What is the criteria for firinolytic therapy?

• No stroke in 3m.
• Onset of s/s within 180 min.
• SBP < 185 mm Hg
• Platelet count < 100,000 mm3

What are the s/s of organophosphate poisoning?

SLUDGE

• S  salivation
• L  lacrimation
• U urination
• D diarrhea
• G GI upset
• E emesis

Name the types of MIs according to ST elevation in corresponding leads.

SALI

• S  septal:  V1 & V2
• A  anterior:  V3 & V4
• L  lateral:  V5,V6, I, AVL
• I  inFerior:  II, III, AVF

What are the s/s & stages of ethylene glycol poisoning?

Pts with ethylene glycol (anti-freeze) poisoning pass thru 3 stages of toxicity. metabolic & neuro effects occur in the 1st stage & are normally seen in the ED.  Neuro effects incl: inebriation, SEIZURES, & coma.  Metabolic effects incl: hypoglycemia (esp. in kids), hypocalcemia, & acidosis. Stage 2 effects the cardiopulmonary system & may incl: pulmonary edema & heart failure. Stage 3: kidney failure.

In what position would you place the crushed arm of a pt that is dx with compartment syndrome?

At body level.  the extremity should not be positioned above the level of the heart because this may compromise arterial blood flow.  A dependent position will compromise venous return.

What sense is lost after the patching of one eye?

Depth perception.

Pts may have difficulty climbing stairs.  All driving & operating of machinery should be avoided.

Days 0,3,7,14,28.

Never administered in gluteal area of adult and older children due to decreased efficacy.

CA pts are at risk for pericardial effusion. Pts with pericardial effusion may exhibit symptoms of cardiac tamponade, incl. HTN, muffled heart sounds, and JVD. Also, pulsus paradoxus and  a drop in BP of > 10 mm Hg on inpiration.

Which of the following is true regarding s/s of copperhead snake bite:

• numbness @ site
• C/O diplopia
• Increased platelet count
• Increased INR

Increased INR

Copperhead snakes are pit vipers, and their venom has a hemotoxin that injures blood vessels, causes tissue necrosis, and affects blood clotting. Copperheads are the least venomous of the pit vipers and do not cause systemic symptoms in adults. Kids however are more vulnerable to the effects of envenomation due to size.

Which of the following s/s is associated with acute pancreatitis in the adult pt?

• N/V
• HTN
• Hyperglyemia
• Epigastic pain radiating to back

Epigastic pain radiating to back

Which of the following tests is most important for the pt with Addison's disease?

• electrolyes
• bedside glucose
• head CT
• plasma cortisol level

plasma cortisol level

Addison's disease (adrenal crisis) is a condition in which the adrenal cortex does not product enough glucocorticoid & mineralocortcoid hormones. Plasma cortisol levels are diagnostic of this condition.

Hyperkalemia

Rhabdomyolysis is caused by a breakdown in muscle tissue and subsequent release of myoglobin, causing the urine to become dark brown. this accumulation of myoglobin causes a fluid shift into the interstitial space.

During a hazmat situation, the RN can deliver complete medical care in which zone of decon?

• Hot zone
• Warm zone
• Cold zone
• Any zone

Cold zone

Pts in the cold zone are properly decontaminated and can receive full medical tx. Pts in the hot zone are considered highly contaminated & minimal control such as airway control, antidotes, hemorhage control are provided. Pts in the warm zone are considered to have some contamination and stabilization is provided.

Croup is classified as a(n):

• upper airway obstruction
• lower airway obstruction
• lung tissue (parenchymal) disease
• disordered control of breathing

Croup is classified as an upper airway obstruction, a blockage of the extrathoracic, large airways. Other disorders in this category incl: anaphylaxis, FB obstruction, & retropharyngeal abscess.

Which of the following s/s are consistant with serotonin syndrome?

• Hyporeflexia
• Hallucinations
• Bradycardia
• Flat affect

Hallucinations

s/s of serotonin syndrome incl: restlessness, tachycardia, hyperthermia, hyperreflexia, & hallucinations.

A young man with a snake bite to the hand comes to the ED. You notice 2 fang marks on the dorsal aspect of the left hand. There is eccymosis & swelling. He states a pain level 5. Your priority intervention is:

• measure circumference of extremity
• remove his rings
• start IV of NS
• get PT/aPTT samples

Remove rings

Copperheads are pit vipers.  Their venom contains proteoltyic enzymes, toxic protiens, & cytolytic enzymes. When envenomization occurs pts have pain at the site & develop ecchymosis & swelling that spreads; if the bite is on an extremity, there is a > risk of compartment syndrome developing.

A peace corps volunteer returns home & goes to the ED c/o flu-like s/s x8d that are getting worse. The pt has a fever; T: 104 F, shaking chills, & orthostatic changes in v/s. Additional questions should focus on assessment of risk for:

• toxic shock syndrome
• meningitis
• malaria
• rabies

Your pt has a chest tube inserted to tx a pneumothorax. While assessing the function of the tube, you notice bubbling in the water seal chamber on exhalation. You should:

• increase amount of suction
• clamp drainage system and check for leaks.
• decrease the amount of suction.
• continue to monitor the system

Your pt arrives to the ED with a crushed black widow spider in a bag & a bite mark on LLE & has s/s of envenomization. The MD orders Valium. You will know that the drug has been effective when:

• seizure activity stops
• pt is sedated
• wound erythemia is reduced
• abdominal pain is relieved

s/s of a black widow bite may incl: pain at the site, chest, back, & shoulder pain or abdominal pain w/rigidity. Although antivenom maybe needed in severe cases, tx is often for symptomatic relief.  

Your pt is dx w/deep frostbite to both feet. Your intial plan of care would incl:

• scrub both feet with antiseptic solution.
• place both feet in a dependent position
• place both feet in a pan of 105-115 F water
• administer analgesics for severe pain.

For every 1 liter increase in oxygen, what is the increased % of oxygen?

i.e. if a pt is put on 2L nasal cannula what % of oxygen are they receiving?

For every 1 liter of oxygen the % of oxygen increases 4%.

If a pt is on 2L of oxygen they will be receiving 29% oxygen.  (RA 21% + 8% from the 2L =29%)

1. peripheral vasoconstriction
2. increased capillary permiability
3. release of glucocorticoids
4. diaphoresis
5. decreased gastric motility

1. increased heart rate
2. increased contractility & automaticity

1. increased respiratory rate
2. bronchodialation

Correction of the obstruction. Examples:

• have preganant lady roll from belly to lt side.
• needle decompression  & chest tube for pneumo.
• fibrinolytic tx for PE.

True or False:

PRBCs contain clotting factors.

False.

FFP & platelets need to be given with PRBCs to provide clotting.

3:1 ratio because due to the osmolarity of the solution, as much as 75% of the volume will leak into surrounding tissue.  Blood products & colloids are given at a 1:1 ratio.

The isotonic solutions should be warmed to prevent hypothermia.

In the average adult male pt., what % of blood volume must be lost to begin to see s/s of hypovolemia?

• 5%
• 10%
• 20%
• 40%

True or False

Hypotension is a late finding in the pediatric hypovolemic pt.

1. Lasix
2. Nitrates
3. MSO4

• Dopamine (inotropin)
• Dobutamine (Doburex)
• Inamrione (Inocor)

Blood pressure.

If the pt is hypotensive afterload needs to be

What electrolyte imbalance is caused by multiple blood transfusions?

Hypocalcemia

Assess for Chvostek’s sign (facial spasm)

True or False

Generally, pts that have had an MI and have damaged > 40% of their left ventricle are at risk of developing cardiogenic shock.

• S3/S4 heart sounds
• Dysrhymias
• Decreased peripheral pulses
• Peripheral edema
• Poor cap. Refill

1. ACE inhibitors
2. Nitrites
3. Nitroprusside (Nipride)

1. Volume
2. Volume

   and yes:

  3. Volume

What is the definative difference between mild anaphlaxis and severe anaphylaxis?

Mild:  Normal BP & Minimal respiratory distress

Severe:  Hypotensive & severe respiratory distress

1. O2
2. Benadryl (antihistamines)
3. Corticosteroids
4. Albuterol
5. Beta 2 agonists
6. Zantac

Dotrocogin Alpha (Xigris) is a FDA approved drug used to combat the vasoconstrictive effects of septic shock. Ideally, it needs to be given in the first 24h of sepsis and is run over a 96h period.  It is very  expensive.

Sympathetic nerve tracts run down along the spinal column. Parasympathetic nerve tracts run down the anterior neck. When the spine is damaged & SNS influence is discontinued, the PNS takes over compete unrestrained control.

Mild preeclampsia is indicated by an increase in SBP of 30mm or more and an increase in DBP of 15mm or more, on two occasions at least 6h a part.

1. Heart rate
2. Color
3. Respiratory Effort
4. Muscle tone
5. Reflex irratibility

In the pt with cold septic shock. What would be an indicator that current interventional tx is sucessful?

• urine output 20 ml/h
• rise in serum pH
• positive Babinski sign
• core temp of 99.0 F

Rise in serum pH to a more alkaline state.  Remember that in cold (late) septic shock Acid-based values turn from a Respiratory alkalosis (in warm shock) to a combined metabolic/respiratory acidosis in cold shock. So, if the serum pH is returning to > alkaline state it would indicate that tx is working.

Which of the following assessment findings is indicative of hypovolemic shock?

• pulsus paradoxus
• hemoglobin of 10 mg/dl & hemocrit of 38%
• widening of pulse pressure
• central venous pressue of 4 mm Hg

Pulses pardoxus is indicative of hypovolemic shock.  It is characterized by an abnormal drop (> 10 mm Hg) in SBP on inspiration.

The ED nurse would expect a pt in early shock to have:

• metabolic acidosis
• metabolic alkalosis
• respiratory acidosis
• respiratory alkalosis

Respiratory alkalosis develops in the intial phase of shock. A compensatory mechanism of tachypnea is initated as a decrease in peripheral tissue perfusion occurs resulting in hypoxia. In early shock the pt hyperventilates to increase oxygenation, thus blowing off carbon dioxide.

Which assessment finding indicates that the compensatory response mechanisms for shock are failing?

• increase in cap refill time
• cool, clammy skin
• pale, moist skin
• mottled skin

Mottled skin would indicate that compensatory mechanisms for shock are failing. During the compensatory stage of shock, the skin is typically cool, pale, & clammy as a result of peripheral vasoconstriction & increased sweat gland activity. If the cause of shock is not corrected, and compensatory mechanisms continue, the sme physiologic events that were initiated t compensate for a decreased CO will lead to detremental effects.  Impaired cellular function leads to acidosis. the resultant decrease in cardiac contractility and loss of vasomotor tone produce mottled skin.

The nurse would expect a pt who is admitted to the ED in the early stages of septic shock to present with:

• weak, thready pulses & low BP
• decreased urine output
• warm, flushed, & moist skin
• hyperventilation & pulmonary congestion

The nurse would expect a pt who is admitted in the early (hyperdynamic, aka warm shock) stages of septic shock to present with warm, flushed, & moist skin; tachycardia with full, bounding pulses; tachypnea; confusion; normal or slightly decreased BP.

In the pt with early septic shock, which respirator symptom would the ED nurse expect to note?

• increased mucus production
• bilateral crackles
• hyperpnea
• respiratory acidosis

Hyperpnea is common in early sepsis.

275-295 mOsm/liter

A hyperosmolar state (>295) could cause brain cells to become dehydrated, thereby causing a change in level of consiousness.

4ml of LR x pt's wt in kg x % of BSA burned.

• First 1/2 of this volume over first 8h.
• Second 1/2 of this volume over the next 16h.

More than half of those with IBS have underlying depression or anxiety.

·        Pts with massive burns frequently develop gastric distention and paralytic ileus form the stress of the injury, therefore must be kept NPO while in the ED.  An NG tube should be placed and gastric output should be measured and recorded. Aspirate should be checked for occult blood and pH should be checked every 2 hours.  Tagamet or Zantac may be ordered. 

·        Afterdrop is a common phenomenon in hypothermic pts (also postop pts) in whom the core temperature continues to drop after the cause of hypothermia is removed. Usually about 2 degrees F. This occurs because of vasodialation causing peripherally sequestered cold blood returning to central circulation.

True or False

The elderly are more at risk for hypothermia.

True 

The elderly are more at risk for hypothermia due to an impaired hypothalamic function

·        When assessing a pt for heatstroke, the nurse would expect to find a temp > 106 F. In addition: tachhypnea, hypotension, lethargy, or coma.

·        Exertional heatstroke, which is common in athletes, occurs with exercise during periods of high heat or humidity. Nonexertional heatstroke, which is not associated with activity may also occur in high heat or humidity but also in saunas, hot tubs.  Since exertional heatstroke manifests differently that nonexertional heatstroke, the nurse would expect to find that the pt with exertional heatstroke will have to continue to sweat and have moist and clammy skin. The pt with nonexertional heatstroke will have hot and flushed skin and will not sweat.  Both forms of heatstroke will cause variations in pulse rate.

·        The nurse should expect to stop all cooling measures when the pts body temperature reaches 102 F.  This is because the pts body temp will continue to drop after the measures have been removed.

·        A decreased WBC (leucopenia) and a decreased platelet count (thrombocytopenia) always occur in pts with radiation exposure and manifest anywhere form 1-5w from the incident, depending on the amount of exposure. In cases of mild exposure (100 rads) these symptoms usually manifest 4-5w later.  In moderate exposure (300-600 rads)  3w later. In high exposure (>600 rads) 1-3w later.  Such a pt would have a decreased protection against infection, anemia, and decreased coagulation. 

·        Frequent airway assessments are vital during the first 48 hours after burn injury.  Although the victim may not suffer mechanical airway obstruction as a result of the burn, the pt. will have edema as fluid shift from plasma to the interstitial spaces.  The large fluid replacement can add to this edema.  After 48 hours the burn pt enters the diuretic phase , characterized by an increase in urine output and decreased edema, the danger of airway obstruction decreases at this point.  If burn injuries occur in an enclosed environment, the toxic products of combustion can cause deterioration of pulmonary function.

• The red, burned appearance of frostbite is caused as ice crystals enlarge, and cells rupture, enzymatic and metabolic activity becomes interrupted.  Such interruption results in histamine release and increased capillary permeability with resultant red blood cell aggregation and microvascular occlusion.

·        Extreme caution must be used while moving, transporting, manipulating, or intubating a hypothermic pt. in order to prevent ventricular fibrillation.  Also, at temperatures at or below 85 degrees, defibrillation and drug therapy are ineffective.

A 6m old infant in brought to the ED with sudden onset of severe colicky pain & vomiting. The nurse should assess for:

• blood or mucus in stool
• relationship of feeding to onset of s/s.
• a palpable olive-shaped mass in the epigastrium.
• projectile vomiting.

(Methemoglobinemia is a disorder characterized by the presence of a higher than normal level of methemoglobin (metHb) in the blood. Methemoglobin is a form of hemoglobin that does not bind oxygen. When its concentration is elevated in red blood cells, anemia and tissue hypoxia can occur.)

• 100% oxygen
• hyperbaric oxygen
• ascorbic acid IV
• methylene blue IV

GI upset, diaphoresis, fever, & tinnitus are common s/s of which of the following conditions?

• GERD
• Acute salicylate tox.
• appendicitis
• Acute acetaminophen tox.

Assess the cerebellum by:

• asking pt to swallow.
• asking pt to read a statement & do what it says.
• instruct pt to close his eyes, hold his arms out, & alternate touching his nose with each finger.
• instruct pt to close his eyes & extend his arms straight out with palms up.

Advise pts that they may experience:

• irregular heartbeat
• facial flushing
• headache
• lightheadedness
• dizziness
• nausea
• SOB
• CP

1 to 2 mg/kg IV

or 

2 to 4 mg/kg IM

Comments: rapid onset, short duration (3-5 min). S/E: muscle fasciculations, rise in IOP & ICP.

1. Fentanyl: 2-3 ug/kg given at at rate of 1-2 ug/kg per minute IV for analgesia in awake pts.
2. Atropine: 0.02 mg/kg IV push
3. Lidocaine:  1.5-2 mg/kg IV over 30-60s.

What EKG changes might the ED nurse see in a pt with ischemia?

True or False:

20% of pts having an MI will not experience chest discomfort.

True

The following pt populations are less likely to experience chest discomfort:

• Diabetics
• Elderly pts >85y (most common s/s is SOB)
• Pts who have had a cardiac transplant will NOT experience chest pain.
• Women

M  morphine

O  oxygen

N  nitro

A aspirin

• peripheral edema
• hepatomegaly
• splenomegaly
• ascites
• JVD
• increased central venous pressure

• tachypnea
• tachycardia
• cough
• rales
• basilar crackles
• gallop rhythm
• increased pulmonary artery pressures.
• hemoptysis
• cyanosis
• pulmonary edema

Beck's triad is a collection of three medical signs associated with acute cardiac tamponade, an emergency condition wherein fluid accumulates around the heart and impairs its ability to pump blood. The result is the triad of low arterial blood pressure, increased central venous pressure, and distant heart sounds.^[1]

True or False

In septic shock, the very old & the very young may not respond to the pyrogens given off by the cells and may present without a fever.

True or False

Hypodynamic (late/cold) septic shock occurs when the BP goes so low that the SNS & RAS is activated.  At this late point, cold shock looks just like hypovolemic shock.

True or False

A very low glucose level or an overdose of insulin could cause neurogenic shock.

True or False

A Q wave in lead III alone is not diagnostic of infarction, even if it is otherwise “significant” in size and width. Qs in III are ignored unless other abnormalities are seen.

True

True or False

Q waves are “significant” if they are greater than 1 box in width (longer than 0.04 msec) OR are larger than 1/4 of the R wave. Significant Q waves indicate either myocardial infarction or obstructive septal hypertrophy (IHSS).

When is a Q wave significant?

• Only in lead III
• If it is 0.04s or greater or 25 % as deep as the R wave is high
• In septal, anterior, & inferior infarcts.
• During Ischemia

True or False

A pt with unstable angina with have a positive troponin level.

False.

Troponin will only be positive when there is actually infarction of the myocardium.

• analgesia
• sedation
• decrease preload
• decrease afterload (cause it vasodialates)
• reduces apprehension

What can the ED nurse expect to give the MI pt that is allergic to ASA?

• Page interventional attending
• V/S & continuous monitoring
• Establish IV
• Oxygen
• STAT labs: troponin, CBC, CMP, lipid panel, PT/INR, Mag.
• H&P
• ASA or Plavix
• Metroprolol 5mg IV up to 3 doses (5 min apart)
• Nitrates if pain continues after Bb.
• MSO4
• Hospital gown on pt, monitor & portable oxygen placed on pt/transfer to lab.

• age > or = 65y
• > or = 3 CAD risk factors (incr. chol., family hx, HTN, DM, smoking)
• Prior CAD (cath stenosis > or = 50%)
• ASA in last 7d.
• > or = 2 anginal events at rest in < or = 24h.
• ST deviation > or = 0.5mm
• Elevated Troponin

low risk: <3

intermediate risk:  3 or 4

High risk: > 4

True or false:

The incidence of asymptomatic MI in persons 75-84y is > 40%.

True

Among the elderly assess for acute change in mental status, SOB,new onset weakness

• physical activity
• emotional stress
• cold weather
• after meals
• sex
• may occur at rest

True or False

EKG changes may not be apparent initally in the MI pt.  Especially shortly after the occlusion.

True or False

Troponin levels elevate 3-12h after MI onset, peak in 24h and return to normal in 5-12d.

True or False

The pt with an MI may have an normal temp that changes to an elevated temp that begins to rise 4-8h after MI onset as a nonspecific response to tissue necrosis.

Which EKG finding is consistant with myocardia ischemia?

• ST segment elevation
• ST segment depression
• T wave elevation
• U wave appearance

Which abnormality would the RN be able to detect during an angina attack?

• transient diastolic murmur
• transient abnormal point of maximal impulse
• pulsus paradoxus
• pericardial friction rub

A pt sustained a femur fx 4d ago and now presents to the ED with c/o petechial skin rash. You suspect:

• rhabdomyolysis
• compartment syndrome
• fat embolism syndrome
• pulmonary embolism

Which of the following would you expect to see in a PEDIATRIC pt in compensated shock? The child will:

• remain normotensive up until 10% of blood volume is lost.
• increase stroke volume to maintain BP.
• have a fluid shift from the plasma to the iterstitial spaces.
• increase heart rate to maintain BP.

increase HR to maintain BP & continue perfusion to theheart,  brain and kidneys. Tachycardia is an early sign in compensated shock. The child may stay normotensive up until 25% of blood volume is lost.

The highest priority intervention for the pt with near drowning is directed at:

• removing water from the lungs
• preventing hypothermia
• correcting hypoxia
• correcting metabolic acidosis

correcting hypoxia

Damage to surfactant from both fresh and saltwater can lead to ventilation and perfusion missmatching.

A jockey is brought to the ED after a horse fell on top of her and rolled on top of her.  The jockey is awake and c/o severe pain below the protective vest that extends below her waist. Initial xrays reveal an unstable pelvic fx. The highest priority nursing dx for this pt is:

• altered tissue perfusion
• fluid volume deficit
• imparied gas exchange
• acute pain

Fluid volume deficit.

Hemorrhage is a frequent complication of pelvix fxs, particularly when the fx is unstable, because the pelvic region is very vascular and receives a rich blood supply.

A pt with traumatic brain injury arrives at the ER receiving O2 via NRM & has IV access. Which of the following findings in the inital resuscitation phase indicates that additional intervention is needed?

• drainage from left ear
• SBP of 100 mm Hg
• SaO2 95%
• Glasgow Coma Scale Score: 7

True or False

Compartmental syndrome may develop more quickly in kids because fascial tissue is tighter and the compartment size is smaller than adults.

True.

Needles as small as 25 guage can be used to measure compartment pressure accurately.

True or False

Normal tissue pressure is 10mm Hg or lower.

Which of the following labs would be performed in an attempt to R/O a PE or DVT?

• brain-type natruretic peptide
• BMP
• ESR
• D-dimer

D-dimer

D-dimer is a circulating marker indicating the presence of a thombus. As the fibrin clot breaks down, and elevated D-dimer indicates ongoing coagulation activation and reactive fibrinolysis.

When caring for a victim of radiation exposure, which of the following procedures would be the priority intervention after  proper disposal of the pt's clothes?

• Insert foley to contain contaminated urine
• cleanse contaminated area with alcohol
• decontaminate wounds with saline solution
• wash pt's hair with soap & water

When administerint Methotrexate to a pt dx with etopic pregnancy, the RN should:

• mix the med just prior to administration
• wear a nonpermeable gown & thick nitrile or other nonpermeable gloves.
• take the usual precautions when preparing meds.
• recap the needle to avoid aerosolized particles.

Methotrexate is a cytotoxic drug and should be considered hazardous.  OSHA mandates special saftey precautions. the usual precautions are not enough. It is important to wear PPE such as thick nitrile or other nonpermeable gloves and a nonpermeable gown. Pharmacy staff should mix this drug under controlled conditions at the pharmacy.

When assessing pain in a child who is preverbal or noncommunicative, you would use which of the following scales:

• FACES
• Numeric
• Oucher
• Faces, legs,activity, cry, consolability(FLACC)

Which of the following interventions has the highest priority for a pt that comes to the ED with HTN & signs of a dissecting aortic aneurysm?

• give meperidine for pain relief
• give labetalol to lower BP
• give hydralazine to lower BP
• Give lorazepam to reduce anxiety

Nesiritide (Natrecor) is ordered for a pt dx with heart failure.  Which of following outcomes should the ED RN expect after administration?

• increase HR
• increase preload
• increase BP
• decrease BP

A 47 y.o. pt with a hx of ETOH abuse comes to the ED with a medical complaint. In addition to monitoring the pt for s/s of withdrawl, the RN should expect to administer which of the following in order to prevent development of Wernicke-Korsakoff syndrome?

• Folic acid
• lorazepam
• thiamine
• magnesium

A 25 y.o. man comes to the ED with c/o general malaise, nausea, weakness, & "brown urine". The pt states that he was "jumped" & "beaten up" 2d ago. Which of the following lab results indicates the pt has rhabdomyolysis?

• K: 3.0 mEq/L
• Serum Bicarb: 29 mEq/L
• CK: 25,000 u/L
• BUN to creatine ratio > 10:1

One minute after being delivered in the ED, a newborn has a HR of 120, is actively crying while flexing arms and legs, and is pink in color except for cyanotic extremities. What is the child's Apgar score:

• 10
• 9
• 8
• 7

A 70 y.o. diabetic pt with an increasing amount of confusion is admited to the ED.  The pt's FS is 700mg/dl, and serum ketones are absent. On the basis of these findings, interventions for hyperosmolar, hyperglycemic state (HHS) are started. The highest priority nursing intervention for this pt is:

• fluid replacement
• insulin administration
• electrolyte replacement
• correction of acidosis

A 40 y.o. man collapsed after spraying pesticide to control insects in his garden. The day was hot & the pt was wearing shorts & sandals. Assessment of the pt revealed constricted pupils, weakness, and excessive salivation. The ED RN would prepare to administer which of the following antidotes to this pt?

• N-acetylcysteine
• ethanol
• physostigmine
• atropine

Which of the following statements about d/c inst. suggest the need to provide further instructions to the pt with severe dematitis on hands & dx with scabies:

• I should wash my hands with warm soapy water
• I should apply the med while my skin is still warm from the water.
• I should not apply the med to inflamed or open areas.
• I should not apply the med to my face.

A friend brought a 25 y.o. man to the ED. Upon arrival at the triage desk, the pt is having difficulty standing, is slow to respond to questions, and vomits (nice). The friend states that the pt had spoken to him on the phone an hour ago and he had been well. The pt called the friend back 30 min. later & stated that he suddenly felt very ill & needed to go to the hospital. Upon further assessment you discover that this pt has an occipital H/A & neck pain, his HR 60, and his BP 130/90. Based on your brief initial assessment, the ED RN should institute immediate interventions for the pt with possible:

• food poisoning
• meningitis
• subarachnoid bleed
• migraine h/a

A pt with CA who has a central line device for chemo comes to the triage desk with c/o hoarseness, a sense of fullness in the head, and tightness in the fingers. Based on the pts hx and s/s, the RN would assess for additional s/s associated with:

• CHF
• hyponatremia
• superior vena cava syndrome
• thoracic outlet syndrome

True or False

Studying too much for the CEN can make your brain hurt.

A 35 y.o. primagravida woman who is at 28w gestation comes to the ED c/o severe ab pain & vaginal bleeding. Her uterus is rigid and boardlike. After you complete your primary assessment & interventions, the next priority would be to:

• draw pt/aptt, fibrinogen levels, platelet levels, & fibrin split products.
• attach fetal monitor
• administer mag sulfate IV.
• prepare pt for pelvic exam

Which of the following interventions would be the most appropriate for the pt located in the ED waiting room who is behaving in a bizarre manner, shuting obscenities?

• Thorazine 50mg IM  :)
• Prepare the pt for head CT
• 4 point restraints
• Perform finger stick for blood glucose level.

Any pt with AMS should be tested for hypoglycemia initially. A FS is a rapid tool to r/o hypoglycemia which would cause confusion, combativeness, and/or lethargy.

A pt being tx for ab pain suddenly becomes tremulous, tachycardic, & hypertensive. It is suspected that he is going into ETOH withdrawl. Which of the following med orders should be anticipated:

• compazine
• librium
• paral
• phenobarbital sodium

A 60 y.o. A/A woman arrives at the ED via EMS with c/o weakness, fatigue, and dyspnea. She denies CP. She gives a PMH of IDDM but states her sugars are within range. The pt is placed on a stretcher and triage is done. The primary diagnostic study for this pt would be:

• chem panel
• ABG
• CT of head
• EKG

True or False

When drawing blood cultures fill the aerobic (likes air) before the anaerobic (doesn't like air) bottle.

True

This is because there is usually air in the tubing prior to drawing.

• Ab pain
• vomiting
• prolonged constipation (obstipation)
• distention

True or False

Perforated ulcers most commonly occur in the duodenum.

True.

Constitutes 80% of all ulcers.

True or False

Lower GI bleeding is characterized by bleeding from any source below the ligament of Treitz.

In a pt with prolonged bleeding, anemia is a potential complication. The ED RN assesses anemia by noting signs of pallor in the pt's:

• lips
• gums
• sclera
• nail beds

True or False

Abdominal distention is a common finding in a pt with a AAA.

After initial stabilization in the ED, a pt with 50% total partial-thickness burns and full-thickness burns is prepared for immediate transfrer to a local burn center. Prep for the transfer would include:

• debriding loose tissuue
• cleaning wounds with mild soap and water
• covering wounds with moist compresses
• maintaining NPO status.

True or False

The following would be expected in the pt with an orbital blowout fx:

Photophobia, blurred vision, & blood in the anterior chamber of the eye.

True or False

Sorbitol is no longer routinly administered because it can cause vomiting, abdominal cramping & diarrhea. Activated charcoal is considered to be the most effective agent in preventing toxins from entering the bloodstream. It expels them in the stool.

True or False

Antidiuretic hormone (ADH) is released by the posterior pituitary gland & causes the reabsorption of sodium and water to increase circulating volume in the shock pt.

True or False

Albumin deactivates large molecule heparin 

True or False

Prinzmetal angina has a 50% mortality rate w/i the 1st year of dx. 

True or False

A right sides MI has s/s of parasympatetic nervous system stimulation.

True or False

A left sides MI has s/s of sympathetic nervous system stimulation.

True or False

EKG changes in pericarditis include PR depression as well as ST elevation.

True or False

Osler's nodes (warm painful nodules on the pads of the fingers & toes) & Janeway legions are signs of endocarditis.

True or False

The most common cause of Infective Endocarditis is IVDA.

True or False

The most common cause of Pericarditis is infection of cardiac tissue 2-3d after an MI.

• Lt sides chest pain that may radiate to neck/jaw/arm.
• Associated with inspiration, lying down
• Aggrevated by cough, sneeze, swallowing
• Pain relieved by leaning forward.
• Pericardial friction rub after MI.

1. marked hypotension
2. diminished heart sounds
3. JVD

True or False

Any chest pain lasting longer than 45 min., is probally an MI.

A 12 lead EKG shows ST elevation in leads V1 through V3. The ED RN suspects the acute MI involves the:

• inferior wall
• anteroseptal wall
• lateral wall
• posterior wall

In the pt having an MI, MSO4 is ordered because:

• it is a powerful analgestic & decreases myocardial work load.
• it dialates coronary arteries when used with nitro.
• it produces sedation
• it is an effective & nonaddicting when given in small doses.

The MD orders Lidocaine: a 50mg bolus q 5 min x 2. followed by an infusion of 2mg/min. Lidocaine is ordered in the MI pt because it:

• lowers fibrillation threshold
• decreases heart's oxygen demand
• eliminates irritability within the necrotic areas
• eradicates potentially dangerous PVCs

As your post-MI pt waits for transfer to CCU, the pt becomes tachycardic but the BP remains stable. Which nursing action is most appropriate now?

• Give morphine and reassure pt.
• notify MD
• auscultate the pts lungs
• place pt in low fowler's position.

Upon auscultatin, the RN detects a crescendo-decrescendo systolic murmur in the post MI pt. this is idicative of:

• aortic insufficiency
• papillary muscle dysfunction
• ventricular aneurysm
• early pericarditis

The ED RN would expect a lateral wall MI in pts demonstrating:

• Q waves in leads II,III, and aVF.
• Q waves in leads I, aVL, V5, and V6
• Q waves in leads V1 through V3.
• Tall R waves in leads V1 & V2.

which intervention would be inappropriate for the pt with left ventricular failure?

• assess fluid intake and electrolyte balance
• restrict fluid intake
• maintain infusion of NS
• maintaining the pts intake of dietary sodium to 2g/day

True or False

The ED RN understands that the rationale for administering inotropic and vasodilatative drugs to a pt with CHF is to:

Decrease preload, decrease afterload, & increase contractability.

True or False

Digoxin is ordered in the CHF pt because it is an Positive inotrope and negative chronotrope.

• Drowsiness, lethargy, fatigue, neuralgia, headache, dizziness, and confusion
Shortness of breath
Syncope
Swelling of lower extremities
Bradycardia
Hypotension

• cardiac sx
• valve disease
• rheumatic heart disease
• pacemaker insertion
• recent GI or GU disorder
• IVDA
• body piercings, tattoo.
• pts with valve disease that underwent dental proceedures without ABs

True or False

Endocarditis may cause rupture of the chordae tendineae, form abscesses or fistulas through cardiac vessels/chambers & embolize into blood,lungs, brain, kidney, spleen, bone, or joints.

True or False 

A first degree heart block (one in which the PR interval is >.20s) is indicative of all of the following:

• Inferior wall MI (because of AV node ischemia)
• Hyperkalemia
• Digoxin use
• organic heart disease

what is the tx for VTach?

True or False

In the pt with a temportary pacemaker, there should be a ventricular complex after each pacemaker spike.

True, if this does not happen, it is called loss of capture. Also, it would be very dangerous to increase the pacemaker rate during loss of capture.

Why does the cardiologist mix the blood aspirated from a pericardial centesis in an emesis basin after it is drawn out?

True or False

A ligament attaches bone to bone

True or False

A tendon attaches bone to muscle

True

True or False

Wounds should not be sutured after being open for 8 hours (except face)

True or False

It is OK to shower after having sutures.

True or False

A SPRAIN is an injury to a ligament

True or False

A STRAIN is an injury to a Tendon

True or False

An Aortic Disection is defined as a tear in the intimal layer of the aorta, which exposes the degenerated medial layer to the forces of BP. These forces cleave or dissect the two layers of the arterial wall.

True or False

An Ascending Dissection is the most common & most lethal type of dissection.

True or False

The Tx for AAA is :

• negative inotropes
• Bb
• Ca channel blockers
• Sx

True or False

Puncture wounds in to joint spaces can lead to septic arthritis & puncture wounds into cartilage, bone, & periosteum can cause osteomyeltis.

True or False

Puncture wounds caused by high pressure mechanisms such as paint or grease guns can inject foreign substances into hard to reach places.  These substances will follow tissue planes and can travel down tendon sheaths causing widespread damage. Therefore, immediate surgical intervention is required to preserve tissue.

• diabetes
• long term steroid use
• host immunocompromise
• poor tissue perfusion (Buerger's disease)

True or False

Because of wt. bearing, wounds to the plantar surface of the foot carry a much higher rate of penetration to bone with potential for osteomylelitis.

True or False

Regarding Skin Avulsions:

• Do not use Epi with Lido because of vasoconstriction
• Wound edges should be approximated, NOT trimmed; even gray or dusky areas may heal suprisingly well.

True or False

aprophylactic antibiotis are recommended for

• obvously contaminated wounds
• wounds to the plantar surface of the foot
• immunocompromised pts.
• ABs are NOT recommended for uncomplicated puncture wounds in healthy individuals anymore.

True or False

Suturing of wounds older than 8h have a much higher risk of infection and often may heal better if left open.

But

The face has a richer blood suppy decreasing the risk of infection, therefore, closure of facial wounds after the 8h mark is usually considered.

True or False

Bites, puncture wounds, and contaminated wounds carry a much higher rate of infection. Therefore, debridement & prophylactic ABs may take priority over closure.

What is the difference between Subluxation & Dislocation?

Subluxation: joint injury where some of the articular surfaces of the joint remain intact but are incomplete.

Dislocation: Injury to the joint where the articular surfaces of the bones are no longer in contact.

True or False

Pelvic Fxs carry a high risk for disruptoin of vasculature & nerves in the area. Average blood loss is 2 units with a potential for up to 4000 ml. Nerves at risk are the iliac artery, venous plexus, and sciatic nerve.

True or False

Pelvic Fxs carry a mortality rate of 8-10% (open fxs carry a mortality rate of 40-60%)

• Pelvic wrap
• flexing the kness may decrease discomfort
• external fixators
• sx internal fixation

True or False

When an effused joint is aspirated, if the lab results of the fluid show a WBC count of <60,000 the cause of effusion is likely inflammatory (gout). But if the WBCs are >100,000 it is likely infection.

True or False

Joint effusions most commonly affect the knee.

• Trauma/Sx
• recent infections
• substance abuse
• use of diuretics
• repetitive use of the joint
• arthritis, gout, stds, bleeding disorders.

True or False

After aspiration of a Joint Effusion, the RN should hold pressure to the site for 2-5 min. with a sterile drsg.

True or False

Key points to crutch walking are:

• Fit crutches to pt while wearing shoe on unaffected side.
• The arm pieces should be 2" below axilla
• The crutch should be at a 25 degree angle with the tips at 6-8" to the side & in front of the foot.
• Place crutches 12" forward & approx 6" to the side.
• Adjust crutch hand pieces so that the elbow has a 30 degree angle of flexion.

Compound Fx Tx: true or false

• initiate IV antibiotics early
• If pt goes to sx immediately, cover wound with sterile saline drsgs.
• If pt is delayed going to sx, flush the wound with 1-2 liters sterile saline & apply dry sterile drsg.
• Tetnus
• avoid the use of antibiotic creams & other bacteriostatic solutions as it may inhibit healing if it reaches the bone.

True or False

Carpal Tunnel Syndrome is the entrapment of the Median nerve

True or False

Common causes of Compartment Syndrome incl:

• FXs
• crush injuries
• high pressure injections
• burns (electrical)
• hypothermia/frostbite
• snake/spider bites
• prolonged overuse (forced march, long distance runners)
• recent sx
• casts, wraps, splints, MAST pants

What early complication should the ED RN assess for in the pt with a femoral shaft fx?

• delayed union
• nonunion
• fat emboli
• infection

True or False

Volkmann's Ischemia of nerves and muscles is the most serious complication of a femoral fx in a child.

True: this condition is caused by femoral artery spasm secondary to an intimal tear. s/s incl: pain, pallor, puffiness, pulselessness,paresthesia & paralysis.

The primary tx for a child between the ages of 2-9y with an uncomplicated femoral shaft fx would be?

1. Bryant's skin traction
2. Fixed skeletal traction
3. A double hip spica cast
4. Intrameduallary nailing

Which pelivc fx is considered stable (minor)?

• Straddle fx
• Malgaigne's hemipelvis fracture-dislocation
• combined hemipelvis fx
• fx of the ipsilateral rami

The RN would prepare all of the following pts for sx except:

• bilateral pelvic fx
• open pelvic fx
• major vessel injury
• hypovolemic shock

Bilateral pelvic fx: because this type of fx is usually reduced by skeletal traction of both legs.

True or False

When the RN notes blood at the urethral meatus while assessing a male pt with a pelvic fx foley caths would be contraindicated.

The pricipal of the MAST trousers for a pt with multiple injuries including a pelvic fx include all of the following except:

• Hemostasis (tamponade)
• Autotransfusion
• Decreased venous return
• Increased peripheral vascular resistance

As the RN begins to deflate the MAST trousers on her pt, she knows that further deflation is contraindicated when:

• 5 mm Hg drop in SBP
• 10 mm Hg drop in SBP
• 5mm rise in DBP
• 10 mm rise in DBP

The nurse knows that further deflation of the MAST trousers would be contraindicated once the pt experiences  a 10 mm Hg drop in SBP. Continuous BP & gradual deflation are essential during MAST removal.

The usual procedure for removing MAST is to deflate the abdomen first then the leg compartments.

Which statement best describes a fx hip?

• the affected leg is shortened & externally rotated
• the affected leg is shortened & internally rotated
• the affected leg is shortened & not rotated.
• the pt has no deformity but has pain on affected side

True or False

In a pt with an impacte femoral neck fx, the RN would expect to see: Groin pain on the affected side & limited ROM in the affected leg.

True or False

The following assessment is characteristic of an anterior shoulder dislocation: after trauma:development of a sudden, severe sholder pain. the pt resists passive movement & has loss of shoulder symmetry.

A pt with a hx of IVDA comes to the ED with c/o fever, general malaise, and night sweats. Which of the following assessment findings in this pt is specific for endocarditis?

• Heart murmur
• SOB
• CP
• Splenomegaly

True or False

pts with lap belt injuries are at particular risk for mesenteric and bowel injuries when rapid decelleration forces suddenly trap the viscera against the spine..

A 35 y.o. man comes to the ED with c/o severe scrotal pain, fever, pyuria, & urethral discharge. You suspect:

• syphillis
• chlamydia
• trichomonas
• asotemia

A contraindication for the use of GP llb/lla inhibitor tx would be:

• platelet count > 150,000
• unstable angina that is being managed
• NSTEMI
• Arterioveous malformation

True or False

Many tattoo pigments contain metallic compounds, such as iron oxide. These pigments can result in MRI images with artifacts that can preclude an accurate dx as well as increase skin temp. high enough to cause burns.

Which of the following assessment findings in a 2 y.o. child with diarrhea is consistant with moderate dehydration?

• alert and restless
• dry skin & mucous membranes
• absent tears
• decreased skin elasticity

True or false:

Lasix, increases venous capacitance & decreases left ventricle filling pressure