EMERGENCY DEPARTMENT
A 55-year-old male presents to the ED with sudden onset chest pain, shortness of breath, and nausea. He appears pale and diaphoretic. What is the nurse’s priority action?
A. Administer oxygen via nasal cannula
B. Attach cardiac monitor and obtain vital signs
C. Notify the physician immediately
D. Obtain a 12-lead ECG
D. Obtain a 12-lead ECG
Rationale:
Chest pain with associated symptoms may indicate acute myocardial infarction (MI). A 12-lead ECG is critical for diagnosis and must be performed within 10 minutes of arrival. Oxygen and monitoring are also important, but ECG is prioritized for timely diagnosis.
A patient is prescribed a combination of ACE inhibitors and potassium-sparing diuretics. Which of the following should the nurse monitor closely?
A) Hyperkalemia
B) Hypokalemia
C) Hypernatremia
D) Hyponatremia
A) Hyperkalemia
Rationale: Both ACE inhibitors and potassium-sparing diuretics can increase potassium levels, so it's important to monitor for signs of hyperkalemia.
A patient in the ICU is receiving a continuous infusion of norepinephrine (Levophed) for septic shock. Which of the following is a priority nursing assessment during the infusion?
A) Monitoring urine output
B) Assessing for signs of hyperglycemia
C) Monitoring respiratory rate
D) Measuring blood pressure every 30 minutes
A) Monitoring urine output
Rationale: Norepinephrine is a potent vasopressor that can cause renal vasoconstriction, which may lead to reduced renal perfusion and decreased urine output. Monitoring urine output is essential to assess renal function.
A patient in labor is receiving an epidural analgesia with bupivacaine (Marcaine). The nurse notices that the patient’s blood pressure has dropped significantly. What is the most appropriate action for the nurse to take?
A) Administer a dose of epinephrine
B) Increase the rate of the IV fluids
C) Administer oxygen via mask
D) Discontinue the epidural infusion immediately
B) Increase the rate of the IV fluids
Rationale: Hypotension is a common side effect of epidural anesthesia due to vasodilation. Increasing IV fluids helps to restore circulatory volume and may alleviate the hypotension.
A patient with schizophrenia is prescribed haloperidol (Haldol), an antipsychotic medication. Which of the following side effects should the nurse monitor for during therapy?
A) Increased appetite and weight gain
B) Muscle stiffness and tremors
C) Increased heart rate and palpitations
D) Excessive sedation and dizziness
B) Muscle stiffness and tremors
Rationale: Haloperidol is a first-generation antipsychotic that can cause extrapyramidal symptoms (EPS), including muscle stiffness, tremors, and rigidity. These are common side effects of typical antipsychotics.
A patient involved in a house fire arrives at the ED with hoarseness, facial burns, and soot around the mouth. What is the priority nursing intervention?
A. Start a large-bore IV
B. Administer pain medication
C. Prepare for endotracheal intubation
D. Administer humidified oxygen
C. Prepare for endotracheal intubation
Rationale:
Signs of inhalation injury (hoarseness, facial burns, soot) indicate a high risk of airway compromise. Early intubation is often necessary before swelling obstructs the airway. Delay can result in failed intubation and respiratory arrest.
A patient is receiving a beta-blocker for hypertension. Which of the following findings would be a cause for concern?
A) Heart rate of 56 bpm
B) Blood pressure of 130/80 mmHg
C) Respiratory rate of 18 breaths per minute
D) Oxygen saturation of 98%
A) Heart rate of 56 bpm
Rationale: Beta-blockers can cause bradycardia, so a heart rate of 56 bpm may require adjustment or monitoring. Bradycardia can be a sign of excessive beta-blocker effects.
A patient with acute myocardial infarction (MI) is being treated with thrombolytics. What is the most important nursing intervention during the first 24 hours of therapy?
A) Monitoring for signs of infection
B) Assessing for signs of bleeding
C) Administering vitamin K if bleeding occurs
D) Encouraging early ambulation to prevent clots
B) Assessing for signs of bleeding
Rationale: Thrombolytics, such as tissue plasminogen activator (tPA), dissolve clots but also increase the risk of bleeding, including intracranial hemorrhage. Close monitoring for bleeding is crucial during this period.
A postpartum patient is being treated with oxytocin (Pitocin) to prevent hemorrhage. What is the most important nursing assessment while administering this medication?
A) Assessing for signs of water retention
B) Monitoring for signs of uterine hyperstimulation
C) Checking the patient's temperature every hour
D) Observing for signs of nausea and vomiting
B) Monitoring for signs of uterine hyperstimulation
Rationale: Uterine hyperstimulation (also known as tachysystole) can lead to uterine rupture or impaired uterine involution, which paradoxically increases bleeding. This is the most important and immediate concern when giving oxytocin.
A patient is receiving a selective serotonin reuptake inhibitor (SSRI) like fluoxetine (Prozac) for depression. The nurse should be especially cautious about which of the following side effects in the first few weeks of treatment?
A) Increased suicidal thoughts
B) Hyperactivity and agitation
C) Weight loss and anorexia
D) Hypertension and tachycardia
A) Increased suicidal thoughts
Rationale: SSRIs can increase the risk of suicidal thoughts, particularly in adolescents and young adults, during the initial weeks of therapy. Close monitoring is required during this period, especially after increasing the dosage.
A patient arrives at the ED after a fall, is awake but confused, and has one dilated pupil. What is the most appropriate immediate action?
A. Obtain blood glucose
B. Prepare for a CT scan of the head
C. Start an IV and draw labs
D. Place the patient in Trendelenburg position
B. Prepare for a CT scan of the head
Rationale:
A dilated pupil with altered mental status suggests increased intracranial pressure (ICP), possibly from a brain bleed. A head CT is urgently needed to assess for traumatic brain injury. Other interventions can follow once life-threatening conditions are ruled out.
A nurse is administering insulin to a diabetic patient. Which of the following would be the most appropriate intervention if the patient shows signs of hypoglycemia (shakiness, sweating, confusion)?
A) Administer the next dose of insulin
B) Encourage the patient to drink a glass of water
C) Provide 15 grams of fast-acting carbohydrates
D) Withhold all food and fluids
C) Provide 15 grams of fast-acting carbohydrates
Rationale: In cases of hypoglycemia, the nurse should provide 15 grams of fast-acting carbohydrates (e.g., glucose tablets, juice) to rapidly raise blood sugar levels.
A patient on a ventilator develops acute hypotension. The healthcare provider orders a dopamine infusion. Which of the following is the most likely effect of low-dose dopamine (1–5 mcg/kg/min) in this patient?
A) Increased heart rate
B) Increased renal perfusion
C) Increased blood pressure
D) Bronchodilation
B) Increased renal perfusion
Rationale: Low-dose dopamine primarily acts on dopamine receptors in the kidneys, leading to vasodilation and improved renal perfusion. It is often used in hypotensive patients to help preserve kidney function.
A pregnant woman in labor is given meperidine (Demerol) for pain relief. Which of the following is a common side effect of meperidine during labor?
A) Tachycardia
B) Respiratory depression
C) Hyperactivity
D) Increased urine output
B) Respiratory depression
Rationale: Meperidine is an opioid that can cause respiratory depression, especially in both the mother and neonate. It is important for the nurse to monitor for respiratory rate and oxygen saturation.
A patient with a history of bipolar disorder is started on lithium therapy. The nurse should educate the patient on the importance of maintaining:
A) A low-salt diet
B) Adequate fluid intake
C) Regular exercise
D) A high-protein diet
B) Adequate fluid intake
Rationale: Lithium is a mood stabilizer that has a narrow therapeutic window. Dehydration or changes in sodium levels can increase the risk of lithium toxicity. It’s essential for the patient to maintain adequate fluid intake and avoid drastic changes in salt consumption.
A 2-year-old is brought in with a barking cough, inspiratory stridor, and mild retractions. What is the best initial nursing intervention?
A. Provide humidified oxygen and keep the child calm
B. Suction the airway immediately
C. Insert an oral airway and call respiratory therapy
D. Administer IV corticosteroids immediately
A. Provide humidified oxygen and keep the child calm
Rationale:
These are signs of croup. Keeping the child calm and administering humidified oxygen helps reduce airway spasm. Agitation can worsen stridor. Suctioning and airway insertion may increase distress and worsen obstruction.
A nurse is educating a patient about the use of warfarin (Coumadin) for anticoagulation therapy. Which of the following instructions is important for the patient to follow?
A) "Increase intake of vitamin K-rich foods, like spinach, to improve the effectiveness of the medication."
B) "You should avoid aspirin and NSAIDs while on this medication, as they increase bleeding risk."
C) "You can stop taking the medication if you feel fine and your INR is normal."
D) "Warfarin does not interact with other medications, so you can take anything alongside it."
B) "You should avoid aspirin and NSAIDs while on this medication, as they increase bleeding risk."
Rationale: Warfarin increases the risk of bleeding, and using aspirin or NSAIDs can further increase this risk.
A critically ill patient is being treated with an intravenous (IV) infusion of propofol (Diprivan) for sedation. Which of the following side effects is most commonly associated with propofol therapy?
A) Respiratory depression
B) Increased intracranial pressure
C) Hypertension
D) Tachycardia
A) Respiratory depression
Rationale: Propofol is a potent sedative and can cause significant respiratory depression, requiring close monitoring of the patient’s airway and oxygenation status, especially in the ICU.
A postpartum patient is prescribed ibuprofen (Motrin) for pain management. The nurse should provide which of the following teaching points?
A) "Take the medication on an empty stomach to increase absorption."
B) "This medication is safe to take while breastfeeding."
C) "Ibuprofen can cause drowsiness, so avoid driving."
D) "Increase your intake of vitamin K while on this medication."
B) "This medication is safe to take while breastfeeding."
Rationale: Ibuprofen is classified as safe for use during breastfeeding because only small amounts pass into breast milk. It is also effective for managing mild to moderate postpartum pain.
A patient is prescribed lorazepam (Ativan) for anxiety. Which of the following is the most important nursing consideration when administering this medication?
A) Ensure the patient takes it on an empty stomach for better absorption.
B) Monitor for signs of respiratory depression, especially in elderly patients.
C) Instruct the patient to avoid caffeine to enhance the drug’s effects.
D) Instruct the patient to continue taking the medication even if they feel better.
B) Monitor for signs of respiratory depression, especially in elderly patients.
Rationale: Lorazepam is a benzodiazepine that can cause respiratory depression, particularly in the elderly or those with pre-existing respiratory conditions. It is also important to educate patients about the potential for dependence or tolerance.
A trauma patient’s blood pressure drops to 80/50 mmHg, heart rate is 130 bpm, and skin is cold and clammy. What should the nurse do first?
A. Administer vasopressors
B. Begin fluid resuscitation with isotonic IV fluids
C. Prepare for surgery
D. Draw blood for type and crossmatch
B. Begin fluid resuscitation with isotonic IV fluids
Rationale:
This patient is showing signs of hypovolemic shock. The first-line treatment is rapid infusion of isotonic fluids (e.g., normal saline or lactated Ringer’s) to restore intravascular volume. Vasopressors may be used later if fluids alone are insufficient.
A patient is receiving a narcotic analgesic for pain management post-surgery. The nurse should monitor for which of the following side effects?
A) Tachycardia
B) Hyperactivity
C) Respiratory depression
D) Increased urine output
C) Respiratory depression
Rationale: Opioid analgesics like narcotics can lead to respiratory depression, which is a serious side effect that requires careful monitoring, especially in post-surgical patients.
A nurse is caring for a patient who is receiving intravenous heparin for deep vein thrombosis (DVT). The nurse notices that the patient has developed new-onset bruising and petechiae. What is the most important action the nurse should take?
A) Administer vitamin K
B) Increase the heparin infusion rate
C) Notify the healthcare provider immediately
D) Encourage the patient to ambulate
C) Notify the healthcare provider immediately
Rationale: New bruising and petechiae are signs of potential heparin-induced thrombocytopenia (HIT) or bleeding complications. The nurse should notify the healthcare provider immediately to assess the situation and potentially adjust the medication.
A nurse is caring for a patient who is receiving magnesium sulfate for the prevention of preeclampsia and seizures. Which of the following findings would be a cause for concern and require immediate action?
A) Respiratory rate of 14 breaths per minute
B) Deep tendon reflexes 2+
C) Urine output of 30 mL/hour
D) Serum magnesium level of 9 mg/dL
D) Serum magnesium level of 9 mg/dL
Rationale: A magnesium level of 9 mg/dL is above the therapeutic range and can indicate magnesium toxicity. Symptoms of toxicity include respiratory depression, absent deep tendon reflexes, and cardiac arrest. Immediate action is required to prevent serious complications.
A patient with generalized anxiety disorder (GAD) is started on buspirone (Buspar). Which of the following statements by the patient indicates an understanding of the medication?
A) "I should expect to feel relief from my anxiety symptoms immediately after starting the medication."
B) "I can stop taking the medication if I feel my anxiety improves."
C) "It may take several weeks for the medication to start working."
D) "I should avoid eating grapefruit while taking this medication."
C) "It may take several weeks for the medication to start working."
Rationale: Buspirone is an anxiolytic that may take several weeks to become effective. It is not fast-acting like benzodiazepines. It is also not associated with dependence, unlike other medications in this class.