 37.2C (99.0F). Lungs sounds are diminished bilaterally throughout, with crackles at the bases. The patient is visiting from Florida and has been in town for 4 days; the current elevation is 9500 feet. What condition should the ER nurse be most concerned about?
A) Pulmonary embolism
B) Pneumonia
C) Pneumothorax
D) High-altitude pulmonary edema

Answer 31

D) High-altitude pulmonary edema

The assessment findings are concerning because of shifting of fluid into the lungs due to maladaptation to high altitude exposure (9500 feet elevation). Findings consistent with a pulmonary embolism include tachypnea, tachycardia, hypotension, and dyspnea. Pneumonia is not associated with exposure to high altitude, and there is no recent history of a respiratory illness or fever. A pneumothorax would result in the patient having absent or diminished breath sounds over the area of the pneumothorax.

Question 32

1-32 The patient arrives complaining of a sudden onset of chest pain. The patient is anxious and tachypneic. The initial priority intervention for the ER nurse to perform for this patient would be to:
A) Obtain ECG
B) Obtain IV access
C) Obtain arterial blood gas
D) Administer supplemental O2

Answer 32

D) Administer supplemental O2

Question 33

1-33 Which is the term used to describe a form of shock that occurs following a large pulmonary embolism that has resulted in unstable patient hemodynamics with decreased tissue perfusion.
A) Cardiogenic shock
B) Distributive shock
C) Hypovolemic shock
D) Obstructive shock

Answer 33

D) Obstructive shock

Question 34

1-34 An appropriate intervention in the treatment of acute respiratory distress syndrome (ARDS) is:
A) Mechanical ventilation
B) Treating the underlying cause
C) Decreasing fluid intake to avoid pulmonary edema
D) Using high tidal volumes to open collapsed alveoli

Answer 34

A) Mechanical ventilation

ARDS is a severe pulmonary disorder than can be sudden or progressive, resulting in infiltrates, dyspnea, and hypoxemia. Decreased compliance of the lungs along with alveolar collapse can lead to severe hypoxemia; therefore, the initiation of mechanical ventilation will aid in the patient receiving adequate oxygenation.

Question 35

1-35 Which diagnostic finding is consistent with the presence of an esophageal injury?
A) Widening of the mediastinum on chest radiography
B) Esophageal tissue in the nasogastric tube
C) Elevated central venous pressure (CVP)
D) Abnormal echocardiogram (ECG)

Answer 35

A) Widening of the mediastinum on chest radiography

Air from an esophageal injury leak into the thoracic area, allowing air into the mediastinum; this results in widening of the mediastinum. Widened mediastinum may also be seen with aortic disruption and a pneumothorax. CVP would be elevated with a tension pneumothorax or cardiac tamponade, not an esophageal injury.

Question 36

1-36 A patient presents to triage with complaints of runny nose, headache, and a nonproductive cough for 3 days. The patient is able to speak without difficulty and reports a history of moderate to severe COPD. Vital signs are BP 158/88, HR 106, RR 22, SpO2 88% room air, temp 37.1C (98.8). The priority intervention for the emergency nurse to implement is which of the following?
A) Apply low flow supplemental oxygen
B) Call a code because the patient is hypoxic
C) Obtain a chest radiograph
D) Obtain an arterial blood gas analysis

Answer 36

A) Apply low flow supplemental oxygen

Question 37

1-37 When caring for an elderly patient with dementia, the emergency nurse is aware that a patient with dementia will directly exhibit which of the following first?
A) Inaccurate medical history
B) Disruptive behavior
C) Impaired communication
D) Sensory overload

Answer 37

C) Impaired communication

The patient with dementia will require additional time to communicate

Question 38

1-38 In caring for a patient with MS, the ER nurse is aware that common healthcare issue that affects the quality of life in this patient population is:
A) Hypertension
B) Diabetes
C) Depression
D) Elevated cholesterol

Answer 38

C) Depression

Comorbid conditions such as hypertension, diabetes, and elevated cholesterol have the same rate in patients with MS as in the general population.

Question 39

1-39 A patient presents to the ER with a 2-week history of repeatedly falling, accompanied by ascending weakness and tingling in the feet and fingers. There is loss of the knee-jerk reflex and the patient is complaining of being unable to take a deep breath and of overall difficulty in breathing. Vital signs are BP 120/70, HR 72, RR 22, SpO2 96% on room air. The ER nurse suspects the patient may have which of the following?
A) Myasthenia gravis
B) Guillain-Barre’ syndrome (GBS)
C) Bell’s palsy
D) Botulism

Answer 39

B) Guillain-Barre’ syndrome (GBS)

GBS, also called acute inflammatory demyelinating polyneuropathy (AIDP) is characterized by the rapid onset of numbness, weakness, and often paralysis of the legs, arms, breathing muscles, and face. Paralysis is ascending, meaning that it travels upward from the toes, upward along the lower extremities, and from fingers along the upper extremities toward the torso. Absence or loss of tendon reflexes is also evident as GBS progresses.

Myasthenia gravis is a defect in neuromuscular junction transmission of acetylcholine. Symptoms include, most notably ocular, facial and neck weakness, as well as weakness of the upper extremities. The patient may demonstrate an abnormal smile, dysphagia, and the inability to manage their oral secretions, as well as difficulty speaking.

Bell’s palsy is a unilateral facial paralysis involving cranial nerve VII (facial nerve) that may result from the presence of herpes simplex virus within the facial nerve.

Botulism is caused by the Clostridium botulinum toxin. Botulism can be spread from home-canned or preserved food that has been improperly prepared. Symptoms include diplopia, blurred vision, drooping eyelids, muscle weakness, and dry mouth. Foodborne botulism usually begins 18-36 hours after consuming the contaminated food item.

Question 40

1-40 A patient with a history of chronic headaches presents to the ER with a severe headache that has grown in intensity over the last 2 weeks. A computed tomography angiography of the brain reveals no acute pathology. The patient typically uses nonsteroidal anti-inflammatories for pain relief and notes that over the last 2 weeks, they have had to increase the frequency of NSAID use to 4-5 days per week. The ED provider decides to place the patient on propanolol (Inderal) for prophylactic pharmacologic therapy. Which of the following statements by the patient would indicate a need for further education?
A) “I will take my propanolol (Inderal) as need with the onset of headache.”
B) “I will not discontinue this medication without first notifying my HCP.”
C) “The reason for this medication is to reduce my headache frequency and severity.”
D) “This medication may improve the effectiveness of my other headache medication.”

Answer 40

A) “I will take my propanolol (Inderal) as need with the onset of headache.”

The use of a beta-blocker is started if the patient is using a headache relief product such as acetaminophen, aspirin, and nonsteroidal anti-inflammatories more than 3 days per week or having two or more disabling migraine headache symptoms per month. Prophylactic medications must be taken daily, with or without the presence of a headache in order to be effective. Any beta-blocker requiers a 10-14 day taper down period to prevent rebound hypertension and tachycardia.

Question 41

1-41 The emergency nurse is reviewing the medication orders for a patient newly diagnosed with a subarachnoid hemorrhage. Which of the following orders would cause the ER nurse to question the provider?
A) Nimodipine 60mg q4hours
B) Infuse 0.9% NaCl at 150mL/hr
C) Dexamethasone 16mg daily
D) Atorvastatin 40mg daily

Answer 41

C) Dexamethasone 16mg daily

High dose corticosteroids are not recommended for patients with an acute SAH. Nimodipine is used to treat vasospasms that occur in patients with an acute subarachnoid hemorrhage. Isotonic IV fluids are used to hemodilute and increase blood volume, thereby resulting in an increase in cerebral blood flow. Some studies have shown that the administration of a statin will help to increase cerebral blood flow and reduce vasospasm in patients with subarachnoid hemorrhage.

Question 42

1-42 A patient with a 2 year history of uncontrolled hypertension presents to the ER with a complaint of severe headache. A CT scan of the head reveals the presence of a large subarachnoid hemorrhage. Which of the following is a late sing of increased intracranial pressure?
A) Tachypnea
B) Narrowing pulse pressure
C) Bradycardia
D) Behavioral changed.

Answer 42

C) Bradycardia

Late signs of intracranial pressure include the presence of Cushing’s triad: bradycardia, widening pulse pressure, and apnea. In addition, late signs of intracranial pressure may also include unresponsiveness, dilated nonreactive pupils, and posturing. Early signs of intracranial pressure include headaches, n/v, changes in mental status, and behavioral changes.

Question 43

1-43 A 3 week old infant presents to the ER with a temp of 38.3C (100.9). The infant has a normal physical exam, normal chest radiograph, and a white blood cell count of 15,000 and appears sleepy. The emergency provider decides to perform a lumbar puncture. What disease process can be confirmed by this procedure?
A) Hyponatremia
B) Meningitis
C) Otitis Media
D) Subarachnoid hemorrhage

Answer 43

B) Meningitis

Group B streptococcus pneumoniae is the most common cause of meningitis in newborns. The mortality can be as high as 56%. Hyponatremia is a cause of seizures in the neonate and is related to supplementation of breast milk with either water or formula that has been diluted with too much water. Subarachnoid hemorrhage can be diagnosed with a lumbar puncture, however it is commonly diagnosed with a CT scan. The use of a lumbar puncture in suspected subarachnoid hemorrhage can lead to herniation of the brain stem in the presence of increased intracranial pressure and patient death.

Question 44

1-44 The emergency nurse is caring for a patient with the following symptoms: severe headache, neck stiffness, fever, and inability to tolerate bright lights. The patient has been administered intravenous antibiotics and an antipyretic for fever. The nurse identifies that additional patient education is required for their diagnosis of bacterial meningitis when the patient states:
A) My girlfriend will need to be evaluated for this disease.”
B) “I will have to cancel my dinner plans with friends for this evening.”
C) “I need to take medication to reduce my fever.”
D) “I will take my antibiotics until my symptoms go away.”

Answer 44

D) “I will take my antibiotics until my symptoms go away.”

Chemoprophylaxis is required for anyone who is exposed directly to oral secretions of the infected individual. Pts with meningeal disease are contagious and should limit their interactions with other until their symptoms are gone.

Question 45

1-45 An elderly patient presents to the ER after demonstrating aggressive behavior in the group home residence. The ER nurse observes the patient to be pale and diaphoretic and displaying tonic-clonic movement. Which laboratory test has the greatest priority for this patient?
A) Dilantin (phenytoin) level
B) Blood glucose level
C) Blood alcohol level
D) Vitamin B6 (thiamine)

Answer 45

B) Blood glucose level

Low BGL can cause mental status changes and seizures in patients with no seizure history.

Question 46

1-46 A patient presents to the ER complaining of two tonic-clonic seizure episodes within the previous 3 days despite being compliant with daily doses of levetiracetam (Keppra). Which of the following statement made by the patient indicates that additional education is required for this medication?
A) “I use the rowing machine at the gym every day.”
B) “I use medication to help with sleep.”
C) “I keep hydrated to protect my kidneys.”
D) “I limit alcohol to two drinks per night.”

Answer 46

D) “I limit alcohol to two drinks per night.”

Drinking alcohol, even in small amounts, may trigger seizures. Keppra suppressed CNS and alcohol in combination with that may sedate the patient too much.

Question 47

1-47 A patient presents to the emergency department following a bar fight. The patient reports being punched in the face and having their neck forced backward. A few hours later, the patient began noticing upper extremity weakness with associated sensory loss. They also report being unable to urinate, and the bladder scan reveals 300mL of urine in their bladder. The most likely cause of this patient’s symptoms is:
A) Brown-Sequard syndrome
B) Anterior cord syndrome
C) Central cord syndrome
D) Posterior cord syndrome

Answer 47

C) Central cord syndrome

Brown-Sequard syndrome is consistent with hemiparaplegia on the same side as the cord injury and hemianesthesia on the opposite side of the cord injury, below the level of injury.

Anterior is consistent with motor paralysis and a loss of pain and temperature sensation below the level of the injury, with a preservation of proprioception, touch, and vibratory sense.

Central results from a hyperextension injury of the cervical spinal cord. Common symptoms include upper and lower extremity weakness, with deficits more pronounced in the upper extremities. In addition, the patient may experience varying degrees of sensory loss, impaired pain, temperature, light touch, an position sense below the level of the injury. These symptoms may also lead to a neurogenic bladder. Symptoms are usually self-limiting.

Posterior is consistent with preserved motor function below the level of the injury, with a loss of sensory function.

Question 48

1-48 A pt presents to ER via EMS. The patient has cervical spine precautions in place because of suspected spinal cord injury. Per EMS report, the patient initially was able to move their wrists bilaterally. On initial assessment, the ER nurse determines that the patient is only able to shrug their shoulders. the priority intervention is:
A) Notify the trauma team
B) Document these new findings
C) Determine the patient’s pain level
D) Reassess patient function in 15 minutes

Answer 48

A) Notify the trauma team

Movement of the wrists is a function of C7 innervation. Movement of the shoulders would indicate a worsening condition because this motion would be the result of innervation at the level of C6 and the loss of C7 function. This patient will require immediate diagnostic studies and treatment as deemed necessary by the trauma team.

Question 49

1-49 A patient who weighs 100 kg is ordered to receive tissue plasminogen activator for an acute ischemic stroke. The ER doctor orders a dose of 100mg , with 10% of the dose to be administered via IV push with the remaining dose to be administered over an hour infusion. The emergency nurse verifies the weight dosing and identifies that 0.9mg/kg is the recommended dosing for this medication in the present of an acute ischemic stroke. The next action by the ER nurse is to:
A) Administer 10mg over 1 minute, followed by the administration of 90mg over 59 minutes via infusion pump.
B) Verify with the ER doctor the medication order for the patient.
C) Administer 9mg over 1 minute, followed by the administration of 91mg over 59 minutes via infusion pump.
D) Administer 10mg over 1 minute, followed by the administration of 90mg over 60 minutes via the infusion pump.

Answer 49

B) Verify with the ER doctor the medication order for the patient.

The maximum IV dose of tPA for ischemic stroke is 90mg. The bolus is 10% of the recommended dose administered over 1 minute, and remainder of the dose is given over 60 minutes via infusion pump.

Question 50

1-50 The provider is considering the administration of alteplase (Activase/tPA) to an 82-year-old patient diagnosed with an acute ischemic stroke. In addition to the patient’s age, which other factor would exclude the patient from the administration of alteplase within the recommended extended 3-to-4.5-hour time window?
A) A NIHSS greater than 20
B) NIHSS scale of 3
C) Previous history of a ST-elevation myocardial infarction
D) History of diabetes

Answer 50

D) History of diabetes

Question 51

1-51 Which of the following patients would benefit from the administration of nimodipine (Nimotop) to decrease the risk of associated cerebral infarction?
A) A subarachnoid hemorrhage resulting from traumatic brain injury
B) A subdural hematoma in an elderly patient
C) A subarachnoid hemorrhage resulting from a cerebral aneurysm
D) A subdural hematoma in a patient who abuses alcohol

Answer 51

C) A subarachnoid hemorrhage resulting from a cerebral aneurysm

Nimodipine is a calcium channel blocker proved to improve outcomes of patients with nontraumatic subarachnoid hemorrhage by decreasing cerebral vasospasm and decreasing the incidence of cerebral infarction. This drug is not indicated, and shows no benefit, in traumatic subarachnoid hemorrhage or subdural hematoma, regardless of the cause.

Question 52

1-52 Which type of skull fracture would place the patient at the highest risk for developing an intracranial infection?
A) Basilar skill fracture
B) Linear skull fracture
C) Depressed skull fracture
D) Temporal bone fracture

Answer 52

A) Basilar skull fracture

Basilar skull fractures include a fracture of any of the five bones at the base of the skull. These fractures can cause a laceration of the dura mater, resulting in an open passage of cerebrospinal fluid, which places the patient at risk for intracranial infections such as meningitis, encephalitis, and or brain abscess. A linear skull fracture is a nondisplaced fracture of the cranium and does not increase the risk of intracranial infections. A depressed skull is a fracture extending below the surface of the skull and lacerating the dura mater, which may cause intracranial infections; however, the incidence of infection is statistically higher is basilar skull fractures. Temporal bone fractures increase the risk of epidural hematoma.

Question 53

1-53 A 32 year old female who is 28 weeks pregnant presents with right upper quadrant pain that is radiating to the right scapula area. The patient states that the pain began a short time after having dinner. Based on the patient’s presentation, the most likely diagnosis is:
A) Diverticulitis
B) Cholecystitis
C) Pancreatitis
D) Gastroenteritis

Answer 53

B) Cholecystitis

Cholecystitis - sudden onset of abdominal pain after eating fatty or fried foods. Pain is located in epigastrium and/or upper right quadrant and may be referred to the right shoulder or supraclavicular area.

Diverticulitis - LLQ abdominal pain

Pancreatitis - Left upper abdomen or epigastrium and may radiate through the back

Gastroenteritis - may be generalized, abdominal cramps, possible n/v/d

Question 54

1-54 A patient with a history of esophageal varices presents to the ER complaining of weakness and diaphoresis. The patient suddenly has an emesis of bright red blood. The priority intervention for the ER nurse is:
A) Insert a large-diameter gastric tube
B) Obtain a complete set of vitals
C) Administer high flow oxygen via nonrebreather mask
D) Establish IV access with two large-caliber IV catheters

Answer 54

D) Establish IV access with two large-caliber IV catheters

Question 55

1-55 A child presents to the ER after choking on a chicken bone. The patient’s airway is not obstructed, but swallowing is difficult, and the patient is consistently drooling. The nurse anticipates which diagnostic test to be performed initially?
A) Chest radiograph
B) Bedside ultrasound
C) End-tidal carbon dioxide measurement
D) Direct laryngoscopy

Answer 55

A) Chest radiograph

Question 56

1-56 - A normal full-term newborn has been delivered in the ER. The newborn has been warmed, their temp is being maintained, their airway is being positioned, secretions have been cleared, and they have been stimulated. To evaluate the effectiveness of these interventions, the nurse anticipates the infant’s preductal oxygen saturation target after 1 minute to be approximately:
A) 63%
B) 67%
C) 73%
D) 90%

Answer 56

A) 63%

After baby’s initial cries and deep breaths, fluid moves out of the airways, causing the ductus arteriosus to constrict, and blood now flows from the right side of the heart into the lungs. It typically takes approximately 10 minutes for a normal full-term newborn to achieve oxygen saturation greater than 90%.

1 minute after birth - 60-65%
2 minutes after birth - 65-70%
3 minutes after birth - 70-75%
10 minutes after birth - 85-95%

Question 57

1-57 A 3-year-old child who weighs 20kg is being treated for a 2-day history of vomiting and diarrhea. The child has been orally rehydrated and is now being discharged home with the parents. Which of the following would be most important to include in the initial home care discharge instructions?
A) Administer 1-2 teaspoons of an oral rehydration solution (Pedialyte) every 5 minutes
B) Resume normal meals in small amounts
C) Start a BRAT diet (bananas, rice, applesauce, toast)
D) Do not permit the child to have anything orally for the next 24 hours. If no vomiting occurs, the child may advance to having small amounts of clear liquids.

Answer 57

A) Administer 1-2 teaspoons of an oral rehydration solution (Pedialyte) every 5 minutes

Rehydration is the priority, introducing food too quickly or taking too long to introduce more fluids could be detrimental to the child.

Question 58

1-58 A patient presents to the ER with complaints of upper abdominal fullness, fatigue, and nausea for the past 2 weeks. When obtaining the patient’s history, the triage nurse would be most concerned that the patient may have developed hepatitis A if the patient reports:
A) having engaged in unprotected sexual contact with an individual who may have hep B
B) Have a history of IV drug use and having recently shared needles with other IV drug users
C) Having been camping recently and having sustained a tick bite
D) Having recently traveled overseas to assist in the clean-up activities in a town flooded by heavy rains

Answer 58

D) Having recently traveled overseas to assist in the clean-up activities in a town flooded by heavy rains

Hepatitis A is transmitted by the oral-fecal route and is prevalent in areas of poor sanitation.

Question 59

1-59 A male presents to the ER with complaints of pain and swelling in his right groin area. The patient states the pain intensity has increased, and the swelling has become larger over the past several days. The emergency nurse should anticipate which diagnostic test to best identify the source of the patient’s complaint?
A) Abdominal radiographs
B) CT scan
C) MRI of abdomen
D) Abdominal ultrasound

Answer 59

D) Abdominal ultrasound

The patient’s symptoms are most likely a result of an inguinal hernia. The patient’s physical examination usually is diagnostic, but an ultrasound can be performed to determine if strangulation or an intestinal obstruction is present. An abdominal radiograph would be helpful in diagnosing a bowel obstruction but would not provide enough information to validate a diagnosis of inguinal hernia. A CT scan would be helpful to identify the source the patient’s pain in the absence of any physical signs, bu this patient has a visible bulge, and a CT scan would provide little additional information. An MRI might show the hernia, but ultrasound is the preferred test.

Question 60

1-60 Parents of a 7-month-old states that the infant has not been as active as usual and has been crying and drawing up their legs at intervals. The child’s abdomen is distended, and a mass is palpable in the right upper quadrant. The parents state that earlier today, the child had a small bowel movement that look dark red with mucus in it. the child’s symptoms are most consistent with which of the following conditions:
A) Intussusception
B) Pyloric stenosis
C) Appendicitis
D) Incarcerated hernia

Answer 60

A) Intussusception

Intussusception is the telescoping or prolapse of a segment of bowel into an adjacent segment, causing the classic symptoms of abdominal pain, a palpable abdominal mass, and “currant-jelly stools” with blood mucus. It is more commonly seen in children between the ages of 3 months and 5 years. Sudden, acute cramping pain and the child drawing up their legs are the most commonly reported signs. the child may be pain free between episodes.

Pyloric stenosis causes muscular thickening of the pylorus, leading to a functional gastric outlet syndrome. This disorder is the most common cause of intestinal obstruction in infancy. The infant typically presents with a previously normal feeding history and suddenly develops projectile emesis after eating. Occasionally, an olive shaped mass can be palpated in the right upper quadrant.

Appendicitis does not match the patient’s symptoms. Appendicitis occurs in all age groups but is rare in infants.

An incarcerated hernia typically presents as an asymptomatic bulge of a bowel loop that becomes more prominent with crying, laughing, or coughing. If circulation to the bowel loop is compromised, symptoms would include pain and swelling at the site of the herniation, nausea, and vomiting, and signs of a bowel obstruction. IN children, these hernias are most commonly found in the inguinal area where firm, tender masses can be palpated in the inguinal canal or scrotal area.

Question 61

1-61 Correct placement of NG is best confirmed by which method?
A) pH determination of NG tube aspirate
B) Obtaining a chest radiograph
C) Placing the end of the NG tube in a container of water
D) Auscultating for air over the epigastric region

Answer 61

B) Obtaining a chest radiograph

Question 62

1-62 A patient has an elevated serum lipase level and left upper quadrant abdominal pain that radiates to their back. The ER nurse recognizes these signs and symptoms as most likely being associated with which disease process?
A) Hep C
B) Cholecystitis
C)Pyelonephritis
D) Pancreatitis

Answer 62

D) Pancreatitis

An elevated serum lipase is specific to pancreatic disease or injury.

Hepatitis is usually felt in RUQ and lipase is not elevated.

Cholecystitis is RUQ and may radiate to the back. Serum bilirubin and liver enzyme (ALT and AST) may be elevated, but not serum lipase.

Pyelonephritis pain is in flank or back at the costovertebral angle and may radiate to the groin. Serum lipase is not elevated.

Question 63

1-63 Following a motor vehicle collision, a patient arrives in the ER with a suspected blunt abdominal injury. Vitals are bp 100/72, HR 106bpm, RR 18bpm, temp 36.2C (97.2F). The ER nurse should anticipate which of the following to be performed as part of the patient’s initial assessment?
A) CT scan
B) H&H
C) Focused assessment with sonography for trauma exam
D) Diagnostic peritoneal lavage

Answer 63

C) Focused assessment with sonography for trauma exam

American College of Surgeons recommend FAST exam for quick evaluation of peritoneum in patients with blunt abdominal trauma.

CT scan should only be indicated for the hemodynamically stable patient. Although it is useful in determining the management of nonoperative solid organ injuries, a CT scan is not useful in identifying injuries to the diaphragm or GI tract.

H&H will not reflect recent hemorrhage and should only be used as a baseline to compare future levels, especially if the patient needs surgery.

Diagnostic peritoneal lavage is an invasive procedure reserved for the hemodynamically unstable patient. Vital signs of this patient do not suggest hemodynamic instability so FAST exam is appropriate.

Question 64

1-64 A patient presents to the ER with frequency and urgency of urination, associated with the presence of right flank pain. ON physical examination, the pt exhibits and temp of 38.8C (102F) and tenderness over the right costovertebral angle. Which of the following conditions is most consistent with the patient’s signs and symptoms?
A) Bladder infections
B) Nephrolithiasis
C) Pyelonephritis
D) Urethral stricture

Answer 64

C) Pyelonephritis

Symptoms of pyelonephritis is usually include pain on ruination, frequency, and urgency of urination, and flank or back pain on the affected side. Fever is one of the cardinal signs of pyelonephritis and can include the presence of chills. The costovertebral angel is located at the angel made by the vertebral column and the costal margin. When the affected side is percussed over the costovertebral angle, the pt with pyelonephritis will report pain.

Bladder infection does cause painful urination, urinary frequency, and urgency; however, it is not usually associated with fever and tenderness over the costovertebral angle.

Nephrolithiasis can cause painful urination, urinary frequency, urgency as well. The cardinal sign for nephrolithiasis is usually pain in the flank, abdomen, or groin area, depending on where the stone is located. This condition is also not usually associated with fever.

Characteristic symptoms of urethral stricture are painful urination, urinary frequency, urgency, sensation of full bladder and inability to urinate.

Question 65

1-65 The presence of a suspected testicular torsion is best evaluated using which diagnostic study?
A) CT scan
B) Doppler sonography
C) Urine culture and sensitivity
D) Testicular transillumination

Answer 65

B) Doppler sonography

Testicular transillumination is a useful diagnostic tool when a testicular mass is suspected, not for torsion. CT cannot determine blood flow so would not be helpful in this situation.

Question 66

1-66 Follow a motor vehicle collision, an unresponsive and intubated patient is received in the ER. On assessment, a rigid and bruised abdomen is noted, and a bedside ultrasound examination identifies a ruptured bladder. Based on this information, what is the emergency nurse’s priority action?
A) Establish two large-caliber IV’s and begin fluid resuscitation
B) Insert a urinary drainage catheter
C) Prepare pt for a CT scan
D) Administer IV antibiotics

Answer 66

A) Establish two large-caliber IV’s and begin fluid resuscitation

The bladder has an extensive blood supply that is derived from the iliac artery, and injuries resulting from a motor vehicle collision are often associated with a pelvic fracture. For this reason, patients with a ruptured bladder are at risk for ineffective tissue perfusion and deficient fluid volume, so intravenous fluid resuscitation is the priority intervention to avoid the patient becoming hypovolemic.

Question 67

1-67 A patient presents to the ER c/o lower abdominal pain and the inability to void in the past 24 hours. What is the priority intervention the ER nurse should preform?
A) Obtaining a full set of vitals
B) Preparing the pt for abdominal radiograph to assess for bladder calculi
C) Insertion of a urinary catheter
D) Administering an IV fluid bolus of 500mL of NS

Answer 67

C) Insertion of a urinary catheter

Question 68

1-68 A patient who is 32 weeks pregnant is involved in a motor vehicle collision. ON arrival to the ER, the patient is c/o severe abdominal pain. Blood is noted on the sheets around the patient’s lower extremities, and on assessment, the nurse determines the patient is bleeding vaginally. High flow oxygen is administered via face mask. the ER’s next action is to perform which of the following?
A) Establish two large-caliber IV’s and begin fluid resuscitation
B) Perform a type and cross-match for a blood transfusion
C) Initiate continuous fetal monitoring
D) Prepare the patient for a C-section

Answer 68

A) Establish two large-caliber IV’s and begin fluid resuscitation

Patient is most likely experiencing a placental abruption and needs immediate isotonic fluids to prevent hypovolemia

Question 69

1-69 A patient who is diagnosed with a Chlamydia trachomatis vaginal infection should also be screened for what other associated sexually transmitted disease?
A) Human papillomavirus
B) Bacterial vaginosis
C) Candidiasis
D) Gonorrhea

Answer 69

D) Gonorrhea

Gonorrhea and Chlamydia often occur together. Human papillomavirus (HPV) is the most common sexually transmitted disease in the US and it is associated with cervical dysplasia, but not with other sexually transmitted diseases. Bacterial vaginosis is not a sexually transmitted disease, rather, it is caused by a disturbance in the normal vaginal flora. Most cases of Candida infection are caused by the person’s own Candida yeast organisms in the vagina, mouth, and GI tract when these organisms over-multiply with imbalances of pH or hormones.

Question 70

1-70 - The ER nurse is caring for a victim of sexual assault. Which of the following statements made by the victim indicates the need for further education regarding the sexual assault examination process?
A) “Once the exam is finished, I’d like to take a shower.”
B) “I am so anxious, I don’t know how I will get through all of this.”
C) “I really don’t want the police in the room with me during the exam.”
D) “I will need to be seen in a week to have more cultures taken.”

Answer 70

C) “I really don’t want the police in the room with me during the exam.”

Sexually transmitted organisms such as chlamydia and gonorrhea that are transmitted during a sexual assault may not be present in sufficient quantity to yield a positive culture result a the time of initial examination. If the patient is receiving prophylactic treatment, cultures should be obtained if the patient reports having symptoms.

Question 71

1-71 A patient who is 6 days postpartum and breastfeeding present to the emergency department complaining of fever, with right sided breast redness and tenderness. The patient is diagnosed with mastitis. In addition to the antibiotic therapy, which of the following should be included in the discharge instructions for this patient?
A) Avoid hand-expressing or using a mechanical breast pump
B) Have the baby nurse from the unaffected breast only
C) Stop breastfeeding and supplement feedings with formula until the infection clears
D) Apply a warm compress to the breast before breastfeeding.

Answer 71

D) Apply a warm compress to the breast before breastfeeding.

Continuing to empty the infected breast is an important part of recovery. Warm compresses can help alleviate the symptoms and facilitate milk flow.

Question 72

1-72 A patient presents to the ER with symptoms of left lower quadrant abdominal cramping with frequent episodes of blood and mucus-containing diarrhea. The symptoms have been present for the past 3 weeks and the patient has noticed a recent weight loss. The ER nurse anticipates the patient will most likely need further evaluation for which disorder?
A) Ulcerative colitis
B) Colon cancer
C) Salmonella infection
D) Chron’s disease

Answer 72

A) Ulcerative colitis

UC is an inflammatory condition of the large intestine. The hallmark symptoms are left lower quadrant abdominal pain with bloody diarrhea, but also causes weight loss, fever, and tachycardia. Patients can pass between 10 and 20 liquid stools per day.

A change in bowel habits and weight loss may be caused by colon cancer, however, diarrhea is less common in colo-rectal cancer than it is in UC and the diarrhea in colo-rectal cancer does not contain mucus.

Infection diarrhea, such as that caused by salmonella exposure, is characterized by cramping, colicky abdominal pain, and bloody diarrhea. Symptoms resolve within 2 hours.

Chron’s disease can be characterized by cramping abdominal pain which is more likely to be in the RLQ. Bloody, mucus-containing stools are not typical for a patient with Chron’s disease.

Question 73

1-73 A woman who is 10 weeks pregnant presents to the ER complaining of vaginal spotting which mild abdominal cramping and is discharged to home after a diagnosis of threatened abortion is made Which of the following statements made by the patient, indicates a correct understanding of their discharge instructions?
A) “I will keep a count of the number of tampons I use to determine how much I am bleeding.”
B) “I will need to stay on bedrest for at least a day or two.”
C) “I can expect the bleeding to get heavier in a day or two.”
D) “While I am on bed rest, my partner and I can have sexual intercourse as long as it isn’t too rough.”

Answer 73

B) “I will need to stay on bedrest for at least a day or two.”

A patient who is experiencing a threatened abortion will be instructed to maintain bed rest for 24-48 hours or until the bleeding stops.

Tampon use is discouraged in the presence of a threatened abortion.

Question 74

1-74 When suspecting the presence of child maltreatment or neglect in a patient, the ER nurse is required to:
A) document the names of the suspected abusers int eh medical record
B) Inform the parent of the police notification
C) Report the suspected abuse or neglect to the police and child protective services.
D) Review the pediatrician or family physician records.

Answer 74

C) Report the suspected abuse or neglect to the police and child protective services.

Question 75

1-75 A patient is brought to the ER after exhibiting aggressive behavior toward family members. To assess the patient’s current mental state, which question would be most important for the emergency nurse to ask the patient?
A) “What are the voices telling you to do?”
B) “What medications are you currently taking?”
C) “What past medical history do you have?”
D) “What brought this behavior on today?”

Answer 75

A) “What are the voices telling you to do?”

Safety is the first priority for patient exhibiting aggressive or violent behavior. Asking the patient about what their voices are telling them to do can assist in determining the risk for homicidal or suicidal behavior.

Question 76

1-76 A 65-year-old female reports a history of generalized anxiety disorder that is controlled with 0.5mg of alprazolam (Xanax) three times a day as needed. Which of the following patient statements requires additional follow-up and patient education by the emergency nurse?
A) “I do not take the Xanax every day.”
B) “I only take the Xanax before participating in stressful events, such as being in large crowds, in order to prevent anxiety.”
C) “I drink several glasses of wine in one setting on a regular basis.”
D) “I eat a lot of dairy products frequently and sometimes take the Xanax with milk.”

Answer 76

C) “I drink several glasses of wine in one setting on a regular basis.”

Alcohol may intensify the effects of benzodiazepines and is not recommended.

Question 77

1-77 Patient arrives to triage with their child, stating that the child has demonstrated recent behavior changes that include extreme anger with family members, no desire to complete required tasks (attend school or do chores), racing thoughts with rapid speech, and impulsive actions. The ER nurse will be most concerned about which type of psychiatric disorder being demonstrated by the patient?
A) Psychosis
B) Attention-deficit hyperactivity disorder
C) Bipolar disorder
D) Panic disorder

Answer 77

C) Bipolar disorder

Question 78

1-78 Which diagnostic test should the ER nurse anticipate to be performed in a patient with bipolar disorder who has been receiving antipsychotic medications for treatment of acute mania?
A) CBC
B) Liver function tests
C) Bladder scan
D) 12 lead-electrocardiogram

Answer 78

D) 12 lead-electrocardiogram

Most antipsychotic medications can result in prolongation of the QT interval, which can lead to a life-threatening dysrhythmia. Performing an EKG an initiating continuous ECG monitoring in a bipolar patient who is exhibiting acute mania is warranted. While antipsychotic medications may cause urinary retention, this is not the most important diagnostic test to perform. Antipsychotic meds are not commonly associated with hepatic injury. Though clozapine (Clozaril), an atypical antipsychotic, has the risk of causing neutropenia, this is not associated with all antipsychotics and a CBC is not the most important diagnostic test.

Question 79

1-79 On review of a patient’s current medications, the ER nurse identifies that the patient has been prescribed an alternative drug fo rdepression. Which of the following is an alternative medicated used in teh treatment of depression?
A) Bupropion (Wellbutrin)
B) Citalopram (Celexa)
C) Fluoxetine (Prozac)
D) Sertraline (Zoloft)

Answer 79

A) Bupropion (Wellbutrin)

Bupropion can treat depression, anxiety, ADHD, seasonal affective disorder, depressive phase of bipolar, and help mitigate symptoms of nicotine withdrawal symptoms. Citalopram, Fluoxetine, and Sertraline are all considered typical antidepressants.

Question 80

1-80 Which of the following interventions would be appropriate for an emergency nurse to perform following the transfer of a patient? The patient has experienced an acute psychotic episode and states, “I’m coming back here when I get released from the hospital, and I am going to kill Jane Smith.”
A) Ignore the threat because this is normal behavior in patients who are psychotic.
B) Alert proper law enforcement authorities
C) Tell the patient that it is inappropriate to make this statement.
D) Request that the hospital chaplain come and talk to the patient.

Answer 80

B) Alert proper law enforcement authorities

It is important that proper authorities be notified when patients make statements that are very specific in nature and when they name a particular person. that person should be aware of the threat and should be provided the proper protection.

Question 81

1-81 A homeless patient arrives in the ER by EMS after being found wandering on the street and talking to himself. The patient is in possession of proper identification but will not answer to their name. Speech is clear and the patient displays no signs of aggressive behavior but will not make eye contact with the ER nurse or follow simple commands. Which of the following signs and symptoms would alert the ER nurse to an organic cause for their psychosis?
A) Signs of trauma
B) Normal vital signs
C) Auditory hallucinations
D) Clear speech patterns.

Answer 81

A) Signs of trauma

Signs of an organic cause to patient’s behavior include physical trauma such as fractures or contusions, hypoxia, hypotension, hypoglycemia, or impaired speech.

Question 82

1-82 A patient presents to triage with a complaint of headache and appears anxious and restless. The patient tells the ER nurse that the “man at the desk” has followed the patient from Russia, where the patient worked for the CIA and that the headache began after the tracking chip implanted in their brain was activated. The nurse observes no one at the desk, and the patient has identification that indicates a local address and that they are a student at nearby college. There is no indication of recent travel or corroboration of the information. The ER nurse suspects that cause of the patient’s symptoms is related to:
A) an anxiety attacks
B) migraine headache
C) dementia
D) psychosis

Answer 82

D) psychosis

Question 83

1-83 Ziprasidone (Geodon) is most appropriate for which of the following psychiatric scenarios? The adult patient:
A) who is exhibiting acute depressive disorder and is tearful and sobbing
B) who is exhibiting acute manic behavior, is in handcuffs, and is being accompanied by police
C) who is having auditory hallucinations and is being told by these voices not to move
D) who is experiencing extrapyramidal effects related to their psychiatric medications

Answer 83

B) who is exhibiting acute manic behavior, is in handcuffs, and is being accompanied by police

Ziprasidone is classified as an antimanic drug that has a rapid onset of action. Patients with hallucinations, without signs of mania would not benefit from this medication.

Question 84

1-84 A patient presents to the ER voicing thoughts of suicidal ideation. Why is it important to identify and address medical issues before treating the mental health issue?
A) Medical problems can mimic mental health problems
B) Mental health problems do not lead to serious illness
C) Medical problems can be resolved more quickly than behavioral problems
D) Once in the ED, the patient is safe from suicide

Answer 84

A) Medical problems can mimic mental health problems

Question 85

1-85 A patient presents to the ER with sudden onset of lip swelling, facial edema, and throat tightness. Vital signs are BP 90/60mmHg, HR 127bpm, RR 22bpm, T 38.6C (97.8F). The emergency nurse anticipates which of the following to be administered to this patient for their signs and symptoms?
A) Epinephrine
B) High-flow oxygen
C) Corticosteroids
D) Aerosol albuterol

Answer 85

A) Epinephrine

While oxygen, corticosteroids, and albuterol may all be required in care for this patient, epinephrine is the priority for someone in anaphylaxis.

Question 86

1-86 A patient presents to the ER stating they were hunting the previous day in a heavily wooded area. This morning the patient noticed a red, itchy rash with many blisters covering their face, neck, back, and arms. The ER provider diagnosis the patient with poison ivy. What medication should the ER nurse anticipated with be prescribed for this patient?
A) A narcotic analgesic
B) An oral antibiotic
C) A topical antifungal agent
D) An oral corticosteroid

Answer 86

D) An oral corticosteroid

The patient’s rash is widespread so it is likely that they will be prescribed an oral corticosteroid such as prednisone.

Question 87

1-87 Which statement is correct regarding hemophilia disorders?
A) There is an increased incidence of hemophilia in females
B) Platelet administration is a common treatment in hemophilia
C) Hemophilia is an inherited sex-linked genetic disorder
D) Two common triggers of hemophilia are hypoxia and dehydration

Answer 87

C) Hemophilia is an inherited sex-linked genetic disorder

Hemophilia is an inherited sex-linked disease that alters factor production and function. The mother is the carrier and passes the trait onto her children. Active disease is most often expressed in males. Complications from hemophilia are often seen with trauma and invasive procedures, rather than hypoxia and dehydration (like in Sickle Cell episode). Treatment for hemophilia may include replacement of factor and administration of plasma or cryoprecipitate. Platelets are administered as part of the treatment for severe thrombocytopenia.

Question 88

1-88 An elderly patient arrives to the ED following a fall at home. The patient’s daily medication includes clopidogrel (Plavix) 300mg daily. The pateint is diagnosed with an intracranial bleed. the ER nurse anticipates which of the following actions to be taken?
A) Administer vitamin K IV immediately.
B) Administer protamine sulfate IV immediately
C) Discontinue the clopidogrel (Plavix) immediately
D) Decrease the next dose of clopidogrel (Plavix)

Answer 88

C) Discontinue the clopidogrel (Plavix) immediately

Vitamin K is the antidote for warfarin (Coumadin). Protamine sulfate is the antidote for heparin. Clopidogrel is an antiplatelet drug given as a 300mg loading dose and then administered at 75mg daily. The patient has been taking an excessive amount of the medication, resulting in the intracranial hemorrhage secondary to the fall. There is no chemical antidote or reversal agent for Clopidogrel.

Question 89

1-89 A patient with a history of leukemia and who is currently undergoing chemotherapy treatment is being discharged from the ED following a facial laceration repair. Which statement best indicates to the ER nurse the patient’s understandings of the discharge instructions?
A) “ I should return to the ED immediately for a temperature of 37.3C (99.1F).”
B) “I might not see the common signs of infection.”
C) “Because I have a high white blood cell count, I am protected from getting an infection.”
D) “Pus will be expected during the healing because of my high white blood cell count.”

Answer 89

B) “I might not see the common signs of infection.”

Patients with a weakened immune system from chemotherapy may not see the typical signs of infection.

Question 90

1-90 An African American patient presents to the ER triage with a complaint of chest pain, shortness of breath, fever, cough, and wheezing. The patient’s medications include lisinopril, metformin, and hydroxyurea. The patient is a poor historian and is refusing to answer questions. The ER nurse should be most concerned about which potential diagnosis?
A) Acute chest syndrome
B) Acute myocardia infarction
C) Chronic obstructive bronchitis
D) Superior vena cava syndrome

Answer 90

A) Acute chest syndrome

The patient presentation, in conjunction with their race and current medication history (hydroxyurea) is consistent with a diagnosis of sickle cell disease. Acute chest syndrome is one the leading causes of mortality in patient with sickle cell disease. Symptoms of acute chest syndrome include chest pain, dyspnea, cough, and hypoxemia, accompanied by wheezing and pulmonary infiltrates on chest radiograph. Acute chest syndrome can quickly progress to acute pulmonary failure. Hydroxyurea stimulates the production of fetal hemoglobin, providing for increased oxygen-carrying hemoglobin in the patient, and is an effective treatment modality for patients with sickle cell disease.

Fever cough and wheezing are not associated with myocardial infarction.

Chronic obstructive bronchitis (a component of COPD) is not associated with chest pain or fever. The adventitious breath sound normally heard with this condition is rhonchi. Wheezing can be associated with emphysema, another component of COPD.

Superior venta cava syndrome is a cancer complication that occurs when a mass obstructs the superior vena cava. An obstruction occurs either inside or outside the vena cava and results in reduced blood flow back to the heart. Symptoms include facial, neck, and arm swelling, chest pain, and shortness of breath, and hoarseness. Cerebral edema and airway obstruction can also occur. Fever and wheezing are not symptoms of superior vena cava syndrome.

Question 91

1- 91 Which of the following lab test values would alert an emergency nurse that a patient with disseminated intravascular coagulation is beginning to improve?
A) Elevated D-dimer
B) Increased platelet count
C) Prolonged partial thromboplastin time
D) Increased prothrombin

Answer 91

B) Increased platelet count

DIC causes a massive consumption of platelets, which leads to the extensive clotting that occurs; therefore, an increase in the patient’s platelet count would indicate that the DIC is lessening and the patient is beginning to improve. DIC causes an elevated D-dimer and fibrin degradation factor A. As DIC gets worse, the patient would have a prolonged PTT.

Question 92

1-92 The emergency nurse anticipates heparin to be administered for the treatment of disseminated intravascular coagulation in which of the following situations?
A) Postpartum bleeding
B) Multiple traumatic injuries
C) Excessive fibrin that has caused digital ischemia
D) Envenomation from a snake bite

Answer 92

C) Excessive fibrin that has caused digital ischemia

A patient with DIC and excessive fibrin that has caused acral cyanosis (bluish or purple discoloration) and ischemia in the digits, which may result in the loss of a digits, may benefit from the administration of heparin. A patient with bleeding from DIC (from trauma, snake bite, or postpartum bleeding) would not benefit from heparin because heparin continues to cause a risk for bleeding.

Question 93

1-93 A patient complains of transient palpitations and occasional numbness and tingling of their fingers and nose. While vital signs are being obtained, the ER nurse observes a sudden onset of carpal spasms on the arm on which the blood pressure cuff is being inflated. The nurse recognizes that this finding is consistent with the presence of:
A) Hypocalcemia
B) Hypercalcemia
C) Hypokalemia
D) Hyperkalemia

Answer 93

A) Hypocalcemia

This patient’s response is called Trousseau’s sign.

Hypercalcemia generally presents with muscle weakness and depressed deep tendon reflexes.

Hypokalemia may present with hyporeflexia.

Hyperkalemia may present with muscle weakness and flaccid paralysis.

Question 94

1-94 Which of the following conditions caused by an insufficient amount of available antidiuretic hormone results in the patient urinary large amounts of diluted urine?
A) Diabetes insipidus
B) Adrenal crisis
C) Syndrome of inappropriate antidiuretic hormone (SIAH)
D) Cushing’s syndrome

Answer 94

A) Diabetes insipidus

Diabetes insipidus is a life-threatening condition caused by insufficient production of antidiuretic hormone (ADH) by the hypothalamus, or insufficient ADH being released by the posterior pituitary gland. The patient will excrete large amounts of diluted urine and complain of fatigue and weight loss. Treatment for DI is fluid replacement and ADH replacement with medications such as desmopressin acetate (DDAVP).

Adrenal crisis, also known as acute adrenal insufficiency, is a life-threatening condition caused by a decrease in cortisol and aldosterone levels. This results in sodium and water loss from both the kidneys and GI tract, causing the patient to become hypotensive and hypovolemic. As the body loses sodium, an increase in potassium occurs, leading to hyperkalemia and the development of fatal dysrhythmias. Treatment includes fluid replacement, correction of hyperkalemia, and hydrocortisone administration.

Syndrome of inappropriate antidiuretic hormone (SIADH) is a life-threatening condition in which the pituitary gland releases excessive amounts of ADH. The patient will present with dilutional hyponatremia and water intoxication, which can result in seizures. The patient will also complain of headache, fatigue, and weight gain without the presence of edema. Treatment for SIADH depends on the severity of the patient’s hyponatremia. Fluid restriction should be initiated. Severe hyponatremia is treated with hypertonic saline and the administration of furosemide (Lasix).

Cushing’s syndrome is the result of prolonged exposure to glucocorticoids - either endogenous or exogenous - causing the patient to develop a cushingoid appearance. There is an increased amount of adipose tissue to the face, upper back, and base of the neck.

Question 95

1-95 Which assessment finding in a patient with adrenal crisis would alert the emergency nurse to prepare for an expected complication?
A) Hypokalemia
B) Hypotension
C) Hyperglycemia
D)Bradycardia

Answer 95

B) Hypotension

Patients in adrenal crisis are at high risk of developing hypoglycemia, hyponatremia, hypovolemia/hypotension, and hyperkalemia. The presence of hypotension should alert the nurse to the need for fluid resuscitation and immediate replacement of adrenal hormones.

Question 96

1-96 A patient arrives to the ER via EMS with sudden onset of altered level of consciousness. The patient was found wandering at the local bus statin, is able to answer questions only after much thought, and is unable to recognize that they are currently in a hospital. The patient appears very anxious, is diaphoretic, and has uncontrolled tremors to bilateral arms. Which of the following diagnostic testing would be the first priority for the ER nurse to obtain in order to assist in proper diagnosis of this problem?
A) Serum creatinine
B) Urinalysis
C) White blood cell count
D) Serum glucose

Answer 96

D) Serum glucose

Any patient with AMS should have an immediate POC blood glucose done.

Question 97

1-97 When providing discharge instructions to the parents of a child, the nurse is aware that the parents have understood the importance of avoiding products that contain aspirin when they state which of the following?
A) “There is an association between the use of aspirin-containing products in febrile children and the development of Reye’s syndrome.”
B) “Aspirin is less effective in controlling fevers in the pediatric population because of their immature and developing neurologic system.”
C) “Aspirin has been shown to increase the risk of febrile seizures given its slower onset of action.”
D) “There is an association between the use of aspirin in febrile children and the development of asthma.”

Answer 97

A) “There is an association between the use of aspirin-containing products in febrile children and the development of Reye’s syndrome.”

Reye’s syndrome is a rare yet rapidly progressing syndrome that results in encephalopathy. Fatty deposits in the liver lead to AMS and altered glucose regulation.

Question 98

1-98 Which of the following may be a subtle sign of sepsis that should be considered by the triage nurse during the initial assessment of a patient presenting to the ER?
A) Systolic bp greater than 90mmHg
B) RR greater than 22bpm
C) Temperature of 37C (98.6)
D) Capillary refill less than 2 seconds

Answer 98

B) RR greater than 22bpm

Question 99

1-99 A patient presents to the ER with possible signs and symptoms of compartment syndrome 2 days following surgery for a fractured left tibia/fibula. Which of the following would alert the emergency nurse that this patient may be experiencing possible organ failure?
A) Rales
B) Jaundice
C) Dark, scanty urine
D) Generalized edema

Answer 99

C) Dark, scanty urine

Significant muscle damage and cellular destruction releases myoglobin, a muscle protein, into the bloodstream. As the myoglobin enters the kidneys, it causes the appearance of dark red or brown urine. The myoglobin can also clog the renal glomerulus, resulting in an acute renal injury. If the myoglobin is not flushed from the kidneys with large amounts of fluid, permanent renal impairment or injury can result.

Question 100

1-100 A patient presents to triage with a complaint of continuous chest pain for the past 3 days. Vital signs are BP 108/70, HR 68, RR 18, SpO2 99% on room air, temp 37C (98.6F). The patient describes the pain as sharp, located on the right side of the chest, and made worse by breathing and arm movement. The patient denies shortness of breath and any trauma or recent surgeries but does report having an upper respiratory infection the previous week. The ER nurse anticipates the cause of the patient’s symptoms is which of the following?
A) Pericarditis
B) Pulmonary contusion
C) Anxiety
D) Constochondritis

Answer 100

D) Costochondritis

Costochondritis is an inflammation of the costal cartilage and can present as sharp pain that is worse on breathing in or with movement. Because the pain is reproducible, it is most likely related to costochondritis, which can occur following URI’s, particularly when patients have been coughing.

Pericarditis can be caused by bacterial, fungal, or viral infections, but sometimes the cause is unknown. With pericarditis, the pain can also be sharp and increase with movement, but pain is usually worse when the patient is lying down. In addition, the patient may have fever, fatigue, and possibly weight loss.

Pulmonary contusions are often the result of blunt force trauma and may develop over several days. Pulmonary contusions are characterized by blood moving to the lung tissue following blunt trauma to the chest, which can result in tissue edema. There may be point tenderness over the site and the patient may appear to be short of breath or working hard to breathe.

Question 101

1-101 A young mother presents to triage with her toddler, stating the child fell while walking and now will not move their left arm. However, the child fell on their right side. What should the ER triage nurse do next?
A) Order a radiograph of the right arm per standing orders
B) Suspect child maltreatment because the story does not match the injury
C) Ask the mother if she attempted to prevent the child from falling by holding onto the opposite arm.
D) Assess the injured left arm by using passive ROM

Answer 101

C) Ask the mother if she attempted to prevent the child from falling by holding onto the opposite arm.

Assess for the presence of possible radial head subluxation injury (nursemaid’s elbow) cause by pulling on the child’s arm. Subluxation is partial joint disruption (partial dislocation) that maintains some contact with the articulating surfaces. A radiograph is frequently unwarranted in radial subluxation as the diagnosis can be made by physical examination. The subluxation can be easily relocated with good return of function. It is not necessary to immobilize the extremity following relocation of the subluxation. If the arm was fractured, it is not best practice to use passive ROM to assess the extremity.

Question 102

1-102 A patient presents to triage complaining of pain in the right distal forearm after falling onto their out-stretched arm. There is an obvious deformity above the patient’s right wrist. Right radial pulse is present, and color and sensation are intact distally, however, the patient is unable to sustain a wrist grip. The ER nurse is aware that it is best to immobilize the right forearm using a(n):
A) traction splint
B) padded rigid long arm splint
C) soft splint
D) ice application

Answer 102

B) padded rigid long arm splint

Splinting of the extremity is indicated when there is evidence of deformity, pain, bony crepitus, edema, ecchymosis, open soft tissue injury, paralysis, or paresthesia. Always immobilize joints above and the below a suspected fracture site. Tractions splints are used for actual or potential femur or proximal tibial fractures and would not be indicated for an upper extremity. Soft splints include pillows and slings and could be an option if a rigid splint is not available. The presence of an obvious deformity makes the use of a rigid splint the best choice of treatment for this patient.

Question 103

1-103 The ER nurse is preparing to discharge a female geriatric patient who presents to the ER for severe “heartburn.” Medication reconciliation reveals the patient is on alendronate (Fosamax). What information should the ER nurse provide to the patient?
A) Always take alendronate with food
B) Sit or stand upright for 30 minutes after taking alendronate
C) Have calcium blood levels monitored monthly
D) Take alendronate at bedtime

Answer 103

B) Sit or stand upright for 30 minutes after taking alendronate

A side effect of alendronate is esophageal irritation so the patient must remain upright for 30 minutes. IN severe cases, the esophageal irritation can result in esophageal erosion. The pt should take the medication on an empty stomach with a full glass of water to promote absorption of the drug and avoid eating or drinking 30 minutes after taking the medication. Alendronate is a bisphosphonate that works by inhibiting the resorption of the bone and increasing bone mass. Calcium levels need to be monitored in patients taking hormones such as calcitonin and teriparatide.

Question 104

1-104 A patient is observed walking into the ER with a severely increased thoracic curve, or “humpback.” The emergency nurse knowns that this condition is referred to as:
A) scoliosis
B) lordosis
C) genu varum
D) kyphosis

Answer 104

D) Kyphosis

Kyphosis (dowager’s hump) is collapse of the spine that produces the appearance of a shortened trunk. Genu varum is a bow-legged appearance of the legs in children.

Question 105

1-105 A motorcyclist arrives to the ER via EMS following a collision with a motor vehicle. The motorcyclist who was thrown across the hood of the car was helmeted and wearing leather clothing. The patient’s primary survey is within normal limits. The secondary survey reveals pain and paresthesia to the right arm and hand, with pronounced weakness but no swelling, pallor, or coolness in the extremity. The ER nurse anticipates the patient has the signs and symptoms of which of the following?
A) Brachial plexus injury
B) Compartment syndrome
C) Fracture of the humerus
D) Brachial artery dissection

Answer 105

A) Brachial plexus injury

The brachial plexus arises from the C5 to T1 spinal nerves. These nerves are responsible for supplying motor control and sensation to the arm, wrist, and hand. Injury to the ses spinal nerves will result in pain and paresthesia to teh arm and wrist and hand weakness.

Compartment syndrome occurs when pressure increases within a fascial compartment

Question 106

1-105 A motorcyclist arrives to the ER via EMS following a collision with a motor vehicle. The motorcyclist who was thrown across the hood of the car was helmeted and wearing leather clothing. The patient’s primary survey is within normal limits. The secondary survey reveals pain and paresthesia to the right arm and hand, with pronounced weakness but no swelling, pallor, or coolness in the extremity. The ER nurse anticipates the patient has the signs and symptoms of which of the following?
A) Brachial plexus injury
B) Compartment syndrome
C) Fracture of the humerus
D) Brachial artery dissection

Answer 106

A) Brachial plexus injury

The brachial plexus arises from the C5 to T1 spinal nerves. These nerves are responsible for supplying motor control and sensation to the arm, wrist, and hand. Injury to the ses spinal nerves will result in pain and paresthesia to the arm and wrist and hand weakness.

Compartment syndrome occurs when pressure increases within a fascial compartment. Signs and symptoms include pain out of proportion to the injury, pallor, decreased pulse, paresthesia, and paralysis, and the area feels firm to palpations.

Fractures must be ruled out. A fractured humerus would likely include deformity, ecchymosis, swelling, and inability to raise the arm.

Signs and symptoms of an arterial dissection may be similar to compartment syndrome with decreased radial pulses. It would be reasonable to rule out this injury with arteriogram, but this patient does not have the key symptoms, such as swelling, pallor, or coolness of the extremity.

Question 107

1-106 A construction worker is brought to the ER by their coworkers. The patient reports that while descending from a ladder, they unintentionally fired a nail gun into their right thigh. Immediately following, the patient was unable to straighten their leg and their coworkers had to cut the patient’s jeans off from around the nail head. A radiograph reveals the presence of a foreign body embedded in the patient’s right femur. The nurse anticipates that this injury will be managed as a(n):
A) Foreign body
B) Open fracture
C) Comminuted fracture
D) High-pressure grease injury

Answer 107

B) Open fracture

An injury is classified as an open fracture if a penetrating foreign body enters the bone or creates an opening in the tissue directly over the bone. Comminuted fractures occur from severe direct trauma to the bone and result in more than two bone fragments. High-pressure injection injuries from a pain or grease gun can result in the substance traveling down the fascial plane or tendon sheath, causing severe infection or permanent impairment. Immediate surgical intervention is necessary to drain the foreign substance from the tissue and preserve function.

Question 108

1-107 The ER nurse is preparing to discharge a patient who has received treatment to close a facial laceration. The nurse recognizes the patient’s understanding of the discharge instructions when stating the following:
A) “I will be sure to call my doctor in the morning of a prescription for an antibiotic.”
B) “I need to place a thin layer of antibiotic ointment over the sutures daily.”
C) “I will be sure to have my staples removed after 3 weeks.”
D) “I will return to the ER in 14 days for suture removal.”

Answer 108

B) “I need to place a thin layer of antibiotic ointment over the sutures daily.”

Uncomplicated wounds in a healthy individual do not usually require systemic antibiotics, but topical, antibiotic ointment is suggested. Staple wound closures are limited to areas where a scar will not be apparent and are therefore not indicated for facial wounds. Facial sutures are typically removed in 3-5 days. Sutures over joints require 14 days to heal before removal.

Question 109

1-108 The ER nurse is caring for a patient who was found lying on the floor for 2 days, unable to get up following a fall. The patient’s skin assessment reveals an area of purple discoloration along the patient’s greater trochanter, which is boggy and warm to the touch. The ER nurse recognizes this wound as a(n):
A) stage 1 pressure ulcer
B) area of bruising
C) potential deep tissue injury
D) stage 4 pressure ulcer

Answer 109

C) potential deep tissue injury

A deep tissue injury is described as a purple or maroon localized area of discolored intact skin or blood-filled blister resulting from damage of underlying tissue form pressure and or shear.

A stage 1 pressure ulcer is described as intact skin with nonblanchable redness of a localized area, usually over a bony prominence. This is inconsistent with a wound that is boggy and warm to the touch. A stage 4 pressure ulcer is described as full thickness tissue loss with exposed bone, tendon, or muscle.

A bruise is the extravasation of blood in the tissues as a result of blunt force impact to the body. This is not the most accurate description relating to the etiology of this wound.

Question 110

1-109 Which wound is the highest risk of development of osteomyelitis?
A) Laceration to the palmar surface of the hand resulting from a carving knife
B) Stage 1 pressure injury to the heel
C) Laceration to the elbow form breaking glass
D) Deep puncture wound in the foot form stepping on a nail

Answer 110

D) Deep puncture wound in the foot form stepping on a nail

A puncture wound of the foot is associated with deep penetration resulting from weight bearing on a sharp object with frequent penetration of a metatarsal bone. The patient will complain of pain, redness, and swelling within 4-7 days following injury as the infection begins to develop.

Question 111

1-110 What is the priority assessment for patient who has sustained traumatic laceration to the upper arm?
A) Rang of motion in the fingers
B) The presence of a distal or radial pulse
C) Capillary refill
D) Skin color and temp

Answer 111

B) The presence of a distal or radial pulse

Question 112

1-111 An elderly patient arrives to the ER via EMS with profuse epistaxis that has persisted for over an hour. After initiating universal precautions, the next priority intervention for the ER nurse to preform is which of the following?
A) Obtain a bp
B) Initiate IV access
C) Maintain airway patency
D) Initiate direct pressure by instructing the patient to pinch their nostrils

Answer 112

C) Maintain airway patency

Posterior nasal bleeding can interfere with a patient’s airway patency. Posterior bleeding can be chronic and is most common in elderly patients who may have a history of hypertension and who take an anticoagulation-type medication. Instructing the patient to pinch their nostrils is effective with an anterior nasal bleed but will not act to minimize the amount of bleeding in a posterior nasal bleed. Anterior nasal bleeds usually arise from the area of the Kieselbach plexus. This patient, however, is showing signs of a posterior bleed.

Question 113

1-112 A patient presents to triage and tells the ER nurse that they are experiencing a severe throbbing-type headache pain located over the frontal left region. The patient has a history of polymyalgia rheumatica. The ER nurse suspects that patient’s current discomfort is related to the presence of which of the following:
A) Temporomandibular joint dislocation
B) Temporal arteritis
C) Cluster headache
D) Sinusitis

Answer 113

B) Temporal arteritis

Temporal arteritis is also referred to as systemic arterial vasculitis and produces a severe frontal throbbing type of pain. Palpation over the temporal region results in severe discomfort for the patient. Patients who experience temporal arteritis have a history of polymyalgia rheumatica and are usually ove the age of 50.

Temporomandibular joint dislocation (TMI) is a joint dislocation at the anterior and superior joint that results in spasms and muscle contraction of the jaw muscles, leading to the condyles not being able to return to their normal position. TMJ can be result of trauma or from simply opening the mouth too wide such as during dental work.

Cluster headaches occur commonly in men and are related to a dysfunction of the trigeminal nerve. This headache is characterized by an intense unilateral pain in the orbital or temporal region lasting from 15 minutes to 3 hours.

Sinusitis results from the blockage of drainage from the paranasal sinuses. It can be caused by a recent upper respiratory infection or allergic rhinitis. The patient experiences dull achy discomfort over the affected sinus.

Question 114

1-113 A patient with a history of diabetes presents to the ER complaining of increasing swelling and severe pain the left eye with movement of the eye. On assessment, the patient demonstrates decreased visual acuity, decreased pupillary reflexes, and the presence of erythema and edema of the upper and lower eyelids and of the left cheek area. The ER nurse anticipates the patient has signs and symptoms of:
A) Conjunctivitis
B) Anterior uveitis
C) Iritis
D) Orbital cellulitis

Answer 114

D) Orbital cellulitis

Orbital cellulitis is a serious emergency that involves the eye itself, resulting in painful movement, reduced visual acuity, and severe swelling and redness of the orbital area. patients who are immunocompromised or who have a history of diabetes are more susceptible to complicating infections. Orbital cellulitis is to be considered to be a life-threatening infection process because of the potential for the infection to enter the brain, resulting in meningitis.

Conjunctivitis involves the eyelid and conjunctiva and results in redness, some edema, and drainage. Conjunctivitis does not affect the patient’s visual acuity. The patient will usually not experience pain with eye movement.

Anterior uveitis is the inflammation of the upper eyelid. It is associated with the presence of excessive tearing, redness of the eye, and decreased visual acuity. Pain will not be present with eye movement.

Question 115

1-114 An unresponsive patient involved in a high-speed motor vehicle collision with multiple facial injuries arrives in the ER via EMS. Because of the presence of numerous facial injuries, it is determined that the patient is at risk for an upper airway obstruction. Which of the following maneuvers is best to initiate to prevent an upper airway obstruction?
A) Maintain the patient in semi-Fowlers position at a 45-degree angle to maintain airway patency
B) Place airway adjunct into the patient
C) Place the patient in a left lateral “recovery” position to maintain an open airway
D) Assist the emergency provider to control facial bleeding using vessel ligation to prevent the occlusion of the upper airway as the result of significant bleeding.

Answer 115

B) Place airway adjunct into the patient

A NPA can be placed in patients who are either conscious or unconscious. An oropharyngeal airway is only used in patient who have an absent gag reflex. These devices can maintain an open airway until further interventions can be preformed, such as endotracheal intubation or cricothyroidotomy to maintain airway patency.

Up to 10% of patient with significant blunt force facial injuries will also have the presence of a corresponding cervical spine injury; therefore, cervical spine immobilization should be maintained until the presence of a cervical injury can be determined by radiographic studies.

Placing the patient into a left lateral position is not recommended. Rather, cervical spine immobilization should be maintained until the presence of a cervical injury can be determined by radiographic studies.

Vessel ligation should only be performed under direct visualization after careful identification of the bleeding vessel.

Question 116

1-115 A patient presents to the ER after being splashed in both eyes with a cleaning solution. During assessment, the ER nurse notes the presence of bilateral corneal clouding and prepares to irrigate the eyes. The ER nurse knows that the irrigation may be discontinued when:
A) The ocular pH reaches 7.0 in each eye
B) 1 hour has passed
C) the pain in each eye has been relieved
D) 1000mL of irrigation solution has been used.

Answer 116

A) The ocular pH reaches 7.0 in each eye

Normal ocular pH is 7.0-7.3. Irrigation is performed until the ocular pH is within normal range.

The duration of irrigation is determined by a resulting normal pH, not the length of the irrigation. Depending on the chemical substance, irrigation may take more or less time before reaching normal ocular pH.

Relief of pain is not a determining factor in discontinuation of irrigation.

Volume of the irrigating solution is not a determining factor in discontinuation of irrigation.