Nursing Interventions
A patient suddenly develops dyspnea, pleuritic chest pain, HR 132, RR 34, and SpO₂ 86%. The patient is anxious and has a history of recent hip surgery.
What is the nurse's priority action?
A. Obtain a sputum culture
B. Apply oxygen and assess airway/breathing
C. Place the patient flat
D. Encourage ambulation to prevent further thrombosis
B!
Which documentation statement is the most objective?
A: Patient stated: "my pain is 10/10" and was crying during assessment
B: Patient was displaying drug seeking behavior
C: Patient appeared to only have pain when she was telling the story
D: Patient seemed to not care about plan of care
A
A patient presents with crushing chest pain and diaphoresis.
Vital signs:
BP: 82/54 mmHg
HR: 52/min
SpO₂: 95%
ECG suggests an inferior STEMI.
Which prescription should the nurse question?
A. Continuous cardiac monitoring
B. Aspirin as prescribed
C. Nitroglycerin sublingually
D. Preparation for urgent reperfusion therapy
Answer: C
Rationale: The patient is hypotensive. Nitroglycerin can further reduce preload and blood pressure and may be particularly problematic with right ventricular involvement in an inferior MI.
A patient with diabetic ketoacidosis has:
Glucose: 620 mg/dL
pH: 7.14
HCO₃⁻: 8 mEq/L
K⁺: 2.8 mEq/L
The provider prescribes an IV regular insulin infusion.
What should the nurse do?
A. Start insulin immediately
B. Hold insulin and notify the provider regarding the potassium level
C. Administer sodium bicarbonate before anything else
D. Give oral potassium and start insulin simultaneously
Answer: B
Rationale: Insulin drives potassium into cells and can cause a dangerous further decrease in serum potassium. With significant hypokalemia, potassium replacement is prioritized before insulin according to the treatment protocol. Continuous cardiac monitoring is also important.
patient was last known well 90 minutes ago.
CT shows no intracranial hemorrhage. The patient takes warfarin and has an INR of 2.4.
Which statement is most appropriate?
A. Administer thrombolytic therapy immediately
B. Give aspirin and discharge the patient
C. Recognize that the elevated INR makes IV thrombolytic therapy inappropriate
D. Lower the patient's BP aggressively to normal immediately
Answer: C
Rationale: The patient has an acute ischemic stroke presentation, but therapeutic anticoagulation with an elevated INR is a contraindication to IV thrombolytic therapy. The stroke team should continue evaluating the patient for other appropriate reperfusion and supportive interventions.
A patient develops facial swelling, wheezing, hypotension, and generalized urticaria minutes after receiving an antibiotic.
Which medication should the nurse administer first?
A. IV diphenhydramine
B. IV methylprednisolone
C. IM epinephrine
D. Nebulized albuterol
c! WHY?
Which approach is most appropriate when documenting an emotionally charged encounter?
A: Document suspected motives when the patient's behavior is difficult
B: Document the staff member's frustation so that the record reflects what happened
C: Leave out difficult interactions
D: Use neutral language describing the observable behaviors and statements
D!
A patient is rescued from a burning building. The patient has headache, confusion, facial burns, and soot around the mouth. SpO₂ is 100%.
Which interpretation is most accurate?
A. Carbon monoxide poisoning is unlikely because SpO₂ is normal
B. The patient should receive high-concentration oxygen
C. The patient can be discharged if chest x-ray is normal
D. Oxygen should be withheld because saturation is already 100%
Answer: B
Rationale: Standard pulse oximetry can appear falsely reassuring in carbon monoxide poisoning because it cannot reliably distinguish oxyhemoglobin from carboxyhemoglobin. High-concentration oxygen is indicated when CO poisoning is suspected.
A 4-year-old child presents with drooling, muffled voice, high fever, and a tripod position. The child becomes increasingly agitated when staff attempt to examine the throat.
What should the nurse do?
A. Use a tongue depressor to inspect the throat
B. Force the child to lie supine
C. Keep the child calm and prepare for controlled airway management
D. Obtain a throat culture immediately
Answer: C
Rationale: This presentation is concerning for severe upper-airway obstruction, historically associated with epiglottitis. Agitation and unnecessary airway manipulation can precipitate complete obstruction. The child should remain calm while the airway team prepares for definitive management.
A patient arrives after a high-voltage electrical injury. There are relatively small external burns, but the patient reports severe muscle pain.
Which assessment is particularly important?
A. Serum creatine kinase and urine characteristics
B. Visual acuity only
C. Bowel sounds
D. Skin temperature of the feet only
Answer: A
Rationale: Electrical injuries can cause deep tissue damage and rhabdomyolysis despite limited external findings. Muscle breakdown can cause myoglobinuria and acute kidney injury.
A 71-year-old patient arrives 45 minutes after suddenly developing right-sided weakness and expressive aphasia. Blood glucose is 108 mg/dL. BP is 196/108. CT shows no intracranial hemorrhage.
Which intervention should the nurse anticipate?
A. Administer alteplase immediately without further assessment
B. Rapidly lower the BP to 120/80
C. Determine whether the patient meets criteria for thrombolytic therapy
D. Give aspirin before obtaining further neurologic assessment
C!! WHY?
A patient refuses a recommended treatment. Which documentation is most appropriate?
A: Patient declined the recommended treatment after risks, benefits, and alternatives were discussed.
B: Patient refused because they are not cooperating
C: Patient refused, no further documentation is needed
D: Patient is noncompliant and refusing to listen
A
A patient with severe traumatic brain injury is being monitored for increased intracranial pressure. Which findings should concern the nurse? Select all that apply.
A. Decreasing level of consciousness
B. Projectile vomiting
C. Unequal pupils
D. Increasing systolic blood pressure with widening pulse pressure
E. Bradycardia
F. Increased urine output after receiving IV fluids
A,B,C,D,E
A patient rescued from a house fire has facial burns, soot around the mouth, a hoarse voice, and increasing respiratory distress. SpO₂ is 99%.
Which interpretation is most appropriate?
A. The normal SpO₂ indicates that the airway is currently safe
B. The patient is primarily experiencing fluid-volume deficit
C. The patient is at high risk for progressive airway edema
D. The patient should receive oxygen only if SpO₂ decreases below 90%
Answer: C
Rationale: Pulse oximetry can initially appear normal despite significant inhalation injury. Facial burns, soot, hoarseness, and respiratory symptoms are concerning for airway edema, which can progress rapidly.
7. Increased ICP
A patient with severe traumatic brain injury suddenly develops:
BP: 190/60 mmHg
HR: 48/min
Irregular respirations
Unequal pupils
What should the nurse do first?
A. Lower the patient's blood pressure rapidly
B. Notify the provider/emergency team and prepare for immediate management of increased ICP
C. Administer an oral antihypertensive
D. Place the patient in Trendelenburg position
Answer: B
Rationale: Hypertension with widening pulse pressure, bradycardia, and abnormal respirations is Cushing's triad, suggesting critically increased intracranial pressure and possible herniation. This is an emergency requiring immediate intervention.
A 64-year-old patient presents with diaphoresis, nausea, and vague epigastric discomfort. The patient denies chest pain. BP is 88/54, HR 112, RR 22, SpO₂ 94%. The ECG shows ST-segment elevation in leads II, III, and aVF.
Which action should the nurse take first?
A. Administer sublingual nitroglycerin
B. Establish two large-bore IVs and prepare for rapid reperfusion
C. Administer IV morphine
D. Place the patient in a supine position with legs elevated
B!
Which statement best reflects objective documentation?
A: Patient was extremely anxious and unreasonable
B: Patient declined blood draw and stated "I do not want another needle"
C: Patient is trying to make the staff look bad
D: Patient refused to cooperate with anything
B
A 27-year-old patient is brought to the ED after a high-speed motor vehicle collision. The patient has multiple rib fractures and an open femur fracture. Initially, the patient is alert with a respiratory rate of 24/min and SpO₂ of 96% on room air. Thirty minutes later, the patient becomes restless and confused. Vital signs are:
BP: 88/54 mmHg
HR: 132/min
RR: 32/min
SpO₂: 91%
Which finding requires the nurse's most immediate intervention?
A. Open femur fracture
B. Restlessness and confusion
C. Respiratory rate of 32/min
D. Blood pressure of 88/54 mmHg
Answer: B
Rationale: Acute restlessness and confusion can be an early indication of inadequate oxygenation or cerebral perfusion. The nurse should immediately reassess airway and breathing and evaluate for causes such as hemorrhagic shock or worsening respiratory compromise.
A 24-year-old patient is brought to the ED after a motorcycle crash. The patient has an unstable pelvic fracture and suspected internal bleeding.
Initial assessment:
BP: 86/48 mmHg
HR: 142/min
RR: 30/min
SpO₂: 94%
Skin: cool, pale, diaphoretic
Mental status: anxious and restless
After 1 L of isotonic crystalloid, the BP is 84/46 mmHg and HR is 140/min.
Which intervention should the nurse anticipate next?
A. Administer another 2 L of crystalloid rapidly
B. Prepare for blood product administration and hemorrhage control
C. Administer IV furosemide
D. Place the patient in Trendelenburg position
Answer: B
Rationale: Persistent hypotension and tachycardia despite initial fluid resuscitation strongly suggest ongoing hemorrhagic shock. In major trauma, excessive crystalloid can worsen dilutional coagulopathy and hypothermia. Blood products and definitive hemorrhage control are priorities.
A patient develops sudden severe dyspnea after insertion of a central venous catheter. The patient is hypotensive, tachycardic, and has absent breath sounds on the right. The trachea appears deviated to the left.
Which action should the nurse take?
A. Obtain a stat chest x-ray before intervention
B. Prepare for immediate needle/finger decompression
C. Increase IV fluids and reassess in 30 minutes
D. Place the patient supine and administer morphine
Answer: B
Rationale: This presentation is classic for tension pneumothorax with obstructive shock. Treatment is immediate decompression; waiting for imaging can be life-threatening.
A patient with a head injury develops BP 184/62, HR 48, irregular respirations, and decreasing level of consciousness.
What should the nurse recognize?
A. Neurogenic shock
B. Cushing response associated with increased ICP
C. Hypovolemic shock
D. Normal response to pain
B
Why is objective documentation important especially in the Emergency cases that may involve litigation later?
A: Because emotional language makes a chart legally invalid
B: Beceause objective documentation eliminates all legal risk
C: Because the medical record may later be reviewed to understand what occured
D: Because staff should only document information that supports their decisions
C
A patient with acute kidney injury has a potassium level of 7.1 mEq/L. The ECG shows peaked T waves followed by progressive QRS widening.
Which medication is intended to stabilize the myocardium without directly lowering serum potassium?
A. Regular insulin
B. Sodium zirconium cyclosilicate
C. Calcium gluconate
D. Sodium bicarbonate
Answer: C
Rationale: IV calcium stabilizes the cardiac membrane and reduces the risk of ventricular dysrhythmias. It does not significantly lower serum potassium. Insulin/dextrose shifts potassium intracellularly, while potassium binders remove potassium from the body.
A patient develops wheezing, hypotension, facial edema, and urticaria after receiving an IV antibiotic.
The nurse administers IM epinephrine. Five minutes later, the patient remains hypotensive.
Which intervention should the nurse anticipate?
A. Repeat epinephrine according to protocol and continue aggressive supportive management
B. Administer only diphenhydramine and observe
C. Administer IV furosemide
D. Place the patient in a seated position and encourage slow breathing
Answer: A
Rationale: Persistent cardiovascular or respiratory compromise after initial epinephrine may require repeat IM epinephrine and escalation of resuscitative measures. Antihistamines are adjunctive—they do not replace epinephrine.
A 25-year-old patient is brought to the ED after a high-speed motor vehicle collision. The patient has a pelvic fracture and abdominal tenderness.
Initially:
BP 106/70 mmHg
HR 116/min
RR 24/min
SpO₂ 97%
Skin cool and pale
Twenty minutes later:
BP 80/46 mmHg
HR 142/min
RR 32/min
SpO₂ 93%
Increasing agitation
Which intervention should the nurse prioritize?
A. Administer IV opioid analgesia
B. Prepare for massive hemorrhage resuscitation and blood products
C. Insert an indwelling urinary catheter
D. Obtain a repeat abdominal ultrasound
Answer: B
Rationale: The patient's worsening tachycardia, hypotension, tachypnea, agitation, and pallor strongly suggest ongoing hemorrhagic shock. With major trauma and suspected internal bleeding, rapid hemorrhage control and appropriate blood-product resuscitation are priorities. Pain control and diagnostic procedures must not delay resuscitation.