Question

A nurse is caring for a patient who is exhibiting ventricular tachycardia (VT). The patient is pulseless on arrival. The nurse should prepare for what intervention?

Answer 1

Correct Answers:

Defibrillation

Rationale :

⚡️Pulseless VT is a shockable rhythm that requires immediate defibrillation to restore perfusing rhythm.

🫀Defibrillation delivers an unsynchronized shock, which is the correct approach when there is no pulse.

🚨Rapid defibrillation is a key part of ACLS because delays greatly reduce survival chances.

🧭While CPR continues between shocks, the definitive rhythm correction for pulseless VT is defibrillation.

📌Core Message

Defibrillation is the priority because pulseless VT is a shockable rhythm needing an unsynchronized shock.

Answer 2

Correct Answers:

Bleeding

Rationale :

🩸t-PA is a thrombolytic, so the main danger is hemorrhage from systemic clot breakdown.

🧠The highest concern is intracranial bleeding, so neuro checks help detect sudden worsening status early.

🧪Nursing monitoring includes signs like bruising, hematuria, GI bleeding, and drops in Hgb/Hct.

🏥Because bleeding can be rapid and life-threatening, early recognition is essential after t-PA.

📌Core Message

After t-PA, monitor closely for bleeding, especially intracranial hemorrhage and systemic bleeding signs.

Answer 3

Correct Answers:

Hypertensive emergencies are associated with evidence of target organ damage.

Rationale :

🎯A hypertensive emergency is defined by severe BP elevation with target organ damage (brain, heart, kidneys, eyes).

👁️Examples of end-organ injury include stroke symptoms, chest pain/MI, pulmonary edema, acute kidney injury, or retinal changes.

💉Because organ damage is present, BP reduction must be carefully controlled using IV medications and close monitoring.

⛑️In contrast, hypertensive urgency lacks acute organ injury, making target organ damage the defining separator.

📌Core Message

The defining difference is target organ damage, which makes it a hypertensive emergency requiring urgent controlled treatment.

Answer 4

Correct Answers:

Encourage the patient to engage in a moderate amount of exercise.

Rationale :

🚶Moderate exercise like walking promotes collateral circulation, improving arterial blood flow to ischemic tissues.

🦵Regular activity can reduce claudication over time by improving muscle efficiency and perfusion.

📈This intervention directly targets altered peripheral tissue perfusion by enhancing oxygen delivery through vascular adaptation.

🛠️Exercise therapy is a cornerstone of PAD management alongside risk-factor control to improve functional capacity.

📌Core Message

Moderate exercise improves PAD perfusion by boosting collateral circulation and supporting better tissue oxygenation.

Answer 5

Correct Answers:

1.95 mL/hr

Rationale :

⚖️Convert weight: 143 lb ÷ 2.2 = 65 kg to ensure correct mg/kg/hr dosing.

🧮Calculate dose per hour: 1.5 mg/kg/hr × 65 kg = 97.5 mg/hr for the ordered infusion.

🧴Use concentration: 50 mg/mL, so volume per hour is 97.5 ÷ 50 = 1.95 mL/hr.

✅This keeps dosing accurate by aligning units across weight, dose rate, and concentration.

📌Core Message

After converting to 65 kg, the ordered 97.5 mg/hr becomes 1.95 mL/hr using 50 mg/mL.

Answer 6

Correct Answers:

Petechiae

Rationale :

🔴A platelet count of 17,000/mm³ indicates severe thrombocytopenia with high bleeding risk.

🧷Low platelets cause capillary bleeding, leading to tiny non-blanching spots called petechiae.

🧫Petechiae reflect impaired primary hemostasis, where platelets normally form the initial plug.

🛡️This finding signals need for bleeding precautions due to fragile clot formation.

📌Core Message

Severe thrombocytopenia commonly presents with petechiae from impaired platelet plug formation.

Answer 7

Correct Answers:

There could be decreased production of platelets

Rationale :

🏭Thrombocytopenia means low platelet count, which can result from decreased production in the bone marrow.

🧫Platelets are made by megakaryocytes, so marrow problems can reduce platelet supply.

🩺Low platelet levels increase risk of bleeding, making the underlying cause (like production failure) important to understand.

📚Explaining decreased production gives a clear, accurate disease mechanism tied to the definition of thrombocytopenia.

📌Core Message

Thrombocytopenia can occur from reduced bone marrow production leading to a low platelet count and bleeding risk.

Answer 8

Correct Answers:

1 tab

Rationale :

🧾Total daily dose is 3.9 g/day = 3900 mg/day, which must be split evenly into 4 doses.

➗Per dose amount is 3900 ÷ 4 = 975 mg to match the ordered schedule.

💊Available tablets are 975 mg each, so one dose equals one tablet.

🧠Aligning ordered mg with tablet strength prevents dosing errors and ensures correct therapy.

📌Core Message

Dividing 3900 mg/day into 4 gives 975 mg per dose, which equals 1 tablet of 975 mg.

Answer 9

Correct Answers

Blank 1 Correct Option: Thrombus formation
Blank 2 Correct Option: an anticoagulant

Rationale :

🫀Atrial fibrillation causes ineffective atrial contraction leading to blood stasis in the atria (often the left atrial appendage).

🧲Stasis increases the chance of thrombus formation, which can break off and cause an ischemic stroke.

🛡️Prescribing an anticoagulant lowers the risk by reducing the blood’s ability to form fibrin clots.

📋Choice of warfarin vs DOAC is guided by stroke-risk scoring (like CHA₂DS₂-VASc) and patient factors.

📌Core Message

A-fib leads to atrial clot formation from blood stasis, so anticoagulation is used to prevent stroke.

Answer 10

Correct Answers:

Call the physician immediately

Rationale :

🚨“Worst headache ever” suggests possible subarachnoid hemorrhage from aneurysm rupture, which is a medical emergency.

🧠Rupture can cause rapid increases in intracranial pressure and sudden neurologic decline.

📞Immediate provider notification supports urgent diagnostics and treatment to prevent worsening bleeding and complications.

⏱️Time-sensitive action is critical because early intervention improves outcomes in suspected aneurysmal bleeding.

📌Core Message

A sudden “worst headache ever” may signal aneurysm rupture and subarachnoid hemorrhage, so urgent provider notification is the priority.

1 :
A nurse is caring for a patient who is exhibiting ventricular tachycardia (VT). The patient is pulseless on arrival. The nurse should prepare for what intervention?

3 :
The staff educator is teaching emergency department nurses about hypertensive crisis. The nurse educator should explain that hypertensive urgency differs from a hypertensive emergency in which way.

4 :
A nurse has written a plan of care for a patient diagnosed with peripheral arterial insufficiency. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. Which intervention is the most appropriate for this diagnosis?

5 :
A patient weighing 143 pounds must be given phenobarbital 1.5 mg/kg/hr. you have available to you 50 mg/ml. What will your infusion rate be?

6 :
A patient's blood work reveals a platelet level of 17,000/mm³. When inspecting the patient's integumentary system, what finding would be most consistent with this platelet level?

7 :
A patient newly diagnosed with thrombocytopenia is admitted to the medical unit. After the admission assessment the patient asks the nurse to explain the disease. What should the nurse explain to the patient?

8 :
You must give someone with an acute exacerbation of rheumatoid arthritis 3.9 grams/day of Aspirin divided into 4 doses. You have available to you aspirin in 975 mg tablets. How many tablets will you give per dose?

9 :
Complete the sentence using the list of options provided.

Correct Answers

10 :
A patient diagnosed with cerebral aneurysm reports "the worst headache ever" to the nurse. What action is the priority for the nurse?

1 : A nurse is caring for a patient who is exhibiting ventricular tachycardia (VT). The patient is pulseless on arrival. The nurse should prepare for what intervention?

3 : The staff educator is teaching emergency department nurses about hypertensive crisis. The nurse educator should explain that hypertensive urgency differs from a hypertensive emergency in which way.

4 : A nurse has written a plan of care for a patient diagnosed with peripheral arterial insufficiency. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. Which intervention is the most appropriate for this diagnosis?

5 : A patient weighing 143 pounds must be given phenobarbital 1.5 mg/kg/hr. you have available to you 50 mg/ml. What will your infusion rate be?

6 : A patient's blood work reveals a platelet level of 17,000/mm³. When inspecting the patient's integumentary system, what finding would be most consistent with this platelet level?

7 : A patient newly diagnosed with thrombocytopenia is admitted to the medical unit. After the admission assessment the patient asks the nurse to explain the disease. What should the nurse explain to the patient?

8 : You must give someone with an acute exacerbation of rheumatoid arthritis 3.9 grams/day of Aspirin divided into 4 doses. You have available to you aspirin in 975 mg tablets. How many tablets will you give per dose?

9 : Complete the sentence using the list of options provided.

Correct Answers

10 : A patient diagnosed with cerebral aneurysm reports "the worst headache ever" to the nurse. What action is the priority for the nurse?

1 :
A nurse is caring for a patient who is exhibiting ventricular tachycardia (VT). The patient is pulseless on arrival. The nurse should prepare for what intervention?

3 :
The staff educator is teaching emergency department nurses about hypertensive crisis. The nurse educator should explain that hypertensive urgency differs from a hypertensive emergency in which way.

4 :
A nurse has written a plan of care for a patient diagnosed with peripheral arterial insufficiency. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. Which intervention is the most appropriate for this diagnosis?

5 :
A patient weighing 143 pounds must be given phenobarbital 1.5 mg/kg/hr. you have available to you 50 mg/ml. What will your infusion rate be?

6 :
A patient's blood work reveals a platelet level of 17,000/mm³. When inspecting the patient's integumentary system, what finding would be most consistent with this platelet level?

7 :
A patient newly diagnosed with thrombocytopenia is admitted to the medical unit. After the admission assessment the patient asks the nurse to explain the disease. What should the nurse explain to the patient?

8 :
You must give someone with an acute exacerbation of rheumatoid arthritis 3.9 grams/day of Aspirin divided into 4 doses. You have available to you aspirin in 975 mg tablets. How many tablets will you give per dose?

9 :
Complete the sentence using the list of options provided.

10 :
A patient diagnosed with cerebral aneurysm reports "the worst headache ever" to the nurse. What action is the priority for the nurse?