Question: A patient in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and begins vomiting. What action by the nurse takes priority?
Answer Options: Maintain airway patency Call for an electrocardiogram Administer an aspirin Notify the provider
Answer: C. Administer an aspirin
Question: In administering an angiotensin-converting enzyme inhibitor to a patient recovering from a myocardial infarction (MI), the nurse correlates its purpose to which mechanism of action?
Answer Options: Decrease preload Control sympathetic nervous system response to decreased cardiac output Reduce afterload Increase contractility
Answer: C. Reduce afterload
Question: A patient has a pulmonary embolism and is started on oxygen. The student nurse asks why the patient’s oxygen saturation has not significantly improved. What response by the nurse is best?
Answer Options: Maybe the patient has respiratory distress syndrome Breathing so rapidly results in respiratory acidosis The blood clot interferes with perfusion in the lungs The patient needs immediate intubation and mechanical ventilation
Answer: C. The blood clot interferes with perfusion in the lungs
Question: During acute respiratory distress syndrome (ARDS), the patient’s lung cells that produce surfactant have become damaged. As the nurse, you know this will lead to:
Answer Options: Bronchoconstriction Alveolar collapse Pulmonary edema Upper airway obstruction
Answer: B. Alveolar collapse
Question: A nurse is caring for a patient on mechanical ventilation and finds the patient agitated and thrashing about. What action should the nurse take first?
Answer Options: Reassure the patient that he or she is safe Sedate the patient immediately Assess the cause of the agitation Restrain the patient’s hands
Answer: C. Assess the cause of the agitation
Question: You are caring for a patient with acute respiratory distress syndrome (ARDS). As the nurse, you know that prone positioning can be beneficial for some patients with this condition. Which findings below indicate this type of positioning was beneficial for your patient with ARDS? Select all that apply.
Answer Options: A. PaO₂ increase from 59mmHg to 82mmHg B. PaO₂ decrease from 82mmHg to 59mmHg C. Improvement in lung sounds D. PaCO₂ increase
Answer: A. PaO₂ increase from 59mmHg to 82mmHg C. Improvement in lung sounds
Question: Which arterial blood gas (ABG) results does the nurse recognize as most indicative of impending respiratory failure? Normal PaCO₂ = 35-45mmHg Normal PaO₂ = 90-100mmHg
Answer Options: PaCO₂ 45mmHg; PaO₂ 70mmHg PaCO₂ 48mmHg; PaO₂ 60mmHg PaCO₂ 33mmHg; PaO₂ 66mmHg PaCO₂ 30mmHg; PaO₂ 80mmHg
Answer: B. PaCO₂ 48mmHg; PaO₂ 60mmHg
Question: A patient is being treated for sepsis secondary to aspiration pneumonia and is on a 100% non-rebreather mask. Which of the following cues best correlates with acute respiratory distress syndrome (ARDS) development?
Answer Options: Patient is confused Bradypnea BP 180/92 PaO₂ remains 45mmHg
Answer: D. PaO₂ remains 45mmHg
Question: The ER team is performing CPR on a patient when the patient’s spouse arrives at the ER. Which action would the nurse take first?
Answer Options: Give the spouse a business card with the hospital’s crisis team number Request that the patient’s spouse sit in the waiting room Ask the spouse if they wish to be present during the resuscitation Suggest that the spouse begin to pray for the patient
Answer: C. Ask the spouse if they wish to be present during the resuscitation
Question: On a hot, humid day, an ER nurse is caring for a patient who is confused and has the following vital signs: Temp 104.1 F; pulse 132; respirations 26; BP 106/66. Which intervention is the most appropriate?
Answer Options: Administer acetaminophen 650mg PO Encourage the patient to drink ice water Submerge the patient in an ice bath Start an IV and infuse 0.9% normal saline
Answer: C. Submerge the patient in an ice bath
Question: A patient presents to the emergency department after prolonged exposure to the cold. The patient is difficult to arouse and speech is incoherent. Which intervention is most appropriate given this patient’s condition?
Answer Options: Place the patient in a hot shower Administer warmed intravenous fluids to the patient Vigorously massage the extremities Wrap the patient in blankets
Answer: D. Wrap the patient in blankets
Question: A new graduate RN has taken a job in Las Vegas, Nevada. Which of the following populations is least at risk for heat-related illnesses?
Answer Options: Construction workers Older adults Homeless Professional hockey players
Answer: D. Professional hockey players
Question: An emergency room nurse is triaging victims of a multi-casualty event. Which patient would receive care first?
Answer Options: A 26-year-old male who is lethargic and has pale, cool, clammy skin A 30-year-old distraught mother holding her crying child A 65-year-old conscious male with a 1 cm head laceration A 48-year-old with a simple fracture of the lower leg
Answer: A. A 26-year-old male who is lethargic and has pale, cool, clammy skin
Question: You are caring for a 56-year-old female with a terminal diagnosis who is near death. Family has called you to the room and state they are concerned about her loud, wet respirations. Which nursing interventions are most appropriate at this time? Select all that apply.
Answer Options: Reposition the patient onto one side to reduce gurgling Assist the patient to cough and deep breathe to mobilize secretions Use nasopharyngeal suctioning to remove the secretions Place a small towel under the patient’s mouth to catch secretions Administer an ordered anticholinergic drug to dry the secretions
Answer: A. Reposition the patient onto one side to reduce gurgling D. Place a small towel under the patient’s mouth to catch secretions E. Administer an ordered anticholinergic drug to dry the secretions