Crisis Management

In the days following a colon resection and ileostomy creation, which patient action indicates an alteration in body image?

Which is a late sign of hypoxemia?

How many chest compressions per minute are performed during cardiopulmonary resuscitation of the adult?

The patient with chest pain is undergoing an electrocardiogram (ECG). Which ECG finding prompts the activation of the cardiac catheterization lab?

The hospitalized patient is found unresponsive and the cardiopulmonary monitor shows ventricular fibrillation. Upon assessment, no pulse or respiratory effort are appreciated. A code blue is called and the defibrillator is being brought to the room. Which initial intervention is appropriate?

The hospitalized patient is found to be in ventricular tachycardia on electrocardiogram. Upon assessment, no pulse or respiratory effort are noted. Which medication is administered first?

Which drug, if ordered for the patient with second-degree heart block, does the nurse hold and contact the provider?

The nurse is caring for the patient in cardiac arrest. Which rhythm, if found on electrocardiogram, does the nurse most anticipate to be treated with unsynchronized defibrillation?

The unresponsive patient in the emergency department is found on electrocardiogram to have pulseless electrical activity (PEA). The nurse most suspects which two causes of the patient's condition?

The patient who presented to the emergency department complaining of chest pain is found to have a heart rate of 32 beats per minute and a blood pressure of 90/50 mm Hg. The nurse prepares to administer which medication?

The patient's heart rate is 28 bpm and the systolic blood pressure is 80 mmHg. One dose of atropine 0.5 mg IV push has been administered with no response. The patient is unstable, but conscious. Which next intervention is appropriate? 

The nurse is notified the patient's heart monitor shows ventricular fibrillation. Initial assessment reveals strong peripheral pulses and even, unlabored respirations with an oxygen saturation of 98%. Which action does the nurse take first?

The unresponsive patient was pulled from a frozen lake. A regular heart rhythm is noted on the monitor with a rate of 28 bpm. Upon assessment, there is no palpable pulse. The first responders report which rhythm to the receiving hospital?

The unresponsive patient is found to have the following heart rhythm on electrocardiogram (ECG).  Which initial intervention is appropriate?

Which is the correct ratio of crystalloid fluid administration to estimated blood loss to resuscitate the patient in hemorrhagic shock?

A school nurse is caring for an elementary school student who is gasping for breath after being stung by a bee. The child's airway is currently patent and heart rate is 100 bpm. No epinephrine or advanced airway is available. Which intervention is appropriate?

Which statement is true regarding the provision of cardiopulmonary resuscitation (CPR) in the community with an automated external defibrillator (AED)?

The patient with a central venous catheter develops substernal chest pain, hypotension, and cough. There is evidence of air in the line. Which action does the nurse take first​?

Which situation prompts the patient to be compelled to a healthcare facility without consent?

Which patient is seen first in the emergency department?

A patient scheduled to undergo a Whipple procedure (pancreaticoduodenectomy) is extremely agitated and apprehensive, though still wants to undergo the procedure. Which interventions does the nurse employ to decrease the patient's anxiety? Select all that apply.

The single parent of the child with a severe developmental disorder confides in the nurse that caring for the child is becoming impossible to do alone. Which actions by the nurse are most appropriate? Select all that apply. 

The patient is verbally aggressive with a nurse and threatens physical violence unless he is given an IV dose of hydromorphone (Dilaudid). Which initial action by the nurse is appropriate?

The nurse is creating fire safety flyers for the hospital. What does the E in RACE signify?

The nurse is creating fire safety flyers for the hospital. What does the R in RACE signify?

An adult weighing 70 kg is in the burn unit with burns on the front of both legs and the genital region. His fluid requirements were correctly determined using the Parkland formula. He received 2,660 mL during the first 8 hours after his injury. How much fluid should he receive in the next 16 hours?

Which patients are seen first in the hospital following a mass casualty event?

The provider orders albumin for a patient with traumatic amputation and hemorrhage. Which patient characteristic prompts the nurse to clarify the order with the provider?

The patient with a history of depression and generalized anxiety disorder presents to the clinic seeking information on advance directives. Which action(s) by the nurse are appropriate? Select all that apply.

The nurse is planning an informational session at the community center to help parents identify when their children are at an increased risk for suicide. The nurse includes information about which activities in the class? Select all that apply.

The community health nurse is teaching an outreach course on how parents can help to prevent suicide attempts in their at-risk children. Which statement by a parent indicates a need for further teaching?

The 17-year-old male patient is brought to the clinic for a yearly check-up. The nurse observes the patient to be unkempt, with greasy hair and significant body odor. The patient has a flat affect during questioning. When the nurse provides education on safety practices such as wearing a seatbelt when in the car, not driving with impaired persons, and using protection during sexual intercourse, the patient retorts, “I don’t really see the point in wearing a seatbelt, if it helps me die more quickly.” Which initial response by the nurse is most appropriate?

The resident of a large, long-term care facility has reactivated tuberculosis and is infectious. Which action does the nurse take?

Rank these conditions from most (1) to least (4) life-threatening.

The 76-year-old patient with atrial fibrillation tells the nurse in a slurred voice that the right arm “just isn’t working right.” Which action does the nurse take first?

Following traumatic bilateral leg amputations, the 5-year-old child requires a STAT blood transfusion to treat hemorrhagic shock. The child's blood type is unknown. Which action is most appropriate? 

Which breath sound is the most concerning after endotracheal extubation?

The nurse suspects the patient dealing with a longstanding psychiatric trauma is entering Phase 3 of general adaptation syndrome. Which term is used to describe this phase?

The elderly patient with moderate Alzheimer’s disease was brought to the emergency department (ED) for rapidly worsening mental status, fever, and anorexia over the last 24 hours. Portable chest x-ray shows a consolidation in the left lower lobe.Which diagnosis is most accurate?

Which is the best action by the nurse in the neonatal intensive care unit (NICU) in response to a tornado warning?

The nurse working in the pediatric unit finds the two-year-old patient crying on the floor near his hospital crib. The child's parents were present for the fall, are visibly upset, and tell the nurse that she crawled over the edge and fell to the floor. Which action by the nurse is appropriate?

The nurse is caring for a woman who gave birth via forceps delivery within the last 24 hours. The patient describes significant rectal pressure but has had normal bowel movements. The nurse reports the finding to the provider with concerns for which postpartum complication?

The patient with significant respiratory distress is diagnosed with a tension pneumothorax on portable chest x-ray. Which intervention is most appropriate for this patient? 

The patient with bipolar disorder exhibits mania with which action?

The nurse suspects severe anxiety in the patient who reports which symptoms? Select all that apply.

The patient with a long history of alcohol use disorder is admitted to the hospital for observation at risk for alcohol withdrawal syndrome. The nurse anticipates which symptoms to peak 24 to 36 hours after the patient’s last drink? Select all that apply.

The nurse caring for the patient being treated for delirium tremens implements which nursing intervention for the patient?

The nurse is assessing a patient who was reported to have an altered level of consciousness. The patient presents with rapid speech, impaired judgement, and rapidly fluctuating emotional state. After admission and treatment, the patient returns to a functional baseline. Which diagnosis best describes the patient’s behavior?

While completing a patient’s history, the patient states: “I just don’t like the life I am living. I wish it were over.” Which is the most appropriate response from the nurse?

The nurse is conducting a history during a wellness exam. The patient states, “Honestly, I’m really stressed right now. My son is going to college, and my dad is moving in with us. Thankfully, I got a promotion at work so we will be able to move to a place without stairs. I’ve been leaning on my wife and friends a lot and trying to keep exercising and doing yoga.” How does the nurse interpret the patient’s reports?