Question

A nurse is caring for a 73-year-old client in the emergency department (ED).

Answer 1

Correct Answers:

Administer broad-spectrum antibiotics.
Measure lactate level.
Rapidly administer 30 ml/kg of normal saline.
Obtain blood cultures.

Rationale :

🦠Broad-spectrum antibiotics should be given as early as possible to treat suspected infection, a key component of the sepsis bundle.

🧪Measuring lactate levels helps assess tissue perfusion and the severity of sepsis, as elevated lactate indicates hypoperfusion.

💧Administering 30 ml/kg of normal saline rapidly restores circulatory volume to improve blood pressure and organ perfusion.

🧫Blood cultures must be drawn before starting antibiotics to identify the causative pathogen and guide targeted therapy.

🚫Inserting an NG tube, cross-matching blood, or collecting wound/urine specimens may be appropriate later, but do not fall within the first-hour sepsis care bundle.

📌Core Message

Initiate broad-spectrum antibiotics, obtain blood cultures, measure lactate, and give rapid fluid resuscitation within the first hour of sepsis recognition.

Answer 2

Correct Answers:

Metformin

Rationale :

💡Metformin interacts with contrast material, increasing the risk for lactic acidosis, especially in clients with renal impairment.

🧬Contrast-induced nephropathy can occur, and metformin clearance relies heavily on renal function, making this combination hazardous.

🧪Current guidelines recommend holding metformin before and after procedures involving iodinated contrast.

⚠️Other medications like atorvastatin, carvedilol, and nitroglycerin do not significantly interact with contrast to increase renal risk.

📌Core Message

Metformin must be withheld before contrast procedures to reduce the risk of lactic acidosis and renal complications.

Answer 3

Correct Answers:

Atrial fibrillation

Rationale :

📉Atrial fibrillation (AF) often causes irregular palpitations, dizziness, and fatigue due to a rapid, irregular heart rhythm.

📊AF leads to a pulse deficit, where the apical and radial pulses differ due to poor cardiac output.

📈ECG findings typically show no P waves, irregular rhythm, and varying ventricular response.

❌Other dysrhythmias such as sinus tachycardia or first-degree AV block would not cause an irregular rhythm with a pulse deficit.

📌Core Message

Atrial fibrillation is identified by irregular rhythm, pulse deficit, and poor perfusion symptoms like dizziness and palpitations.

Answer 4

Correct Answers:

The patient has had no urine output since admission.

Rationale :

🚫Norepinephrine is a vasopressor that causes vasoconstriction, which can worsen perfusion to the kidneys in a client with anuria.

🧪The absence of urine output suggests poor renal perfusion, and starting a vasoconstrictor could lead to renal ischemia or failure.

⚠️Vasopressors should only be used after adequate fluid resuscitation and if hypotension persists.

📉Although low CVP and tachycardia are concerning, anuria is a more critical red flag requiring provider consultation before proceeding.

📌Core Message

Do not start norepinephrine in a patient with no urine output, as it can worsen renal perfusion and lead to organ damage.

Answer 5

Correct Answers:

Ask him to blow into a syringe

Rationale :

🌬️This maneuver is a vagal stimulation technique (Valsalva), used to slow conduction through the AV node during supraventricular tachycardia (SVT).

🔁It’s a noninvasive, first-line treatment for stable SVT before using medications or electrical interventions.

📉The goal is to terminate the reentrant circuit causing SVT and restore normal sinus rhythm.

⚡Defibrillation is reserved for unstable clients, and amiodarone is not the first-line medication for narrow-complex SVT.

📌Core Message

In stable SVT, first use vagal maneuvers like blowing into a syringe to restore normal rhythm noninvasively.

Answer 6

Correct Answers:

Dyspnea

Rationale :

💦Circulatory overload occurs when the infusion rate or volume exceeds the heart’s ability to manage fluid, leading to pulmonary congestion.

💁‍♂️Dyspnea is a classic sign due to fluid accumulation in the lungs, especially in older or heart-compromised patients.

📈Other signs may include crackles, cough, and increased blood pressure, but dyspnea is usually the earliest symptom.

❌Flushing, vomiting, or bradycardia are not hallmark signs of fluid overload.

📌Core Message

Dyspnea is a key indicator of circulatory overload during blood transfusion, requiring immediate intervention.

Answer 7

Correct Answers:

Irregular

Rationale :

🔄Atrial fibrillation is characterized by disorganized electrical activity in the atria, producing an irregular ventricular rhythm.

📉This leads to uneven pulse intervals, which can be felt as irregularly irregular radial or apical pulses.

📋It’s important to assess pulse deficit and correlate with ECG findings for diagnosis.

❌Bounding, slow, or non-palpable pulses are not typical of AF and suggest other issues.

📌Core Message

Atrial fibrillation produces an irregular pulse due to disorganized atrial activity and variable ventricular response.

Answer 8

Correct Answers:

No sedative is ordered for the patient.

Rationale :

🛌Clients receiving neuromuscular blocking agents like cisatracurium require sedation, as the drug paralyzes muscles but does not affect consciousness or pain perception.

🧠Without sedation, the patient could be mentally aware and in distress, unable to move or communicate.

🧾Best practice includes concurrent use of sedatives and analgesics to ensure comfort and humane care.

⚠️Lack of cough reflex or voice response is expected but not as urgent as the lack of sedation.

📌Core Message

Neuromuscular blockers must be paired with sedation to prevent conscious paralysis and distress in ventilated patients.

Answer 9

Correct Answers:

Nitroglycerin Drip

Rationale :

🩸Nitroglycerin reduces preload and afterload, lowering blood pressure and relieving cardiac workload in heart failure with high BP.

💤With an ejection fraction of 40% and elevated systolic BP, afterload reduction is the priority to improve cardiac output.

🚫Dopamine and saline bolus could worsen volume overload, especially with marginal urine output.

💊Isosorbide is long-acting and not suitable for acute management.

📌Core Message

Start a nitroglycerin drip to reduce afterload and relieve cardiac stress in heart failure with elevated blood pressure.

Answer 10

Correct Answers:

Provide 02 at 100% per non-rebreather mask.

Rationale :

🔴Oxygen delivery is the first priority in a client with signs of shock (cool skin, tachycardia, hypotension) to prevent hypoxia and preserve organ function.

💉Other actions like IV access and blood draws are critical, but oxygenation addresses the immediate threat to life.

🔁Shock reduces tissue perfusion, so maximizing oxygen content in the blood is vital.

📉Hypotension combined with low O2 perfusion must be reversed immediately to prevent multi-organ failure.

📌Core Message

Oxygenation is the immediate priority in shock management to prevent tissue hypoxia and organ failure.

1 :
A nurse is caring for a 73-year-old client in the emergency department (ED).

Answer Options

2 :
A nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts with contrast material and places the client at risk for acute kidney injury?

3 :
A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

4 :
Norepinephrine has been prescribed for a patient who was admitted with dehydration and hypotension. Which data indicate that the nurse should consult with the health care provider before starting the norepinephrine?

5 :
Mr Jones came to the ER complaining of chest palpitations. He states his heart feels like it is "racing". The nurse found the following rhythm on the monitor. What is the next step would the nurse expect to take first?

6 :
A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload?

7 :
A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect?

8 :
Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse?

9 :
The nurse is caring for a client who has heart failure with an EF of 40%. The client has a BP of 170/67 with an HR of 60. He currently is in normal sinus rhythm and has an amber urine output of 45ml in the last 3 hours. Which medication would the nurse expect to give first?

10 :
A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention prescribed by the health care provider should the nurse implement first?

1 : A nurse is caring for a 73-year-old client in the emergency department (ED).

Answer Options

2 : A nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts with contrast material and places the client at risk for acute kidney injury?

3 : A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

4 : Norepinephrine has been prescribed for a patient who was admitted with dehydration and hypotension. Which data indicate that the nurse should consult with the health care provider before starting the norepinephrine?

5 : Mr Jones came to the ER complaining of chest palpitations. He states his heart feels like it is "racing". The nurse found the following rhythm on the monitor. What is the next step would the nurse expect to take first?

6 : A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload?

7 : A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect?

8 : Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse?

9 : The nurse is caring for a client who has heart failure with an EF of 40%. The client has a BP of 170/67 with an HR of 60. He currently is in normal sinus rhythm and has an amber urine output of 45ml in the last 3 hours. Which medication would the nurse expect to give first?

10 : A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention prescribed by the health care provider should the nurse implement first?

1 :
A nurse is caring for a 73-year-old client in the emergency department (ED).

2 :
A nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts with contrast material and places the client at risk for acute kidney injury?

3 :
A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

4 :
Norepinephrine has been prescribed for a patient who was admitted with dehydration and hypotension. Which data indicate that the nurse should consult with the health care provider before starting the norepinephrine?

5 :
Mr Jones came to the ER complaining of chest palpitations. He states his heart feels like it is "racing". The nurse found the following rhythm on the monitor. What is the next step would the nurse expect to take first?

6 :
A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload?

7 :
A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect?

8 :
Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse?

9 :
The nurse is caring for a client who has heart failure with an EF of 40%. The client has a BP of 170/67 with an HR of 60. He currently is in normal sinus rhythm and has an amber urine output of 45ml in the last 3 hours. Which medication would the nurse expect to give first?

10 :
A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention prescribed by the health care provider should the nurse implement first?