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A patient with renal failure has a potassium level of 7.0 mEq/L. The ECG shows peaked T waves and widening of the QRS complex.
Which medication should the nurse expect to administer first?
A. Regular insulin with dextrose
B. Calcium gluconate
C. Furosemide
D. Sodium polystyrene sulfonate
Answer: B. Calcium gluconate
Rationale: IV calcium stabilizes the cardiac membrane and is the priority when severe hyperkalemia is producing ECG changes. Calcium does not significantly lower serum potassium; insulin/dextrose and other therapies are used to shift or remove potassium.
A 25-year-old patient is brought to the ED after a diving accident. The patient has a suspected cervical spinal cord injury.
Assessment:
BP: 78/42 mmHg
HR: 48/min
RR: 18/min
Skin: warm and dry
Patient reports numbness and weakness below the neck
Which type of shock is most likely?
A. Hypovolemic shock
B. Cardiogenic shock
C. Neurogenic shock
D. Septic shock
Answer: C. Neurogenic shock
Rationale: Neurogenic shock occurs after loss of sympathetic nervous system tone, commonly with high spinal cord injury. The classic pattern is hypotension with relative bradycardia and warm, dry skin. Hypovolemic shock usually produces tachycardia and cool, clammy skin.
A patient with COPD exacerbation is receiving oxygen. Which finding requires the most immediate attention?
A. SpO₂ of 90%
B. Mild productive cough
C. Increasing somnolence with worsening respiratory acidosis
D. Respiratory rate of 22/min
Answer: C
Rationale: Increasing somnolence with worsening hypercapnic respiratory acidosis suggests ventilatory failure. Oxygenation alone does not adequately assess ventilation; mental status and CO₂ retention are critical.
A patient with severe asthma arrives in respiratory distress. Initially the patient has loud expiratory wheezing.
Thirty minutes later, the nurse notes:
Increasing fatigue
Minimal air movement
Very faint breath sounds
Increasing PaCO₂
Altered mental status
What does this indicate?
A. Improvement because the wheezing has decreased
B. Impending respiratory failure
C. Resolution of bronchospasm
D. Anxiety-related hyperventilation
Answer: B
Rationale: In severe asthma, a "silent chest" is ominous, not reassuring. Minimal air movement means critically reduced ventilation. Rising PaCO₂ and altered mental status indicate respiratory muscle fatigue and impending respiratory failure.
A patient with a cervical spinal cord injury develops:
BP 78/42 mmHg
HR 44/min
Warm, dry skin
Which type of shock should the nurse suspect?
A. Hypovolemic shock
B. Cardiogenic shock
C. Neurogenic shock
D. Septic shock
Answer: C
Rationale: Neurogenic shock results from loss of sympathetic vascular tone following significant spinal cord injury. The combination of hypotension, bradycardia, and warm/dry skin distinguishes it from typical hypovolemic shock, which usually produces tachycardia and cool skin.
A patient suddenly develops right-sided weakness and aphasia. The patient's spouse states:
"I saw him completely normal at 08:10. At 08:35 I noticed he couldn't speak properly."
It is now 09:00.
Which information is most important to communicate to the stroke team?
A. The patient's breakfast intake
B. The exact last-known-well time
C. The patient's usual blood pressure
D. The patient's smoking history
Answer: B
Rationale: Time of symptom onset or last known well is critical in determining eligibility for time-sensitive stroke therapies. The nurse should communicate the precise timeline immediately.
A patient with chest pain is prescribed sublingual nitroglycerin. Before administering it, which finding is most concerning?
A. Pain rated 8/10
B. HR 104/min
C. BP 84/52 mmHg
D. History of hypertension
Answer: C
Rationale: Nitroglycerin causes vasodilation and can significantly worsen hypotension. A patient who is already hypotensive requires immediate reassessment rather than routine administration.
A 31-year-old patient is brought to the ED after a high-speed MVC. The patient has abdominal tenderness and a suspected pelvic fracture.
Vital signs:
BP: 102/70 mmHg
HR: 124/min
RR: 26/min
SpO₂: 97%
Skin: cool and pale
The patient suddenly says, "I'm very thirsty," and becomes increasingly restless.
What should the nurse do first?
A. Administer IV opioid analgesia
B. Prepare for hemorrhage control and blood-product resuscitation
C. Obtain a urine specimen
D. Reassure the patient that the vital signs are stable
Answer: B
Rationale: Tachycardia, pallor, restlessness, and intense thirst can be early signs of significant blood loss even before profound hypotension develops. With suspected pelvic/abdominal trauma, occult hemorrhage must be assumed until proven otherwise. The nurse should rapidly support circulation and prepare for hemorrhage control and blood products.
A
patient with multiple rib fractures suddenly becomes severely dyspneic. Assessment reveals:
BP 78/44 mmHg
HR 140/min
RR 36/min
Distended neck veins
Absent breath sounds on the right
Tracheal deviation toward the left
Which action should the nurse anticipate?
A. Obtain a chest x-ray before treatment
B. Prepare for immediate decompression of the chest
C. Administer IV furosemide
D. Place the patient supine and reassess in 15 minutes
Answer: B
Rationale: This is classic for tension pneumothorax with obstructive shock. It is a clinical emergency; treatment should not be delayed for a chest x-ray in a crashing patient. Immediate decompression followed by definitive chest drainage is required.
A patient presents with severe substernal chest pressure radiating to the jaw. The ECG demonstrates ST elevation in leads II, III, and aVF.
The patient suddenly develops:
BP 78/44 mmHg
HR 54/min
Clear lungs
Jugular venous distention
Which finding is most important for the nurse to recognize?
A. Left ventricular failure
B. Right ventricular involvement
C. Acute pulmonary edema
D. Cardiogenic shock caused by mitral stenosis
Answer: B
Rationale: Inferior STEMI can involve the right ventricle, producing hypotension, bradycardia, and elevated right-sided filling pressures. Clear lungs and JVD support right ventricular involvement. These patients are particularly preload dependent, so interventions that markedly reduce preload can worsen hypotension.
A patient overdoses on amitriptyline and develops hypotension, seizures, and a widened QRS complex.
Which medication should the nurse anticipate?
A. Sodium bicarbonate
B. Naloxone
C. N-acetylcysteine
D. Protamine sulfate
Answer: A
Rationale: Sodium bicarbonate is used in significant TCA toxicity, particularly with QRS widening, ventricular dysrhythmias, hypotension, or seizures, because sodium loading and alkalinization can reduce cardiac toxicity.
A patient develops sudden, severe tearing chest pain radiating to the back. There is a significant difference in blood pressure between the arms.
Which intervention should the nurse question?
A. IV beta blocker therapy as prescribed
B. Continuous cardiovascular monitoring
C. Preparation for definitive imaging
D. Administration of thrombolytic therapy for presumed STEMI
Answer: D
Rationale: Aortic dissection can mimic acute coronary syndrome, but thrombolytic therapy can be dangerous in dissection because of the risk of catastrophic bleeding. The presentation should prompt urgent evaluation for dissection.
A patient arrives with sudden confusion, slurred speech, and unilateral weakness. Which assessment should the nurse perform immediately because it can identify a potentially reversible stroke mimic?
A. Temperature
B. Blood glucose
C. Urine output
D. Serum cholesterol
Answer: B
Rationale: Hypoglycemia can mimic acute stroke, producing focal neurological deficits and altered mental status. Point-of-care glucose should be checked rapidly in patients with suspected stroke.
A patient with DKA has:
Glucose: 640 mg/dL
pH: 7.08
HCO₃⁻: 7 mEq/L
K⁺: 2.7 mEq/L
Which order should the nurse question?
A. Continuous ECG monitoring
B. IV potassium replacement
C. IV regular insulin infusion immediately
D. Frequent electrolyte monitoring
Answer: C
Rationale: Insulin drives potassium into cells and can cause a dangerous further decrease in serum potassium. With significant hypokalemia, potassium replacement is required before insulin therapy is initiated. This is. The glucose has decreased from 580 mg/dL to 210 a classic emergency-nursing safety trap.
A patient with suspected sepsis has received initial fluid resuscitation. The patient's BP remains 76/42 mmHg and MAP is approximately 53 mmHg.
Which intervention should the nurse anticipate?
A. Vasopressor therapy
B. Fluid restriction only
C. Oral antihypertensive medication
D. Diuretic therapy
Answer: A
Rationale: Persistent hypotension despite appropriate initial fluid resuscitation suggests septic shock. Vasopressors, commonly norepinephrine, may be required to restore adequate perfusion pressure.
A patient has a regular wide-complex tachycardia at 210/min. The patient has a pulse but is confused, diaphoretic, and hypotensive at 68/40 mmHg.
What is the priority intervention?
A. Vagal maneuvers
B. IV adenosine
C. Synchronized cardioversion
D. Unsynchronized defibrillation
Answer: C. Synchronized cardioversion
Rationale: This is unstable tachycardia with a pulse. Hypotension, altered mental status, and ischemic chest discomfort are signs of instability. Synchronized cardioversion is indicated.
A patient with severe asthma initially has loud wheezing. After receiving several bronchodilator treatments, the nurse notes that wheezing has almost completely disappeared. The patient is increasingly fatigued and has very little air movement.
What is the nurse's priority interpretation?
A. The patient is improving
B. The bronchodilator therapy has been successful
C. The patient may be developing severe airflow obstruction and respiratory failure
D. The patient is experiencing anxiety
Answer: C
Rationale: A silent or nearly silent chest in severe asthma is an ominous finding. It can mean airflow is so severely restricted that little air is moving enough to produce wheezing. Increasing fatigue suggests impending respiratory failure.
A patient being treated for septic shock has a urinary catheter. Over the past 2 hours, urine output has fallen to 10 mL/hr.
What does this finding most strongly suggest?
A. Improved renal perfusion
B. Possible inadequate organ perfusion
C. Excessive oral intake
D. Resolution of shock
Answer: B
Rationale: Falling urine output can indicate decreased renal perfusion and worsening shock. Urine output is an important marker of end-organ perfusion.
A patient with DKA has been receiving IV insulin. The glucose has decreased from 580 mg/dL to 210 mg/dL, but the anion gap remains elevated.
What should the nurse anticipate?
A. Stop insulin immediately
B. Continue treatment of ketoacidosis and add dextrose as indicated
C. Administer additional potassium regardless of the current level
D. Discharge the patient because the glucose is below 250 mg/dL
Answer: B
Rationale: Resolution of DKA is not determined solely by normalization of serum glucose. If significant ketoacidosis persists, insulin must continue to suppress ketogenesis. Dextrose may patient with suspected sepsis has received initial fluid resuscitation. The patient's BP remains 76/42 mmHg and MAP is approximately be added to allow insulin to continue safely while glucose falls.
A postoperative patient suddenly develops severe dyspnea and chest pain.
Vital signs:
BP 76/44 mmHg
HR 138/min
RR 36/min
SpO₂ 79%
The patient becomes confused.
Which condition is most concerning?
A. Stable pulmonary embolism
B. Massive/high-risk pulmonary embolism with obstructive shock
C. Mild atelectasis
D. Anxiety attack
Answer: B
Rationale: Sudden hypoxemia, tachycardia, hypotension, and altered mental status after surgery strongly suggest a high-risk PE causing hemodynamic instability. This requires immediate resuscitative management.
A patient with an acute inferior STEMI receives nitroglycerin for chest pain. Shortly afterward:
BP decreases from 104/68 to 72/44 mmHg
HR: 58/min
Lungs remain clear
Which complication should the nurse suspect?
A. Right ventricular infarction
B. Acute pulmonary edema
C. Hypertensive crisis
D. Left ventricular failure
Answer: A
Rationale: Inferior myocardial infarction can involve the right ventricle, which is highly preload-dependent. Nitroglycerin decreases preload and can cause profound hypotension in right ventricular infarction. Clear lungs and hypotension support this possibility
A patient is found unconscious. Assessment reveals:
RR: 6/min
SpO₂: 76%
HR: 52/min
Pinpoint pupils
Minimal response to painful stimuli
What is the priority?
A. Obtain a toxicology screen
B. Support ventilation and administer naloxone
C. Obtain a urine sample
D. Administer activated charcoal
Answer: B
Rationale: The immediate life threat is severe respiratory depression. Airway and ventilation take priority, while naloxone is administered for suspected opioid toxicity. Diagnostic testing should not delay life-saving treatment.
Several patients are brought to the ED after being exposed to a malfunctioning furnace. One patient reports headache, dizziness, and confusion. SpO₂ is 99%.
Which action is most appropriate?
A. Discharge because oxygen saturation is normal
B. Administer high-concentration oxygen and evaluate for carbon monoxide toxicity
C. Withhold oxygen because the SpO₂ is already 99%
D. it cannot reliably distinguish oxyhemoglobin from carboxyhemoglobin. A Treat only if the SpO₂ decreases below 90%
Answer: B
Rationale: Standard pulse oximetry may appear normal in carbon monoxide poisoning because it cannot reliably distinguish oxyhemoglobin from carboxyhemoglobin. A significant exposure with neurological symptoms warrants immediate oxygen therapy and further evaluation.
A patient rescued from an enclosed-space house fire has:
Facial burns
Soot around the mouth
Hoarse voice normal SpO₂ does not exclude serious inhalation injury. Early airway management may become
Stridor
SpO₂ 99%
Which intervention is most important?
A. Apply topical burn cream
B. Prepare for early airway management
C. Wait for SpO₂ to fall
D. Encourage oral fluids
Answer: B
Rationale: Stridor and hoarseness indicate impending upper-airway obstruction. Airway edema can progress rapidly, and a normal SpO₂ does not exclude serious inhalation injury. Early airway management may become increasingly difficult as edema develops.
A 34-week pregnant patient presents with painless, bright-red vaginal bleeding. Vital signs are currently stable.
Which intervention is contraindicated until placenta previa has been excluded?
A. Establish IV access
B. Continuous fetal monitoring
C. Vaginal examination
D. Monitor maternal vital signs
Answer: C
Rationale: Painless third-trimester bleeding is characteristic of placenta previa. A digital vaginal examination can disrupt the placenta and cause severe hemorrhage. Placental location should be evaluated before performing such an examination.