Sie sind auf Seite 1von 21

A 42-year-old man was admitted to the emergency room due to difficulty of breathing, restlessness, and

coughing up of frothy secretions. Further assessment confirmed acute pulmonary edema. The physician
ordered IV glyceryl trinitrate and sublingual nitroglycerine. How will glyceryl nitrate particularly help this
patient?
It treats chest pain in myocardial infarction.
It increases blood pressure by increasing cardiac supply
It increases the pumping action of the heart
It allows more blood flow in the heart through vasodilation

Answer: D – Glyceryl trinitrate is a potent vasodilator indicated for angina and heart failure. It dilates the
blood vessels allowing more blood flow in the heart and reducing the pumping effort of the heart. It
relieves symptoms of heart failure such as breathlessness and dyspnea on effort. Option A is incorrect;
this drug prevents and treats angina pectoris. Morphine is the first line of drug for MI chest pain.

The patient is diagnosed with severe angioedema. Physical assessment reveals difficulty of breathing due
to laryngeal edema. What is the recommended treatment for this patient?

Endotracheal intubation and mechanical ventilation


Epinephrine
Steroids and histamine blockers
All of the above

Answer: D – Severe acute angioedema with laryngeal edema may progress rapidly, and for this reason,
establishment of airway should be done. Epinephrine, steroid and histamine blockers are given to dilate
the airways, relieve the inflammation, and to provide cardiac support in case of acute respiratory failure
and shock.

In the emergency room, the nurse is admitting a patient with symptoms of acute pulmonary edema.
When caring for a patient with decreased tissue perfusion, which of the following symptoms would alert
the nurse of an imminent danger?

Capillary refill - 3 seconds


Diminished peripheral pulses
Urine output - 30ml/hr
Cool extremities
Answer: B – Changes in vital signs, absent or weak peripheral pulse, slow capillary refill, scanty urine, and
changes in level of consciousness are general indicators of inadequate vascular status and poor tissue
perfusion. The nurse must report this finding immediately. Option A and C are normal findings, but they
require careful monitoring for continuous deterioration of condition.
A 57-year-old woman lost consciousness as she was shopping in a grocery store. The patient was revived
shortly after the arrival of the EMT. In the emergency room, the patient is pulseless and unconscious.
Which of the following is an appropriate action of the nurse?

Prepare the defibrillator.


Prepare the cardioverter.
Administer chest compressions.
Prepare to administer epinephrine drugs to increase peripheral vasoconstriction and cardiac output.

Answer: C – To manage an unconscious patient, immediate assessment and revival of the airways,
breathing and circulation are the priority actions. Chest compression and rescue breathing are initially
done until advanced cardiac life support can be administered. ACLS involves restoration of cardiac
rhythm through defibrillation, administration of intravenous emergency drugs, and intubation to
maintain a patent airway. Option B in not required; a cardioverter is a device that converts abnormal
cardiac rhythm into normal rhythms.
An emergency nurse assigned to float in the cardiac care unit assesses the patients who are admitted to
her care. Which of the following patients requires an immediate medical intervention?

A 79-year-old patient with pneumonia, complaining of body weakness.


A 36-year-old heart failure patient, complaining of light-headedness.
A 47-year-old post angiography, complaining of mild discomfort on the leg.
A 66-year-old patient with a heart rate of 100beats per minute.

Answer: B – Lightheadedness may indicate tachyarrhythmia. The nurse should check for shortness of
breath, dizziness, sudden body weakness and fluttering in the chest to confirm tachyarrhythmia. Options
A, C and D are usual assessment findings in these patients.

Pronestyl SR (Procainamide hydrochloride) is an antiarrhythmic agent given to patients with ventricular


tachycardia to decrease excitability of myocardial muscle electrical stimulation. When giving the initial
dose of this IV drug, the nurse should do all of these, EXCEPT:
Check the blood pressure.
Check the heart rate.
Give 20mg/min until resolution of tachycardia.
Place the patient in high-fowler’s position.
Answer: D – Patient should remain flat on bed during IV infusion to minimize hypotension from the drug.
Fast IV push or IV infusion (17mg/kg) could lead to rapid decrease of blood pressure. Other signs of rapid
infusion are irregular pulse, flushing, headache, tightness in the chest, loss of consciousness and cardiac
arrest. Options A, B and C are correct nursing actions.

A 45-year-old man presents with sudden severe pain around the scapula. Assessment findings include
different blood pressure readings obtained on the upper extremities, decreased urine output, and
jugular venous distention. The nurse would suspect:

Myocardial infarction
Pericarditis
 Pleurisy
 Aortic dissection

Answer: D – The symptoms sudden severe pain around the scapula and different blood pressure readings
on both arms indicate a poor prognosis of aortic dissection. Option A is incorrect; although oliguria or
anuria is present in MI, the characteristic of MI pain is chest tightness radiating to the left arm or neck.
Options B and C are incorrect, chest pain in pericarditis and pleurisy is pleuritic in nature.

A patient is diagnosed with hypertrophic cardiomyopathy. While the nurse is preparing the patient for
ECG and administration of an IV drug, the patient asks how the drug can help her. The nurse informs the
patient that the IV drug will help reduce the force of heart contractions. Which of the following drugs
will be most likely administered to the patient?

Spironolactone
Verapamil
Enalapril
Nitroglycerine
Answer: B – Beta blockers and calcium channel blockers, such as verapamil, are typical treatments of
hypertrophic cardiomyopathy. These drugs work by slowing the heart rate and decreasing myocardial
contractility. It allows the heart more time to fill with blood and flow out more easily. Spironolactone is a
potassium-sparing diuretic; enalapril is an angiotensin converting enzyme inhibitor, while nitroglycerin is
a vasodilator.
A patient has undergone aortic valve replacement surgery. In the immediate post-op period, the nurse
should assess the patient every 15 minutes and note which of the following complications that could
lead to valve failure?

allergic skin reactions


thrombosis
bleeding
infection

Answer: B - Aortic valve failure is a rare complication occurring in 1 out of 100 patients. Clot formation or
thrombosis in the new valve is a cause for concern because it prevents the valve from opening and
closing properly. This event warrants reoperation to save the patient’s life. Bleeding and infection are
serious complications as well, but they are expected after the surgery. For example, bleeding may be due
to an anticoagulant that the patient is taking. In severe cases, surgery may be necessary to stop the
bleeding. Infection is fairly common after surgery, and may range from minor skin infection or within the
cavity and breastbone. Aggressive antibiotic therapy is needed to prevent infection.
The nurse is examining a 47-year-old man complaining of pain in the chest, shoulder, jaw and neck.
According to the patient, his chest pains occur regardless of activity or rest. The physician ordered
Enoxaparin SQ for unstable angina. During the therapy, the patient should be checked for:

Bleeding
Stomach discomforts
Swollen ankles
All of the above

Answer: D – Bleeding is a common side effect of enoxaparin, a drug that prevents clots and prevents
myocardial infarction in angina. Stomach discomforts and swollen ankles caused by internal bleeding are
danger signs that should be immediately reported to the physician.

A patient with peripheral arterial disease has been prescribed trental (Pentoxifylline) as an adjunct
therapy. While checking the patient record, the nurse should look for medical conditions that are
contraindicated to this drug. The following medical conditions are contraindicated to this medication
except:
Coronary artery disease
Kidney disease
Peptic ulcer disease
Cerebrovascular accident
Answer: A – Trental (Pentoxifylline) is used to treat intermittent claudication due to chronic occlusive
arterial disease. This drug may be given safely to a patient with coronary artery disease. Symptoms, such
as chest pain, hypotension, and arrhythmia, should immediately be reported to the physician. If the
patient has a history of stroke, bleeding in the eye, kidney disease, PUD, and any recent major surgery,
the physician should be alerted immediately.

A 43--year-old woman came to the facility by herself, complaining of palpitations that occur numerous
times a day, regardless of activity. ECG confirms the physician’s diagnosis of paroxysmal supraventricular
tachycardia. The patient seems distressed about this. What is an appropriate response of the nurse to
this patient?

“You can go home; this is a sign of mild anxiety.”


 “We’ll need to keep you for further assessment; you may develop blood clots.”
 “We’ll keep you for a few hours for blood tests to rule out myocardial infarction.”
 “You’ll need to take blood-thinning medications to minimize episodes of palpitations.”

Answer: B – Paroxysmal supraventricular tachycardia is characterized by irregular, rapid heart rate that
occurs periodically and resolves on its own. The condition lasts for hours or days and may be felt as a
fluttering sensation in the chest. This condition is caused by caffeine, alcohol, smoking, stress, or
myocarditis. Paroxysmal supraventricular tachycardia decreases the cardiac output and leads to
thrombus because the blood becomes stagnant. Clots could turn into an embolus, which could lead to a
stroke. Paroxysmal supraventricular tachycardia is managed by vagal stimulation to halt the
dysrhythmias. Sedatives and propanolol hydrochloride may be administered. In severe cases,
cardioversion may be necessary to prevent heart failure and cardiogenic shock.

A patient is complaining of lightheadedness, which occurred after exercising. While being assessed, the
patient suddenly loses consciousness. Further assessment showed diminished pulses and cool
extremities. What is the next action of the nurse?

Assess airway and breathing


 Administer cardiopulmonary resuscitation
 Place the patient in a supine position and elevate the legs
 Administer oxygen and hook to a cardiac monitor

Answer: A – Syncope or transient loss of consciousness occurs because of poor cerebral perfusion. The
condition is precipitated by light-headedness. The initial action of the nurse is to assess the airway and
check for presence of breathing. If pulseless, CPR should be done without delay. Otherwise, place the
patient in a supine position and elevate the legs to increase venous return and blood flow to the vital
organs. To detect arrhythmia, hook the patient to a cardiac monitor and assess for tachycardia or
irregular pulse.
A patient comes in with swelling of the face, lips and tongue. Medical history from the wife shows the
patient has non-ischemic heart failure and has been taking ACE inhibitors for two years. Further
assessment shows a blood pressure of 170/100mmHg and a heart rate of 75. Patient is tachypneic. What
is the most likely diagnosis?

Nephritic syndrome
Acquired angioedema
Cushing’s disease
Chronic Kidney Disease

Answer: B – The patient may be suffering from angioedema, which is an allergic reaction to the
medication. It differs from hives, which is characterized by welts on the skin. In angioedema, the swelling
appears under the skin (edema of the dermis, subcutaneous tissue and mucosa) and around the eyes
and lips. Acquired angioedema occurs from an allergic reaction to ACE inhibitors. When caring for this
patient, the nurse should ensure airway patency. The causative factor (i.e. medication) should be
discontinued. Edema in nephritic syndrome and chronic kidney diseases is generalized. An upper body
obesity is commonly seen in Cushing’s syndrome.

The physician prescribes IV dopamine, to be infused 10mcg/kg/min. The patient has a heart rate of
40beats per minute. After the nurse reports that the patient’s heart rate is not increasing, the physician
orders to up-titrate the dose to 15mcg/kg/min. When carrying out this order, which of the following is
not a nursing task for this patient?

Diluted and cloudy dopamine is administered immediately.


Dilute dopamine in D5W
Hold the dose if the heart rate reaches 50beats per minute
None of the above

Answer: A – Dopamine is a potent vasopressor that corrects hemodynamic imbalances. When


administering this drug, the nurse should frequently check for adequate urine output and vital signs.
Signs of arrhythmia, decreasing pulse pressure, severe bradycardia, hypovolemia, vaso-occlusive disease,
and extravasation of the drug should be referred to the physician. Option A is incorrect; diluted
dopamine appears clear. A cloudy solution is contaminated and should not be administered. Dopamine
should never be diluted with alkaline solution; the most recommended diluent is NSS or D 5W. Option C is
also correct; the nurse should halt the infusion in severe bradycardia.
A patient is complaining of severe headache. Assessment findings include a blood pressure of
220/120mmHg and a heart rate of 130beats per minute. The patient is having a hypertensive emergency.
The physician orders nitroprusside IV. Which of the following actions by the nurse is correct in this case?
Immediately stop nitroprusside infusion after the patient’s blood pressure drops to almost normal level.
Maintain nitroprusside infusion within 10-40g/kg/min.
Hook the patient to a cardiac monitor.
B and C

Answer: C – Hypertensive emergency is characterized by systole of more than 180mmHg and diastole of
more than 120mmHg. Rapid management of hypertensive emergency is crucial because it can lead to
stroke. When giving IV nitroprusside, a drug that rapidly decreases the blood pressure, the nurse should
monitor the vital signs more frequently. Typically, the patient is hooked to a cardiac monitor. Option B is
incorrect, safe dosage is within 2-20g/kg/min. Option A is also incorrect; do not stop the IV meds
abruptly; a rebound in the blood pressure may occur.

The patient reported increasing difficulty of breathing. The patient was diagnosed with congestive heart
failure. Blood tests were done before the patient was started on antihypertensives and diuretics. While
examining the laboratory results, the nurse notes which of the following tests as a good marker of heart
failure?

Creatinine
Serum Potassium
Chest X-ray
BNP
Administer continuous oxygen.
Monitor ECG.
Monitor for signs of digitalis toxicity.
Encourage oral hygiene.

Answer: B – Diltiazem hydrochloride is an anti-arrhythmic, anti-anginal and antihypertensive drug. An


acute adverse reaction to this drug is heart failure, recurring chest pain and hypertension. The nurse
should continually monitor patient’s vital signs and ECG readings (option B). The nurse should keep the
emergency equipment on hand during therapy; this includes oxygen (option A) and
cardioverter/fibrillator. Option C is correct if the patient is taking digoxin. Option D is incorrect; this is a
long-term effect of diltiazem use.

A patient with right ventricular infarction is a known hypertensive and type 2 diabetic. Which of the
following symptoms is distinctive of right ventricular infarction?
Cold clammy skin
Jugular vein distention
Tachycardia and hypotension
Clear lungs sound
Answer: D – These symptoms are present in ventricular infarction, but the presence of clear lung sounds
highly indicates the occurrence of right ventricular infarction. Infarction of the right side of the heart
causes venous congestion. On the other hand, abnormal breath sounds like crackles and rales are highly
indicative of left ventricular infarction.

The ECG reading of a patient shows flat T-waves. The patient is complaining of muscle weakness. An
electrolyte imbalance is suspected. Which of the following laboratory tests should be done to confirm
the diagnosis?

Serum calcium
Serum potassium
Serum magnesium
Serum phosphate
Answer: B – Flat, T waves on ECG indicate hypokalemia; therefore, serum potassium should be checked.
The normal serum potassium level is 3.5-5.0 mEq/L. Hypokalemia is treated with infusion of potassium
chloride.

A nurse is reviewing the record of a newly admitted pediatric patient. The nurse notes that the physician
who assessed the patient documented the presence of a 3 rd heart sound on auscultation. The nurse
understands that this finding is highly indicative of:

Ventricular failure
Physiologic heart sound
Pericarditis
Valvular failure

Answer: B – The third heart sound found in this patient is normal. In older patients (40 and above), the
presence of a 3rdheart sound indicates a failing ventricular function (option A). In pericarditis, the nurse
will expect to hear a friction rub. Murmurs are auscultated in patients with valvular failure.

The nurse is assigned to a patient who is admitted due to cardiac ischemia. Diagnostic results reveal a
thrombus in the patient’s left anterior descending artery. This artery supplies blood to which of the
following parts of the heart?
Right atrium
Left ventricle, posterior surface
Left ventricle, anterior wall
Right ventricle

Answer: C – The left anterior descending coronary artery delivers blood to the left ventricle, anterior
wall. The right atrium is supplied by the right coronary artery. The circumflex artery supplies oxygen-rich
blood to the left ventricle, posterior surface.

Blood tests are ordered for a 47 year-old-male patient suspected of myocardial infarction. The nurse is
reviewing the laboratory results and notes which of the following findings that correspond to myocardial
infarction?

Increased WBC
Increased Troponin I
Increased LDH1
Increased LDH2

A. I, II
B. I, II, III
C. II, III, IV
D. I, II, III, IV

Answer: D – All the laboratory findings confirm the diagnosis of MI. Even the slightest increase in
troponin I and LDH indicate myocardial injury and infarction. In addition, white blood cells increase as
the body responds to the presence of necrotic tissue after the infarction.
A 67-year-old female patient is prescribed with oral persantine (dipyridamole) after an aortic valve
replacement surgery. The nurse gives instructions to the patient on how the prescribed drug is taken.
The patient needs further instructions if which of the following is stated by the patient during the
evaluation:

“I need to take the medication on an empty stomach.”


“I will be taking the medication at the same time each day.”
“I should take aspirin instead of acetaminophen for pain relief.”
“I keep a record of my blood pressure and pulse rate.”
Answer: C – Persantine (Dipyridamole) is a coronary vasodilator and an anti-platelet aggregator. It is used
as a diagnostic aid in thallium perfusion of the myocardium. The oral form is usually prescribed to
patients who had undergone cardiac valve replacement to prevent thromboembolism. The patient must
take caution in taking aspirin and NSAIDs, as these medications increase the risk for bleeding. To
enhance drug absorption, the medication should be taken on an empty stomach. If gastric distress
occurs, the medicine can be taken with food or milk. The patient should also keep a record of blood
pressure and pulse rate and to seek immediate treatment for chest pain. The nurse must reiterate to the
patient the importance of taking the medicine on regular intervals to maintain the drug’s therapeutic
level in the blood.

A 42-year-old woman is seeking treatment for swelling of the left ankle, which is accompanied by dull
pain. The pain is aggravated by standing for a long period of time. On assessment, tortuous and dilated
leg veins are noted. Trendelenburg’s test is performed. The nurse determines that the patient is positive
for Trendelenburg test if which of the following results is noted:
The veins fill from the proximal end.
The veins fill from the distal end.
Severe pain occurs when the left leg is elevated
Swelling is aggravated by when elevating the left leg.

Answer: A – If the veins fill from the proximal end, the patient is positive for Trendelenburg’s test. This
test is done by placing the patient flat on bed with the legs elevated above the heart. If the patient sits
up, normally the veins fill up from the distal end. If the valves are incompetent, the veins fill from the
proximal end.

A 77-year-old man was admitted 1 hour ago with signs and symptoms of myocardial infarction. The
patient was attached to a cardiac monitor for frequent assessment. If the nurse notes premature
ventricular contractions on the ECG rhythm strip, which of the following must be the priority action of
the nurse?

Administer oxygen.
Monitor for escalating PVCs.
Inform the physician.
Review electrolytes; check for the patient’s serum potassium levels.

Answer: A – The priority intervention, in a case of premature ventricular contractions, is to administer


oxygen to increase oxygenation. The physician must be notified immediately to identify the cause and to
provide the appropriate treatment. Electrolyte imbalances can lead to dysrhythmias; for example,
hypokalemia can lead to PVC. If the patient complains of chest pain, notify the physician and monitor for
escalating PVS and presence of multifocal PVCs
A 75-year-old woman is admitted for lightheadedness, dizziness, and shortness of breath. The ECG strip
shows P waves at a rate of 40beats per minute. The physician orders atropine sulfate IV. After
administering the drug, the nurse carefully assesses the patient for signs of atropine sulfate, which
includes:

Agitation, excitement and confusion


Dry mouth, blurred vision, and sensitivity to light.
Constipation and urinary retention
All of the above

Answer: A – These symptoms indicate atropine toxicity. Geriatric patients are prone to develop toxicity
even with small doses of atropine. Repeated injections of atropine sulfate result in restlessness,
accompanied by marked palpitations and delirium. In severe cases, the patient may fall into a coma or
death due to respiratory failure. To avoid these fatal effects, physicians usually start atropine on geriatric
patients within a low-dosing range. Options B and C are expected anticholinergic effects of the drug.

A 3-year-old boy has a ventricular fibrillation presenting as prolonged QT interval in the ECG rhythm
strip. Which of the following clinical manifestations is expected to be seen in this patient?

Palpable pulse rate 180beats per minute


Unresponsive and pulseless
Palpable pulse rate >200beats per minute
Syncope

Answer: B - Ventricular tachycardia can convert to ventricular fibrillation. The patient may suddenly
become unresponsive and pulseless due to erratic firing of the SA node. This is managed by defibrillation
accompanied by alternating lidocaine and epinephrine. A heart rate from 120-200beats per minute
indicates ventricular tachycardia (option A). The patient is treated with repeated cardioversion and 1%
lidocaine if the rhythm does not convert. If the heart rate ranges between 180 and 240beats per minute
without P waves in the ECG, this indicates supraventricular tachycardia (option C). Option D is incorrect;
syncope may be a sign of decreased cerebral oxygenation due to irregular heart rate.

A 12-year-old boy, who was brought by his mother to the emergency room, was diagnosed with acute
bacterial endocarditis. The nurse notes small hemorrhages on the boy’s palms and soles. This classical
sign of bacterial endocarditis is called:

Osler nodes
Janeway lesions
Splinter hemorrhages
Petechial rash

Answer: B – Janeway lesions are a classical finding in endocarditis. These lesions present as small
hemorrhages on the palms and soles. Osler nodes are tender nodules found on the fingers and toe pads.
Splinter hemorrhages are characterized by linear subungual lesions. Option D, petechial rash, is not an
expected assessment in endocarditis.
The nurse is examining a 49-year-old male patient who came in with signs of hypovolemic shock. A low
pulse pressure is noted. The nurse understands that low pulse pressure is more commonly seen in
patients with:
Severe anxiety
Hyperthermia
Atherosclerosis
Mitral valve regurgitation

Answer: D – Low pulse pressure (subtract diastolic pressure from systolic pressure) is commonly seen in
patients with conditions reflecting reduced stroke volume, reduced ejection velocity, or obstruction of
blood flow during systole. Examples are heart failure, shock, hypovolemia and mitral regurgitation. On
the other hand, high pulse pressure is commonly seen in patients with conditions that reflect elevated
stroke volume, reduced systemic vascular resistance, and reduced distensability of the arteries, such as
in anxiety, exercise, bradycardia, atherosclerosis, aging, hypertension, and fever.

The nurse administered amiodarone (Cordarone) to a 59-year-old male patient who was brought to the
emergency room demonstrating signs and symptoms that are indicative of atrial dysrhythmias. As a
precautionary action, the nurse must ensure that the patient undergoes this test when giving
amiodarone:

Electrocardiography
Echocardiography
Pulmonary function test
Blood glucose level

Answer: C – Amiodarone (Cordarone) can cause pulmonary toxicity; therefore, baseline pulmonary
function tests must be done when giving this drug. This patient is continually monitored for prolonged or
persistent dysrhythmias; thus, the need for ECG during therapy. Blood glucose levels should be
monitored, especially in patients with a history of diabetes, when administering beta-blockers as they
masks the signs of hypoglycemia.
A 43-year-old patient with heart failure is presenting with dyspnea on rest, productive cough and
dysrhythmias. BP is 170/100 mm Hg, and the pulse rate is 82 beats per minute. The physician notes
hypokalemia. The nurse notes that the patient is already taking ACE inhibitors, beta blockers, loop
diuretics, and digoxin at home. In addition to these drugs, the nurse anticipates to also administer:

Spironolactone (Aldactone)
Losartan (Cozaar)
Verapamil (Isoptin)
Hydralazine (Apresoline)

Answer: A - Low serum potassium may cause dysrhythmias and digitalis toxicity. Loop diuretics lead to
the excretion of sodium and potassium in the urine; therefore, the risk for hypokalemia is increased in
patients taking these medications. Spironolactone or potassium sparing diuretics may be prescribed to
prevent hypokalemia. These diuretics may also relieve the other signs of pulmonary congestion.

The nurse is admitting a 49-year-old male patient suspected of acute myocardial infarction. In order for
the patient to become eligible for emergency percutaneous coronary intervention, the nurse assigned to
care for the patient must ensure that:

The patient has an atherosclerotic lesion in the coronary artery.


The percutaneous coronary intervention is done within 1 hour after arrival to the ER.
The patient and the family have expressed fears and thoughts on the procedure.
The patient’s clotting factors are within the normal levels.

Answer: B – An important criterion for eligibility for emergency percutaneous coronary intervention is
the time interval between arrival at the emergency room and the time PCI is performed. The procedure
must be done within 1 hour. The duration of oxygen deprivation is directly related to the number of dead
cells, and doing the procedure within 60 minutes ensures better cardiac rehabilitation. Clotting factors
should be normal, but because of the speedy decision to perform PCI, the physician must weigh the
benefits of continuing the procedure despite abnormal level of clotting factors. The nurse’s task is to
continually monitor for bleeding.

A 40-year-old male patient with heart failure is on digoxin therapy. The patient comes to the facility
seeking treatment for nausea, vomiting, malaise and anorexia. Laboratory tests show serum potassium
level of 2. 65mEq/L, indicating toxicity. To reverse the digitalis toxicity, the nurse administers:

IV Potassium chloride
Calcium channel blockers
Amiodarone (Cordarone)
None of the above

Answer: D – To reverse the digitalis toxicity, digoxin immune FAB or Digibind is administered. This drug
combines with the digitalis to make it unavailable for use. Since digoxin is unavailable for use, atrial
fibrillation and heart failure symptoms may eventually develop or worsen. In order to prevent repeat
episodes of digitalis toxicity, potassium levels should be monitored frequently. Increased potassium in
the patient’s dietary intake is also encouraged. Options B and C are incorrect; calcium channel blockers
and amiodarone would intensify the toxicity
The nurse is attending to a 32-year-old female patient who is admitted due to arterial insufficiency. The
patient complains of right leg pain at rest. The patient record reveals that the patient has a history of
pain in the right leg that worsens at night. Which of the following nursing interventions should be done
to relieve the pain while waiting for the physician?

Elevate the right leg above the heart level


Apply hot compress on the right leg to promote vasodilation.
Direct the patient to sit on the edge of the bed with the legs dangling
Continually monitor for absence of peripheral pulse.

Answer: C – A distinct clinical manifestation of arterial insufficiency is intermittent claudication. This is


initially characterized by pain that is worsened with activity and relieved by rest. As the condition
worsens, the pain may occur at rest. This is due to ischemia of the distal extremity, caused by poor blood
circulation. In order to relieve pain, the affected leg is placed on a dependent position to enhance blood
flow to the extremities. Option B promotes vasodilation, but this intervention may cause tissue trauma,
especially in cases where the extremity is poorly supplied by blood. Option D is an important assessment
tool, but it does not aid in minimizing the leg pain.

A 35 year-old man, a chronic smoker for 10 years, is seeking treatment for foot pain. The affected foot
has an intense red-blue discoloration with no palpable pulse. The nurse expects the physician to make
which of the following diagnoses?
Raynaud’s disease
Buerger’s disease
Zollinger - Ellison syndrome
None of the above

Answer: B – Buerger’s disease is characterized by inflammation of intermediate and small arteries and
veins resulting in thrombus formation and occlusion of the blood vessels. This disease is primarily caused
by an autoimmune vasculitis. It also occurs in young male adults. Raynaud’s disease is characterized by
intermittent vasoconstriction of the small arteries. Zollinger – Ellison syndrome is a gastrointestinal
disease characterized by peptic ulcer, hyperacidity, and gastrin secreting tumors of the stomach.

A nurse is preparing a female patient complaining of increasing pressure on the chest, coupled with
shortness of breath and anxiety. A diagnosis of pericardial effusion is made. Pericardiocentesis is
ordered. Which of the following ECG findings indicates that the needle has made contact with the
epicardium?

Depressed ST segment
Prolonged QRS complex
Elevated ST segment
Presence of U wave
Answer: C – To guide the insertion of the needle, the cable of the precordial lead is attached to the
aspirating needle. As the needle makes contact with the epicardium, the ECG reading will show an
elevated ST segment. A positive outcome of the procedure is immediate relief of symptoms, increased
blood pressure and a fall in the central venous pressure.
The physician has ordered CVP monitoring every hour to a patient who is exhibiting signs of hypovolemic
shock. Which of the following nursing interventions should be done to ensure accuracy of the readings?

Place the patient in a supine position with every reading.


Ink-mark the phlebostatic axis on the patient’s chest.
Place the patient in the same position as the previous reading.
Place the stopcock parallel to the patient’s chest

Answer: B – The phlebostatic axis is the junction that connects the line from the 4 th intercostal space and
the line between the anterior and posterior surface of the chest. To ensure accuracy of CVP readings the
zero of the manometer should always be placed at this standard point. If this point used, the reading will
be accurate from a supine position up to 45° backrest.

The emergency nurse is placing the ECG leads on a patient with angina. On the ECG strip, the nurse
interprets that the _______________ represents the time needed for SA node stimulation, atrial
depolarization, and AV node conduction before ventricular depolarization.

P wave
QRS complex
ST segment
QT interval
Answer: C – The ST segment represents the time required from SA node stimulation, atrial
depolarization, and AV node conduction until ventricular depolarization occurs. P wave represents the
start of the impulse in the SA node. QRS complex represents the ventricular depolarization. QT interval
represents the total time of ventricular depolarization and repolarization.
Gastrointestinal Emergencies

A 27-year-old woman with a penetrating trauma in the lower left abdomen is being admitted to the
emergency room. The patient is unconscious. Breathing and pulses are noted. Which of the following
should be the initial action of the nurse?

Prepare the patient for laparotomy and obtain informed consent from a relative.
Place nasogastric tube.
Establish IV access.
Secure airway and administer supplemental oxygen.

Answer: D – Follow the ABCDE in routine emergency care. Establish the airway and administer
supplemental oxygen. If it is necessary and ordered, the patient is intubated to secure the airway. The
next action is to establish IV access for circulatory support. Nasogastric tube is inserted to empty the
stomach contents and accumulated blood. As the physicians determine the appropriate treatment,
pressure must be applied to the open wound by placing a sterile dressing over it. Abdominal evisceration
requires immediate surgical treatment. Informed consent is obtained from relatives. While in the
absence of the relative, the surgery is done according to the necessity and discretion of the surgeon.
An emergency nurse should be knowledgeable and discerning of the signs and symptoms of a condition
that requires emergency medical interventions. When a patient comes in with acute appendicitis, what
should the nurse look for?

Insidious acute pain


Diffuse abdominal pain
RLQ pain that worsens during movement
Abdominal distention

Answer: C – Acute appendicitis is characterized by right lower quadrant pain at the McBurney’s point.
The pain is aggravated by ambulation, movement and coughing. The patient may also present with
tachycardia, low grade fever and diminished bowel sounds. The nurse may see abdominal guarding and
rigidity with rebound tenderness. Option B is an early symptom of appendicitis (mild appendicitis).
Options A and D are characteristics of intestinal obstruction.

A 17-year-old presents with right upper quadrant pain. The patient’s vomitus is green in color. He reports
intermittent abdominal pain in the same area during the previous days. What is the likely diagnosis?

Acute cholecystitis
IBD
Renal colic
Biliary colic

Answer: D - Biliary colic is caused by obstruction of the gall bladder by a stone. The pain is intermittent
because of the passing of the stone in the common bile duct. It is characterized by hypochondriac pain
that radiates to the back. In acute cholecystitis, the pain radiates to the shoulder tip. In IBD, the pain is
located in the lower abdomen and rectal area. Renal colic is characterized by pain in the lower abdomen,
flank or groin.

An emergency nurse must be adept in patient assessment and care management. In a patient with
appendicitis, how will the nurse elicit the psoas sign?

Ask the patient to flex the right hip against the resistance of the nurse’s hand placed on the patient’s
right knee.
Internally rotate the patient’s right hip while flexing the right knee.
Place the hand at the costal margin in the RUQ of the abdomen while the patient’s breathes in.
A and B

Answer: A – A positive psoas sign is indicative of appendicitis. This is elicited by flexing the right hip
against the resistance of the nurse’s hand placed on the patient’s right knee. Increasing abdominal pain
is a positive psoas sign. Option B refers to the obturator sign, which is also a test for appendicitis. Option
C refers to Murphy’s sign, which is a test for acute cholecystitis
A 44-year-old woman comes in with abdominal pain and dizziness. Further assessment shows
generalized weakness, hypotension and tachycardia. The laboratory test shows increased blood urea and
normal creatinine levels. These findings suggest which of the following conditions?

Chronic kidney disease


Diverticulitis
Cholecystitis
Upper GI hemorrhage

Answer: D – Options B, C and D all present with abdominal pain. However, weakness, hypotension and
tachycardia point towards shock, which may be caused by low circulating blood or bleeding. In kidney
diseases, BUN and creatinine are elevated. However, in severe gastrointestinal bleeding the BUN
increases as the digested blood produce urea; creatinine remains normal.
A 25-year-old bus driver was involved in a vehicular accident before consult. He complains of epigastric
pain and back pain during the assessment. The nurse is preparing the patient for a battery of tests.
Which of the following is true regarding the diagnosis of pancreatic injury?

The patient is symptom-free during the early post-injury period.


Flank ecchymoses is a sign of pancreatic injury
 Signs of peritoneal irritation may indicate pancreatic injury.
 All of the above

Answer: D – Blunt injury arising from vehicular accidents could cause pancreatic injury. The physician
may find seatbelt marks, flank ecchymosis, and severe peritoneal irritation as positive indication for
pancreatic injury. The patient is mostly symptom-free during the early post-injury period, therefore a
high-degree of assessment and monitoring should be done in order not to miss pancreatic injuries.

A nurse is assigned to work in the triage area of the emergency unit. While screening the patients, the
nurse first refers which of the following high-risk patients to the emergency physician?

Dehydration with lethargy


Penetrating wound in the abdomen
Fever 101°F
Vomiting without signs of dehydration

Answer: B – Upon arrival of the patients, the triage nurse must assess the acuity and the urgency of the
condition. The patients given above require immediate care; however, the priority should be given to the
patient with a penetrating wound in the abdomen because of the high risk for hypovolemia and shock.
The patient with dehydration and lethargy should be seen within the next 10 minutes. Immediate needs
must be given while waiting. High fever and vomiting without signs of dehydration should be seen within
30 minutes. Further assessment and testing may be done while waiting
An 18-month-old girl is rushed to the emergency room because of abdominal distention and vomiting of
digested food particles. The child is irritable and restless as well. Which of the following is the most likely
diagnosis?

Hepatitis
Inflammatory bowel disease
Gastroenteritis
Bowel obstruction

Answer: D – Bowel obstruction is characterized by abdominal distention caused by the accumulation of


fecal material in the colon. Due to increased abdominal pressure, the child may frequently vomit.
Hepatitis is characterized by RUQ tenderness and jaundice. Inflammatory bowel disease is associated
with abdominal distention and bloody diarrhea. Gastroenteritis presents with vomiting and diarrhea
without abdominal distention.

The parents of a 2-year-old boy tell the emergency nurse that before the admission, their child was
always complaining of stomach pain that usually went away on its own. The parents brought the child to
the ER after vomiting greenish secretions. If the physician suspects intussusception, what other clinical
findings are expected?

Currant jelly stool


Abdominal distention
 Sausage-like mass on the right lower quadrant of the abdomen
 All of the above

Answer: D – Some cases of intussusception present with currant jelly stool (10%), which is more
commonly found during rectal examination. The abdomen distention and tenderness occur during the
late stages of the condition. Physicians may also palpate a sausage-like mass (invagination of one part of
the bowel into an adjacent part of the bowel) in the right lower quadrant (distal colon) or in the upper
abdomen. Intussusception is managed by surgery.

A 25-year-old male is seeking treatment for rectal pain. Upon inspection, the nurse finds an object
lodged in the patient’s rectum. As a nurse, which of the following interventions should be done first?

Prepare the procedure room for immediate removal of the object.


Obtain a patient history as to the nature and type of foreign body embedded.
Minimize the number of the people that will work with this patient.
Assess for bleeding or other signs of rectal injury.

Answer: C – Patients should be provided with appropriate privacy. Patients with foreign bodies in the
rectum usually delay treatment because of embarrassment. After providing privacy, the nurse must
assess for bleeding or other signs of rectal injury, such as lacerations, that may result from repeated
attempts to remove the objects. The nurse must first determine the nature of the object embedded and
the location in order to determine whether the object can be extracted in the emergency room or in the
operating room
A 38-year-old woman is seeking treatment for black stools. The patient reports mild abdominal pain.
While obtaining patient history, the nurse notes that the patient had a nasal injury 1 week ago. The
nurse tells the patient:

“Can you recall the foods taken in the past few days?”
“This is a sign of bleeding in the stomach.”
“The black stools may be due to swallowed blood.”
“Take extra caution when taking NSAIDs as they can cause GI bleeding.”

Answer: C – Upper GI bleeding that results in melena (black tarry stool) is usually caused by a non-GI
related condition. These include a recent episode of epistaxis, dental work, and nasal and maxillofacial
trauma. Since the patient had a recent nasal injury, the nurse may suspect swallowed blood as the
source of bleeding. True GI bleeding causes include peptic ulcer disease, gastric ulcer, gastritis, and
bleeding esophageal varices. Some foods and medication may cause black stools, but given the history of
nasal injury, the best answer is Option A. Option C and D are incorrect, the physician determines
whether the bleeding is caused by GI-related conditions after further assessment and testing.

A 79-year-old woman is admitted because of a protruded, red, and fleshy mass out of the anus. Upon
inspection, the physician notes that the rectum has prolapsed. Which of the following is the
recommended treatment during the acute stage?
Surgical reduction of prolapsed rectum
Teach perineum - strengthening exercises
Administer anti-diarrheal medications
Manually reduce the prolapsed rectum

Answer: D – Rectal prolapse usually occurs during defecation, especially with constipation and straining.
As the disease progresses, the rectum may prolapse during daily activities, such as walking. The
prolapsed part appears as a dark red sausage-like mass out of the anus. The initial management is to
determine the underlying cause of the condition; it may be from too much straining, rectal fullness,
rectal ulcer or it may be secondary to intussusception. The treatment that follows depends on the
underlying cause. Initially, the rectum may be manually replaced. If the rectum continually prolapses and
when the patient cannot manually replace the rectum anymore, then surgery is done. Surgical reduction
includes sphincter repair or resection of the prolapsed rectum. Option C is incorrect, antidiarrheal meds
can lead to constipation. Before discharge the nurse can provide methods (option B) to prevent rectal
prolapse in the future.

The nurse is assessing an 80-year-old patient who was diagnosed with Zenker diverticula. The nurse
understands that this condition is characterized by:

Protrusion of a sac in the small intestines


A vestigial remnant of the omphalomesenteric duct
Protrusion of a sac in the posterior hypopharynx
Protrusion of a sac in the distal esophagus.
Answer: C – Zenker’s diverticulum is characterized by protrusion of a sac or pouch at the posterior
hypopharynx; it commonly afflicts the elderly. The most common symptom of this condition is
oropharyngeal dysphagia. Options A and B refer more to Meckel’s diverticulum, which is commonly
found in younger children. Option D refers to epiphrenic diverticula. With all these types of diverticula,
the primary problem is the risk of retaining undigested food, which could result in regurgitation and
aspiration pneumonia in the upper GI diverticula and infection in the lower GI diverticula.

A 38-year-old woman is seeking treatment because of difficulty and pain when swallowing solid foods or
liquids. The woman is also complaining of chest pain and a feeling like ‘tiny bits of food are stuck in the
middle of the chest’. After ruling out cardiac-related angina, the physician suspects diffused esophageal
spasm. The nurse expects what kind of diet for this patient?

Nothing by mouth
Soft diet
Liquid diet
Osterized feeding via nasogastric tube

Answer: B – Diffuse spasm of the esophagus is initially managed with sedative, nitrates, and calcium
channel blockers to counter the pain and the spasm. Small, frequent meals are recommended to
minimize esophageal pressure that can lead to spasm. Options A, C and D are necessary only if the
condition worsens and fails to respond to conservative treatment.