CEN - Practice Exam |Questions With 100% Correct Answers | Latest Updated 2024

CEN - Practice Exam |Questions With 100% Correct Answers | Latest Updated 2024 The nurse is caring for a patient who has a high fever, central nervous system dysfunction and tachycardia. The nurse should recognize that the patient may be experiencing A. myxedema crisis. B. Beck's triad. C. thyroid storm. D. hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Correct Answer: C. Thyroid storm Which of the following assessment findings associated with a skull fracture indicate the need for further intervention? A. otorrhea, nausea, and vomiting B. decreasing level of consciousness and restlessness C. early evidence of periorbital ecchymosis and photophobia D. rhinorrhea and headache or dizziness Correct Answer: B. decreasing level of consciousness and restlessness Upon initial assessment of a male patient involved in a motor vehicle crash, the nurse observes bruises in various stages of healing to his torso. He denies any medical history. When asked about the bruising, the patient avoids eye contact, states that he fell yesterday, and asks if his male partner has arrived to the ED. The nurse suspects: A. the patient may have undiagnosed coagulopathy. B. the bruising was sustained during the motor vehicle crash. C. the patient may be a victim of domestic violence. D. the bruising is a result of the stated fall. Correct Answer: C. the patient may be a victim of domestic violence. The nurse is caring for a patient who became unresponsive after diving head-first into a shallow pool. The patient is experiencing refractory hypotension. The nurse should prepare for the administration of a. lactated Ringers. b. norepinephrine. c. normal saline. d. epinephrine. Correct Answer: b. norepinephrine A 3-year-old child who has acute respiratory distress is admitted to the emergency department. The child is sitting forward and drooling, and the neck is extended. These findings support the diagnosis of A. epiglottitis. B. bronchiolitis. C. croup. D. aspiration of a foreign body. Correct Answer: A. epiglottitis The nurse understands that adenosine is administered A. IV push over 1-2 seconds. B. as a bolus over 10-15 minutes. C. as a bolus over 1 hour. D. IV push over 1-2 minutes. Correct Answer: A. IV push over 1-2 seconds. A man who briefly lost consciousness after a motor vehicle crash is alert and oriented upon arrival at the emergency department. The patient states that he is fine except for an abrasion where his head hit the door frame of the vehicle. The patient complains of blurred vision 1 hour later. The nurse should FIRST A. repeat the neurologic assessment. B. obtain orthostatic vital signs. C. assess visual acuity. D. obtain blood glucose measurement. Correct Answer: A. repeat the neurologic assessment. After a non-traumatic resuscitation, the patient has a perfusing ECG rhythm and a stable blood pressure, but the patient remains comatose. The nurse should NEXT prepare for A. initiation of targeted temperature management. B. initiation of stroke protocol. C. transport to the cardiac catheterization lab. D. transport to the neurovascular suite. Correct Answer: A. initiation of targeted temperature management. After a patient has an episode of violent behavior in the waiting room, an important intervention is to A. tell the patient to get himself under control. B. instruct the patient to be quiet and speak only when spoken to. C. allow the patient to go home as soon as possible. D. encourage the patient to verbalize his feelings about the situation. Correct Answer: D. encourage the patient to verbalize his feelings about the situation. The nurse is caring for a patient with complaints of progressive, ascending paralysis starting from the feet and progressing over the last week. It would be a PRIORITY for the nurse to monitor the patient's A. pupillary response. B. peripheral pulses. C. respiratory status. D. Blood glucose Correct Answer: C. respiratory status. A patient with acute cocaine intoxication should be expected to have A. rising core body temperature. B. drowsiness. C.flaccid extremities. D. first-degree AV block. Correct Answer: A. rising core body temperature. Which of the following ocular conditions requires the HIGHEST treatment priority? A. periorbital hematoma with edema B. hyphema following a blow to the eye C. a retained metal foreign body D. sudden, painless loss of vision in one eye Correct Answer: D. sudden, painless loss of vision in one eye A patient presents with complaints of fatigue and exhaustion, and reveals a recent move across country for a new high stress job. The patient admits to recent increase in alcohol consumption. The nurse suspects the patient is experiencing: A. schizophrenia. B. situational crisis. C. psychotic depression. D. acute mania. Correct Answer: B. situational crisis. The nurse is caring for a patient who suddenly stops breathing and is in ventricular fibrillation. The nurse should FIRST A. perform synchronized cardioversion at 200 joules. B. provide oxygen and ventilation via a bag-mask device. C. start chest compressions. D. administer 1 mg of intravenous epinephrine. Correct Answer: C. start chest compressions. A patient presents with his family members, who state that he has struck his brother and has been violent and paranoid. The nurse should FIRST A. place the patient into a treatment room with the door open. B. assess the brother for possible injuries. C. escort the patient to the quiet room to await the social worker. D. notify police of the assault. Correct Answer: A. place the patient into a treatment room with the door open. Human tetanus immune globulin provides passive immunity for A. 1 year. B. 30 days. C. 6 months. D. 72 hours. Correct Answer: B. 30 days. A patient who is trembling, sweating, and hyperventilating is having an anxiety attack. Arterial blood gas analysis is likely to show which of the following? A. oxygen saturation < 96% B. pH < 7.35 C. HCO3-level > 26 mEq/L D. PaCO2 < 35 mm Hg Correct Answer: D. PaCO2 < 35 mm Hg A pediatric patient is treated for otitis media complicated by a ruptured tympanic membrane. Discharge education is proven effective when the patient's father states, A. I will position my son upright in bed when he goes to sleep. B. I will keep my son from getting his ear wet. C. I will feed him soft foods until the ear drum heals itself. D. I will use antibiotic ear drops four times a day for one week. Correct Answer: B. I will keep my son from getting his ear wet. Assessment of a patient who has acute cholecystitis is MOST likely to reveal A. pain that radiates to the left shoulder and positive results on a stool guaiac test. B. pain in the left upper quadrant of the abdomen and positive results on a guaiac test of vomitus. C. pain in the right upper quadrant of the abdomen and slight scleral icterus. D. epigastric pain that radiates to the back and watery stools. Correct Answer: C. pain in the right upper quadrant of the abdomen and slight scleral icterus. Manual uterine massage is recommended for early postpartum hemorrhage because massage will A. enhance uterine atony. B. improve bladder tone. C. expel retained products of conception. D. stimulate uterine contractions. Correct Answer: D. stimulate uterine contractions. A child with an extremity fracture is being prepared for admission prior to surgery. The child has a low-grade fever and may have been exposed to chickenpox. The nurse should A. isolate the patient in a negative-pressure room. B. anticipate administering diphenhydramine (Benadryl). C. advise the receiving nurse to initiate isolation if vesicles develop. D. anticipate administering methylprednisolone (SoluMedrol). Correct Answer: A. isolate the patient in a negative-pressure room. A patient who has ingested antifreeze is undergoing treatment. An indication that further treatment is needed is A. metabolic acidosis. B. pupillary constriction. C. rotary nystagmus. D. hyperreflexia. Correct Answer: A. metabolic acidosis. Cerebrospinal fluid found in the ears indicates A. pharyngeal trauma. B. a subarachnoid hemorrhage. C. injury to the cervical spine. D. a basilar skull fracture. Correct Answer: D. a basilar skull fracture. A pediatric patient is diagnosed and treated for conjunctivitis. What statement made by the caregivers indicates understanding of discharge instructions? A. "My child cannot return to school until the infection has resolved." B. "My child can return to school immediately because this is a viral infection." C. "My child needs to practice good hand hygiene after using the bathroom." D. "My child can sleep in the same bed as her sister during nap time." Correct Answer: A. "My child cannot return to school until the infection has resolved." A patient with tuberculosis is considered infectious as long as A. the tuberculin skin test is positive. B. a productive cough is present. C. pulmonary tuberculosis is evident on the chest radiograph. D. viable tubercle bacilli are discharged in the sputum Correct Answer: D. viable tubercle bacilli are discharged in the sputum What is the PRIORITY treatment for a patient with signs and symptoms of heat exhaustion? A. Establish IV access. B. Administer oxygen. C. Initiate cooling measures. D. Obtain blood samples. Correct Answer: C. Initiate cooling measures. The nurse is caring for a patient who is 2 days postpartum, is hypertensive and complaining of a severe headache. The nurse should prepare to administer A. magnesium sulfate. B. acetaminophen. C. methylergonovine maleate (Methergine). D. oxytocin (Pitocin). Correct Answer: A. magnesium sulfate. A patient presents with right-sided facial droop and slurred speech that started 2 hours ago. The patient's blood glucose level is 105 mg/dL and vital signs are as follows: BP 210/122 mmHgHR 72 beats/min RR 19 breaths/min O2 sat 98% on room air The nurse should FIRST anticipate an order for: A. rechecking blood glucose. B. evaluation by a neurologist. C. antihypertensive medication. D. administering tPA immediately. Correct Answer: C. antihypertensive medication. To assess pronator drift, the nurse should instruct the patient to A. hold both arms straight out with your eyes closed. B. touch your finger to your nose, alternating your right and left hands. C. smile and show me your teeth. D. slide the left heel of your foot down your right shin. Correct Answer: A. hold both arms straight out with your eyes closed. Which of the following signs and symptoms are characteristic of pertussis? A. pleuritic chest pain and chills B. vocal changes and difficulty swallowing C. inspiratory stridor and drooling D. paroxysmal coughing and fever Correct Answer: D. paroxysmal coughing and fever A patient who has been in a motorcycle crash is awake, alert, and oriented, but complains of severe neck pain. Shortly after arrival, the patient experiences respiratory arrest. Appropriate INITIAL management of the airway should consist of A. administration of oxygen by a nasal cannula. B. head-tilt maneuver and placement of an oropharyngeal airway. C. endotracheal intubation. D. jaw-thrust maneuver and ventilation with a bag-mask device. Correct Answer: D. jaw-thrust maneuver and ventilation with a bag-mask device. The nurse is caring for a patient with a long history of alcohol abuse who now has coffee-ground emesis and hypotension. The nurse should prepare for emergent administration of A. ondansetron (Zofran). B. blood products. C. hypertonic saline. D. thiamine. Correct Answer: B. blood products. An indwelling urinary catheter is ordered for a patient who has sustained a straddle injury to his external genitalia. Before catheter insertion, the nurse should assess the patient for A. blood at the urinary meatus. B. scrotal or penile swelling. C. the ability to void spontaneously. D. penile tenderness Correct Answer: A. blood at the urinary meatus. Prior to discharge, the nurse should ensure a patient treated for priapism A. is instructed to return for cystoscopy. B. has complete resolution of pain. C. can urinate without difficulty. D. has received intravenous antibiotics. Correct Answer: C. can urinate without difficulty. The nurse is caring for a patient with altered mental status, poor oral intake, and diarrhea for several days. The patient's laboratory tests are as follows: pH 7.29HCO3 14 mEq/Lserum glucose level 380 mg/dLserum potassium level 3.0 mEq/Lurinalysis positive for ketonesAn order for regular insulin 10 units IV is received. The nurse should A. hold the insulin and request an order for a potassium replacement first. B. hold the insulin and request an order for D5 0.45 NS to be given first. C. administer the insulin, but slow IV push over 5 minutes. D. administer the insulin, but request that D5 0.45 NS also be infused. Correct Answer: A. hold the insulin and request an order for a potassium replacement first. The skin of a patient in early septic shock is most likely to be A. cool and pale. B. cool and cyanotic. C. warm and flushed. D. warm and pale. Correct Answer: C. warm and flushed. A patient presents with purulent nasal discharge and a frontal area headache that worsens when bending over. Which of the following nursing interventions is MOST effective? A. Place the patient in a supine position. B.Apply heat to the face. C. Provide a darkened environment. D. Perform nasal lavage. Correct Answer: B. Apply heat to the face. A patient presents with a shoulder dislocation. The nurse knows the PRIORITY intervention is to A. promptly consult an orthopedic physician. B. apply a shoulder immobilizer. C. reduce as soon as possible. D. prepare the patient for surgery. Correct Answer: C. reduce as soon as possible. A trauma patient arrives at the emergency department conscious and with stable vital signs. On initial assessment, which of the following findings is most concerning? A. weak pedal pulses B. subcutaneous crepitus of the left upper chest C. absent bowel sounds D. distention of the bladder Correct Answer: B. subcutaneous crepitus of the left upper chest The nurse is caring for a patient who took an unknown amount of acetaminophen. The initial acetaminophen level was below the toxic level. The nurse should anticipate A. transferring the patient to the critical care unit. B. repeating the acetaminophen level in 4 hours. C. discharging the patient home. D. monitoring vital signs for 2 hours. Correct Answer: B. repeating the acetaminophen level in 4 hours. The earliest indication of increased intracranial pressure is A. widened pulse pressure. B. decreased heart rate. C. abnormal respirations. D. altered level of consciousness. Correct Answer: D. altered level of consciousness. What is the PRIORITY intervention for a patient who presents with the following vital signs? BP 65/42 mm HgHR 145 beats/minRR 6 breaths/min T (rectal) 102˚F (38.8˚C) O2 sat 85% on room air A. Establish IV access. B. Start manual ventilations. C. Apply pads to chest. D. Prepare for intubation. Correct Answer: B. Start manual ventilations. A patient in the emergency department is receiving a 1 g IV infusion of phenytoin (Dilantin) for control of seizures. During the infusion, the patient's QRS complex widens markedly. The nurse should turn off the infusion and prepare for possible A. status epilepticus. B. extravasation at the IV site. C. hypertensive crisis. D. cardiac arrest Correct Answer: D. cardiac arrest After an incident involving a young child with a negative outcome, the team is scheduled for a debriefing. The purpose of a formal debriefing is to: A. support staff by allowing time for reflection and communication B. allow staff to explain all the rationales to the hospital's risk management team C. provide a time for the rest of the department to listen to the chain of events of the incident. D. provide staff with an opportunity to explain their actions and rationales to the patient's family. Correct Answer: A. support staff by allowing time for reflection and communication A patient presents with the complaint of "something is in my eye." A piece of metal is removed and a rust ring is noted. Discharge teaching has been successful when the patient states: A. "I will need to wear an eye patch for a few days." B. "I will need to rest my eyes for a week." C. "I will take antibiotics until the rust coloring goes away." D. "I will follow up with an ophthalmologist in 24 hours." Correct Answer: D. "I will follow up with an ophthalmologist in 24 hours." The nurse is caring for a patient who was found in a garage with a running car. The patient is reporting nausea, a headache and is lethargic. The nurse should recognize that the patient will benefit MOST from administration of a. intravenous fluids. b. high-flow oxygen. c. an antiemetic. d. dextrose. Correct Answer: b. high-flow oxygen. The nurse is caring for a patient who has a serum potassium level of 2.2 mEq/L. The nurse would question orders for: A. aldactone (Spironolactone). B. potassium. C. furosemide (Lasix) D. magnesium sulfate. Correct Answer: C. furosemide (Lasix) A patient's eyes are irrigated with 2 L of normal saline solution after being contaminated by plaster dust. Immediately following copious irrigation, the conjunctival pH is 7.0. This reading indicates that A. treatment has been effective. B. the cornea has probably been damaged. C. continued irrigation is necessary. D. visual impairment may be permanent. Correct Answer: A. treatment has been effective. A patient experiencing a manic episode of bipolar disorder is likely to have A. flight of ideas. B. delusions of persecution. C. psychomotor retardation. D. complaints of exhaustion. Correct Answer: A. flight of ideas. The nurse is caring for a hemodynamically unstable patient who was involved in a motor vehicle collision. Which of the following criteria would indicate that tranexamic acid should be administered? A. bleeding scalp wound with a pressure dressing applied B. unstable pelvic fracture with blood at the urinary meatus C. open fracture of the left lower extremity with bone exposed D. LeFort II fracture with trismus and pain Correct Answer: B. unstable pelvic fracture with blood at the urinary meatus A patient who sustains a head injury has increased pressure on the left oculomotor nerve. Assessment of the left eye is MOST likely to reveal A. ptosis of the eyelid. B. ciliary spasm of the eyelid. C. conjunctival edema. D. dilation of the pupil. Correct Answer: D. dilation of the pupil. A patient suspected of having anorexia nervosa is being triaged. The emergency nurse expects which blood abnormality commonly related to this disease? A. metabolic acidosis B. increased glomerular filtration rate C. hyperkalemia D. decreased blood urea nitrogen Correct Answer: A. metabolic acidosis A 175-lb (80-kg) adult patient who sustained electrical burns is administered an IV solution of lactated Ringer's containing sodium bicarbonate. Fluid administration is deemed adequate if the patient's A. urine output is 75 to 100 mL/h. B. serum pH is 7.25. C. cardiac monitor shows only rare premature ventricular contractions. D. urine is pink-tinged. Correct Answer: A. urine output is 75 to 100 mL/h. A 6-month-old presents to the emergency department with report from the parents of intermittent abdominal distension and bloody mucus in the stools. The nurse suspects: A. rotavirus. B. gastroenteritis. C. pyloric stenosis. D. intussusception. Correct Answer: D. intussusception. A patient becomes increasingly agitated after receiving 2 mg lorazepam (Ativan). The nurse should recognize that this response is A. unexpected, since the condition is exacerbated. B. expected, since this is a typical side effect. C. expected, and the patient needs to be restrained. D. unexpected, and the patient needs more lorazepam (Ativan). Correct Answer: A. unexpected, since the condition is exacerbated. A patient presents with a history of abdominal pain, nausea, and vomiting for 2 days. Upon standing, the patient complains of dizziness. The nurse should anticipate an order to do which of the following FIRST? A. Insert a nasogastric tube. B. Administer pain medication. C. Initiate IV access. D. Draw blood for a CBC. Correct Answer: C. Initiate IV access. A patient presents to the emergency department after engaging in an altercation involving a gun. After lifesaving interventions have been performed the nurse should: A. Label wounds as entrance or exit wounds. B. Give family religious belongs that the patient was wearing. C. Place clothes in a plastic bag. D. Place paper bags on the patient's hands. Correct Answer: D. Place paper bags on the patient's hands. An adolescent patient presents with symptoms of depression and suicidal thoughts. The highest priority for the patient is to: A. notify the guardian of the patient for treatment consent. B. complete intake for pending transfer to psychiatric facility. C. initiate medical clearance including blood and urine collection. D. initiate measures for suicide prevention and safety. Correct Answer: D. initiate measures for suicide prevention and safety. A patient presents after a pit viper bite to the leg. The patient has sudden onset of bleeding from the nose and blood in his urine. Blood is oozing from the venipuncture and intravenous insertion sites. The nurse should expect A. decreased fibrin split products. B. a decreased prothrombin time. C. a decreased platelet count. D. increased Factor XIII. Correct Answer: C. a decreased platelet count. A patient is being discharged with a presumptive diagnosis of primary herpes simplex viral infection. The patient understands discharge instructions if she states, A. Acyclovir will cure my herpes. B. I know that this first episode will last only 4 or 5 days. C. My boyfriend will not get this if he uses a condom. D. If I get pregnant, I can pass the disease to my baby. Correct Answer: D. If I get pregnant, I can pass the disease to my baby. The FIRST intervention for an infant with complete airway obstruction after inhalation of a foreign body is A. back blows. B. intubation. C. abdominal thrusts. D. a finger sweep. Correct Answer: A. back blows. The nurse notices that a co-worker has been chronically tardy, fatigued, apathetic, and increasingly distracted at work. The nurse suspects: A. a hangover. B. paranoia. C. compassion fatigue. D. drug diversion. Correct Answer: C. compassion fatigue. A 14-year-old patient whose airway is obstructed is conscious and unable to speak. The nurse should FIRST A. encourage the patient to cough. B. administer back blows. C. remove the obstruction with Magill forceps. D. administer abdominal thrusts Correct Answer: D. administer abdominal thrusts Which spinal cord injury is characterized by greater loss of motor function in the upper extremities than in the lower extremities? A. anterior-cord syndrome B. central-cord syndrome C. posterior-cord syndrome D. Brown-Sequard syndrome Correct Answer: B. central-cord syndrome A patient is being treated for an acute exacerbation of chronic obstructive pulmonary disease. An improvement in the patient's condition is indicated if the patient is A. able to speak in uninterrupted sentences. B. able to cough up thick, yellow sputum. C. using pursed-lip breathing techniques. D. maintaining the tripod position. Correct Answer: A. able to speak in uninterrupted sentences. An ED nurse is planning to implement an intervention to reduce the risk of workplace violence. The nurse understands that in order to successfully improve staff safety, they should: A. implement a Multidisciplinary Violence Prevention Program with on-going training. B. increase security presence in the ED and train them to deal with violent patients. C. install metal detectors and screening points at each ED entrance. D. train nursing assistants in physical de-escalation techniques for violent patients. Correct Answer: A. implement a Multidisciplinary Violence Prevention Program with on-going training. A recently widowed 86-year-old male with multiple chronic health conditions is brought to the ED by a family member after they found multiple doses of the patient's medication missing. The patient is alert, oriented and able to participate in his initial assessment. The patient is at highest risk for: A. neglect. B. dementia. C. suicide. D. substance abuse. Correct Answer: C. suicide. In which of the following cases has the nurse breached patient confidentiality? A. notifying the health department about measles B. reporting HIV status to the patient's employer C. notifying the police about a possible homicide D. `reporting sudden unexpected deaths to the coroner Correct Answer: B. reporting HIV status to the patient's employer Which solution is BEST when covering an open orthopedic injury in moist dressings? A. chlorhexidine B. normal saline C. iodine-based solutions D. hydrogen peroxide Correct Answer: B. normal saline A patient with Guillain-Barré syndrome should be expected to have a tingling sensation in the extremities, ascension of symmetric paralysis, and A. tonic-clonic seizures. B. spasticity. C. a positive Babinski's sign. D. decreased deep tendon reflexes. Correct Answer: D. decreased deep tendon reflexes. An 11-year-old patient is admitted to the emergency department one hour after receiving a blow to the right eye. The patient is unable to look upward with the injured eye. The nurse should suspect a A. blowout fracture. B. traumatic infarction of the optic nerve. C. hyphema. D. vitreous hemorrhage. Correct Answer: A. blowout fracture. The treatment of choice for a patient presenting with headache in the right temporal region and jaw pain is A. dexamethasone (Decadron), IV. B. morphine sulfate, IV. C. administration of oxygen. D. sumatriptan (Imitrex), SQ. Correct Answer: A. dexamethasone (Decadron), IV. Which type of breath sounds would MOST likely be heard in a patient who has acute pulmonary edema? A. bilateral crackles (rales) B. diminished breath sounds C. pleuritic rub D. stridor Correct Answer: A. bilateral crackles (rales) An adolescent patient presents to the emergency department with complaints of sore throat, fatigue, malaise, and fever. The patient has cervical lymphadenopathy and pain across the upper abdomen. Which of the following is the BEST test to help make the diagnosis? A. indirect laryngoscopy B. Monospot C. posterior-anterior and lateral chest radiographs D. purified protein derivative (PPD) testing Correct Answer: B. Monospot Which of the following medications should a nurse anticipate administering initially to an adult patient in status epilepticus? A. fosphenytoin (Cerebyx) B. phenobarbital C. flumazenil (Romazicon) D. diazepam (Valium) Correct Answer: D. diazepam (Valium) Which finding would be MOST likely in a patient with an acute aortic dissection? A. expiratory wheezing bilaterally B. increased body core temperature C. decreased body core temperature D. upper extremity blood pressure variation Correct Answer: D. upper extremity blood pressure variation A man who weighs 165 lb (75 kg) arrives at the emergency department immediately after sustaining a 40% partial-thickness burn. Using the formula 4 mL/kg multiplied by the percent of body surface area burned, IV fluids should be administered at what rate during the first 8 hours? A. 1000 mL/h B. 750 mL/h C. 375 mL/h D. 500 mL/h Correct Answer: B. 750 mL/h Appropriate nursing care for a child who has gastroenteritis includes instructing the parents to A. keep the child NPO for 12 hours. B. give orange juice for rehydration. C. withhold dairy products. D. offer plain mashed potatoes for solid food. Correct Answer: C. withhold dairy products. A patient presents with Koplik's spot on the buccal mucosa, a maculopapular rash and rhinorrhea. The nurse should suspect A. roseola. B. coxsackievirus. C. measles. D. Fifth disease. Correct Answer: C. measles. A patient reports sexual assault. Vital signs are stable, no visible injury is noted, and the patient is able to clearly describe the events that took place. What acuity level should be assigned using the five-tier Emergency Severity Index (ESI) criteria? A. level 4 B. level 1 C. level 3 D. level 2 Correct Answer: D. level 2 A patient presents with dyspnea, tachycardia, elevated temperature and petechiae on the upper half of the body. The nurse should suspect A. pulmonary embolism. B. malignant hyperthermia. C. fat embolism. D. tension pneumothorax. Correct Answer: C. fat embolism. A patient has just been prescribed the "morning after" pill, and the nurse has administered the first dose. Which of the following statements indicates the patient understands discharge teaching? A. I will take the other two tablets in 24 hours. B. My menstrual period will occur in 3 to 4 days. C. Using condoms will prevent me from getting pregnant. D. The medication may make me feel nauseated. Correct Answer: D. The medication may make me feel nauseated. After an occlusive dressing has been applied to a patient's open chest wound, the nurse should assess for A. stridorous respirations. B. increased work of breathing C. dullness on the injured side.. D. Tracheal deviation toward the injured side. Correct Answer: B. increased work of breathing Assessment of a patient with a hemorrhagic stroke affecting the left cerebral hemisphere is likely to reveal a. expressive, receptive, or global aphasia. b. deviation of the head and eyes to the right. c. blindness in the left half of both visual fields. d. left hemiparesis or hemiplegia. Correct Answer: a. expressive, receptive, or global aphasia. Which clotting disorder is caused by the absence or deficiency of factor IX? a. hemophilia B b. hypercoagulation c. hemophilia C d. Von Willebrand Disease Correct Answer: a. hemophilia B When assessing a wound for a foreign body, a nurse should FIRST A. determine the mechanism of injury. B. obtain a wound culture. C. soak the wound prior to inspection. D. probe the wound manually. Correct Answer: A. determine the mechanism of injury. Which of the following solutions is appropriate for INITIAL resuscitation of patients who have major burns? A. D5W B. D5 0.45 NS C. 3% NS D. lactated Ringer's Correct Answer: D. lactated Ringer's A patient presents after being splashed in the eyes with a cleaning solution. Corneal clouding is noted bilaterally and an order is given to irrigate the patient's eyes. Irrigation may be discontinued after: A. Each eye has been irrigated with 1,000 mL of irrigation solution. B. 2 hours have passed. C. The ocular pH reaches 7.0 bilaterally. D. The pain is a 2 on a 0-10 scale. Correct Answer: C. The ocular pH reaches 7.0 bilaterally Which of the following patients has a contraindication for tetanus prophylaxis? A. a 46-year-old who is HIV-positive B. a 24-year-old in her second trimester of pregnancy C. a 36-year-old with acute pneumonia D. an 18-year-old with a known egg allergy Correct Answer: C. a 36-year-old with acute pneumonia A patient has an open pneumothorax secondary to a gunshot injury. What is the proper sequence of steps in management? A. Initiate an IV of lactated Ringer's solution, check for a pulse, and place the patient on the affected side. B. Apply an occlusive dressing to the wound, check for a pulse, and initiate an IV of normal saline solution. C. Initiate an IV of normal saline solution, apply an occlusive dressing to the wound, and prepare for intubation. D. Obtain baseline vital signs, initiate an IV of lactated Ringer's solution, and place the patient on the unaffected side. Correct Answer: B. Apply an occlusive dressing to the wound, check for a pulse, and initiate an IV of normal saline solution. The cardinal signs of facial fractures are pain, swelling, and A. salivation. B. bleeding. C. fractured teeth. D. asymmetry. Correct Answer: D. asymmetry. An adult patient sustains blunt trauma to the abdomen in a motor vehicle crash. The patient refuses to allow any invasive treatments. Initial assessment reveals an ecchymotic area in the left upper quadrant. The nurse should A. obtain consent from a relative for treatment. B. assess the patient's neurological status C. allow the patient to leave after signing a medical release form. D. request an order to sedate the patient. Correct Answer: B. assess the patient's neurological status A patient who sustained major trauma has a blood pressure of 84/56 mm Hg, a heart rate of 124 beats/min, and respirations of 42 breaths/min. Breath sounds are absent on the left side, the trachea is deviated to the right, and the left thigh is deformed. The nurse should FIRST prepare to assist with a. application of a traction splint. b. pericardiocentesis. c. chest tube insertion. d. needle decompression. Correct Answer: d. needle decompression. A 10-month-old infant who has a sudden onset of wheezing, cough, and stridor should immediately be assessed for A. presence of abdominal breathing. B. unequal breath sounds. C. axillary subcutaneous emphysema on palpation. D. a history of bronchodilator use. Correct Answer: B. unequal breath sounds. What life-threatening orthopedic injury is caused by internal soft tissue swelling compromising vascular and neurologic structures? A. compartment syndrome B. fat embolism C. osteomyelitis D. hematoma Correct Answer: A. compartment syndrome A patient who has chest pain and palpitations is given a dose of adenosine (Adenocard) by rapid IV push. The optimal outcome is A. the chest pain decreases. B. a transient decrease in heart rate. C. the systolic blood pressure increases. D. the supraventricular tachycardia resolves. Correct Answer: D. the supraventricular tachycardia resolves. Neurogenic shock is MOST likely indicated if a patient has a blood pressure of A. 100/80 mm Hg and a heart rate of 146 beats/min. B. 82/48 mm Hg and a heart rate of 125 beats/min. C. 120/74 mm Hg and a heart rate of 50 beats/min. D. 86/50 mm Hg and a heart rate of 52 beats/min. Correct Answer: D. 86/50 mm Hg and a heart rate of 52 beats/min. Which of the following is the MOST effective method to reduce the transmission of tuberculosis in the emergency department? A. negative-pressure room B. ultraviolet radiation C. use of paper surgical masks D. handwashing Correct Answer: A. negative-pressure room Which of the following statements by a patient with shingles indicates that discharge teaching has been effective? A. I should launder all my bedding in hot water. B. I can return to work when my lesions are crusted. C. I should use cortisone cream on my lesions. D. I should take all of my antibiotics. Correct Answer: B. I can return to work when my lesions are crusted. The nurse is caring for a patient who is complaining of eye pain and burning after having a chemical splashed in the face. The nurse's IMMEDIATE action should be to A. insert an intravenous line. B. assess visual acuity. C. apply an eye patch. D. irrigate the eyes. Correct Answer: D. irrigate the eyes. The nurse is about to administer nitroglycerin when the patient tells the nurse they took sildenafil (Viagra) earlier today. The nurse's IMMEDIATE action should be to A. administer half the dose. B. notify the pharmacy. C. administer the nitroglycerin. D. notify the physician. Correct Answer: D. notify the physician. Immediate intervention for a patient who has a large dermal avulsion injury of the arm should focus on A. minimizing the loss of mobility. B. controlling hemorrhage. C. minimizing scarring. D. preventing infection. Correct Answer: B. controlling hemorrhage. A nurse is assessing a patient who is tachycardic and tachypneic. The patient has recently traveled cross country on an airplane. The nurse should be MOST concerned that the patient may have: A. a pleural effusion B. a pneumothorax C. pneumonia D. a pulmonary embolism Correct Answer: D. a pulmonary embolism What is the treatment of choice for testicular torsion? A. surgical intervention B. scrotal sling C. antibiotics D. bed rest Correct Answer: A. surgical intervention A patient reports weakness, fatigue, nausea and vomiting. On assessment, the nurse notes hyperpigmentation of the knuckles and elbows. The nurse should suspect A. hyperthyroidism. B. Addisonian crisis. C. diabetic ketoacidosis. D. diabetes insipidus. Correct Answer: B. Addisonian crisis. What is the most appropriate electrical therapy for the patient whose electrocardiogram (ECG) tracing is showing ventricular fibrilation A. external pacemaker B. defibrillation C. transvenous pacemaker D. synchronized cardioversion Correct Answer: B. defibrillation A patient who has a neck injury is to be moved. The nurse should protect the patient's cervical spine by A. asking the patient not to move his head. B. placing the patient on a long backboard. C. immobilizing the head by placing a hand over the forehead and chin. D. stabilizing the head and neck in a neutral position. Correct Answer: D. stabilizing the head and neck in a neutral position. An infant dies suddenly in the emergency department. Which of the following BEST assists the family members in the grieving process? A. Obtain prescriptions for sedatives. B. Provide assurance that things will be all right. C. Give them a copy of the medical record. D. Offer to provide a lock of the infant's hair. Correct Answer: D. Offer to provide a lock of the infant's hair. A patient who sustained a leg laceration from a chainsaw is unsure if he has ever received a tetanus immunization. The patient should receive A. 0.5 mL of tetanus, diphtheria toxoids, and pertussis vaccine. B. 250 U of tetanus immune globulin and 0.5 mL of tetanus, diphtheria toxoids, and pertussis vaccine. C. 5 mL of immune (gamma) globulin. 0D. .5 mL of tetanus, diphtheria toxoids. Correct Answer: B. 250 U of tetanus immune globulin and 0.5 mL of tetanus, diphtheria toxoids, and pertussis vaccine. A patient who has a serum potassium level of 2.6 mEq/L should be MOST closely monitored for A. edema of the extremities. B.weakness of the respiratory muscles. C. increased neuromuscular irritability. D. carpopedal spasm. Correct Answer: B.weakness of the respiratory muscles. A patient who sustained a gunshot wound is bleeding from the arm. After applying a pressure dressing, the nurse should next evaluate A. changes in neurovascular status. B. development of fever. C. presence of pain. D. presence of bleeding at the dressing. Correct Answer: A. changes in neurovascular status. Nitroglycerin reduces myocardial oxygen consumption because its primary effect is to A. enhance contractility. B. slow the heart rate. C. reduce preload. D. increase afterload. Correct Answer: C. reduce preload. A 4-year-old patient is brought to the emergency department the day after having a tonsillectomy. The patient is diaphoretic, tachycardic, and crying, and has obvious oral bleeding. The nurse should FIRST A. place the patient on continuous cardiac monitoring. B. suction bloody secretions from the mouth. C. administer oxygen via nonrebreather mask. D. initiate an IV of lactated Ringer's solution at 50 mL/h. Correct Answer: B. suction bloody secretions from the mouth. An elderly woman presents with vague complaints of abdominal pain. The patient states that the people she lives with are stealing from her. The nurse should A. arrange for protective custody of the patient. B. call the family to discuss the situation. C. assess the patient for signs of neglect and maltreatment. D. obtain consent for evaluation by social services. Correct Answer: C. assess the patient for signs of neglect and maltreatment. The FIRST step in the triage assessment of a patient with a behavioral health concern is the: A. across the room assessment. B. environment of care checklist. C. health history questionnaire. D. chief complaint. Correct Answer: A. across the room assessment. Which of the following patients should receive the HIGHEST priority of care? A. a confused and unkempt patient who is brought in by the police B. a diabetic patient with a lacerated finger C. a patient whose medical history is unremarkable, but complains of flank pain D. a patient without previous health problems complaining of lower back pain Correct Answer: A. a confused and unkempt patient who is brought in by the police Which of the following indicates significant dehydration in a 6-month-old infant with a history of vomiting and diarrhea? A. has three loose stools in 3 hours B. cries loudly during the physical examination C. has two bouts of projectile vomiting D. does not urinate for more than 8 hours Correct Answer: D. does not urinate for more than 8 hours Which of the following will be found in a patient with a severe asthma exacerbation? A. infiltrates on the chest radiograph B. a loose and barking productive cough C. expiratory or absent wheezing D. prolonged inspiratory respirations Correct Answer: C. expiratory or absent wheezing Which of the following statements about subdural hemorrhage is true? A. It may initiate an acute or chronic onset of symptoms. B. It results from a tear in the middle meningeal artery. C. It occurs between the skull and the dura. D. It results from a thrombosed artery. Correct Answer: A. It may initiate an acute or chronic onset of symptoms. A patient presents with a decreased level of consciousness and hypoxemia despite supplemental oxygen and has minimal air movement on auscultation. The nurse should anticipate A. initiation of continuous positive pressure ventilation. B. administration of magnesium sulfate. C. insertion of a chest tube. D. insertion of an endotracheal tube. Correct Answer: D. insertion of an endotracheal tube. Which of the following triage assessments in a toddler indicates the need for IMMEDIATE treatment? A. temperature of 102°F (38.8°C) B. respirations of 60 breaths/min C. systolic blood pressure of 90 mm Hg D. sinus arrhythmia of 140 beats/min Correct Answer: B. respirations of 60 breaths/min The nurse is caring for a patient who presents to the emergency department complaining of anxiety, chest pain and shortness of breath. The patient reports a recent decrease in mobility due to an orthopedic procedure. Which INITIAL diagnostic procedure has the highest priority? A. pulmonary arteriography B. CT scan of the chest C. echocardiogram D. ultrasound of the leg and pelvic veins Correct Answer: B. CT scan of the chest The nurse is assessing a patient who was involved in a motor vehicle accident. The patient has muffled heart sounds, jugular vein distension and dyspnea. Vital signs are as follows: BP 67/49 mm HgHR 120 beats/minRR 28 breaths/minO2 sat 90% on room air The nurse recognizes that the patient may be experiencing: A. laryngeal injury. B. ruptured diaphragm. C. cardiac tamponade. D. pneumothorax. Correct Answer: C. cardiac tamponade. A patient complains of lower abdominal discomfort and is only able to urinate a small amount at a time. The patient's bladder is distended. What is the FIRST intervention that the nurse should take? A. Obtain a urology consultation. B. Insert an indwelling urinary catheter C. Prepare the patient for CT scan. D. Perform a bladder scan. Correct Answer: B. Insert an indwelling urinary catheter Which of the following is the BEST description of bronchiolitis? A. a bacterial infection with a sudden onset resulting in inflammation of the epiglottis B. a viral infection with a rapid onset accompanied by barking cough C. a viral infection with a slow onset causing lower respiratory tract inflammation D. a bacterial infection with a sudden onset accompanied by decreased breath sounds Correct Answer: C. a viral infection with a slow onset causing lower respiratory tract inflammation A nebulized bronchodilator is administered to a 6-year-old child with severe asthma. Treatment may be deemed effective if the patient has A. a respiratory rate that has decreased to 14 breaths/min. B. a prolonged expiratory phase. C. an increased peak expiratory flow rate. D. diminished breath sounds bilaterally. Correct Answer: C. an increased peak expiratory flow rate. Following the transfusion of a unit of packed red blood cells, a patient develops dyspnea, tachypnea, and posterior bilateral crackles. The nurse should anticipate an order for A. nesiritide (Natrecor). B. digoxin (Lanoxin). C. furosemide (Lasix). D. calcium chloride. Correct Answer: C. furosemide (Lasix). The triage nurse should prioritize which of the following patients? A. 2-year-old with coughing and stridor who reportedly swallowed an earring B. 4-year-old with a cough and fever for 3 days C. 19-year-old with complaints of a cough and blood-tinged sputum D. 50-year-old with inspiratory and expiratory wheezing and a history of asthma Correct Answer: A. 2-year-old with coughing and stridor who reportedly swallowed an earring A patient admitted in hypertensive emergency is given a nicardipine (Cardene) drip. Treatment has been effective if the patient's mean arterial pressure decreases by A. 20% to 25% over 4 to 6 hours. B. 20% to 25% over 1 to 2 hours. C. 10% to 15% over 2 to 4 hours. D. 10% to 15% over 30 to 60 minutes. Correct Answer: B. 20% to 25% over 1 to 2 hours. A patient complains of chest pain that worsens with inspiration or lying supine and lessens by leaning forward. The nurse should suspect A. endocarditis. B. pleurisy. C. pericarditis. D. costochondritis. Correct Answer: C. pericarditis. An 82-year-old patient sustained a fractured hip in a recent fall. In evaluating the patient's condition, the nurse should be especially concerned about the A. degree that the affected leg is rotated outward. B. patient's history of drug allergies. C. cause of the fall. D. time the fall occurred. Correct Answer: C. cause of the fall. A patient presents with pain and swelling to the hand after being hit with the stream of a high-pressure grease gun. It would be a PRIORITY for the nurse to A. prepare the patient for a MRI. B. apply direct pressure to the hand. C. apply a sterile dressing to the hand. D. prepare patient for the operating room. Correct Answer: D. prepare patient for the operating room. A patient who has a long-leg cast has pain out of proportion to the injury and decreased sensation in the affected leg. Urinalysis reveals myoglobinemia. These findings MOST likely indicate A. fat emboli. B. deep vein thrombosis. C. compartment syndrome. D. nerve laceration. Correct Answer: C. compartment syndrome. Which of the following pieces of information is useful in the assessment of a patient with suspected hepatitis A? A. history of diarrhea B. unusual odor of feces C. time of last bowel movement D. color of stools Correct Answer: D. color of stools The triage nurse is called to assist a laboring patient in their vehicle. The significant other states that the baby's head delivered just before arrival, but the shoulders seem to be preventing complete delivery. The nurse recognizes which of the following as the PRIORITY intervention for the neonate? A. suction the mouth, then the nose B. clamp the umbilical cord 4-5 cm from the umbilicus C. perform the initial APGAR score D. gently pull light pressure on the posterior shoulder Correct Answer: A. suction the mouth, then the nose A woman presents to the emergency department reporting pelvic pain, nausea, and vomiting. She states she is 2-weeks late for her menstrual cycle, and she had a positive pregnancy test the prior day. The physician is suspicious of an ectopic pregnancy with possible rupture. What is the PRIORITY intervention? A. Initiate IV therapy with D5NS. B. Administer methotrexate (MTX) therapy. C.Give RhoGAM if the mother is Rh positive. D. Prepare the patient for surgery. Correct Answer: D. Prepare the patient for surgery. The nurse caring for a patient with a low platelet count should recognize that it is important to A. apply firm pressure to venipuncture sites. B. assess body temperature using a rectal thermometer. C. administer medications intramuscularly. D. apply heat to injured areas. Correct Answer: A. apply firm pressure to venipuncture sites. A patient who has missed the last three dialysis appointments is found to have peaked T-waves and runs of intermittent ventricular tachycardia on the ECG. Which laboratory finding would be MOST consistent with this patient's presentation? A. serum chloride level of 98 mEq/L B. serum sodium level of 135 mEq/L C. serum potassium level of 7.5 mEq/L D. serum calcium level of 7.9 mg/dL Correct Answer: C. serum potassium level of 7.5 mEq/ The INITIAL drug of choice in the treatment of anaphylaxis is A. prednisone (Sterapred). B. diphenhydramine (Benadryl). C. epinephrine (Adrenalin). D. famotidine (Pepcid). Correct Answer: C. epinephrine (Adrenalin). Which of the following substances should be used to counteract the effects of heparin? A. sodium bicarbonate B. vitamin K C. protamine sulfate D. quinidine sulfate Correct Answer: C. protamine sulfate What electrolyte imbalance is the most likely underlying cause for the rhythm shown in the electrocardiogram (ECG) tracing above? (jpeaked T waves) A. hypermagnesemia B. hypercalcemia C. hypokalemia D. hyperkalemia Correct Answer: D. hyperkalemia A trauma patient is in the emergency department with suspected cardiac tamponade. The nurse should prepare to treat this condition with A. pericardiocentesis. B. transthoracic pacing. C. antidysrhythmics. D. needle thoracostomy. Correct Answer: A. pericardiocentesis. A patient who is at 36 weeks gestation and has eclampsia is receiving a magnesium infusion. Signs and symptoms of magnesium toxicity include A. hypertension. B. hallucinations. C. hypoxemia. D. hyperreflexia. Correct Answer: C. hypoxemia. The nurse is caring for a patient who has an ectopic pregnancy. The patient has stable vital signs and states that she has an appointment with her obstetrical physician tomorrow. The nurse should prepare the patient for A. admission to the operating room. B.a repeat ultrasound examination. C. administration of methotrexate (Folex) D. administration of Rh immune globulin (RhoGAM) Correct Answer: C. administration of methotrexate (Folex) A patient with hypertension is complaining of "tearing" chest and back pain. The nurse should be MOST concerned that the patient is experiencing A. a tension pneumothorax. B. acute aortic dissection. C. a pulmonary embolism. D. cardiac tamponade. Correct Answer: B. acute aortic dissection. Which of the following drugs is commonly used to treat symptomatic bradycardia? A. atropine sulfate B. diltiazem (Cardizem) C. calcium chloride D. metoprolol (Lopressor) Correct Answer: A. atropine sulfate When caring for a patient with a suspected blunt cardiac injury, the nurse should FIRST prepare to administer A. supplemental oxygen. B. sublingual nitroglycerin. C. lidocaine (Xylocaine). D. a narcotic analgesic. Correct Answer: A. supplemental oxygen. Hypovolemic patients who require massive transfusions should be given warmed blood because cold blood A. increases oxygen-carrying capacity. B. lacks calcium-binding citrate C. increases the risk of myocardial dysrhythmias. D. exacerbates metabolic alkalosis. Correct Answer: C. increases the risk of myocardial dysrhythmias. What is a PRIORITY diagnostic test that should be performed when treating a patient with a suspected dysrhythmia? A. troponin level B. electrocardiogram C. CT scan of the chest D. chest X-ray Correct Answer: B. electrocardiogram Myocardial infarction is MOST likely to be fatal A. 2 to 5 days after the onset of the chest pain. B. 1 to 2 weeks after the onset of the chest pain. C. 6 to 12 hours after the onset of the chest pain. D. during the first 2 hours after the onset of the chest pain. Correct Answer: D. during the first 2 hours after the onset of the chest pain.