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A patient presents complaining of fatigue and headache. The nurse observes a bright red ringed lesion on the lower left calf and drooping of the right side upper and lower facial fold. The nurse should recognize that the MOST likely cause of these findings is
Detailed Rationale
The bright red ringed lesion is characteristic of erythema migrans, the classic rash of Lyme disease. The unilateral facial droop (which can involve both upper and lower face in Lyme disease, unlike the upper motor neuron pattern of a stroke) is Bell's palsy, a common neurological manifestation of Lyme disease.
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Which of the following is the MOST commonly used objective measure of patient response to treatment of an acute asthma attack?
Detailed Rationale
Peak expiratory flow rate (PEFR) is a simple, quick, and objective bedside measure of airflow obstruction. It is used to assess severity initially and to monitor response to bronchodilator therapy. While other measures are important, PEFR is the most specific and commonly used objective gauge of improvement in asthma exacerbations.
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A patient comes to the emergency department 8 hours after undergoing treatment of a Colles' fracture of the left forearm. The patient states that the fourth and fifth fingers of that hand are "blue." Further assessment reveals no edema, pain, or decreased sensation. The patient can move all fingers without difficulty. This suggests
Detailed Rationale
Isolated blue discoloration of the 4th/5th fingers (ulnar distribution) without pain, sensory deficit, or motor loss is most consistent with benign ecchymosis (bruising) tracking distally from the fracture site. Compartment syndrome presents with severe pain out of proportion, paresthesia, pallor, and paralysis (the 5 P's).
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A patient presents with sharp abdominal pain, nausea, and vomiting following an insect bite earlier in the day. The nurse should suspect that the patient was bitten by a
Detailed Rationale
Black widow spider envenomation causes severe, cramping abdominal pain (mimicking an acute abdomen), muscle rigidity, nausea, and vomiting due to the neurotoxic effects of the venom. Systemic symptoms can be significant.
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A patient with a history of chronic hypertension is being treated for hypertensive crisis. Blood pressure must be lowered cautiously to
Detailed Rationale
In hypertensive crisis, the body's autoregulation of blood flow to vital organs (brain, heart, kidneys) is set at a higher pressure. A rapid, drastic reduction in BP can precipitate hypoperfusion, leading to stroke, myocardial infarction, or renal failure. The goal is a gradual, controlled reduction.
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A patient with chronic low back pain presents to the emergency department. Which of the following symptoms indicates a serious complication of chronic back pain?
Detailed Rationale
Urinary (or fecal) incontinence, along with saddle anesthesia and bilateral leg weakness, constitutes cauda equina syndrome. This is a neurosurgical emergency caused by compression of the nerve roots at the end of the spinal cord. It requires immediate imaging and decompression to prevent permanent disability.
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A natural disaster struck the community. The staff is determining how many patients they can accept. Which of the following is the PRIORITY consideration?
Detailed Rationale
During disaster surge capacity planning, the absolute priority is safety. If the facility itself is structurally damaged, it cannot safely care for patients or staff. All other considerations (resources, staff stress, morgue space) are secondary to the physical integrity of the building.
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An administration of 50% dextrose is anticipated for a patient withdrawing from alcohol. To avoid complications of this therapy, which of the following drugs should be administered INITIALLY?
Detailed Rationale
Thiamine (Vitamin B1) must be administered BEFORE glucose in patients with suspected alcohol use disorder or malnutrition. Giving glucose without thiamine can precipitate or worsen Wernicke's encephalopathy, a devastating neurological condition caused by thiamine deficiency.
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A patient presents with a foreign body sensation to the eye. Which of the following additional findings would be MOST concerning for corneal abrasion?
Detailed Rationale
Fluorescein dye is used to detect corneal abrasions. Under a cobalt blue light, the dye will stain the area of epithelial defect, highlighting the abrasion. This is a definitive diagnostic finding. Accommodation issues and bilateral changes are less specific. Decreased IOP is not typical for a simple abrasion.
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A pregnant woman in her third trimester presents following a motor vehicle crash. Upon placing her supine, she becomes hypotensive. This is MOST likely due to
Detailed Rationale
This is supine hypotensive syndrome. After 20 weeks, the gravid uterus can compress the inferior vena cava when the mother is supine, reducing venous return to the heart and causing hypotension. It is relieved by positioning the patient on her left side.
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Which of the following symptoms in a 3-year-old child suggest a diagnosis of pertussis?
Detailed Rationale
Pertussis (whooping cough) is characterized by severe paroxysms (fits) of coughing, often followed by an inspiratory "whoop," post-tussive vomiting, and cyanosis/hypoxia. Fever may be low-grade or absent. The other options describe asthma, epiglottitis, and croup, respectively.
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A 2-year-old child in shock is prepared for intubation. A nurse should anticipate that the physician will request
Detailed Rationale
A common rule of thumb for pediatric endotracheal tube sizing is that the external diameter of the tube should approximate the diameter of the child's little finger. Cuffed tubes are now commonly used even in young children when managed appropriately. Fixed sizes (like 5mm) are not age-appropriate for all 2-year-olds.
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Following an assault, a patient presents with hypotension, decreased breath sounds on the right side, a respiratory rate of 36 breaths/min, and dullness to percussion over the right lateral chest. Which of the following should a nurse suspect?
Detailed Rationale
Decreased breath sounds PLUS dullness to percussion (indicating fluid, not air) in the context of trauma and hypotension is classic for a hemothorax (blood in the pleural space). Tension pneumothorax causes hyper-resonance, tracheal deviation, and severe respiratory distress.
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A patient presents with fever, stiff neck, headache, and photophobia. The patient has a history of hydrocephalus with a recent ventricular shunt revision. A nurse should prepare for
Detailed Rationale
The symptoms are classic for meningitis. In a patient with a ventricular shunt, infection (shunt meningitis/ventriculitis) is a major concern. A lumbar puncture is necessary to obtain CSF for analysis and culture to guide antibiotic therapy. Mannitol might be used for increased ICP, but diagnosis comes first.
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Which of the following patients is at the GREATEST risk for complications?
Detailed Rationale
Circumferential burns, even if partial thickness, pose a significant risk for compartment syndrome as edema develops beneath the non-elastic eschar. This can compromise circulation and nerve function distal to the burn, requiring escharotomy. The other injuries, while serious, do not carry the same immediate risk of limb-threatening ischemia.
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A patient has a puncture wound to the hand from a high-pressure injection of paint thinner. After initial assessment is completed and pain medication administered, which of the following is the NEXT priority intervention?
Detailed Rationale
High-pressure injection injuries are surgical emergencies. The injected material (paint thinner) spreads rapidly along tissue planes, causing severe inflammation, necrosis, and compartment syndrome. Immediate, extensive surgical debridement in the operating room is required to remove the contaminant and necrotic tissue and prevent amputation.
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A child has been diagnosed with pertussis. Which of the following medications should the nurse expect to administer?
Detailed Rationale
Pertussis (whooping cough) is a bacterial infection caused by Bordetella pertussis. The primary treatment is antibiotics, specifically macrolides like azithromycin, to eradicate the bacteria, reduce transmission, and may lessen symptom severity if given early.
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A nurse is experiencing conflict with another staff nurse. Which action is MOST appropriate?
Detailed Rationale
The most appropriate first step in resolving interpersonal conflict is direct, professional communication between the involved parties. This approach promotes problem-solving, mutual understanding, and professional accountability. Involving the manager should be reserved for unresolved issues or those involving policy violations. Requesting reassignment avoids the problem. Complaining to others is unprofessional and creates a toxic work environment.
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Which of the following findings on a diagnostic thoracentesis is considered positive for an empyema?
Detailed Rationale
An empyema is an infection in the pleural space, defined by the presence of pus (purulent fluid). While excessive fluid (pleural effusion) may be present, it is not diagnostic of infection. Hemorrhagic fluid suggests trauma or malignancy. Lymphatic fluid (chyle) suggests thoracic duct injury.
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A patient experiences numbness and decreased range of motion to their hands after hitting their head diving off a riverbank. Cervical spine radiographs are unremarkable. [Note: The prompt seems to ask for the nurse's action, though no direct question stem appears on the provided text. Based on the list, the likely choices for a question about next steps are:]
Detailed Rationale
With a mechanism of injury (diving) and neurological symptoms (numbness, decreased ROM in hands), cervical spine injury must be presumed until definitively ruled out. Normal initial radiographs do not rule out ligamentous injury or spinal cord injury without radiographic abnormality (SCIWORA). Cervical spine precautions (collar, immobilization) must be maintained pending further evaluation (e.g., CT, MRI, or clinical clearance). Removing the collar based on normal X-rays is unsafe.
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A patient with a history of IV drug abuse presents with a fever and malaise. Assessment findings include the presence of a cardiac murmur and splinter hemorrhages in the nailbeds. A nurse should suspect
Detailed Rationale
This is a classic presentation of infective endocarditis (IE) in an IV drug user: fever, malaise (systemic infection), new or changing cardiac murmur (valvular damage), and peripheral embolic phenomena like splinter hemorrhages (tiny bleeds under nails). Mitral stenosis is a structural problem but doesn't explain the fever and emboli. MI and heart failure are not the primary suspicions given the full constellation of symptoms.
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Which of the following findings would MOST likely be exhibited by a patient with an acute surgical abdomen and peritonitis?
Detailed Rationale
Peritonitis is inflammation of the peritoneal lining. A key sign is rebound tenderness and guarding, but also characteristic is pain that is exacerbated by any movement (including coughing, walking) or palpation, as this agitates the inflamed peritoneum. Vomiting often follows pain onset. Constipation or diarrhea can occur. Hematemesis is more specific for upper GI bleeding.
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Which of the following is the PRIORITY assessment for a patient presenting with a forearm laceration?
Detailed Rationale
For any extremity injury, the priority assessment is neurovascular status (the '5 Ps': pain, pallor, pulselessness, paresthesia, paralysis) distal to the injury. This determines if there is immediate vascular or nerve compromise requiring emergency intervention. Mechanism of injury is important for understanding contamination and force. Vaccination history (tetanus) and baseline function are secondary after ensuring limb viability.
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A patient presents with pain in the left orbit, rhinorrhea, and nasal congestion. Which of the following actions would be a PRIORITY for the nurse to take?
Detailed Rationale
This cluster of symptoms (unilateral orbital pain, rhinorrhea, congestion) is highly suggestive of sinusitis or a potential complication like orbital cellulitis. However, the question's structure implies a priority action. In an emergency context, the nurse's first action is always to assess and manage the ABCs (Airway, Breathing, Circulation). Applying oxygen would be a priority if there are any signs of respiratory distress or hypoxia, which can occur with severe infection or if the airway is compromised. The other options are specific treatments that require an order and are not the universal first nursing action.
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When caring for a patient with traumatic brain injury, a nurse should optimize cerebral perfusion and prevent secondary brain injury by:
Detailed Rationale
For traumatic brain injury (TBI), maintaining adequate cerebral perfusion pressure (CPP) is critical. Elevating the head of the bed 30 degrees and keeping the head in a neutral, midline position promotes venous drainage from the brain, reducing intracranial pressure (ICP). Hyperventilation (lowering PaCO2) is used only transiently for signs of herniation, not routinely, and a PaCO2 of 50 would be too high (hypoventilation). Urine output targets are lower. Dextrose 50% is hypertonic and not a standard TBI measure; hyperglycemia can worsen outcomes.
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An adolescent who has experienced extreme weight loss and depression is brought to the emergency department after verbalizing suicidal thoughts. The patient states, 'I'm so fat. I just don't care about anything else.' Which of the following psychological conditions is of PRIMARY concern in this patient?
Detailed Rationale
In emergency triage and assessment, the condition posing the most immediate threat to life takes priority. The patient has verbalized suicidal thoughts, indicating active suicidal ideation, which is a psychiatric emergency requiring immediate intervention to ensure safety. While depression and an eating disorder are significant concerns, the acute risk of self-harm is the primary focus. Identity disturbance is less acute.
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A patient who states that they have been bitten by 'something' is weak, nauseated, vomiting, and has a headache. Examination reveals erythema and swelling, and a necrotic center at the site of injury on the dorsum of the right foot. This was MOST likely caused by a
Detailed Rationale
The brown recluse spider bite classically presents with localized tissue necrosis (a 'necrotic center') which can develop over hours to days. Systemic symptoms like nausea, vomiting, headache, and weakness can also occur. The black widow spider bite causes severe muscle cramps and rigidity, not necrosis. Scorpion stings cause neurotoxic symptoms (agitation, salivation). Centipede bites are painful but not typically necrotic.
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A patient diagnosed with acute bacterial iritis is sent home with prescriptions for a cycloplegic agent and pain medication. The patient returns 3 hours later because of severe photophobia. The patient MOST likely
Detailed Rationale
Photophobia is a hallmark symptom of iritis (anterior uveitis). The cycloplegic agent dilates the pupil, which helps with pain but does not immediately resolve the photophobia. The patient likely needs reinforcement of instructions, including wearing dark sunglasses, as light will continue to cause discomfort until the inflammation subsides with treatment (which includes the cycloplegic and possibly steroids). It is not necessarily a sign of misdiagnosis or allergy.
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When providing discharge teaching for the instillation of ophthalmic ointments, the nurse should instruct the patient to apply the ointment and:
Detailed Rationale
To increase contact time of the medication and minimize systemic absorption via the nasolacrimal duct, patients should be instructed to gently press on the inner corner of the eye (medial canthus/nasolacrimal duct) for 1-2 minutes after administering drops or ointment. Blinking will spread the ointment but also increase drainage. Pressure on the closed lid is not as effective. An eye shield is not standard for ointment administration.
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A patient who has noncardiogenic pulmonary edema will MOST likely exhibit
Detailed Rationale
Noncardiogenic pulmonary edema (e.g., from ARDS, neurogenic, high-altitude) results from increased capillary permeability, leading to fluid leaking into the alveoli. This causes impaired gas exchange and the auscultatory finding of diffuse bilateral crackles (rales). Muffled heart sounds, JVD, and peripheral edema are signs of cardiogenic (pump failure) edema, where the primary problem is increased hydrostatic pressure from heart failure.
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Which of the following assessment findings differentiates neurogenic shock from other forms of shock?
Detailed Rationale
Neurogenic shock results from loss of sympathetic tone, usually due to spinal cord injury above T6. The classic presentation is hypotension with bradycardia (due to unopposed vagal tone) and warm, dry skin (due to vasodilation and loss of thermoregulation). In hypovolemic, cardiogenic, and septic shock, the skin is typically cool and clammy, and tachycardia is present. Weak pulses and hypotension are common to all shock states.
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A pregnant woman is having an eclamptic seizure and her blood pressure is 180/110 mm Hg. The physician orders magnesium sulfate. One hour later, the nurse should suspect magnesium toxicity if the patient develops
Detailed Rationale
Magnesium sulfate is a CNS depressant and muscle relaxant used for seizure prophylaxis in preeclampsia/eclampsia. Toxicity is assessed by monitoring deep tendon reflexes (DTRs). Loss of patellar reflexes is an early sign of magnesium toxicity, occurring at serum levels of 8-12 mEq/L. Urine output >30 mL/h is desired. Hypertension may persist but is not a sign of Mg toxicity. Brisk reflexes would indicate possible CNS irritability, not toxicity.
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A patient presents with right anterior chest pain after moving furniture 2 days ago. The pain is reproducible with movement and deep inspiration. Palpation elicits point tenderness at the right costal margin. The pain is MOST likely related to
Detailed Rationale
The mechanism (lifting), localized point tenderness, and pain with movement and inspiration are classic for a musculoskeletal injury, specifically a rib fracture or severe contusion. Costochondritis is inflammation of costochondral junctions, usually more midline. Endocarditis presents with systemic symptoms (fever, murmur). Gallstone pain is typically in the RUQ/epigastrium and radiates to the back/shoulder, not reproducible with palpation.
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A patient with an allergy to sulfites presents with moderate difficulty swallowing, facial swelling, and dyspnea. A nurse should anticipate administration of
Detailed Rationale
The patient is presenting with signs of anaphylaxis (facial swelling, dyspnea, dysphagia). The first-line and most critical treatment for anaphylaxis is epinephrine. It acts rapidly to reverse bronchoconstriction, vasodilation, and angioedema. Diphenhydramine (an antihistamine) and corticosteroids are important adjuncts but do not replace epinephrine for immediate life-threatening symptoms. Dimenhydrinate is for nausea/vertigo. Ceftriaxone is an antibiotic, not indicated for an allergic reaction.
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INITIAL intervention for a patient with a penetrating injury to the eyeball would include
Detailed Rationale
For a penetrating eye injury with an impaled object, the initial nursing intervention is to prevent further damage. The object should NEVER be removed, as this could cause extrusion of intraocular contents. The object should be stabilized (secured) in place. Then, both eyes are patched. Patching the unaffected eye prevents consensual movement (both eyes move together), which would cause movement and potential further injury to the affected eye. Instilling any drops (steroid, anesthetic) is contraindicated as it could introduce infection or increase intraocular pressure. Ophthalmologist evaluation is necessary but is not the 'initial intervention' by the nurse.
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After receiving a breathing treatment and oxygen at 4 L per minute per nasal cannula, a patient with COPD has the following trending vital signs: Initial: HR 85, RR 45, O2 sat 85%, ETCO2 65 mm Hg. Current: HR 76, RR 34, O2 sat 98%, ETCO2 50 mm Hg. Which PRIORITY intervention should be completed NEXT?
Detailed Rationale
This patient with COPD was hypoxemic and hypercapnic (high ETCO2 indicates high PaCO2). After treatment, oxygenation has improved dramatically to 98%, but this is potentially dangerous. In COPD patients with chronic hypercapnia, their drive to breathe is primarily from hypoxemia (hypoxic drive). Over-correction of hypoxemia can remove this drive, leading to hypoventilation, a rise in PaCO2, and CO2 narcosis. The PRIORITY is to titrate oxygen to a target saturation of 88-92% to correct hypoxia without causing hypercapnia. Weaning the flow rate down is the correct action. The decrease in ETCO2 is a good sign. BiPAP might be needed if the patient deteriorates but isn't indicated by the improving trend.
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A 28-year-old man who has had pain in the left eye for the past 36 hours has a yellow-orange ring on the cornea. The patient's pain is MOST likely due to
Detailed Rationale
A yellow-orange ring on the cornea is pathognomonic for a corneal rust ring, which occurs when an iron-containing metallic foreign body (like from grinding metal) becomes embedded in the cornea and oxidizes. The history of pain for 36 hours suggests a retained foreign body, not just a superficial abrasion. Subconjunctival hemorrhage is painless and red. Chemical burns and UV light exposure (welder's flash) cause diffuse damage, not a discrete ring.
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Which of the following statements about a nurse's duty to report suspected child abuse is true?
Detailed Rationale
Mandatory reporters, including nurses, are required by law to report *suspected* child abuse. They do not need definitive proof; a reasonable suspicion is sufficient. Most state laws provide immunity from civil or criminal liability for reports made in good faith, even if the suspicion is later unfounded. Good Samaritan laws typically apply to emergency care provided at the scene, not to mandated reporting duties. The nurse has an independent duty to report and should not defer the decision.
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A patient presents to the emergency department with left-sided facial drooping, weakness in left arm and leg, and difficulty speaking. The emergency nurse should suspect:
Detailed Rationale
This patient presents with classic signs of an acute stroke: unilateral facial droop, arm/leg weakness, and speech difficulty (likely aphasia). While these symptoms can occur in both ischemic (85% of strokes) and hemorrhagic strokes, the emergency nurse's initial suspicion should be for an acute ischemic stroke because it has a time-sensitive treatment (fibrinolytics, thrombectomy). Atypical migraine can have neurological symptoms but is less common and not typically this focal. Chronic subdural hematoma has a slower onset. The initial management (CT scan) will differentiate between ischemic and hemorrhagic.
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In a patient with diabetes insipidus, serum osmolality is
Detailed Rationale
Diabetes insipidus (DI) is characterized by the inability to concentrate urine due to a lack of ADH (central DI) or kidney resistance to ADH (nephrogenic DI). This leads to the excretion of large volumes of very dilute urine. The loss of free water causes dehydration and increases the concentration of solutes in the blood, resulting in hypernatremia and an INCREASED serum osmolality (>295 mOsm/kg). Urine osmolality is typically low (<300 mOsm/kg).
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Which of the following patients is MOST likely to receive immediate hyperbaric oxygen therapy?
Detailed Rationale
Hyperbaric oxygen (HBO) therapy for carbon monoxide (CO) poisoning is indicated for severe cases to prevent delayed neurological sequelae. Common criteria include: loss of consciousness, neurological deficits, cardiovascular instability, carboxyhemoglobin (COHb) level >25% (or >20% in pregnant women, due to fetal risk), and sometimes persistent symptoms despite normobaric oxygen. A pregnant woman with a COHb of 20% meets a specific high-risk criterion because CO crosses the placenta and fetal hemoglobin has a higher affinity for CO. Headaches the next day suggest possible delayed sequelae, but acute severe poisoning takes precedence. A COHb of 7% in a smoker may be near baseline. Transient cognitive changes are a consideration, but pregnancy adds urgency.
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Which of the following findings would MOST significantly increase a patient's potential for wound infection?
Detailed Rationale
The time since injury is a major factor in wound infection risk. After 6-12 hours, most wounds are considered contaminated, and the risk of infection increases significantly. For this reason, many lacerations older than 12 hours may not be primarily closed. An outdated tetanus shot is a risk for tetanus, not necessarily for a routine wound infection. A small blood loss (15 mL) or daily aspirin use does not inherently increase infection risk.
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Positive end-expiratory pressure (PEEP) is ordered to
Detailed Rationale
The primary purpose of PEEP is to maintain a positive pressure in the airways at the end of expiration. This prevents alveolar collapse (atelectasis) and helps keep alveoli open, thereby improving gas exchange by increasing the functional residual capacity (FRC). It does not prevent pulmonary edema (it may help redistribute fluid). It INCREASES FRC. It typically improves the V/Q ratio by opening under-ventilated alveoli.
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A patient with a blunt injury to the chest has a traumatic aortic disruption. A nurse should prepare to
Detailed Rationale
Traumatic aortic disruption (often at the ligamentum arteriosum) is a life-threatening injury. Patients often have severe hypotension from massive hemorrhage. Aggressive fluid resuscitation with blood products and crystalloids is critical to maintain perfusion while preparing for definitive surgical repair. Pain management is important but secondary to resuscitation. Chest tube insertion might be needed for associated hemothorax. Gastric decompression is not the primary intervention.
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A patient presents complaining of fatigue and headache. The nurse observes a bright red ringed lesion on the lower left calf and drooping of the right side upper and lower facial fold. The nurse should recognize that the MOST likely cause of these findings is
Detailed Rationale
The bright red ringed lesion is characteristic of erythema migrans, the classic rash of Lyme disease. The unilateral facial droop (which can involve both upper and lower face in Lyme disease, unlike the upper motor neuron pattern of a stroke) is Bell's palsy, a common neurological manifestation of Lyme disease.
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Which of the following is the MOST commonly used objective measure of patient response to treatment of an acute asthma attack?
Detailed Rationale
Peak expiratory flow rate (PEFR) is a simple, quick, and objective bedside measure of airflow obstruction. It is used to assess severity initially and to monitor response to bronchodilator therapy. While other measures are important, PEFR is the most specific and commonly used objective gauge of improvement in asthma exacerbations.
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A patient comes to the emergency department 8 hours after undergoing treatment of a Colles' fracture of the left forearm. The patient states that the fourth and fifth fingers of that hand are "blue." Further assessment reveals no edema, pain, or decreased sensation. The patient can move all fingers without difficulty. This suggests
Detailed Rationale
Isolated blue discoloration of the 4th/5th fingers (ulnar distribution) without pain, sensory deficit, or motor loss is most consistent with benign ecchymosis (bruising) tracking distally from the fracture site. Compartment syndrome presents with severe pain out of proportion, paresthesia, pallor, and paralysis (the 5 P's).
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A patient presents with sharp abdominal pain, nausea, and vomiting following an insect bite earlier in the day. The nurse should suspect that the patient was bitten by a
Detailed Rationale
Black widow spider envenomation causes severe, cramping abdominal pain (mimicking an acute abdomen), muscle rigidity, nausea, and vomiting due to the neurotoxic effects of the venom. Systemic symptoms can be significant.
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A patient with a history of chronic hypertension is being treated for hypertensive crisis. Blood pressure must be lowered cautiously to
Detailed Rationale
In hypertensive crisis, the body's autoregulation of blood flow to vital organs (brain, heart, kidneys) is set at a higher pressure. A rapid, drastic reduction in BP can precipitate hypoperfusion, leading to stroke, myocardial infarction, or renal failure. The goal is a gradual, controlled reduction.
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A patient with chronic low back pain presents to the emergency department. Which of the following symptoms indicates a serious complication of chronic back pain?
Detailed Rationale
Urinary (or fecal) incontinence, along with saddle anesthesia and bilateral leg weakness, constitutes cauda equina syndrome. This is a neurosurgical emergency caused by compression of the nerve roots at the end of the spinal cord. It requires immediate imaging and decompression to prevent permanent disability.
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A natural disaster struck the community. The staff is determining how many patients they can accept. Which of the following is the PRIORITY consideration?
Detailed Rationale
During disaster surge capacity planning, the absolute priority is safety. If the facility itself is structurally damaged, it cannot safely care for patients or staff. All other considerations (resources, staff stress, morgue space) are secondary to the physical integrity of the building.
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An administration of 50% dextrose is anticipated for a patient withdrawing from alcohol. To avoid complications of this therapy, which of the following drugs should be administered INITIALLY?
Detailed Rationale
Thiamine (Vitamin B1) must be administered BEFORE glucose in patients with suspected alcohol use disorder or malnutrition. Giving glucose without thiamine can precipitate or worsen Wernicke's encephalopathy, a devastating neurological condition caused by thiamine deficiency.
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A patient presents with a foreign body sensation to the eye. Which of the following additional findings would be MOST concerning for corneal abrasion?
Detailed Rationale
Fluorescein dye is used to detect corneal abrasions. Under a cobalt blue light, the dye will stain the area of epithelial defect, highlighting the abrasion. This is a definitive diagnostic finding. Accommodation issues and bilateral changes are less specific. Decreased IOP is not typical for a simple abrasion.
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A pregnant woman in her third trimester presents following a motor vehicle crash. Upon placing her supine, she becomes hypotensive. This is MOST likely due to
Detailed Rationale
This is supine hypotensive syndrome. After 20 weeks, the gravid uterus can compress the inferior vena cava when the mother is supine, reducing venous return to the heart and causing hypotension. It is relieved by positioning the patient on her left side.
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Which of the following symptoms in a 3-year-old child suggest a diagnosis of pertussis?
Detailed Rationale
Pertussis (whooping cough) is characterized by severe paroxysms (fits) of coughing, often followed by an inspiratory "whoop," post-tussive vomiting, and cyanosis/hypoxia. Fever may be low-grade or absent. The other options describe asthma, epiglottitis, and croup, respectively.
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A 2-year-old child in shock is prepared for intubation. A nurse should anticipate that the physician will request
Detailed Rationale
A common rule of thumb for pediatric endotracheal tube sizing is that the external diameter of the tube should approximate the diameter of the child's little finger. Cuffed tubes are now commonly used even in young children when managed appropriately. Fixed sizes (like 5mm) are not age-appropriate for all 2-year-olds.
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Following an assault, a patient presents with hypotension, decreased breath sounds on the right side, a respiratory rate of 36 breaths/min, and dullness to percussion over the right lateral chest. Which of the following should a nurse suspect?
Detailed Rationale
Decreased breath sounds PLUS dullness to percussion (indicating fluid, not air) in the context of trauma and hypotension is classic for a hemothorax (blood in the pleural space). Tension pneumothorax causes hyper-resonance, tracheal deviation, and severe respiratory distress.
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A patient presents with fever, stiff neck, headache, and photophobia. The patient has a history of hydrocephalus with a recent ventricular shunt revision. A nurse should prepare for
Detailed Rationale
The symptoms are classic for meningitis. In a patient with a ventricular shunt, infection (shunt meningitis/ventriculitis) is a major concern. A lumbar puncture is necessary to obtain CSF for analysis and culture to guide antibiotic therapy. Mannitol might be used for increased ICP, but diagnosis comes first.
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Which of the following patients is at the GREATEST risk for complications?
Detailed Rationale
Circumferential burns, even if partial thickness, pose a significant risk for compartment syndrome as edema develops beneath the non-elastic eschar. This can compromise circulation and nerve function distal to the burn, requiring escharotomy. The other injuries, while serious, do not carry the same immediate risk of limb-threatening ischemia.
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A patient has a puncture wound to the hand from a high-pressure injection of paint thinner. After initial assessment is completed and pain medication administered, which of the following is the NEXT priority intervention?
Detailed Rationale
High-pressure injection injuries are surgical emergencies. The injected material (paint thinner) spreads rapidly along tissue planes, causing severe inflammation, necrosis, and compartment syndrome. Immediate, extensive surgical debridement in the operating room is required to remove the contaminant and necrotic tissue and prevent amputation.
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A child has been diagnosed with pertussis. Which of the following medications should the nurse expect to administer?
Detailed Rationale
Pertussis (whooping cough) is a bacterial infection caused by Bordetella pertussis. The primary treatment is antibiotics, specifically macrolides like azithromycin, to eradicate the bacteria, reduce transmission, and may lessen symptom severity if given early.
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A nurse is experiencing conflict with another staff nurse. Which action is MOST appropriate?
Detailed Rationale
The most appropriate first step in resolving interpersonal conflict is direct, professional communication between the involved parties. This approach promotes problem-solving, mutual understanding, and professional accountability. Involving the manager should be reserved for unresolved issues or those involving policy violations. Requesting reassignment avoids the problem. Complaining to others is unprofessional and creates a toxic work environment.
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Which of the following findings on a diagnostic thoracentesis is considered positive for an empyema?
Detailed Rationale
An empyema is an infection in the pleural space, defined by the presence of pus (purulent fluid). While excessive fluid (pleural effusion) may be present, it is not diagnostic of infection. Hemorrhagic fluid suggests trauma or malignancy. Lymphatic fluid (chyle) suggests thoracic duct injury.
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A patient experiences numbness and decreased range of motion to their hands after hitting their head diving off a riverbank. Cervical spine radiographs are unremarkable. [Note: The prompt seems to ask for the nurse's action, though no direct question stem appears on the provided text. Based on the list, the likely choices for a question about next steps are:]
Detailed Rationale
With a mechanism of injury (diving) and neurological symptoms (numbness, decreased ROM in hands), cervical spine injury must be presumed until definitively ruled out. Normal initial radiographs do not rule out ligamentous injury or spinal cord injury without radiographic abnormality (SCIWORA). Cervical spine precautions (collar, immobilization) must be maintained pending further evaluation (e.g., CT, MRI, or clinical clearance). Removing the collar based on normal X-rays is unsafe.
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A patient with a history of IV drug abuse presents with a fever and malaise. Assessment findings include the presence of a cardiac murmur and splinter hemorrhages in the nailbeds. A nurse should suspect
Detailed Rationale
This is a classic presentation of infective endocarditis (IE) in an IV drug user: fever, malaise (systemic infection), new or changing cardiac murmur (valvular damage), and peripheral embolic phenomena like splinter hemorrhages (tiny bleeds under nails). Mitral stenosis is a structural problem but doesn't explain the fever and emboli. MI and heart failure are not the primary suspicions given the full constellation of symptoms.
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Which of the following findings would MOST likely be exhibited by a patient with an acute surgical abdomen and peritonitis?
Detailed Rationale
Peritonitis is inflammation of the peritoneal lining. A key sign is rebound tenderness and guarding, but also characteristic is pain that is exacerbated by any movement (including coughing, walking) or palpation, as this agitates the inflamed peritoneum. Vomiting often follows pain onset. Constipation or diarrhea can occur. Hematemesis is more specific for upper GI bleeding.
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Which of the following is the PRIORITY assessment for a patient presenting with a forearm laceration?
Detailed Rationale
For any extremity injury, the priority assessment is neurovascular status (the '5 Ps': pain, pallor, pulselessness, paresthesia, paralysis) distal to the injury. This determines if there is immediate vascular or nerve compromise requiring emergency intervention. Mechanism of injury is important for understanding contamination and force. Vaccination history (tetanus) and baseline function are secondary after ensuring limb viability.
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A patient presents with pain in the left orbit, rhinorrhea, and nasal congestion. Which of the following actions would be a PRIORITY for the nurse to take?
Detailed Rationale
This cluster of symptoms (unilateral orbital pain, rhinorrhea, congestion) is highly suggestive of sinusitis or a potential complication like orbital cellulitis. However, the question's structure implies a priority action. In an emergency context, the nurse's first action is always to assess and manage the ABCs (Airway, Breathing, Circulation). Applying oxygen would be a priority if there are any signs of respiratory distress or hypoxia, which can occur with severe infection or if the airway is compromised. The other options are specific treatments that require an order and are not the universal first nursing action.
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When caring for a patient with traumatic brain injury, a nurse should optimize cerebral perfusion and prevent secondary brain injury by:
Detailed Rationale
For traumatic brain injury (TBI), maintaining adequate cerebral perfusion pressure (CPP) is critical. Elevating the head of the bed 30 degrees and keeping the head in a neutral, midline position promotes venous drainage from the brain, reducing intracranial pressure (ICP). Hyperventilation (lowering PaCO2) is used only transiently for signs of herniation, not routinely, and a PaCO2 of 50 would be too high (hypoventilation). Urine output targets are lower. Dextrose 50% is hypertonic and not a standard TBI measure; hyperglycemia can worsen outcomes.
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An adolescent who has experienced extreme weight loss and depression is brought to the emergency department after verbalizing suicidal thoughts. The patient states, 'I'm so fat. I just don't care about anything else.' Which of the following psychological conditions is of PRIMARY concern in this patient?
Detailed Rationale
In emergency triage and assessment, the condition posing the most immediate threat to life takes priority. The patient has verbalized suicidal thoughts, indicating active suicidal ideation, which is a psychiatric emergency requiring immediate intervention to ensure safety. While depression and an eating disorder are significant concerns, the acute risk of self-harm is the primary focus. Identity disturbance is less acute.
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A patient who states that they have been bitten by 'something' is weak, nauseated, vomiting, and has a headache. Examination reveals erythema and swelling, and a necrotic center at the site of injury on the dorsum of the right foot. This was MOST likely caused by a
Detailed Rationale
The brown recluse spider bite classically presents with localized tissue necrosis (a 'necrotic center') which can develop over hours to days. Systemic symptoms like nausea, vomiting, headache, and weakness can also occur. The black widow spider bite causes severe muscle cramps and rigidity, not necrosis. Scorpion stings cause neurotoxic symptoms (agitation, salivation). Centipede bites are painful but not typically necrotic.
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A patient diagnosed with acute bacterial iritis is sent home with prescriptions for a cycloplegic agent and pain medication. The patient returns 3 hours later because of severe photophobia. The patient MOST likely
Detailed Rationale
Photophobia is a hallmark symptom of iritis (anterior uveitis). The cycloplegic agent dilates the pupil, which helps with pain but does not immediately resolve the photophobia. The patient likely needs reinforcement of instructions, including wearing dark sunglasses, as light will continue to cause discomfort until the inflammation subsides with treatment (which includes the cycloplegic and possibly steroids). It is not necessarily a sign of misdiagnosis or allergy.
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When providing discharge teaching for the instillation of ophthalmic ointments, the nurse should instruct the patient to apply the ointment and:
Detailed Rationale
To increase contact time of the medication and minimize systemic absorption via the nasolacrimal duct, patients should be instructed to gently press on the inner corner of the eye (medial canthus/nasolacrimal duct) for 1-2 minutes after administering drops or ointment. Blinking will spread the ointment but also increase drainage. Pressure on the closed lid is not as effective. An eye shield is not standard for ointment administration.
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A patient who has noncardiogenic pulmonary edema will MOST likely exhibit
Detailed Rationale
Noncardiogenic pulmonary edema (e.g., from ARDS, neurogenic, high-altitude) results from increased capillary permeability, leading to fluid leaking into the alveoli. This causes impaired gas exchange and the auscultatory finding of diffuse bilateral crackles (rales). Muffled heart sounds, JVD, and peripheral edema are signs of cardiogenic (pump failure) edema, where the primary problem is increased hydrostatic pressure from heart failure.
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Which of the following assessment findings differentiates neurogenic shock from other forms of shock?
Detailed Rationale
Neurogenic shock results from loss of sympathetic tone, usually due to spinal cord injury above T6. The classic presentation is hypotension with bradycardia (due to unopposed vagal tone) and warm, dry skin (due to vasodilation and loss of thermoregulation). In hypovolemic, cardiogenic, and septic shock, the skin is typically cool and clammy, and tachycardia is present. Weak pulses and hypotension are common to all shock states.
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A pregnant woman is having an eclamptic seizure and her blood pressure is 180/110 mm Hg. The physician orders magnesium sulfate. One hour later, the nurse should suspect magnesium toxicity if the patient develops
Detailed Rationale
Magnesium sulfate is a CNS depressant and muscle relaxant used for seizure prophylaxis in preeclampsia/eclampsia. Toxicity is assessed by monitoring deep tendon reflexes (DTRs). Loss of patellar reflexes is an early sign of magnesium toxicity, occurring at serum levels of 8-12 mEq/L. Urine output >30 mL/h is desired. Hypertension may persist but is not a sign of Mg toxicity. Brisk reflexes would indicate possible CNS irritability, not toxicity.
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A patient presents with right anterior chest pain after moving furniture 2 days ago. The pain is reproducible with movement and deep inspiration. Palpation elicits point tenderness at the right costal margin. The pain is MOST likely related to
Detailed Rationale
The mechanism (lifting), localized point tenderness, and pain with movement and inspiration are classic for a musculoskeletal injury, specifically a rib fracture or severe contusion. Costochondritis is inflammation of costochondral junctions, usually more midline. Endocarditis presents with systemic symptoms (fever, murmur). Gallstone pain is typically in the RUQ/epigastrium and radiates to the back/shoulder, not reproducible with palpation.
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A patient with an allergy to sulfites presents with moderate difficulty swallowing, facial swelling, and dyspnea. A nurse should anticipate administration of
Detailed Rationale
The patient is presenting with signs of anaphylaxis (facial swelling, dyspnea, dysphagia). The first-line and most critical treatment for anaphylaxis is epinephrine. It acts rapidly to reverse bronchoconstriction, vasodilation, and angioedema. Diphenhydramine (an antihistamine) and corticosteroids are important adjuncts but do not replace epinephrine for immediate life-threatening symptoms. Dimenhydrinate is for nausea/vertigo. Ceftriaxone is an antibiotic, not indicated for an allergic reaction.
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INITIAL intervention for a patient with a penetrating injury to the eyeball would include
Detailed Rationale
For a penetrating eye injury with an impaled object, the initial nursing intervention is to prevent further damage. The object should NEVER be removed, as this could cause extrusion of intraocular contents. The object should be stabilized (secured) in place. Then, both eyes are patched. Patching the unaffected eye prevents consensual movement (both eyes move together), which would cause movement and potential further injury to the affected eye. Instilling any drops (steroid, anesthetic) is contraindicated as it could introduce infection or increase intraocular pressure. Ophthalmologist evaluation is necessary but is not the 'initial intervention' by the nurse.
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After receiving a breathing treatment and oxygen at 4 L per minute per nasal cannula, a patient with COPD has the following trending vital signs: Initial: HR 85, RR 45, O2 sat 85%, ETCO2 65 mm Hg. Current: HR 76, RR 34, O2 sat 98%, ETCO2 50 mm Hg. Which PRIORITY intervention should be completed NEXT?
Detailed Rationale
This patient with COPD was hypoxemic and hypercapnic (high ETCO2 indicates high PaCO2). After treatment, oxygenation has improved dramatically to 98%, but this is potentially dangerous. In COPD patients with chronic hypercapnia, their drive to breathe is primarily from hypoxemia (hypoxic drive). Over-correction of hypoxemia can remove this drive, leading to hypoventilation, a rise in PaCO2, and CO2 narcosis. The PRIORITY is to titrate oxygen to a target saturation of 88-92% to correct hypoxia without causing hypercapnia. Weaning the flow rate down is the correct action. The decrease in ETCO2 is a good sign. BiPAP might be needed if the patient deteriorates but isn't indicated by the improving trend.
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A 28-year-old man who has had pain in the left eye for the past 36 hours has a yellow-orange ring on the cornea. The patient's pain is MOST likely due to
Detailed Rationale
A yellow-orange ring on the cornea is pathognomonic for a corneal rust ring, which occurs when an iron-containing metallic foreign body (like from grinding metal) becomes embedded in the cornea and oxidizes. The history of pain for 36 hours suggests a retained foreign body, not just a superficial abrasion. Subconjunctival hemorrhage is painless and red. Chemical burns and UV light exposure (welder's flash) cause diffuse damage, not a discrete ring.
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Which of the following statements about a nurse's duty to report suspected child abuse is true?
Detailed Rationale
Mandatory reporters, including nurses, are required by law to report *suspected* child abuse. They do not need definitive proof; a reasonable suspicion is sufficient. Most state laws provide immunity from civil or criminal liability for reports made in good faith, even if the suspicion is later unfounded. Good Samaritan laws typically apply to emergency care provided at the scene, not to mandated reporting duties. The nurse has an independent duty to report and should not defer the decision.
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A patient presents to the emergency department with left-sided facial drooping, weakness in left arm and leg, and difficulty speaking. The emergency nurse should suspect:
Detailed Rationale
This patient presents with classic signs of an acute stroke: unilateral facial droop, arm/leg weakness, and speech difficulty (likely aphasia). While these symptoms can occur in both ischemic (85% of strokes) and hemorrhagic strokes, the emergency nurse's initial suspicion should be for an acute ischemic stroke because it has a time-sensitive treatment (fibrinolytics, thrombectomy). Atypical migraine can have neurological symptoms but is less common and not typically this focal. Chronic subdural hematoma has a slower onset. The initial management (CT scan) will differentiate between ischemic and hemorrhagic.
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In a patient with diabetes insipidus, serum osmolality is
Detailed Rationale
Diabetes insipidus (DI) is characterized by the inability to concentrate urine due to a lack of ADH (central DI) or kidney resistance to ADH (nephrogenic DI). This leads to the excretion of large volumes of very dilute urine. The loss of free water causes dehydration and increases the concentration of solutes in the blood, resulting in hypernatremia and an INCREASED serum osmolality (>295 mOsm/kg). Urine osmolality is typically low (<300 mOsm/kg).
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Which of the following patients is MOST likely to receive immediate hyperbaric oxygen therapy?
Detailed Rationale
Hyperbaric oxygen (HBO) therapy for carbon monoxide (CO) poisoning is indicated for severe cases to prevent delayed neurological sequelae. Common criteria include: loss of consciousness, neurological deficits, cardiovascular instability, carboxyhemoglobin (COHb) level >25% (or >20% in pregnant women, due to fetal risk), and sometimes persistent symptoms despite normobaric oxygen. A pregnant woman with a COHb of 20% meets a specific high-risk criterion because CO crosses the placenta and fetal hemoglobin has a higher affinity for CO. Headaches the next day suggest possible delayed sequelae, but acute severe poisoning takes precedence. A COHb of 7% in a smoker may be near baseline. Transient cognitive changes are a consideration, but pregnancy adds urgency.
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Which of the following findings would MOST significantly increase a patient's potential for wound infection?
Detailed Rationale
The time since injury is a major factor in wound infection risk. After 6-12 hours, most wounds are considered contaminated, and the risk of infection increases significantly. For this reason, many lacerations older than 12 hours may not be primarily closed. An outdated tetanus shot is a risk for tetanus, not necessarily for a routine wound infection. A small blood loss (15 mL) or daily aspirin use does not inherently increase infection risk.
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Positive end-expiratory pressure (PEEP) is ordered to
Detailed Rationale
The primary purpose of PEEP is to maintain a positive pressure in the airways at the end of expiration. This prevents alveolar collapse (atelectasis) and helps keep alveoli open, thereby improving gas exchange by increasing the functional residual capacity (FRC). It does not prevent pulmonary edema (it may help redistribute fluid). It INCREASES FRC. It typically improves the V/Q ratio by opening under-ventilated alveoli.
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A patient with a blunt injury to the chest has a traumatic aortic disruption. A nurse should prepare to
Detailed Rationale
Traumatic aortic disruption (often at the ligamentum arteriosum) is a life-threatening injury. Patients often have severe hypotension from massive hemorrhage. Aggressive fluid resuscitation with blood products and crystalloids is critical to maintain perfusion while preparing for definitive surgical repair. Pain management is important but secondary to resuscitation. Chest tube insertion might be needed for associated hemothorax. Gastric decompression is not the primary intervention.
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