Evidence-Based Nursing Practice Guidelines for Fall Prevention, Exams of Nursing

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Relias ED RN A Test questions with correct

answers

Your patient's chest tube dressing has accidentally come off and you are preparing to place a new one. You have a slit drain sponge, 4 x 4 gauzes, tape, scissors, and antiseptic swabs. What else do you need? - ANSWER: ➡ Petrolatum gauze You want to implement the new evidence-based practice guidelines in managing patients to prevent falls on your unit. What provides the STRONGEST evidence for interventions? - ANSWER: ➡ Systematic reviews Upon triage of a patient, they state that they have suicidal ideation with intent. What would you do NEXT? - ANSWER: ➡ Institute suicide precautions. Which of the following wounds has the highest risk for developing osteomyelitis? - ANSWER: ➡ Puncture wound from stepping on a rusty nail What type of diet would a patient with diverticulitis follow? - ANSWER: ➡ High fiber diet Answer is NOT high residual diet An elderly patient is brought in with new onset of confusion and gradual onset of headache in the last 48 hours. The patient states that they had a fall 3 days ago. Based on the history and presenting complaints, what diagnostic test do you anticipate the provider to order? - ANSWER: ➡ CT scan of the brain What medication is used in reversing the effects of opioid overdose? - ANSWER: ➡ Naloxone (Narcan®) What are you MOST likely to see during your initial assessment of a patient with chronic obstructive pulmonary disease (COPD)? - ANSWER: ➡ Pursed lip breathing

Under what circumstances can the hospital transfer an unstable patient to another facility and maintain compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA)? - ANSWER: ➡ The necessary treatment is not available at the current hospital. The life-threatening and rare complication of hypothyroidism is known as: - ANSWER: ➡ Myxedema coma A patient presents with acute onset of chest pain and goes into cardiac arrest immediately upon arrival. What is a possible reversible cause of cardiac arrest? - ANSWER: ➡ Tension Pneumothorax A patient presents with an episode of hypertensive crisis, a blood pressure of 220/118, and the provider has put in the order for nitroprusside. What demonstrates that the treatment has been effective? - ANSWER: ➡ Systolic blood pressure reaches 160 mm Hg A patient arrives with suspected appendicitis. What action, if observed, would require additional training for the unlicensed assistive personnel (UAP)? - ANSWER: ➡ The UAP offers the patient a ginger ale. You see a fellow nurse placing an opioid medication in their pocket rather than administering it as ordered. What would you do NEXT? - ANSWER: ➡ Tell your immediate supervisor. You are administering haloperidol (Haldol®) to a patient with acute symptoms of Schizophrenia. What changes in the electrocardiogram (ECG) are possible as a result of this medication? - ANSWER: ➡ Prolonged QT interval A patient presents with a 5-day history of runny nose, headache, and productive cough. The patient is unable to speak full sentences, reports having a history of moderate to severe COPD, and has a SpO2 reading of 89%. What intervention do you anticipate implementing FIRST for this patient? - ANSWER: ➡ Provide oxygen A patient who is 24 weeks pregnant presents with fever and right upper quadrant pain. The patient states that the pain is radiating to the right shoulder blade, and started an hour after having a pizza for lunch. She is tachycardic, tachypneic, and

diaphoretic on the initial triage assessment. What is the MOST likely diagnosis for this patient? - ANSWER: ➡ Cholecystitis A patient arrives with acute onset of central chest pain. The patient is tachycardic and tachypneic and appears very anxious and restless. What would be the MOST important initial intervention for this patient? - ANSWER: ➡ Administer oxygen Answer is NOT Obtain electrocardiogram A patient is being treated with an anticoagulant for pulmonary embolism (PE). What patient assessment finding indicates that a heparin infusion would be stopped IMMEDIATELY? - ANSWER: ➡ Decreased level of consciousness A new nurse observes their preceptor giving the incorrect dosage of a medication to a patient. Implementing the ethical principle veracity, what action would the new nurse take? - ANSWER: ➡ Inform the charge nurse about what happened and document it. What is the appropriate intervention for patients with Acute Respiratory Distress Syndrome (ARDS)? - ANSWER: ➡ Mechanical ventilation What is a common assessment finding in a patient with a tension pneumothorax? - ANSWER: ➡ Distended neck veins What is the current recommended dose of intravenous or intraosseous epinephrine in adult patients with cardiac arrest? - ANSWER: ➡ 1 mg every 3-5 minutes What type of medication is used in the emergency care setting to help manage the symptoms of alcohol withdrawal? - ANSWER: ➡ Benzodiazepines A patient who is 27 weeks pregnant presents with painless bright red vaginal bleeding. What condition correlates with the presenting symptoms? - ANSWER: ➡ Placenta Previa A patient who is 32 weeks pregnant presents with a three-day history of headache and significant swelling of the lower extremities and face. The patient's vital signs are BP: 160/90, HR: 105/min, RR: 19/min, Spo2: 94% on RA, Temp: 97.3 F. What

medication do you anticipate the provider to order FIRST? - ANSWER: ➡ Labetalol (Trandate®) You are assessing a patient who had an altercation involving a clenched fist injury. You notice that his right hand is swollen significantly with pain and bruising. What would you be MOST concerned about for the patient? - ANSWER: ➡ Rheumatoid arthritis Loss of function Osteomyelitis Active bleeding A patient with a history of advanced-stage leukemia presents with a history of increasing shortness of breath in the last 4 days. The patient is anemic and has multiple bruises on their extremities. What is the MOST likely cause of bruising? - ANSWER: ➡ Thrombocytopenia A patient presents with a facial burn with significant facial swelling and acute respiratory distress. Based on a 1-4 triage acuity scale with 1 being most critical, what is the appropriate category based on the patient presentation? - ANSWER: ➡ 1 A patient is brought in after being struck by lightning during a heavy thunderstorm. What would be the PRIORITY intervention for this patient upon arrival? - ANSWER: ➡ Monitoring cardiac rhythm A patient is being treated in a hyperbaric oxygen chamber for carbon monoxide poisoning. What measurement is the BEST indicator of treatment success? - ANSWER: ➡ Arterial blood gas What do you anticipate is the BEST indicator of adequate hydration in an adult patient with 30% body surface area burn during initial fluid resuscitation? - ANSWER: ➡ Urine output of 0.5 mL/kg/hr A patient with a traumatic brain injury (TBI) is MOST likely to suffer from what condition? - ANSWER: ➡ Answer is NOT myxedema coma Answer is NOT Cerebral palsy

A patient with a history of chronic alcohol use is brought in with possible esophageal varices. What medication is used to stop upper gastrointestinal (GI) bleeding in patients with this condition? - ANSWER: ➡ Octreotide (Sandostatin®) A patient is brought in for a potential overdose of heroin. What is the PRIORITY nursing intervention? - ANSWER: ➡ Maintaining airway and breathing Your patient has just had a paracentesis during which 5 liters of fluid were removed. Which assessment is the PRIORITY? - ANSWER: ➡ Blood pressure During cardiogenic shock what temporary intervention might be ordered to improve perfusion until definitive treatment is provided? - ANSWER: ➡ Inotropic infusion What laboratory value would you monitor closely if your patient is vomiting coffee- ground emesis? - ANSWER: ➡ Hemoglobin A patient has sustained multiple traumatic injuries after a fall from a height. What is considered an important component of the primary survey assessment? - ANSWER: ➡ Neurological assessment A patient presents after falling from a height and fracturing their right tibia and fibula. What symptom would be reported to the provider IMMEDIATELY? - ANSWER: ➡ Paresthesia of the foot A 22-year old female who is 8 weeks pregnant presents with a sudden onset of left lower abdominal pain and vaginal bleeding. The patient's family member stated that she had a syncopal episode shortly after that. What is the MOST likely diagnosis for her? - ANSWER: ➡ Answer is NOT Abruptio placenta You exit your patient's room and as you walk away you hear a thud. Upon inspection, you find your patient on the floor. What would you do FIRST? - ANSWER: ➡ Assess the patient for injury. A patient is brought in with possible foreign body obstruction and respiratory distress. The provider suctions the patient and unsuccessfully tries to insert an

endotracheal tube (ETT). What type of procedure would you anticipate NEXT? - ANSWER: ➡ Tracheostomy A patient presents with a 1-day history of pain in the right upper abdomen with nausea and vomiting. The provider suspects that the patient has cholecystitis. What lab value supports the diagnosis? - ANSWER: ➡ Elevated bilirubin You are assisting a novice nurse with a blood draw. You observe the nurse draw the blood, place the specimen tubes in a biohazard bag, and leave the room with the unlabeled specimen tubes. What would you do NEXT? - ANSWER: ➡ Re-educate the nurse, then redraw the labs, use patient identifiers and label at the bedside. A patient presents with a two-day history of fever, cough, mild shortness of breath (SOB), sore throat, myalgia, and new onset of loss of taste and smell. What is the patient MOST likely suffering from? - ANSWER: ➡ COVID 19 A patient is brought in with a history of a head-on motor vehicle accident. The patient was not wearing a seat belt and was traveling at 120 mph with the deployment of an airbag. They complain of severe lower abdominal and hip pain. A secondary trauma survey reveals an unstable hip on lateral compression. What would be a PRIORITY intervention in managing this patient? - ANSWER: ➡ Application of pelvic blinder A patient presents with possible organophosphate toxicity. What would you expect to find upon assessment? - ANSWER: ➡ Diaphoresis What symptom is commonly seen in patients with alcohol withdrawal? - ANSWER: ➡ Tachycardia A patient presents after sustaining a roll-over motor vehicle accident. They are complaining of pain around the mid-upper back. On your initial triage assessment, you find that patient has preserved motor function below L5 but is suffering from a loss of sensory function. The assessment findings are consistent with: - ANSWER: ➡ Answer is NOT Anterior cord syndrome Answer is NOT central cord syndrome

You are caring for a patient who has a history of alcohol use and seizures. You suddenly notice the patient becoming diaphoretic, anxious, tachycardic, and has clammy skin. What would you do NEXT? - ANSWER: ➡ Answer is NOT Turn them on their side Answer is NOT Administer propranolol A confused patient is trying to grasp at their IV with their right hand. Which is the LEAST restrictive measure to maintain patient safety? - ANSWER: ➡ Safety "mitt" for right hand only A patient's family has decided to withdraw life-sustaining treatment. When communicating with the family of the patient, what reassurance would you provide?

• ANSWER: ➡ Efforts will be made to make the patient comfortable. A patient is frustrated at the length of time they have been waiting to be triaged. They start to yell obscenities and threaten you with physical violence. Why would this incident be reported to your supervisor? - ANSWER: ➡ You have the right to personal safety in the work environment. A patient who is 8 weeks pregnant presents to triage with vaginal bleeding and lower abdominal pain. RhoGAM will be given for which situation? - ANSWER: ➡ Mother is Rh negative What is the critical goal time from arrival to the ED to CT brain scan based on the American Heart Association stroke recommendations? - ANSWER: ➡ 25 minutes The deficiency of anti-diuretic hormone (ADH) can lead to what endocrine disorders?
• ANSWER: ➡ Answer is NOT Adrenal Insufficiency Answer is NOT Syndrome of inappropriate secretion of ADH (SIADH) A patient presents after an intentional overdose of propranolol approximately 2 hours ago. The patient has severe hypotension and bradycardia. IV fluids and vasopressors are initiated. What nursing assessment findings indicate the treatment has been effective? - ANSWER: ➡ Answer is NOT Increasing serum cortisol

An adult patient who is 70 kg has a full-thickness burn over 30% of their body surface area. What is the anticipated fluid replacement for a patient in the first 8 hours is based on the Parkland formula? - ANSWER: ➡ 4200 mL A patient with dementia has a family member with MPOA, who is unable to be reached. The provider needs a consent signed and allows the patient to sign. What is the MOST appropriate action you would take? - ANSWER: ➡ Report the provider to their supervisor A patient presents after an intentional overdose of propranolol approximately 2 hours ago. The patient has severe hypotension and bradycardia. IV fluids and vasopressors are initiated. What nursing assessment findings indicate the treatment has been effective? - ANSWER: ➡ Increasing serum cortisol Increasing serum glucose Decreasing pulse pressure Decreasing central venous pressure A patient presents with a partial thickness burn to the anterior portion of the chest. Based on the rule of nine estimations, what is the patient's estimated total body surface area burned? - ANSWER: ➡ 18%