infection
A patient has just been admitted with probable bacterial pneumonia and sepsis.Which prescribed action would the nurse implement first?
a. Chest x-ray via stretcher
b. Blood cultures from two sites
c. Ciprofloxacin (Cipro) 400 mg IV
d. Acetaminophen (Tylenol) suppository
Answer: b. Blood cultures from two sites
Rationale:
In a patient with probable bacterial pneumonia and sepsis, obtaining blood cultures before administering antibiotics is critical to identify the causative organism and guide targeted therapy. Cultures from two different sites improve the accuracy of detecting bloodstream infections.
Which information will a patient's glycosylated hemoglobin (A1C) result provide to the nurse?
a. Fasting preprandial glucose levels
b. Glucose levels 2 hours after a meal
c. Glucose control over the past 90 days
d. Hypoglycemic episodes in the past 3 months
Answer: c. Glucose control over the past 90 days
Rationale:
Hemoglobin A1C reflects the average blood glucose levels over the past 2–3 months (about 90 days). It measures the percentage of glucose bound to hemoglobin in red blood cells, which have an average lifespan of 120 days. This test is a key indicator of long-term glycemic control in patients with diabetes.
A patient is apneic and has no palpable pulses. The heart monitor shows sinus tachycardia, rate 132. Which action would the nurse take next? a. Perform synchronized cardioversion.
b. Start cardiopulmonary resuscitation(CPR).
c. Give atropine per agency dysrhythmia protocol.
d. Apply supplemental O2 via non-rebreather mask.
Answer: b. Start cardiopulmonary resuscitation(CPR).
Rationale:
The patient is apneic and pulseless, which indicates cardiac arrest, regardless of the monitor showing sinus tachycardia (which could be a monitor artifact or electrical activity without mechanical pulse). The immediate priority is to begin high-quality CPR to provide circulatory support and oxygenation.
What are early signs of hypoxemia in a patient with anemia?
a) Bradycardia
b) Restlessness
c) Cyanosis
d) Hypertension
Answer: b) Restlessness
Rationale: Restlessness is an early clinical sign of hypoxemia due to inadequate oxygen delivery to tissues, commonly seen in anemia.
A patient presents with chest pain radiating to the arm, and the EKG shows ST elevations. What should the nurse do?
a) Administer morphine and reassess in 30 minutes
b) Give acetaminophen
c) Notify the HCP immediately
d) Encourage deep breathing
Answer: c) Notify the HCP immediately
Rationale: ST elevation indicates possible STEMI, requiring immediate intervention.
Patient seen in the clinic for a bladder infection describes the following symptoms. Which information is most important for the nurse to report to the HCP?
a. Urinary urgency
b. Left-sided flank pain
c. Intermittent hematuria
d. Burning with urination
Answer: b. Left-sided flank pain
Rationale:
Left-sided flank pain suggests that the infection may have progressed from a lower urinary tract infection (cystitis) to pyelonephritis, an infection of the kidney. This condition is more serious and can lead to complications such as sepsis if not treated promptly. Therefore, it is crucial to report this symptom to the healthcare provider immediately.
What do you do for a patient who is having repeated seizures?
a. Give phenytoin (Dilantin) 100 mg IV.
b. Monitor level of consciousness (LOC).
c. Administer lorazepam (Ativan) 4 mg IV.
d. Obtain computed tomography (CT) scan.
Answer: c. Administer lorazepam (Ativan) 4 mg IV.
Rationale:
For a patient having repeated seizures (status epilepticus), the priority is to stop the seizure activity immediately to prevent brain injury. Lorazepam, a benzodiazepine, is the first-line medication for rapid seizure control due to its fast onset and effectiveness when given IV.
During change-of-shift report on a medical unit, the nurse learns that a patient with aspiration pneumonia who was admitted with respiratory distress has become increasingly agitated. Which action would the nurse take first?
a. Give the prescribed PRN sedative drug.
b. Offer reassurance and reorient the patient.
c. Use pulse oximetry to check the oxygen saturation.
d. Notify the health care provider about the patient's status.
Answer: c. Use pulse oximetry to check the oxygen saturation.
Rationale:
Increasing agitation in a patient with aspiration pneumonia and respiratory distress may indicate worsening hypoxia. The nurse’s first priority is to assess the patient’s oxygenation status quickly to identify if the agitation is due to low oxygen levels.
A patient demonstrates decorticate posturing after a head injury. Before performing a lumbar puncture, what is the most important nursing action?
a) Obtain consent for the lumbar puncture
b) Check blood glucose levels
c) Assess for signs of increased intracranial pressure
d) Prepare the patient for MRI
Answer: a) Obtain consent for the lumbar puncture
Rationale: Decorticate posture indicates serious brain injury. Consent must be obtained prior to invasive procedures like lumbar puncture, which may be contraindicated if increased ICP is present
Which assessment data collected by the nurse who is admitting a patient with chest pain suggests that the pain is caused by an acute myocardial infarction (AMI)?// diagnosis for myocardial infarction
a. The pain increases with deep breathing.
b. The pain has lasted longer than 30 minutes
c. The pain is relieved after taking nitroglycerin.
d. The pain is reproducible when the patient raises the arms.
Answer: b. The pain has lasted longer than 30 minutes
Rationale:
Chest pain caused by an acute myocardial infarction (AMI) typically lasts longer than 20–30 minutes and is often described as severe, persistent, and not relieved by rest or nitroglycerin. Prolonged duration of chest pain is a hallmark sign distinguishing AMI from other causes of chest pain like angina or musculoskeletal pain.
Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient who has acute pancreatitis?
a. Nausea and vomiting
b. Hypotonic bowel sounds
c. Muscle twitching and finger numbness
d. Upper abdominal tenderness and guarding
Answer: c. Muscle twitching and finger numbness
Rationale:
Muscle twitching and finger numbness are signs of hypocalcemia, which is a serious complication of acute pancreatitis. Hypocalcemia can lead to tetany, seizures, cardiac arrhythmias, and needs urgent assessment and treatment.
Which nursing action will be included in the plan of care for a patient who is being treated for bleeding esophageal varices with balloon tamponade?
a. Instruct the patient to cough every hour.
b. Monitor the patient for shortness of breath.
c. Verify the position of the balloon every 4 hours.
d.Deflate the gastric balloon if the patient reports nausea.
nswer: b. Monitor the patient for shortness of breath.
Rationale:
Balloon tamponade is used to control bleeding from esophageal varices by applying pressure inside the esophagus and stomach. However, the inflated balloon can obstruct the airway or impair breathing, leading to respiratory complications such as shortness of breath. Monitoring for respiratory distress is critical to detect early signs of airway compromise or balloon displacement.
After a patient who has septic shock receives 2 L of IV normal saline, the central venous pressure is 10 mm Hg and the blood pressure is 82/40 mm Hg. Which medication would the nurse anticipate being prescribed?
a. Furosemide
b. Nitroglycerin
c. Norepinephrine
d. Sodium nitroprusside
Answer: c. Norepinephrine (levophed)
Rationale:
In septic shock, even after adequate fluid resuscitation (e.g., 2 L of IV normal saline), if the blood pressure remains low (as seen here: 82/40 mm Hg), vasopressor support is required to maintain perfusion to vital organs. Norepinephrine (Levophed) is the first-line vasopressor for septic shock because it causes vasoconstriction, increasing systemic vascular resistance and improving blood pressure without significantly compromising organ perfusion.
A 42-year-old patient is brought to the emergency department after a motor vehicle collision and is being evaluated for a possible traumatic brain injury. During the initial assessment, which finding requires immediate communication with the health care provider?
A. The patient reports a history of migraines and took sumatriptan earlier in the day.
B. The patient states they take warfarin (Coumadin) daily for atrial fibrillation.
C. The patient complains of a headache rated 6 out of 10.
D. The patient’s blood pressure is 148/90 mm Hg upon arrival to the ED.
Answer: b
B is correct: Anticoagulant use (e.g., warfarin) significantly increases the risk of intracranial hemorrhage following a head injury. This is a critical safety concern that requires immediate provider notification to evaluate for possible bleeding (e.g., order a STAT CT and check INR). Even without visible signs of bleeding, the internal risk is elevated.
When titrating IV nitroglycerin (Tridil) for a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the medication?
a. Monitor heart rate.
b. Ask about chest pain.
c. Check blood pressure.
d. Observe for dysrhythmias.
Answer: b. Ask about chest pain.
Rationale:
Nitroglycerin (Tridil) is a vasodilator used in the management of myocardial infarction (MI) to reduce myocardial oxygen demand by dilating coronary arteries and decreasing preload and afterload. The primary goal of IV nitroglycerin therapy in this context is relief of chest pain due to myocardial ischemia.
10. Which assessment finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider?
a. Flank tenderness to palpation
b. Blood pressure 82/60 mm Hg
c. Cloudy and foul-smelling urine
d. Temperature 100.1F (57.8C)
Answer: b. Blood pressure 82/60 mm Hg
Rationale:
A blood pressure of 82/60 mm Hg indicates hypotension, which can be a sign of septic shock or severe infection complications in a patient with acute pyelonephritis. Hypotension can lead to inadequate organ perfusion and is a medical emergency requiring immediate intervention. Prompt reporting to the healthcare provider is crucial to prevent further deterioration.
Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective?
a. Increased serum albumin level
b. Decreased indirect bilirubin level
c. Improved alertness and orientation
d. Fewer episodes of bleeding varices
Answer: d. Fewer episodes of bleeding varices
Rationale:
A transjugular intrahepatic portosystemic shunt (TIPS) is a procedure used to reduce portal hypertension by creating a pathway for blood flow between the portal and systemic circulation. One of the main goals of TIPS is to lower the pressure in the portal vein to prevent complications such as bleeding from esophageal or gastric varices.
Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome
a. The patient's serum creatinine level is elevated.
b. The patient reports intermittent chest pressure.
c. The patient's extremities are cool and pulses are weak.
d. The patient has bilateral crackles throughout lung fields.
Answer: a. The patient's serum creatinine level is elevated.
Rationale:
An elevated serum creatinine level indicates impaired kidney function, which is a sign of organ dysfunction. In cardiogenic shock, poor cardiac output leads to inadequate tissue perfusion and oxygen delivery to organs, including the kidneys. When multiple organs start to fail due to hypoperfusion and ischemia, this is known as multiple organ dysfunction syndrome (MODS). Kidney dysfunction, reflected by increased creatinine, is one of the earliest indicators of MODS.
A patient who has been involved in a motor vehicle accident arrives to ED with cool, clammy skin, tachycardia, and hypotension. What intervention should be implemented first?
a. Insert two large-bore IV catheters.
b. Provide O2 at 100% per non-rebreather mask.
c. Draw blood to type and crossmatch for transfusions.
d. Initiate continuous electrocardiogram (ECG) monitoring.
Answer: b. Provide O2 at 100% per non-rebreather mask.
Rationale:
The patient’s presentation—cool, clammy skin, tachycardia, and hypotension—indicates shock, likely from blood loss (hypovolemic shock) after trauma. The priority intervention is to ensure adequate oxygenation to vital organs. Administering high-flow oxygen via a non-rebreather mask rapidly increases oxygen delivery, helping prevent tissue hypoxia.
A patient recovering from heart surgery develops pericarditis and complains of level 6 (0 to 10 scale) chest pain with deep breathing. Which ordered PRN medication will be the most appropriate for the nurse to give?
a. Fentanyl 1 mg IV
b. IV morphine sulfate 4 mg
c. Oral ibuprofen (Motrin) 600 mg
d. Oral acetaminophen (Tylenol) 650 mg
nswer: c. Oral ibuprofen (Motrin) 600 mg
Rationale:
Pericarditis is inflammation of the pericardium, often causing sharp, pleuritic chest pain that worsens with deep breathing or coughing. The primary treatment for pericarditis is to reduce inflammation and relieve pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are the first-line medications because they have both analgesic and anti-inflammatory effects.
1. SATA: Risk factors for bacterial infection:
a -Diabetes Mellitus
b -Atopic dermatitis
c -Moisture
d -Obesity
e -Skin neoplasms
all of them
Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the drug?
a. Bowel sounds
b. Stool frequency
c. Stool occult blood
d. Abdominal distention
Answer c. Stool occult blood ( no occult blood in the stool)
Rationale:
Esomeprazole (Nexium) is a proton pump inhibitor (PPI) prescribed to reduce gastric acid secretion and prevent stress-related gastric ulcers, which are common in patients with extensive burns. The best way to evaluate the effectiveness of the drug is to monitor for signs of gastrointestinal bleeding, which can be detected by testing for occult blood in the stool.
Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock?
a. Check temperature every 2 hours.
b. Monitor breath sounds frequently.
c. Maintain patient in supine position.
d. Assess skin for flushing and itching.
Answer: b. Monitor breath sounds frequently
Rationale:
In cardiogenic shock, the heart’s ability to pump blood is severely impaired, leading to decreased cardiac output and pulmonary congestion due to backup of blood into the lungs. This can cause pulmonary edema, which is life-threatening and requires close monitoring.
A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention would the nurse implement first?
a. Assess pain level.
b. Place on heart monitor.
c. Check potassium level.
d. Assess oral temperature.
b. Place on heart monitor.
Rationale:
Electrical burns can cause cardiac arrhythmias or myocardial damage due to the electrical current passing through the body, potentially affecting the heart's conduction system. Cardiac monitoring is the first priority to detect life-threatening arrhythmias early.
Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute SOB has heart failure?
a. Serum troponin
b. Arterial blood gases
c. B-type natriuretic peptide
d. 12-lead electrocardiogram
Answer: c. B-type natriuretic peptide
Rationale:
BNP is a hormone released by the ventricles in response to increased pressure and volume overload, as seen in heart failure. Elevated BNP levels are a sensitive and specific marker for diagnosing acute decompensated heart failure, especially in patients presenting with shortness of breath (SOB). The higher the BNP, the more likely the SOB is due to heart failure rather than a pulmonary or other cause.