Oncologic Emergency
The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first?
a.
A 35-yr-old patient who has wet desquamation associated with abdominal radiation
b.
A 42-yr-old patient who is sobbing after receiving a new diagnosis of ovarian cancer
c.
A 24-yr-old patient who received neck radiation and has blood oozing from the neck
d.
A 56-yr-old patient who developed a new pericardial friction rub after chest radiation
ANS: C
Because neck bleeding may indicate possible carotid artery rupture in a patient who is receiving radiation to the neck, this patient should be seen first. The diagnoses and clinical manifestations for the other patients are not immediately life threatening.
The nurse receives the patient’s most recent blood work results. Which laboratory value is of greatest concern?
a.
Sodium of 145 mEq/L
b.
Calcium of 15.5 mg/dL
c.
Potassium of 3.5 mEq/L
d.
Chloride of 100 mEq/L
ANS: B
Normal calcium range is 9 to 10.5 mg/dL; therefore, a value of 15.5 mg/dL is abnormally high and of concern. The rest of the laboratory values are within their normal ranges: sodium 136 to 145 mEq/L, potassium 3.5 to 5.0 mEq/L, and chloride 98 to 106 mEq/L.
A patient who was admitted with diabetic ketoacidosis secondary to a urinary tract infection has been weaned off an insulin drip 30 minutes ago. The patient reports feeling lightheaded and sweaty. Which action should the nurse take first?
a.Infuse dextrose 50% by slow IV push.
b.Administer 1 mg glucagon subcutaneously.
c.Obtain a glucose reading using a finger stick.
d.Have the patient drink 4 ounces of orange juice.
ANS: A
The most urgent patient problem is the hypovolemia associated with diabetic ketoacidosis (DKA), and the priority is to infuse IV fluids. The other actions can be done after the infusion of normal saline is initiated.
During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next?
a.Palpate extremities for bilateral pulses.
b.Observe the patient’s respiratory effort.
c.Check the patient’s level of consciousness.
d.Examine the patient for any external bleeding.
ANS: B
Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient’s breathing. The other actions are also part of the initial survey, but assessment of breathing should be done immediately after assessing for airway patency.
Following an earthquake, patients are triaged by emergency medical personnel and transported to the emergency department (ED). Which patient will the nurse need to assess first?
a.
A patient with a red tag
b.
A patient with a blue tag
c.
A patient with a black tag
d.
A patient with a yellow tag
ANS: A
The red tag indicates a patient with a life-threatening injury requiring rapid treatment. The other tags indicate patients with less urgent injuries or those who are likely to die.
The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider?
a.Hematocrit 30%
b.Platelets 95,000/µL
c.Hemoglobin 10 g/L
d.White blood cells (WBC) 2700/µL
ANS: D
The low WBC count places the patient at risk for severe infection and is an indication that the chemotherapy dose may need to be lower or that WBC growth factors such as filgrastim (Neupogen) are needed. Although the other laboratory data indicate decreased levels, they do not indicate any immediate life-threatening adverse effects of the chemotherapy.
The nurse observes that the patient’s calcium is elevated. When checking the phosphate level, what does the nurse expect to see?
a.
An increase
b.
A decrease
c.
Equal to calcium
d.
No change in phosphate
ANS: B
Phosphate will decrease. Serum calcium and phosphate have an inverse relationship. When one is elevated, the other decreases, except in some patients with end-stage renal disease.
Which laboratory value reported by the unlicensed assistive personnel (UAP) indicates an urgent need for the nurse to assess the patient?
a.Bedtime glucose of 140 mg/dL
b.Noon blood glucose of 52 mg/dL
c.Fasting blood glucose of 130 mg/dL
d.2-hr postprandial glucose of 220 mg/dL
ANS: B
The nurse should assess the patient with a blood glucose level of 52 mg/dL for symptoms of hypoglycemia and give the patient a carbohydrate-containing beverage such as orange juice. The other values are within an acceptable range or not immediately dangerous for a patient with diabetes.
During the primary survey of a patient with severe leg trauma, the nurse observes that the patient’s During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next?
a.Palpate extremities for bilateral pulses.
b.Observe the patient’s respiratory effort.
c.Check the patient’s level of consciousness.
d.Examine the patient for any external bleeding.
ANS: D
The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although a complete blood count is indicated, administration of IV fluids should be started first. Completion of the primary survey and further assessment should be completed after the IV fluids are initiated.
Family members are in the patient’s room when the patient has a cardiac arrest and the staff start resuscitation measures. Which action should the nurse take next?
a.
Keep the family in the room and assign a staff member to explain the care given and answer questions.
b.
Ask the family to wait outside the patient’s room with a staff member to provide emotional support.
c.
Ask the family members whether they would prefer to remain in the patient’s room or wait outside the room.
d.
Tell the family members that patients are comforted by having family members present during resuscitation efforts.
ANS: C
Although many family members and patients report benefits from family presence during resuscitation efforts, the nurse’s initial action should be to determine the preference of these family members. The other actions may be appropriate, but this will depend on what is learned when assessing family preferences.
After change-of-shift report on the oncology unit, which patient should the nurse assess first?
a.Patient who has a platelet count of 82,000/µL after chemotherapy.
b.Patient who has xerostomia after receiving head and neck radiation.
c.Patient who is neutropenic and has a temperature of 100.5° F (38.1° C).
d.Patient who is worried about getting the prescribed long-acting opioid on time.
ANS: C
Fever is an emergency in neutropenic patients because of the risk for rapid progression to severe infections and sepsis. The other patients also require assessments or interventions but do not need to be assessed as urgently. Patients with thrombocytopenia do not have spontaneous bleeding until the platelets are 20,000/µL. Xerostomia does not require immediate intervention. Although breakthrough pain needs to be addressed rapidly, the patient does not appear to have breakthrough pain.
The health care provider has ordered a hypotonic intravenous (IV) solution to be administered. Which IV bag will the nurse prepare?
a.
0.45% sodium chloride (1/2 NS)
b.
0.9% sodium chloride (NS)
c.
Lactated Ringer’s (LR)
d.
Dextrose 5% in Lactated Ringer’s (D5LR)
ANS: A
0.45% sodium chloride is a hypotonic solution. NS and LR are isotonic. D5LR is hypertonic.
A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. What action would the nurse take?
a.
Administration of oxygen via facemask
b.
Intravenous administration of 10% glucose
c.
Implementation of seizure precautions
d.
Administration of intravenous insulin
ANS: D
The rapid, deep respiratory efforts of Kussmaul respirations are the body’s attempt to reduce the acids produced by using fat rather than glucose for fuel. Only the administration of insulin will reduce this type of respiration by assisting glucose to move into cells and to be used for fuel instead of fat. The patient who is in ketoacidosis may not experience any respiratory impairment and therefore does not need additional oxygen. Giving the patient glucose would be contraindicated. The patient does not require seizure precautions.
A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). Which patient statement indicates to the nurse that discharge teaching has been effective?
a.
“I’ll take salt tablets when I work outdoors in the summer.”
b.
“I should take acetaminophen (Tylenol) if I start to feel too warm.”
c.
“I need to drink extra fluids when working outside in hot weather.”
d.
“I’ll move to a cool environment if I notice that I’m feeling confused”
ANS: C
Oral fluids and electrolyte replacement solutions such as sports drinks help replace fluid and electrolytes lost when exercising in hot weather. Salt tablets are not recommended because of the risks of gastric irritation and hypernatremia. Antipyretic drugs are not effective in lowering body temperature elevations caused by excessive exposure to heat. A patient who is confused is likely to have more severe hyperthermia and will be unable to remember to take appropriate action.
An emergency department nurse assesses a client who has been raped. With which health care team member would the nurse collaborate when planning this client’s care?
a.
Primary health care provider
b.
Case manager
c.
Forensic nurse examiner
d.
Psychiatric crisis nurse
ANS: C
All other members of the health care team listed may be used in the management of this client’s care. However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault.
A client is admitted with superior vena cava syndrome. What action by the nurse is most appropriate?
a.
Administer a dose of allopurinol.
b.
Assess the client’s serum potassium level.
c.
Gently inquire about advance directives.
d.
Prepare the client for emergency surgery.
NS: C
Superior vena cava syndrome is often a late-stage manifestation. After the client is stabilized and comfortable, the nurse would initiate a conversation about advance directives. Allopurinol is used for tumor lysis syndrome. Potassium levels are important in tumor lysis syndrome, in which cell destruction leads to large quantities of potassium being released into the bloodstream. Surgery is rarely done for superior vena cava syndrome.
The nurse is evaluating the effectiveness of the intravenous fluid therapy in a patient with hypernatremia. Which finding indicates goal achievement?
a.
Urine output increases to 150 mL/hr.
b.
Systolic and diastolic blood pressure decreases.
c.
Serum sodium concentration returns to normal.
d.
Large amounts of emesis and diarrhea decrease.
ANS: C
Hypernatremia is diagnosed by elevated serum sodium concentration. Blood pressure is not an accurate indicator of hypernatremia. Emesis and diarrhea will not stop because of intravenous therapy. Urine output is influenced by many factors, including extracellular fluid volume. A large dilute urine output can cause further hypernatremia.
A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which would alert the nurse to intervene immediately?
a.
Serum chloride level of 98 mEq/L (98 mmol/L)
b.
Serum calcium level of 8.8 mg/dL (2.2 mmol/L)
c.
Serum sodium level of 132 mEq (132 mmol/L)
d.
Serum potassium level of 2.5 mEq/L (2.5 mmol/L)
ANS: D
Insulin activates the sodium–potassium ATPase pump, increasing the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. In hyperglycemia, hypokalemia can also result from excessive urine loss of potassium. The chloride level is normal. The calcium and sodium levels are slightly low, but this would not be related to hyperglycemia and insulin administration.
A triage nurse in a busy emergency department (ED) assesses a patient who reports 7/10 abdominal pain and states, “I had a temperature of 103.9° F (39.9° C) at home.” What should be the nurse’s first action?
a.
Give acetaminophen (Tylenol).
b.
Assess the patient’s current vital signs.
c.
Ask the patient to provide a clean-catch urine for urinalysis.
d.
Tell the patient that it may be 1 to 2 hours before seeing a health care provider.
ANS: B
The patient’s pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how rapidly the health care provider should see the patient. A urinalysis may be appropriate, but this would be done after the vital signs are taken. The nurse will not give acetaminophen before confirming a current temperature elevation.
A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center?
a.
Level I—located within remote areas and provides advanced life support within resource capabilities
b.
Level II—located within community hospitals and provides care to most injured clients
c.
Level III—located in rural communities and provides only basic care to clients
d.
Level IV—located in large teaching hospitals and provides a full continuum of trauma care for all clients
ANS: B
Level I trauma centers are usually located in large teaching hospital systems and provide a full continuum of trauma care for all clients. Both Level II and Level III facilities are usually located in community hospitals. These trauma centers provide care for most clients and transport to Level I centers when client needs exceed resource capabilities. Level IV trauma centers are usually located in rural and remote areas. These centers provide basic care, stabilization, and advanced life support while transfer arrangements to higher level trauma centers are made.
A nurse is caring for a client after surgery. The client’s respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since the client was last assessed 4 hours ago. What action by the nurse is best?
a.
Ask if the client needs pain medication.
b.
Assess using the MEWS score.
c.
Document the findings in the client’s chart.
d.
Increase the rate of the client’s IV infusion.
ANS: B
Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate, respiratory rate, or blood pressure. Even though these readings are not out of the normal range, the nurse would conduct a thorough assessment of the patient, focusing on indicators of perfusion. The MEWS score (Modified Early Warning Score) was developed to identify clients at risk for deterioration. The client may need pain medication, but this is not the priority at this time. Documentation would be done thoroughly but would be done after the assessment. The nurse would not increase the rate of the IV infusion without an order.
A patient presents to the emergency department with reports of vomiting and diarrhea for the past 48 hours. The health care provider orders isotonic intravenous (IV) therapy. Which IV will the nurse prepare?
a.
0.225% sodium chloride (1/4 NS)
b.
0.45% sodium chloride (1/2 NS)
c.
0.9% sodium chloride (NS)
d.
3% sodium chloride (3% NaCl)
ANS: C
Patients with prolonged vomiting and diarrhea become hypovolemic. A solution to replace extracellular volume is 0.9% sodium chloride, which is an isotonic solution. 0.225% and 0.45% sodium chloride are hypotonic. 3% sodium chloride is hypertonic.
The nurse is caring for a newly admitted older adult who has a blood glucose of 300 mg/dL (16.7 mmol/L), a urine output of 185 mL in the past 8 hours, and a blood urea nitrogen (BUN) of 44 mg/dL (15.7 mmol/L). What diabetic complication does the nurse suspect?
a.
Diabetic ketoacidosis (DKA)
b.
Severe hypoglycemia
c.
Chronic kidney disease (CKD)
d.
Hyperglycemic-hyperosmolar state (HHS)
ANS: D
The client most likely has diabetes mellitus type 2 and has a high blood glucose causing increased blood osmolarity and dehydration, as evidenced by an insufficient urinary output and increased BUN. Older adults are at the greatest risk for dehydration due to age-related physiologic changes.
An unresponsive 79-yr-old patient is admitted to the emergency department (ED) during a summer heat wave. The patient’s core temperature is 105.4° F (40.8° C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. What action should the nurse plan to take?
a.
Apply wet sheets and a fan to the patient.
b.
Provide O2 at 2 L/min with a nasal cannula.
c.
Start lactated Ringer’s solution at 1000 mL/hr.
d.
Give acetaminophen (Tylenol) rectal suppository.
ANS: A
The priority intervention is to cool the patient. Antipyretics are not effective in decreasing temperature in heat stroke and 100% O2 should be given, which requires a high flowrate through a non-rebreather mask. An older patient would be at risk for developing complications such as pulmonary edema if given fluids at 1000 mL/hr.
The following four patients arrive in the emergency department (ED) after a motor vehicle collision. In which order should the nurse assess them? (Put a comma and a space between each answer choice [A, B, C, D, E].)
a. A 43-yr-old patient reporting 7/10 abdominal pain
b. A 74-yr-old patient with palpitations and chest pain
c. A 21-yr-old patient with multiple fractures of the face and jaw
d. A 37-yr-old patient with a misaligned lower leg and intact pulses
ANS:
C, B, A, D
The highest priority is to assess the 21-yr-old patient for airway obstruction, which is the most life-threatening injury. The 74-yr-old patient may have chest pain from cardiac ischemia and should be assessed and have diagnostic testing for this pain. The 43-yr-old patient may have abdominal trauma or bleeding and should be seen next to assess circulatory status. The 37-yr-old patient appears to have a possible fracture of the left leg and should be seen soon, but this patient has the least life-threatening injury.