N450 Midterm

“I was taking my contacts out last night, and I think I scratched my cornea,” reports a 27-year-old female. “I’m wearing these sunglasses because the light really bothers my eyes.” Her right eye is red and tearing. She rates her pain as 6/10. Vital signs are within normal limits.
ESI level 5: No resources. This patient will need an eye exam and will be discharged to home with prescriptions and an appointment to follow up with an ophthalmologist.
EMS presents to the ED with an 18-year-old female with a suspected medication overdose. Her college roommates found her lethargic and “not acting right,” so they called 911. The patient has a history of depression. On exam, you notice multiple superficial lacerations to both wrists. Her respiratory rate is 10, and her SpO2 on room air is 86 percent.
ESI level 1: Requires immediate lifesaving intervention. The patient’s respiratory rate, oxygen saturation, and inability to protect her own airway indicate the need for immediate endotracheal intubation.
EMS arrived with an unresponsive 19-year-old male with a single self-inflicted gunshot wound to the head. Prior to intubation, his Glasgow Coma Scale score was 3.
ESI level 1: Requires immediate lifesaving intervention. The patient is unresponsive and will require immediate lifesaving interventions to maintain airway, breathing, circulation, and neuro status; specifically, the patient will require immediate confirmation of endotracheal tube placement.
“I ran out of my blood pressure medicine, and my doctor is on vacation. Can someone here write me a prescription?” requests a 56-year-old male with a history of HTN. Vital signs: BP 128/84, HR 76, RR 16, T 97°F.
ESI level 5: No resources. The patient needs a prescription refill and has no other medical complaints. His blood pressure is controlled with his current medication. If at triage his blood pressure was 188/124 and he complained of a headache, then he would meet the criteria for a high-risk situation and be assigned to ESI level 2. If this patient’s BP was elevated and the patient had no complaints, he or she would remain an ESI level 5. The blood pressure would be repeated and would most likely not be treated in the ED or treated with PO medications.
A 41-year-old male involved in a bicycle accident walks into the emergency department with his right arm in a sling. He tells you that he fell off his bike and landed on his right arm. His is complaining of pain in the wrist area and has a 2-centimeter laceration on his left elbow. “My helmet saved me,” he tells you.
ESI level 3: Two or more resources. At a minimum, this patient will require an x-ray of his right arm and suturing of his left elbow laceration.
A 32-year-old female presents to the emergency department complaining of shortness of breath for several hours. No past medical history, +smoker. Vital signs: RR 32, HR 96, BP 126/80, SpO2 93% on room air, T 98.6°F. No allergies, current medications include vitamins and birth control pills.
ESI level 2: High risk. This 32-year-old female with new-onset shortness of breath is on birth control pills. She is a smoker and is exhibiting signs and symptoms of respiratory distress (SpO2 and respiratory rate.) Based on history and signs and symptoms, a pulmonary embolus, as well as other potential causes for her respiratory distress, must be ruled out.
“I just turned my back for a minute,” cried the mother of a 4-year-old. The child was pulled out of the family pool by a neighbor who immediately administered mouth-to-mouth resuscitation. The child is now breathing spontaneously but continues to be unresponsive. On arrival in the ED, vital signs were: HR 126, RR 28, BP 80/64, SpO2 96% on a non-rebreather.
ESI level 1: Unresponsive. This 4-year-old continues to be unresponsive. The patient will require immediate lifesaving interventions to address airway, breathing, and circulation.
A normal healthy 7-year-old walks into the emergency department accompanied by his father, who reports that his son woke up complaining of a stomach ache. “He refused to walk downstairs and is not interested in eating or playing.” The child vomits at triage. Vital signs: T 100.4°F, RR 22, HR 88, BP 84/60, SpO2100%. Pain 6/10.
ESI level 3: Two or more resources. At a minimum, this child will need a workup for his abdominal pain, which will include labs and a CT or ultrasound—two resources.
A 6-year-old male tells you that he was running across the playground and fell. He presents with a 3-centimeter laceration over his right knee. Healthy, no medications and no allergies, immunizations are up to date.
ESI level 4: One resource. The laceration will need to be sutured—one resource.
“I slipped on the ice, and I hurt my wrist,” reports a 58-year-old female with a history of migraines. There is no obvious deformity. Vital signs are within normal limits, and she rates her pain as 5/10.
ESI level 4: One resource. This patient needs an x-ray to rule out a fracture. A splint is not a resource.
A 4-year-old female is transported to the ED following a fall off the jungle gym at a preschool. A fall of 4 feet. A witness reports that the child hit her head and was unconscious for a couple of minutes. On arrival you notice that the child is crying and asking for her mother. Her left arm is splinted. Vital signs: HR 162, RR 38.
ESI level 2: High-risk situation. This 4-year-old had a witnessed fall with loss of consciousness and presents to the ED with a change in level of consciousness. She needs to be rapidly evaluated and closely monitored.
A 60-year-old man requests to see a doctor because his right foot hurts. On exam the great toe and foot skin is red, warm, swollen, and tender to touch. He denies injury. past medical history includes type 2 diabetes, and psoriasis. Vital signs: T 99.4°F, RR 18, HR 82, BP 146/70, SpO2 99%.
ESI level 3: Two or more resources. This patient has a significant medical history, and based on his presentation, he will require two or more resources, which could include labs and IV antibiotics.
A 52-year-old female requests to see a doctor for a possible urinary tract infection (UTI). She is complaining of dysuria and frequency. She denies abdominal pain or vaginal discharge. No allergies, takes vitamins, and has no significant past medical history. Vital signs: T 97.4°F, HR 78, RR 14, BP 142/70.
ESI level 4: One resource. She will need one resource—lab, which will include a urinalysis and urine culture. She most likely has a UTI that will be treated with oral medications.
“I called my pediatrician, and she told me to bring him in because of his fever,” reports the mother of a 2-week-old. Vital signs: T 101°F, HR 154, RR 42, SpO2 100%. Uncomplicated, vaginal delivery. The baby is acting appropriately.
ESI level 2: High risk. A temperature higher than 100.4°F (38.0°C) in an infant less than 28 days old is considered high risk no matter how good the infant looks. Infants in this age range are at a high risk for bacteremia.
“My right breast is so sore, my nipples are cracked, and now I have a fever. Do you think I will have to stop nursing my baby?” asks a tearful 34-year-old female. She is 3 months post partum and has recently returned to work parttime. Vital signs: T 102.8°F, HR 90, RR 18, BP 108/60, pain 5/10. No past medical history, taking multivitamins, and is allergic to penicillin.
ESI level 3: Two or more resources. At a minimum, she will require labs and IV antibiotics.
Paramedics arrive with a 16-year-old unrestrained driver who hit a tree while traveling at approximately 45 miles per hour. The passenger side of the car had significant damage. The driver was moaning but moving all extremities when help arrived. His initial vital signs were BP 74/50, HR 132, RR 36, SPO2 99%, T 98.6°F.
ESI level 1: Requires immediate lifesaving intervention. The patient is presenting with signs of shock—hypotension, tachycardia, and tachypnea. Based on the mechanism of injury and presenting vital signs, this patient requires immediate lifesaving interventions, including aggressive fluid resuscitation.
EMS arrives with a 45-year-old woman with asthma who has had a cold for week. She started wheezing a few days ago and then developed a cough and a fever of 103. Vital signs: T 101.6°F, HR 92, RR 24, BP 148/86, SpO2 97%.
ESI level 3: Two or more resources. This history sounds more like pneumonia. Because the patient is not in acute respiratory distress, he or she doesn’t meet ESI level-2 criteria. This patient will require labs, a chest x-ray, and perhaps IV antibiotics.
“I have an awful toothache right here,” a 38-year-old male tells you as he points to his right lower jaw. “I lost my dental insurance, so I haven’t seen a dentist for a couple of years.” No obvious swelling is noted. Vital signs are within normal limits. Pain 9/10.
ESI level 5: No resources. This patient will require a physical exam. He has no signs and symptoms of an abscess or cellulitis, so he will be referred to a dentist for treatment. In the emergency department, he may be given medications by mouth. On arrival he rates his pain as 9/10, but because he does not meet the criteria for ESI level 2, he would not be given the last open bed.
I think I have food poisoning,” reports an otherwise healthy 33-year-old female. “I have been vomiting all night, and now I have diarrhea.” The patient admits to abdominal cramping that she rates as 5/10. She denies fever or chills. Vital signs: T 96.8°F, HR 96, RR 16, BP 116/74.
ESI level 3: Two or more resources. Lab studies, IV fluid, and an IV antiemetic are three of the resources this patient will require. The patient is not high risk or in severe pain or distress.
“My migraine started early this morning, and I can’t get it under control. I just keep vomiting. Can I lie down somewhere?” asks a 37-year-old female. Past medical history migraines, no allergies. Pain 6/10, T 98°F, RR 20, HR 102, BP 118/62, SpO2 98%.
ESI level 3: Two or more resources. A patient with a known history of migraines with vomiting will require pain medication, an antiemetic, and fluid replacement. The pain is not severe, 6/10. This patient is not high risk.
“I cut my finger trying to slice a bagel,” reports a 28-year-old healthy male. A 2-centimeter laceration is noted on the left first finger. Bleeding is controlled. Vital signs are within normal limits. His last tetanus immunization was 10 years ago.
ESI level 4: One resource. This patient will require a laceration repair. A tetanus booster is not a resource.
“The smoke was so bad; I just couldn’t breathe.” reports a 26-year-old female who entered her burning apartment building to try to rescue her cat. She is hoarse and complaining of a sore throat and a cough. You notice that she is working hard at breathing. History of asthma; uses inhalers when needed. No known drug allergies. Vital signs: T 98°F, RR 40, HR 114, BP 108/74.
ESI level 1: Requires immediate lifesaving intervention. From the history and presentation, this patient appears to have a significant airway injury and will require immediate intubation. Her respiratory rate is 40, and she is in respiratory distress.
“I’m 7 weeks pregnant, and every time I try to eat something, I throw up,” reports a 27-year-old female. “My doctor sent me to the emergency department because he thinks I am getting dehydrated. T 97°F, RR 18, HR 104, BP 104/68, SpO2 99%. Pain 0/10. Lips are dry and cracked.
ESI level 3: Two or more resources. Lab studies, IV fluid, and an IV antiemetic are three of the resources this patient will require. She is showing signs of dehydration.
“I have this aching pain in my left leg,” reports an obese 52-year-old female. “The whole ride home, it just ached and ached.” The patient tells you that she has been sitting in a car for the last 2 days. “We drove my daughter to college, and I thought it was the heat getting to me.” She denies any other complaints. Vital signs: BP 148/90, HR 86, RR 16, T 98°F.
ESI level 3: Two or more resources. At a minimum, she will require labs and noninvasive vascular studies of her lower leg. She should be placed in a wheelchair with her leg elevated and instructed not to walk until the doctor has seen her.
EMS arrives with an 87-year-old male who fell and hit his head. He is awake, alert, and oriented and remembers the fall. He has a past medical history of atrial fibrillation and is on multiple medications, including warfarin. His vital signs are within normal limits.
ESI level 2: High risk. Patients taking warfarin who fall are at high risk of internal bleeding. Although the patients’ vital signs are within normal limits and he shows no signs of a head injury, he needs a prompt evaluation and a head CT.
“I have this rash in my groin area,” reports a 20-year-old healthy male. “I think it’s jock rot, but I can’t get rid of it.” Using over the counter spray. No known drug allergies. Vital Signs: T 98°F, HR 58, RR 16, BP 112/70.
ESI level 5: No resources. Following a physical exam, this patient will be sent home with prescriptions and appropriate discharge instructions.
EMS arrives with a 17-year-old restrained driver involved in a high-speed motor vehicle crash. The patient is immobilized on a backboard and is complaining of abdominal pain. He has multiple lacerations on his left arm. Vital signs prior to arrival: BP 102/60; HR 86, RR 28, SpO2 96%.
ESI level 2: High-risk situation. The mechanism of injury is significant, and this patient has the potential for serious injuries. He needs to be evaluated by the trauma team and should be considered high risk. If his BP was 70/palp and his HR was 128, he would be an ESI level 1; requires immediate life-saving intervention.
“I just need another prescription for pain medication. I was here 10 days ago and ran out,” a 27-year-old male tells you. “I hurt my back at work, and it’s still bothering me.” Denies numbness, tingling, or bladder or bowel issues. Vital signs are within normal limits. Pain 10+/10.
ESI level 5: No resources. No resources are required. Following a physical exam, this patient will be sent home with appropriate discharge instructions and a prescription if indicated.
EMS arrives with a 32-year-old female who fell off a stepladder while cleaning her first-floor gutters. She has an obvious open fracture of her right lower leg. She has +2 pedal pulse. Her toes are warm, and she is able to wiggle them. Denies past medical history medications, or allergies. Vital signs are within normal limits for her age.
ESI level 3: Two or more resources. An obvious open fracture will necessitate this patient going to the operating room. At a minimum, she will need the following resources: x-ray, lab, IV antibiotics, and IV pain medication.
The medical helicopter is en route to your facility with a 16-year-old male who was downhill skiing and hit a tree. Bystanders report that he lost control and hit his head. He was intubated at the scene and remains unresponsive.
ESI level 1: Requires immediate lifesaving interventions. Prehospital intubation is one of the criteria for ESI level 1. This patient has sustained a major head injury and will require an immediate trauma team evaluation.
A healthy middle-aged man presents to the emergency department with his left hand wrapped in a bloody cloth. “I was using my table saw, and my hand slipped. I think I lost of couple of fingertips.” No past medical history, no med or allergies. Vital signs are within normal limits. Pain 6/10.
ESI level 3: Two or more resources. Based on the patient’s presentation, he will require a minimum IV pain medication and laceration repairs. In addition he may need an x-ray and IV antibiotics.
A 27-year-old female wants to be checked by a doctor. She has been experiencing low abdominal pain (6/10) for about 4 days. This morning, she began spotting. She denies nausea, vomiting, diarrhea, or urinary symptoms. Her last menstrual period was 7 weeks ago. past medical history: previous ectopic pregnancy. Vital signs: T.98°F, HR 66, RR 14, BP 106/68.
ESI level 3: Two or more resources. Based on her history, this patient will require two or more resources—lab and an ultrasound. She may in fact be pregnant. Ectopic pregnancy is on the differential diagnosis list, but this patient is currently hemodynamically stable, and her pain is generalized across her lower abdomen.
“My right leg is swollen, and my calf hurts,” reports a 47-year-old morbidly obese female sitting in a motorized scooter. The patient denies chest pain or shortness of breath, but admits to a history of type 2 diabetes and HTN. Vital signs: T 98°F, RR 24, HR 78, BP 158/82, SpO2 98%. Pain 6/10.
ESI level 3: Two or more resources. This patient is at high risk for a deep vein thrombosis. For diagnostic purposes, she will require two resources: labs and a Doppler ultrasound. If a deep vein thrombosis is confirmed, she will require additional resources—remember, ESI level 3 is two or more resources. If this patient were short of breath or had chest pain, they would meet ESI level-2 criteria.
“I think my son has swimmer’s ear. He spends half the day in the pool with his friends, so I am not surprised,” the mother of a 10-year-old boy tells you. The child has no complaints except painful, itchy ears. Vital signs: T 97°F, HR 88, RR 18, BP 100/68.
ESI level 5: No resources. This child needs a physical exam. Even if eardrops are administered in the emergency department, this does not count as a resource. The family will be sent home with instructions and a prescription.
EMS presents with a 54-year-old female with chronic renal failure who did not go to dialysis yesterday because she was feeling too weak. She tells you to look in her medical record for a list of her current medications and past medical history. Her vital signs are all within normal limits.
ESI level 2: High risk. A complaint of weakness can be due to a variety of conditions, such as anemia or infection. A dialysis patient who misses a treatment is at high risk for hyperkalemia or other fluid and electrolyte problems. This is a patient who cannot wait to be seen and should be given your last open bed.
A 68-year-old female presents to the ED with her right arm in a sling. She was walking out to the mailbox and slipped on the ice. “I put my arm out to break my fall. I was lucky I didn’t hit my head.” Right arm with good circulation, sensation, and movement, obvious deformity noted. past medical history: arthritis, medications, ibuprofen, No known drug allergies. Vital signs within normal limits. She rates her pain as 6/10.
ESI level 3: Two or more resources. It looks like this patient has a displaced fracture and will need to have a closed reduction prior to casting or splinting. At a minimum, she needs x-rays and an orthopedic consult. Her vital signs are stable, so there is no need to uptriage her to an ESI level 2. Her pain is currently 6/10. If she rated her pain as 9/10 and she is tearful, would you up-triage her to an lESI level 2? Probably not, given the many nursing interventions you could initiate to decrease her pain, such as ice, elevation, and appropriate immobilization.
“I just don’t feel right,” reports a 21-year-old female who presented in the ED complaining of a rapid heart rate. “I can barely catch my breath, and I have this funny pressure feeling in my chest.” HR is 178 and regular, RR 32, BP 82/60. Her skin is cool and diaphoretic.
ESI level 1: Requires immediate lifesaving interventions. The patient is hypotensive with a heart rate of 178. She is showing signs of being unstable—shortness of breath and chest pressure. This patient requires immediate lifesaving interventions, which may include medications and cardioversion.
Concerned parents arrive in the ED with their 4-day-old baby girl who is sleeping peacefully in the mother’s arms. “I went to change her diaper,” reports the father, “and I noticed a little blood on it. Is something wrong with our daughter?” The mother tells you that the baby is nursing well and weighed 7 lbs., 2 oz. at birth.
ESI level 5: No resources. The parents of this 4-day-old need to be reassured that a spot of blood on their baby girl’s diaper is not uncommon. The baby is nursing and looks healthy.
“I was using my chainsaw without safety goggles, and I think I got some sawdust in my left eye. It hurts and it just won’t stop tearing,” reports a healthy 36-year-old male. Vital signs are within normal limits.
ESI level 4: One resource. This patient will require eye irrigation. Eye drops are not a resource. A slit lamp exam is part of the physical exam of this patient.
“It hurts so much when I urinate,” reports an otherwise healthy 25-year-old. She denies fever, chills, abdominal pain, or vaginal discharge. Vital signs: T 98.2°F, HR 66, RR 14, BP 114/60.
ESI level 4: One resource. This patient will require one resource—lab. A urinalysis and urine culture will be sent, and depending on your institution, a urine pregnancy test. One or all of these tests count as one resource.
“I was smoking a cigarette and had this coughing fit, and now I feel short of breath,” reports a tall, thin 19-year-old man. No past medical history, No meds or allergies, Vital signs: T 98°F, HR 102, RR 36, BP 128/76, SpO2 92%. Pain 0/10.
ESI level 2: High risk. This young, healthy male has an elevated respiratory rate and a low oxygen saturation. The patient’s history and signs and symptoms are suggestive of a spontaneous pneumothorax. He needs to be rapidly evaluated and closely monitored.
A 26-year-old female is transported by EMS to the ED because she experienced the sudden onset of a severe headache that began after she moved her bowels. She is 28 weeks pregnant. Her husband tells you that she is healthy, takes only prenatal vitamins, and has no allergies. On arrival in the ED, the patient is moaning and does not respond to voice. Emergency medical technicians (EMTs) tell you that she vomited about 5 minutes ago.
ESI level 1: Requires immediate lifesaving intervention. From the history, it sounds like this patient has suffered some type of head bleed. She is currently unresponsive to voice and could be showing signs of increased intracranial pressure. She may not be able to protect her own airway and may need to be emergently intubated.
“I think I’m having a stroke,” reports an anxious 40-year-old female. “I looked in the mirror this morning, and the corner of my mouth is drooping and I can’t close my left eye. You have to help me, please.” No past medical history, no meds. Vital signs all within normal limits.
ESI level 2: High risk. Facial droop is one of the classic signs of a stroke. This patient needs to be evaluated by the stroke team and have a head CT within minutes of arrival in the ED. Many nurses want to make all stroke alerts an ESI level 1. This patient does not meet level 1 criteria as she does not require immediate lifesaving interventions. The triage nurse needs to facilitate moving this patient into the treatment area and initiate the stroke alert process.
An 88-year-old female is brought to the ED by EMS. This morning, she had an episode of slurred speech and weakness of her left arm that lasted about 45 minutes. She has a history of a previous stroke, and she takes an aspirin every day. She is alert and oriented with clear speech and equal hand grasps.
ESI level 2: High-risk situation. The patient’s history indicates that she may have had a transient ischemic attack this morning. The patient is high risk, and it would not be safe for her to sit in the waiting room for an extended period of time.
“It is like I have my period. I went to the bathroom, and I am bleeding. This is my first pregnancy, and I am scared. Do you think everything is OK?” asks a 26-year-old healthy female. Vital signs: BP 110/80, HR 72, RR 18, SpO2 99%, T 98.6°F. She describes the pain as crampy, but rates it as “1” out of 10.
ESI level 3: Two or more resources. Based on her history, this patient will require two or more resources—labs, an ultrasound. On the differential diagnosis list is a spontaneous abortion. Currently, she is hemodynamically stable and has minimal cramping or pain.
A 42-year-old male presents to triage with a chief complaint of “something in his right eye.” He was cutting tree limbs and thinks something went into his eye. No past medical history, no allergies, no medications. On exam, his right eye is reddened and tearing. Pain is 4/10.
ESI level 4: One resource. The only resource this patient will require is irrigation of his eyes. A slit lamp exam is not considered a resource but is part of the physical exam
“Our pediatrician told us to bring the baby to the emergency department to see a surgeon and have some tests. Every time I feed him, he vomits and it just comes flying out,” reports the mother of a healthy appearing 3 week-old. “None of my other kids did this.” Normal vaginal delivery. Vital signs are within normal limits.
ESI level 3: Two or more resources. A 3-week-old with projectile vomiting is highly suspicious for pyloric stenosis. The infant will need, at minimum, labs to rule out electrolyte abnormalities, an ultrasound, and a surgery consult.
“I suddenly started bleeding and passing clots the size of oranges,” reports a pale 34-year-old who is 10 days post partum. “I never did this with my other two pregnancies. Can I lie down before I pass out?” Vital signs: BP 86/40, HR 132, RR 22, SpO2 98%.
ESI level 1: Requires immediate lifesaving intervention. This patient is presenting with signs and symptoms of a post partum hemorrhage. She tells you she is going to pass out, and her vital signs reflect her fluid volume deficit. The patient needs immediate IV access and aggressive fluid resuscitation.
“I have had a cold for a few days, and today I started wheezing. When this happens, I just need one of those breathing treatments,” reports a 39-year-old female with a history of asthma. T 98°F, RR 22, HR 88, BP 130/80, SpO2 99%, No meds, no allergies.
ESI level 4: One resource. This patient will need a hand-held nebulizer treatment for her wheezing. No labs or x-ray should be necessary because the patient does not have a fever.
“I was seen in the ED last night for my fractured wrist. The bone doctor put this cast on and told me to come back if I had any problems. As you can see, my hand is really swollen and the cast is cutting into my fingers. The pain is just unbearable.” Circulation, sensation, and movement are decreased.
ESI level 2: High-risk situation. The recent application of a cast along with swelling of the hand and unbearable pain justifies an ESI level-2 acuity level. He may have compartment syndrome.
A 58-year-old male collapsed while shoveling snow. Bystander CPR was started immediately; he was defibrillated once by the paramedics with the return of a perfusing rhythm. The hypothermic cardiac arrest protocol was initiated prehospital, and he presents with cold normal saline infusing.
ESI level 1: Requires immediate lifesaving intervention. Studies have shown that lowering brain temperature post cardiac arrest decreases ischemic damage. This patient requires immediate lifesaving interventions to airway, breathing, circulation, and neurologic outcome. Even though the patient converted to a stable rhythm, the nurse should anticipate that additional lifesaving interventions might be necessary.
“My doctor told me to come to the ED. I had a gastric bypass 3 weeks ago and have been doing fine, but today I started vomiting and having this belly pain.” The patient, an obese 33-yearold female, rates her pain as 6/10. Vital signs: BP 126/70, HR 76, RR 14, T 98°F.
ESI level 3: Two or more resources. She will need two or more resources—laboratory tests, IV fluid, medication for her nausea, and probably a CT of her abdomen. This patient will be in your emergency department an extended period of time being evaluated. If her pain was 10/10 and she was tachycardic, the patient would meet the ESI level-2 criteria.
“I had a baby 5 weeks ago, and I am just exhausted. I have seen my doctor twice, and he told me I wasn’t anemic. I climb the stairs, and I am so short of breath when I get to the top that I have to sit down, and now my ankles are swollen. What do you think is wrong with me?” asks a 23-year-old obese female.
ESI level 2: High risk. This patient is describing more than just the fatigue or anemia. This patient could be describing the classic symptoms of a low-volume but high-risk situation—peripartum cardiomyopathy, a form of cardiomyopathy that occurs in the last month of pregnancy and up to 5 months postpartum. There is a decrease in the left ventricular ejection fraction which causes congestive heart failure.
“I am so embarrassed!” An 18-year-old tells you that she had unprotected sex last night. “My friend told me to come to the hospital because there is a pill I can take to prevent pregnancy.” The patient is healthy, takes no medications, and has no allergies. Vital signs: T 97°F, HR 78, RR 16, BP 118/80.
ESI level 5: No resources. This patient will need a bedside pregnancy test before receiving medication. She may be an ESI level 4, if your institution routinely sends pregnancy tests to the lab.
A 76-year-old male requests to see a doctor because his toenails are hard. Upon further questioning, the triage nurse ascertains that the patient is unable to cut his own toenails. He denies any breaks in the skin or signs of infection. He has a history of chronic obstructive pulmonary disease and uses several metered-dose inhalers. His vital signs are normal for his age.
ESI level 5: No resources. This elderly gentleman has such brittle toenails that he is no longer able to clip them himself. He requires a brief exam and an outpatient referral to a podiatrist.
EMS arrives with a 42-year-old male who called 911 because of dizziness and nausea every time he tries to move. The patient states, “I feel okay when I lie perfectly still, but if I start to sit up, turn over, or move my head, the room starts to spin and I have to throw up.” No past medical history. Vital signs: T 97.2°F, RR 16, HR 90, BP 130/82, SpO2 99%. Pain 0/10.
ESI level 3: Two or more resources. Based on the history, this patient may have acute labyrinthitis and will require two or more resources—IV fluids and an IV antiemetic.
This patient is the restrained driver of an SUV involved in a high-speed, multicar accident. Her only complaint is right thigh pain. She has a laceration on her left hand and an abrasion on her left knee. Vital signs: BP 110/74, HR 72, RR 16, no medications, no allergies, no past medical history.
ESI level 2: High-risk situation. Based on mechanism of injury, this patient will need rapid evaluation by the trauma team.
“My wife called 911 because my internal defibrillator gave me a shock this morning when I was eating breakfast. Really scared me! I saw my doctor a few days ago, and he changed some of my medications. Could that be why that happened?” The patient has a significant cardiac history and reports taking multiple medications, including amiodarone. Vital signs: T 98.5°F, RR 20, HR 90, BP 120/80.
ESI level 2: High risk. This patient is not someone who should sit in your waiting room. He does not meet the criteria for ESI level 1, but he meets the criteria for ESI level 2. The patient’s internal defibrillator fired for some reason and needs to be evaluated.
“Nurse, I have this pressure in my chest that started about an hour ago. I was shoveling that wet snow, and I may have overdone it,” reports an obese 52-year-old male. He tells you his pain is 10 out of 10 and that he is nauseous and short of breath. His skin is cool and clammy. Vital signs: BP 86/50, HR 52 and irregular.
ESI level 1: Requires immediate lifesaving intervention. The history combined with the signs and symptoms indicate that this patient is probably having an MI. The “pressure” started after shoveling wet snow, and now he is nauseous and short of breath, and his skin is cool and clammy. He needs immediate IV access, the administration of medications, and external pacing pads in place.
“My sister has metastatic breast cancer, and her doctor suggested that I bring her in today to have more fluid drained off her lungs.” The fluid buildup is making it harder for her to breathe. The patient is a cachectic 42-year-old female on multiple medications. Vital signs: T 98.6°F, RR 34, SpO2 95%, HR 92, BP 114/80.
ESI level 2: High risk. Breast cancer can metastasize to the lungs and can cause a pleural effusion. The collection of fluid in the pleural space leads to increasing respiratory distress as evidenced by the increased respiratory rate and work of breathing.
A 58-year-old male presents to the emergency department complaining of left lower-quadrant abdominal pain for 3 days. He denies nausea, vomiting, or diarrhea. No change in appetite. past medical history HTN. Vital signs: T 100°F, RR 18, HR 80, BP 140/72, SpO2 98%. Pain 5/10.
ESI level 3: Two or more resources. Abdominal pain in a 58-year-old male will require two or more resources. At a minimum, he will need labs and an abdominal CT.
“I think he has another ear infection,” the mother of an otherwise healthy 2-year-old tells you. “He’s pulling on his right ear.” The child has a tympanic temperature of 100.2°F and is trying to grab your stethoscope. He has a history of frequent ear infections and is currently taking no medication. He has a normal appetite and urine output, according to the mother.
ESI level 5: No resources. This child has had previous ear infections and is presenting today with the same type of symptoms. He is not ill appearing, and his vital signs are within normal limits. The child requires a physical exam and should be discharged with a prescription.
“My son needs a physical for camp,” an anxious mother tells you. “I called the clinic, but they can’t see him for 2 weeks and camp starts on Monday.” Her son, a healthy 9-yearold, will be attending a summer day camp.”
ESI level 5: No resources. Because the mother could not get an appointment with a primary care physician, she brought her son to the emergency department for a routine physical exam. He will be examined and discharged.
“Last night I had sex, and we used a condom but it broke. I just don’t want to get pregnant,” a teary 18-year-old female tells you. Vital signs are within normal limits.”
ESI level 5: No resources. This patient will need a bedside pregnancy test prior to receiving medication. She may be an ESI level 4 if your institution routinely sends pregnancy tests to the lab.
“I have a fever and a sore throat. I have finals this week, and I am scared this is strep,” reports a 19-year-old college student. She is sitting at triage drinking bottled water. No past medical history, medications: birth control pills, no allergies to medications. Vital signs: T 100.6°F, HR 88, RR 18, BP 112/76.
ESI level 4: One resource. In most EDs, this patient will have a rapid strep screen sent to the lab; one resource. She is able to drink fluids and will be able to swallow pills if indicated.
“This 84-year-old male passed out in the bathroom,” reports the local paramedics. “When we arrived he was in a third-degree heart block with a rate in the 20s and a blood pressure in the 60s. We began externally pacing him at a rate of 60 with an MA in the 50s. He is now alert, oriented, and asking to see his wife.”
ESI level 1: Requires immediate lifesaving intervention. The patient is in third-degree heart block and requires external pacing to preserve airway, breathing, and circulation.
A 16-year-old male wearing a swimsuit walks into the ED. He explains that he dove into a pool, and his face struck the bottom. You notice an abrasion on his forehead and nose as he tells you that he needs to see a doctor because of tingling in both hands.
ESI level 2: High risk. Because of the mechanism of injury and his complaints of tingling in both hands, this patient should be assigned ESI level 2. He has a cervical spine injury until proven otherwise. He is not an ESI level 1 in that he does not require immediate lifesaving interventions to prevent death. At triage, he needs to be appropriately immobilized.
A-25-year-old female presented to the emergency department because of moderate lower abdominal pain with a fever and chills. Two days ago, the patient had a therapeutic abortion at a local clinic. The patient reports minimal vaginal bleeding, Vital signs: T 100.8°F, RR 20, HR 92, BP 118/80, SpO2 99%. Pain 5/10.
ESI level 3: Two or more resources. Based on the history, this patient will require at a minimum labs and IV antibiotics. In addition she may need a gyn consult and IV pain medication.
EMS radios in that they are in route with a 17- year-old with a single gunshot wound to the left chest. On scene the patient was alert, oriented and had a BP of 82/palp. Two large-bore IVs were immediately inserted. Two minutes prior to arrival in the ED, the patient’s HR was 130 and BP was 78/palp.
ESI level 1: Requires immediate lifesaving interventions. The trauma team needs to be in the trauma room and ready to aggressively manage this 17-year-old with a single gunshot wound to the left chest. He will require airway management, fluid resuscitation and, depending on the injury, a chest tube or rapid transport to the operating room.
I was at a family reunion, and we were playing baseball. One of my nephews hit the ball so hard, and I tried to catch it, missed, and it hit me right in the eye. My vision is fine. It just hurts,” reports a 34-year-old healthy female. Vital signs are within normal limits. There are no obvious signs of trauma to the globe, only redness and swelling in the periorbital area. The patient denies loss of consciousness.
ESI level 4: One resource. The history is suggestive of an orbital fracture. The patient will require one resource—an x-ray. She will need a visual acuity check and eye evaluation, but these are not ESI resources.
A 76-year-old male is brought to the ED because of severe abdominal pain. He tells you, “It feels like someone is ripping me apart.” The pain began about 30 minutes prior to admission, and he rates the intensity as 20/10. He has HTN, for which he takes a diuretic. No allergies. The patient is sitting in a wheelchair moaning in pain. His skin is cool and diaphoretic. Vital signs: HR 122, BP 88/68, RR 24, SPO2 94%.
ESI level 1: Requires immediate lifesaving intervention. The patient is presenting with signs of shock—hypotensive, tachycardic, with decreased peripheral perfusion. He has a history of HTN and is presenting with signs and symptoms that could be attributed to a dissecting aortic abdominal aneurysm. He needs immediate IV access, aggressive fluid resuscitation, and perhaps blood prior to surgery.
The patient states that she is 6 weeks post laparoscopic gastric bypass. Two days ago, she began to have abdominal pain with nausea and vomiting of pureed food. She reports a decrease in her fluid intake and not being able to take her supplements because of vomiting. Vital signs: T 97.8°F, RR 20, HR 90, BP 110/70, SpO2 99%. Pain 4/10.
ESI level 3: Two or more resources. Abdominal pain and vomiting post gastric bypass needs to be evaluated. This patient needs labs, IV, antiemetics, and a CT.
A 26-year-old female walks into the triage room and tells you she needs to go into detox again. She has been clean for 18 months but started using heroin again 2 weeks ago when her boyfriend broke up with her. She had called several detox centers but was having no luck finding a bed. She denies suicidal or homicidal ideation. She is calm and cooperative.
ESI level 4: One resource. This patient is seeking help finding a detoxification program that will help her. She is not a danger to herself or others. The social worker or psychiatric counselor should be consulted to assist her. Once a placement has been found, she can be discharged from the emergency department and can get herself to the outpatient program. If your social worker or psychiatric counselor requires a urine toxicology or other lab work, the patient will require two or more resources and then meet ESI level-3 criteria.
“My throat is on fire,” reports a 19-year-old female. It started a couple of days ago, and it just keeps getting worse. Now I can barely swallow, and my friends say my voice is different. I looked in the mirror, and I have this big swelling on one side of my throat.” No past medical history , no meds, no allergies. Vital signs: T 101.6°F, RR24, HR 92, BP 122/80, SpO2 100% on room air.
ESI level 2: High risk. Voice changes, fever, difficulty swallowing, and swelling on one side of the throat can be signs of a peritonsilar abscess. The patient needs to be monitored closely for increasing airway compromise and respiratory distress.
My doctor told me to come to the ED. He thinks my hand is infected,” a 76-year-old female with arthritis, chronic renal failure, and diabetes tells you. She has an open area on the palm of her hand that is red, tender, and swollen. She hands you a list of her medications and reports that she has no allergies. She is afebrile. Vital signs: HR 72, RR 16, BP 102/60.
ESI level 3: Two or more resources. This patient has a complex medical history and presented with an infected hand. At a minimum she will need labs, an IV, and IV antibiotics to address her presenting complaint. Her vital signs are normal, so there is no reason to up-triage her to ESI level 2.
Police escort a disheveled 23-year-old handcuffed male into the triage area. The police report that the patient had been standing in the middle of traffic on the local highway screaming about the end of the world. The patient claims that he had been sent from Mars as the savior of the world. He refuses to answer questions or allow you to take vital signs.
ESI level 2: High risk. This patient is experiencing delusions and may have a past medical history of schizophrenia or other mental illness, or he may be under the influence of drugs. Regardless, the major concern is patient and staff safety. He needs to be taken to a safe, secure area and monitored closely
My dentist can’t see me until Monday, and my tooth is killing me. Can’t you give me something for the pain?” a healthy 38-year-old male asks the triage nurse. He tells you the pain started yesterday, and he rates his pain as 10/10. No obvious facial swelling is noted. Allergic to penicillin. Vital signs: T 99.8°F, HR 78, RR 16, BP 128/74.
ESI level 5. No resources. No resources should be necessary. He will require a physical exam, but without signs of an abscess or cellulitis, this patient will be referred to a dentist. In the ED, he may be given oral medications and prescriptions for antibiotics and/or pain medication. He is not an ESI level 2, even though he rates his pain as 10/10. Based on the triage assessment, he would not be given the last open bed.
I have been on antibiotics for 5 days for mastitis. I am continuing to nurse my baby, but I still have pain and tenderness in my right breast. Now there is this new reddened area,” a 34-year-old new mother tells you. The patient reports having a fever, chills, and just feeling run down. T 102.2°F, RR 20, HR 990, BP 122/80, SpO2 98%. Pain 6/10
ESI level 3: Two or more resources. This patient probably has been on antibiotics for 5 days for mastitis and now presents to the ED due to fever, chills, and feeling rundown. She will require labs, IV antibiotics, a lactation consult if available, and perhaps admission.
A young male walks into triage and tells you that he has been shot. As he rolls up the left leg of his shorts, you notice two wounds. He tells you that he heard three shots. He is alert and responding appropriately to questions. Initial Vital signs: T 98.2°F, HR 78, RR 16, BP 118/80.
ESI level 2: High-risk situation. This patient has two obvious wounds, but until he is thoroughly examined in the trauma room, you can’t rule out the possibility that he has another gunshot wound. The wounds on his thigh look non-life-threatening, but a bullet could have nicked a blood vessel or other structure; therefore, he meets ESI level-2 criteria. His vital signs are within normal limits, so he does not meet ESI level-1 criteria.
An 82-year-old resident of a local assisted living facility called 911 because of excruciating generalized abdominal pain and vomiting that started a few hours ago. The woman is moaning in pain but is still able to tell you that she had a heart attack 6 years ago. Vital signs: T 98°F, RR 28, HR 102, BP 146/80, SpO2 98%. Pain 10/10.
ESI level 2: High risk and severe pain and distress. Abdominal pain in the elderly can be indicative of a serious medical condition, and a pain score of 10/10 is significant. The triage nurse needs to keep in mind that due to the normal changes of aging, the elderly patient may present very differently than a younger patient and is more likely to present with vague symptoms.
“I should have paid more attention to what I was doing,” states a 37-year-old carpenter who presents to the ED with a 3-centimeter laceration to his right thumb. The thumb is wrapped in a clean rag. “I know I need a tetanus shot,” he tells you. BP 142/76, RR 16, T 98.6°F.
ESI level 4: One resource. This patient will require a laceration repair. A tetanus booster is not a resource.
“My son woke me up about 3 hours ago complaining of a right earache. I gave him some acetaminophen but it didn’t help,” the 4-year-old’s mother tells you. No fever, other vital signs within normal limits for age.
ESI level 5: No resources. Following a physical exam, this 4-year-old will be sent home with appropriate discharge instructions and perhaps a prescription.
“How long am I going to have to wait before I see a doctor?” asks a 27-year-old female with a migraine. The patient is well known to you and your department. She rates her pain as 20/10 and tells you that she has been like this for 2 days. She vomited twice this morning. past medical history: migraines, no allergies, medications include Fioricet.
ESI level 3: Two or more resources. At a minimum, this patient will require an IV with fluid, IV pain medication, and an antiemetic. Although she rates her pain as 20/10, she should not be assigned to ESI level 2. She has had the pain for 2 days, and the triage nurse can’t justify giving the last open bed to this patient. The triage nurse will need to address this patient’s concerns about wait time.
EMS arrives with a 75-year-old male with a self-inflicted 6-centimeter laceration to his neck. Bleeding is currently controlled. With tears in his eyes, the patient tells you that his wife of 56 years died last week. Health, No known drug allergies, baby ASA per day, BP 136/82, HR 74, RR 18, SpO2, 98% RA.
ESI level 2: High-risk. This 75-year-old male tried to kill himself by cutting his throat. Because of the anatomy of the neck, this type of laceration has the potential to cause airway, breathing, and/or circulation problems. At the same time, he is suicidal, and the ED needs to ensure that he does not leave or attempt to harm himself further.
“My mother is just not acting herself,” reports the daughter of a 72-year-old female. She is sleeping more than usual and complains that it hurts to pee.” Vital signs: T 100.8°F, HR 98, RR 22, BP 122/80. The patient responds to verbal stimuli but is disoriented to time and place.
ESI level 2: New onset confusion, lethargy, or disorientation. The daughter reports that her mother has a change in level of consciousness. The reason for her change in mental status may be a UTI that has advanced to bacteremia. She has an acute change in mental status and is therefore high risk.
EMS arrives in the ED with a 57-year-old female with multiple sclerosis. She is bedridden, and her family provides care in the home. The family called 911 because her Foley catheter came out this morning. No other complaints. Vital signs are within normal range, currently on antibiotics for a UTI.
ESI level 4: One resource. The patient was brought to the emergency department for a new Foley catheter—one resource. There are no other changes in her condition, and she is already on antibiotics for a UTI, so no further evaluation is needed
“I got my belly button pierced a month ago and now it hurts so bad,” reports a 19-year-old healthy college student who is accompanied by her roommate. They are chatting about plans for the evening. The area is red, tender, and swollen, and pus is oozing from around the site. Vital signs: T 100°F, HR 74, RR 18, BP 102/70, SpO2 100%. Pain 8/10.
ESI level 3: Two or more resources. Based on the history, this patient may have a cellulitis from the navel piercing. At a minimum she will require labs and IV antibiotics.
“Why the hell don’t you just leave me alone?” yells a 73-year-old disheveled male who was brought to the ED by EMS. He was found sitting on the curb drinking a bottle of vodka with blood oozing from a 4-centimeter forehead laceration. He is oriented to person, place, and time and has a Glasgow Coma Scale score of 14.
ESI level 2: High-risk situation. The history of events is unclear. How did the 73-year-old gentleman get the laceration on his forehead? Did he fall? Get hit? Because of his age, presentation, and presence of alcohol, he is at risk for a number of complications.
“This is so embarrassing,” reports a 42-year-old male. “We were having incredible sex, and I heard a crack. Next thing you know, my penis was flaccid, and I noticed some bruising.” The pain is “unbelievable,” 20/10. No meds, No known drug allergies.
ESI level 2: High risk. This patient may be describing a penile fracture, a medical emergency. It is most often caused by blunt trauma to an erect penis. This patient needs to be evaluated promptly.
“I have this infection in my cuticle,” reports a healthy 26-year-old female. “It started hurting 2 days ago, and today I noticed the pus.” The patient has a small paronychia on her right second finger. No known drug allergies. T 98.8°F, RR 14, HR 62, BP 108/70.
ESI level 4: One resource. This young woman needs an incision and drainage of her paronychia. She will require no other resources.
A 20-year-old male presents to the ED after being tackled while playing football. He has an obvious dislocation of his left shoulder and complains of 10/10, severe pain. Neurovascular status is intact, and vital signs are within normal limits.
ESI level 2: Severe pain and distress. The triage nurse is unable to manage his pain at triage other than applying a sling and ice. He will require IV opioids to reduce his pain and relocate his shoulder.
A 72-year-old female with obvious chronic obstructive pulmonary disease and increased work of breathing is wheeled into triage. Between breaths, she tells you that she “is having a hard time breathing and has had a fever since yesterday.” The SpO2 monitor is alarming and displaying a saturation of 79 percent.
ESI level 1: Requires immediate lifesaving intervention. Immediate aggressive airway management is what this patient requires. Her saturation is very low, and she appears to be tiring. The triage nurse does not need the other vital signs in order to decide that this patient needs immediate care.
A 17-year-old handcuffed male walks into the ED accompanied by the police. The parents called 911 because their son was out of control: verbally and physically acting out and threatening to kill the family. He is cooperative at triage and answers your questions appropriately. He has no past medical history or allergies and is currently taking no medications. Vital signs are within normal limits.
ESI level 2: High-risk situation. Homicidal ideation is a clear high-risk situation. This patient needs to be placed in a safe, secure environment, even though he is calm and cooperative at triage.
“I think I need a tetanus shot,” a 29-year-old female tells you. “I stepped on a rusty nail this morning, and I know I haven’t had one for years.” No past medical history, No known drug allergies, no medications.
ESI level 5: No resources. A tetanus immunization does not count as a resource. The patient will be seen by a physician or midlevel provider and receive a tetanus immunization and discharge instructions. This patient will require no resources.
A 63-year-old cachectic male is brought in from the local nursing home because his feeding tube fell out again. The patient is usually unresponsive. He has been in the nursing home since he suffered a massive stroke about 4 years ago.
ESI level 4: One resource. This patient will be sent back to the nursing home after the feeding tube is reinserted. There is no acute change in his medical condition that warrants any further evaluation. He is unresponsive, but that is the patient’s baseline mental status so he is not an ESI level 1.
A 28-year-old male presents to the ED requesting to be checked. He has a severe shellfish allergy and mistakenly ate a dip that contained shrimp. He immediately felt his throat start to close, so he used his EpiPen. He tells you that he feels okay. No wheezes or rash noted. Vital signs: BP 136/84, HR 108, RR 20, SpO2 97%, T 97°F.
ESI level 2: High-risk situation for allergic reaction. The patient has used his EpiPen but still requires additional medications and close monitoring.
You are trying to triage an 18-month-old whose mother brought him in for vomiting. The toddler is very active and trying to get off his mother’s lap. To distract him, the mother hands him a bottle of juice, which he immediately begins sucking on. The child looks well hydrated and is afebrile.
ESI level 5: No resources. A physical exam and providing the mother with reassurance and education is what this 18-month-old will require. His activity level is appropriate, and he is taking fluids by mouth.
“He was running after his brother, fell, and cut his lip on the corner of the coffee table. There was blood everywhere,” recalls the mother of a healthy 19-month-old. “He’ll never stay still for the doctor.” You notice that the baby has a 2- centimeter lip laceration that extends through the vermilion border. Vital signs are within normal limits for age.
ESI level 3: Two or more resources. A laceration through the vermilion border requires the physician to line up the edges exactly. Misalignment can be noticeable. A healthy 19-month-old will probably not cooperate. In most settings, he will require conscious sedation, which counts as two resources. The toddler’s vital signs are within normal limits for his age, so there is no reason to up-triage to ESI level 2.
A 44-year-old female is retching continuously into a large basin as her son wheels her into the triage area. Her son tells you that his diabetic mother has been vomiting for the past 5 hours, and now it is “just this yellow stuff.” “She hasn’t eaten or taken her insulin,” he tells you. No known drug allergies. Vital signs: BP 148/70, P 126, RR 24.
ESI level 2: High risk. A 44-year-old diabetic with continuous vomiting is at risk for diabetic ketoacidosis. The patient’s vital signs are a concern, as her heart rate and respiratory rate are both elevated. It is not safe for this patient to wait for an extended period of time in the waiting room.
EMS arrives with a 76-year-old male found on the bathroom floor. The family called 911 when they heard a loud crash in the bathroom. The patient was found in his underwear, and the toilet bowl was filled with maroon-colored stool. Vital signs on arrival: BP 70/palp, HR 128, RR 40. His family tells you he has a history of atrial fibrillation and takes a “little blue pill to thin his blood.”
ESI level 1: Requires immediate lifesaving intervention. This 76-year-old patient is in hemorrhagic shock from his GI bleed. His blood pressure is 70, his heart rate is 128, and his respiratory rate is 40, all indicating an attempt to compensate for his blood loss. This patient needs immediate IV access and the administration of fluid, blood, and medications.
When interpreting an ECG rhythm strip, the nurse identifies that ventricular contraction is displayed as the:
1. P wave
2. T wave
3. PR interval
4. QRS Interval

4. The QRS interval represents time taken for depolarization of both ventricles.

1. The P wave represents repolarization of the atria.
2. The T wave represents repolarization of the ventricles.
3. The PR interval represents the time taken for the impulse to spread through the atria.

An electrocardiogram is ordered for a client complaining of chest pain. An early finding in the lead over an infarcted area is:
1. Flattened T waves
2. Absence of P waves
3. Elevated ST segments
4. Disappearance of Q waves

3. This is an early typical finding after a myocardial infarct because of the altered contractility of the heart.

1. Flattened or depressed T waves indicate hypokalemia.
2. This occurs in atrial and ventricular fibrillation.
4. Q waves may become distorted with conduction or rhythm problems, but they do not disappear unless there is cardiac standstill.

At the end of diastole, the degree of ventricular stretch is referred to as:
1 Preload.
2 Afterload.
3 Contractility.
4 Cardiac output (CO).

3. Contractility

Contractility is the degree of ventricular stretch. Preload is the volume in the left ventricle at the end of diastole. Afterload is the resistance against which the left ventricle has to work. CO is the amount of blood ejected from the ventricles in 1 minute.

The cardiac conduction system is the stimulus for:

1. Atrial Filling
2. Ventricular contraction.
3. Systemic vascular resistance (SVR).
4. Afterload.

2. Ventricular Contraction

The electrical conduction system provides the stimulation for depolarization of cardiac cells, resulting in contraction. Right atrial filling results from venous return to the heart. Left atrial filling results from return from the pulmonary capillary bed via the pulmonary veins. SVR is reflective of afterload. Afterload is the resistance against which the left ventricle works.

The formula for CO equals:
1 Stroke volume × heart rate (HR).
2 Patient weight × HR.
3 Contractility × HR.
4 Stroke volume × contractility.

1 Stroke volume × heart rate (HR).

The formula for CO is CO = stroke volume × HR. The CO formula does not include patient weight. Contractility is one of the parameters that influence stroke volume, and preload and afterload should also be considered. Stroke volume is included in the formula for CO, but contractility is one of the parameters for stroke volume.

During a mass disaster drill simulating a terrorist attack, the nurse must triage numerous severely ill individuals. The client who should receive care first is:
1. Cyanotic and not breathing
2. Gasping for breath and conscious
3. Apneic and has an apical rate of 50
4. Having a seizure and is incontinent of urine

2. Gasping for Breath and conscious

Rationale: Disaster triage is based on the principle of the greatest good for the greatest number; those who have a likelihood of survival are treated first. People who are gasping for breath and are conscious have priority over those who are cyanotic and not breathing.

1. Clients who are not breathing and cyanotic have low priority because survival requires multiple time-consuming interventions that detract from the care needed by others.
3. Clients who are not breathing and cyanotic have low priority because survival requires multiple time-consuming interventions that detract from the care needed by others.
4. Those having a seizure have low priority because a seizure is not life threatening.

A man experiences crushing chest pain and is brought to the emergency department. When assessing the ECG tracing, the nurse concludes that the client is experiencing premature ventricular complexes (PVCs). Which abnormalities of the electrocardiogram support this conclusion?
1. Irregular rhythm; abnormal shaped P wave; normal QRS
2. Irregular rhythm; absence of a P wave; wide, distorted QRS
3. Regular rhythm; more than 100 beats per minute; normal P wave; normal QRS
4. Regular rhythm; 100 to 250 beats per minute; absent P wave; wide, distorted QRS

2. A premature ventricular complex (PVC) is a contraction originating in an ectopic focus in the ventricles; it is characterized by a premature, wide, distorted QRS complex with the P wave and PR interval buried in the distorted QRS complex resulting in an irregular rhythm.

1. These occur with a premature atrial complex.

3. These occur with sinus tachycardia.

4. These occur with ventricular tachycardia.

Which assessment parameter will the nurse address during the secondary survey of a patient in triage?

a. Blood pressure and heart rate
b. Patency of the patient’s airway
c. Neurologic status and level of consciousness
d. Presence or absence of breath sound and quality of breathing

a. Blood pressure and heart rate

Vital signs are considered to be a part of the secondary survey in the triage process. Airway, breathing, circulation, and a brief neurologic assessment are components of the primary survey that is done to identify life-threatening conditions.

An 18-year-old female has been admitted to the emergency department (ED) after ingesting an entire bottle of chewable multivitamins in a suicide attempt. The nurse should anticipate which intervention?
a. Induced vomiting
b. Whole bowel irrigation
c. Administration of activated charcoal
d. Administration of fresh frozen plasma
c. Administration of charcoal
Among the most common treatments for poisoning is the administration of activated charcoal. Induced vomiting is not typically indicated, and there is no need for plasma administration. Whole bowel irrigation may be used as an adjunct therapy later in treatment, but the use of activated charcoal is central to the treatment of poisonings.
There has been a mass casualty incident. Which patient would likely be designated “red” during triage at the site of this occurrence?
A. An individual who is distraught at the violence of the incident
B. An individual who has experienced an open arm fracture from falling debris
C. An individual who is not expected to survive a crushing head and neck wound
D. An individual whose femoral artery has been severed and is bleeding profusely
D. An individual whose femoral artery has been severed and is bleeding profusely
Red indicates a life-threatening injury requiring immediate intervention, such as severe bleeding. Emotional trauma would not warrant a “red” designation, whereas a fracture would likely be deemed “yellow,” urgent, but not life-threatening. Those not expected to survive are categorized “blue.”
A mailroom worker was exposed to anthrax (Bacillus anthracis). He is not sure if he inhaled any of it or if it got on his skin because he dropped the envelope when he saw the powder. What treatment(s) should the nurse anticipate?
a. Induce vomiting and administer antitoxin.
b. Patient isolation to prevent spread of virus
c. Immediate vaccinia immune globulin (VIG)
d. Ciprofloxacin (Cipro) to prevent systemic manifestations

d. Ciprofloxacin (Cipro) to prevent systemic manifestations

To treat someone exposed to anthrax, antibiotics are effective to prevent systemic manifestations if treatment is begun early. Ciprofloxacin is the treatment of choice. Botulism is treated by inducing vomiting and administering antitoxin. A patient with hemorrhagic fever will be isolated to prevent the spread of the virus. Vaccinia immune globulin (VIG) is used for smallpox.

A male patient is brought into the ED with multiple stab wounds to the legs, one stab wound to the left abdomen, and gang tattoos on both arms. He refused to identify his attacker and then loses consciousness. Police identify him as the assailant in the fatal stabbing of another man. What is the nurse’s priority?
a. Guard locked access doors.
b. Maintain patient safety from revenge.
c. Maintain personal and work place safety.
d. Attain open patient airway and breathing.

c. Maintain personal and work place safety.

The nurse’s priority is to maintain personal and work place safety. Violence can erupt in the ED when treating gang members if the rival gang seeks revenge, or the patient’s gang members seek to protect the patient with their presence. Staff members can be victims of that violence, so they should maintain a safe work environment by seeking law enforcement and security assistance in maintaining safety for the staff and the patient. ABCs are the usual priority, but this situation does not show any problem with the patient’s airway or breathing

A patient has sought care 3 days after experiencing a series of tick bites. Which manifestation would indicate that a patient is experiencing tick paralysis?

a. Respiratory distress
b. Aggression and frequent falls
c. Decreased level of consciousness
d. Fever and necrosis at the bite sites

a. Respiratory distress

A classic manifestation of tick paralysis is flaccid ascending paralysis, which develops over 1 to 2 days. Without tick removal, the patient dies as respiratory muscles become paralyzed. Aggression, decreased level of consciousness, fever, and necrosis at the bite sites are not characteristic of the problem.

The patient has been part of a community emergency response team (CERT) for a tropical storm in Dallas where it has been 100° F (37.7° C) or more for the last 2 weeks. With assessment, the nurse finds hypotension, body temperature of 104° F (40° C), dry and ashen skin, and neurologic symptoms. What treatments should the National Disaster Medical System (NDMS) nurse anticipate (select all that apply)?

a. Administer 100% O2.
b. Immerse in an ice bath.
c. Administer cool IV fluids.
d. Cover the patient to prevent chilling.
e. Administer acetaminophen (Tylenol).

a. Administer 100% O2.
c. Administer cool IV fluids.The patient is experiencing heatstroke. Treatment focuses first on stabilizing the patient’s ABC and rapidly reducing the core temperature. Administration of 100% O2 compensates for the patient’s hypermetabolic state. Cooling the body with IV fluids is effective. Immersion in an ice bath will cause shivers that increase core temperature, so a cool water bath should be used for conductive cooling. Removing the clothing, covering the patient with wet sheets, and placing the patient in front of a fan will cause evaporative cooling. Excessive covers will not be used. Acetaminophen will not be effective because the increase in temperature is not related to infection.

A nurse is performing triage in the emergency department. Which patient should the nurse see first?

a. 18-year-old patient with type 1 diabetes mellitus who has a 4-cm laceration on right leg
b. 32-year-old patient with drug overdose who is unresponsive with a poor respiratory effort
c. 56-year-old patient with substernal chest pain who is diaphoretic with shortness of breath
d. 78-year-old patient with right hip fracture who is confused; blood pressure is 98/62 mm Hg

b. 32-year-old patient with drug overdose who is unresponsive with a poor respiratory effort

The patient with a drug overdose is unstable and needs to be seen immediately. Patient with chest pain (possible myocardial infarction) should be seen second. Patient with hip fracture should be seen third. Patient with laceration is the most stable and should be seen last.

A 71-year-old woman arrives in the emergency department after ingesting 8 g of acetaminophen (Tylenol). Which question is most important for the nurse to ask?
a. “Do you feel like you have a fever?”
b. “What time did you take the medication?”
c. “Have you tried to commit suicide before?”
d. “Are you experiencing any abdominal pain?”

b. What time did you take the medication?

Acetaminophen will bind to activated charcoal and pass through the gastrointestinal tract without being absorbed. Activated charcoal is most effective if administered within 1 hour of ingestion of acetaminophen and other select poisons.

The nurse provides information to a laboratory employee who was accidentally exposed to anthrax by inhalation. The nurse determines the teaching has been successful if the patient makes which statement?
a. “An antibiotic will be prescribed for 2 months.”
b. “I will need to wear a mask for the next 2 weeks.”
c. “Anthrax can be spread by person-to-person contact.”
d. “Antibiotics are only indicated for an active infection.”

a. “An antibiotic will be prescribed for 2 months.”

Postexposure prophylaxis includes a 60-day course of antibiotics. Ciprofloxacin (Cipro) is the treatment of choice. Antibiotics are indicated after exposure to inhaled anthrax. A mask is not needed. Anthrax is not spread by person-to-person contact; anthrax is spread by direct contact with the bacteria and its spores.

A 47-year-old man who was lost in the mountains for 2 days is admitted to the emergency department with cold exposure and a core body temperature of 86.6o F (30.3o C). Which action is most appropriate for the nurse to take?
a. Administer warmed IV fluids.
b. Position patient under a radiant heat lamp.
c. Place an air-filled warming blanket on the patient.
d. Immerse the extremities in a water bath (102° to 108° F [38.9° to 42.2° C]).

a. Administer warmed IV fluids.

A patient with a core body temperature of 86.6o F (30.3o C) has moderate hypothermia. Active core rewarming is used for moderate to severe hypothermia and includes administration of warmed IV fluids (109.4° F [43° C]). Patients with moderate to severe hypothermia should have the core warmed before the extremities to prevent after drop (or further drop in core temperature). This occurs when cold peripheral blood returns to the central circulation. Use passive or active external rewarming for mild hypothermia. Active external rewarming involves fluid-filled warming blankets or radiant heat lamps. Immersion of extremities in a water bath is indicated for frostbite.

A nurse teaches the emergency department staff about their roles during a disaster with mass casualties. Which primary responsibility should the nurse describe that is expected of all licensed and unlicensed health care staff?
a. Notify local, state, and national authorities.
b. Assist security personnel to patrol the area.
c. Learn the hospital emergency response plan.
d. Contact the American Red Cross for assistance.
c. Learn the hospital emergency response plan.
All health care providers must be prepared for a mass casualty incident. The priority responsibility is to know the agency’s emergency response plan

A 64-year-old male patient admitted to the critical care unit for gastrointestinal hemorrhage complains of feeling tense and nervous. He appears restless with an increase in blood pressure and pulse. If the physical assessment shows no other changes, it is most important for the critical care nurse to take which action?

A. Administer prescribed IV dose of lorazepam (Ativan).
B. Stay with the patient and encourage expression of concerns.
C. Ask a family member to remain at the bedside with the patient.
D. Teach the patient how to use guided imagery to reduce anxiety.

B. Stay with the patient and encourage expression of concerns.

Anxiety is a common problem for critically ill patients. The nurse should first stay with the patient and encourage the patient to express concerns and needs. After expression of feelings, the nurse should determine the appropriate intervention if needed (e.g., lorazepam, guided imagery, family presence) and closely monitor the patient’s hemodynamic parameters.

The critical care nurse is caring for a 55-year-old man who has a catheter in the right radial artery that is being used for continuous arterial blood pressure monitoring following his abdominal aortic aneurysm surgery. Which observation by the nurse would require an emergency intervention?

a. Calculated mean arterial pressure is 74 mm Hg.
b. Patient’s head of bed elevation is at 30 degrees.
c. Capillary refill time in the right hand is 5 seconds.
d. Pressure bag attached to the arterial line is inflated to 270 mm Hg.

c. Capillary refill time in the right hand is 5 seconds.

Neurovascular status distal to the arterial insertion site is monitored hourly. If arterial flow is compromised, the limb will be cool and pale, with capillary refill time longer than 3 seconds. Symptoms of neurologic impairment include paresthesia, pain, or paralysis. Neurovascular impairment can result in loss of a limb and is an emergency. The pressure bag should be inflated to 300 mm Hg. Normal range for mean arterial pressure is 70 to 105 mm Hg. The backrest elevation may be up to 45 degrees unless the patient has orthostatic changes.

The nurse is caring for a 34-year-old woman with acute decompensated heart failure who has a pulmonary artery catheter. Which assessment best indicates that the patient’s condition is improving?

a. Cardiac output (CO) is 3.5 L/minute.
b. Central venous pressure (CVP) is 10 mm Hg.
c. Pulmonary artery wedge pressure (PAWP) is 10 mm Hg.
d. Systemic vascular resistance (SVR) is 1500 dynes/sec/cm-5.

c. Pulmonary artery wedge pressure (PAWP) is 10 mm Hg.

PAWP is the most sensitive indicator of cardiac function and fluid volume status. Normal range for PAWP is 6 to 12 mm Hg. PAWP is increased in heart failure. Normal range for CVP is 2 to 8 mm Hg. An elevated CVP indicates right-sided heart failure or volume overload. Normal cardiac output is 4 to 8 L/minute. CO is decreased in heart failure. SVR is increased in left-sided heart failure. Normal SVR is 800 to 1200 dynes/sec/cm-5.

A 68-year-old male patient diagnosed with sepsis is orally intubated on mechanical ventilation. Which action is most important for the nurse to take?
a. Use the open-suctioning technique.
b. Administer morphine for discomfort.
c. Limit noise and cluster care activities.
d. Elevate the head of the bed 30 degrees.

d. Elevate head of the bed 30 degrees.

The two major complications of endotracheal intubation are unplanned extubation and aspiration. To prevent aspiration all intubated patients and patients receiving enteral feedings must have the head of the bed (HOB) elevated a minimum of 30 to 45 degrees unless medically contraindicated. Closed-suction technique is preferred over the open-suction technique because oxygenation and ventilation are maintained during suctioning, and exposure to secretions is reduced. The nurse should provide comfort measures such as morphine to relieve anxiety and pain associated with intubation. To promote rest and sleep the nurse should limit noise and cluster activities.

The nurse is caring for a 65-year-old man with acute respiratory distress syndrome (ARDS) who is on pressure support ventilation (PSV), fraction of inspired oxygen (FIO2) at 80%, and positive end-expiratory pressure (PEEP) at 15 cm H2O. The patient weighs 72 kg. What finding would indicate that treatment is effective?
a. PaO2 of 60 mm Hg
b. Tidal volume of 700 mL Incorrect
c. Cardiac output of 2.7 L/minute
d. Inspiration to expiration ratio of 1:2
a. PaO2 of 60 mm Hg
Severe hypoxemia (PaO2 less than 40 mm Hg) occurs with ARDS, and PEEP is increased to improve oxygenation and prevent oxygen toxicity by reducing FIO2. A PaO2 level of 60 mm Hg indicates that treatment is effective and oxygenation status has improved. Decreased cardiac output is a complication of PEEP. Normal cardiac output is 4 to 8 L/minute. Normal tidal volume is 6 to 10 mL/kg. PSV delivers a preset pressure but the tidal volume varies with each breath. I:E ratio is usually set at 1:2 to 1:1.5 and does not indicate patient improvement.
Which hematologic problem most significantly increases the risks associated with pulmonary artery (PA) catheter insertion?
a. Leukocytosis
b. Hypovolemia
c. Hemolytic anemia
d. Thrombocytopenia

d. Thrombocytopenia

PA catheter insertion carries a significant risk of bleeding, a fact that is exacerbated when the patient has low levels of platelets. Leukocytosis, hypovolemia, and anemia are less likely to directly increase the risks associated with PA insertion.

Which factor indicates that tracheotomy would be preferable to endotracheal intubation?
a.The patient is unable to clear secretions.
b. The patient is at high risk for aspiration.
c. A long-term airway is probably necessary.
d. An upper airway obstruction is impairing the patient’s ventilation.
c. A long-term airway is probably necessary.
A tracheotomy is indicated when the need for an artificial airway is expected to be long term. Aspiration risk, an inability to clear secretions, and upper airway obstruction are indications for an artificial airway, but these are not specific indications for tracheotomy.
The patient has developed cardiogenic shock after a left anterior descending myocardial infection. Which circulatory-assist device should the nurse expect to use for this patient?
a. Cardiopulmonary bypass
b. Impedance cardiography (ICG)
c. Intraaortic balloon pump (IABP)
d. Central venous pressure (CVP) measurement

c. Intraaortic balloon pump (IABP)

The most commonly used mechanical circulatory-assist device is the intraaortic balloon pump (IABP), and it is used to decrease ventricular workload, increase myocardial perfusion, and augment circulation. Cardiopulmonary bypass provides circulation during open heart surgery. It is not used as an assist device after surgery. ICG is a noninvasive method to obtain cardiac output and assess thoracic fluid status. CVP measurement is an invasive measurement of right ventricular preload and reflects fluid volume problems.

Which interventions should the nurse perform prior to suctioning a patient who has an endotracheal (ET) tube using open-suction technique (select all that apply)?
a. Put on clean gloves.
b. Administer a bronchodilator.
c. Perform a cardiopulmonary assessment.
d. Hyperoxygenate the patient for 30 seconds.
e. Insert a few drops of normal saline into the ET to break up secretions.
c. Perform a cardiopulmonary assessment.
d. Hyperoxygenate the patient for 30 seconds.Suctioning is preceded by a thorough assessment and hyperoxygenation for 30 seconds. Sterile, not clean, gloves are necessary, and it is not necessary to administer a bronchodilator. Instillation of normal saline into the ET tube is not an accepted standard practice.

A 70-year-old patient in the ICU has become agitated and inattentive since his heart surgery. The nurse knows that this ICU psychosis frequently occurs in individuals with pre-existing dementia, history of alcohol abuse, and severe disease. What interventions should the nurse provide this patient to improve the patient’s cognition (select all that apply)?
a. Improve oxygenation.
b. Provide a small amount of beer.
c. Have the family stay with the patient.
d. Enable the patient to sleep on a schedule with dim lights.
e. Decrease sensory overload by conversing away from patient’s room.
a. Improve oxygenation.
d. Enable the patient to sleep on a schedule with dim lights.
e. Decrease sensory overload by conversing away from patient’s room.ICU psychosis is from delirium in most ICU patients. Improving oxygenation, enabling the patient to sleep, and decreasing sensory overload along with orientation is all helpful in improving the patient’s cognition. The beer may or may not be allowed for this patient, and the nurse should not assume that it will help. Having a family member stay with the patient to reorient the patient is helpful, but the family group may increase sensory overload with conversations not involving the patient.

The post-anesthesia care unit (PACU) has several patients with endotracheal tubes. Which patient should receive the least amount of endotracheal suctioning?

a. Transplantation of a kidney
b. Replacement of aortic valve
c. Cerebral aneurysm resection
d. Formation of an ileal conduit

c. Cerebral aneurysm resection

The nurse should avoid suctioning the patient after a craniotomy until it is necessary because suctioning will increase this patient’s intracranial pressure. The patients with a kidney transplantation, aortic valve replacement, or formation of an ileal conduit will not be negatively affected by suctioning, although it should only be done when needed, not routinely.

A 38-year-old teacher who reported dizziness and shortness of breath while supervising recess is admitted with a dysrhythmia. Which medication, if ordered, requires the nurse to carefully monitor the patient for asystole?
a. Atropine sulfate
b. Digoxin (Lanoxin)
c. Metoprolol (Lopressor)
d. Adenosine (Adenocard)

d. Adenosine (Adenocard)

IV adenosine (Adenocard) is the first drug of choice to convert supraventricular tachycardia to a normal sinus rhythm. Adenosine is administered IV rapidly (over 1 or 2 seconds) followed by a rapid, normal saline flush. The nurse should monitor the patient’s ECG continuously because a brief period of asystole after adenosine administration is common and expected. Atropine sulfate increases heart rate, whereas lanoxin and metoprolol slow the heart rate.

The nurse is monitoring the ECGs of several patients on a cardiac telemetry unit. The patients are directly visible to the nurse, and all of the patients are observed to be sitting up and talking with visitors. Which patient’s rhythm would require the nurse to take immediate action?
a. A 62-year-old man with a fever and sinus tachycardia with a rate of 110 beats/minute
b. A 72-year-old woman with atrial fibrillation with 60 to 80 QRS complexes per minute
c. A 52-year-old man with premature ventricular contractions (PVCs) at a rate of 12 per minute
d. A 42-year-old woman with first-degree AV block and sinus bradycardia at a rate of 56 beats/minute

c. A 52-year-old man with premature ventricular contractions (PVCs) at a rate of 12 per minute

Frequent premature ventricular contractions (PVCs) (greater than 1 every 10 beats) may reduce the cardiac output and precipitate angina and heart failure, depending on their frequency. Because PVCs in CAD or acute MI indicate ventricular irritability, the patient’s physiologic response to PVCs must be monitored. Frequent PVCs most likely must be treated with oxygen therapy, electrolyte replacement, or antidysrhythmic agents.

Cardioversion is attempted for a 64-year-old man with atrial flutter and a rapid ventricular response. After the nurse delivers 50 joules by synchronized cardioversion, the patient develops ventricular fibrillation. Which action should the nurse take immediately?
a. Administer 250 mL of 0.9% saline solution IV by rapid bolus.
b. Assess the apical pulse, blood pressure, and bilateral neck vein distention. Incorrect
c. Turn the synchronizer switch to the “off” position and recharge the device.
d. Tell the patient to report any chest pain or discomfort and administer morphine sulfate.

c. Turn the synchronizer switch to the “off” position and recharge the device.

Ventricular fibrillation produces no effective cardiac contractions or cardiac output. If during synchronized cardioversion the patient becomes pulseless or the rhythm deteriorates to ventricular fibrillation, the nurse should turn the synchronizer switch off and initiate defibrillation. Fluids, additional assessment, or treatment of pain alone will not restore an effective heart rhythm.

The nurse performs discharge teaching for a 74-year-old woman with an implantable cardioverter-defibrillator. Which statement by the patient indicates to the nurse that further teaching is needed?
a. “The device may set off the metal detectors in an airport.”
b. “My family needs to keep up to date on how to perform CPR.”
c. “I should not stand next to antitheft devices at the exit of stores.” Incorrect
d. “I can expect redness and swelling of the incision site for a few days.”

d. “I can expect redness and swelling of the incision site for a few days.”

Patients should be taught to report any signs of infection at incision site (e.g., redness, swelling, drainage) or fever to their primary care provider immediately. Teach the patient to inform airport security of presence of ICD because it may set off the metal detector. If hand-held screening wand is used, it should not be placed directly over the ICD. Teach the patient to avoid standing near antitheft devices in doorways of stores and public buildings, and to walk through them at a normal pace. Caregivers should learn cardiopulmonary resuscitation (CPR).

A 50-year-old man who develops third-degree heart block reports feeling chest pressure and shortness of breath. Which instructions should the nurse provide to the patient before initiating emergency transcutaneous pacing?
a. “The device will convert your heart rate and rhythm back to normal.”
b. “The device uses overdrive pacing to slow the heart to a normal rate.”
c. “The device is inserted through a large vein and threaded into your heart.”
d. “The device delivers a current through your skin that can be uncomfortable.

d. “The device delivers a current through your skin that can be uncomfortable.

Before initiating transcutaneous pacing (TCP) therapy, it is important to tell the patient what to expect. The nurse should explain that the muscle contractions created by the pacemaker when the current passes through the chest wall are uncomfortable. Pacing for complete heart block will not convert the heart rhythm to normal. Overdrive pacing is used for very fast heart rates. Transcutaneous pacing is delivered through pacing pads adhered to the skin.

When computing a heart rate from the ECG tracing, the nurse counts 15 of the small blocks between the R waves of a patient whose rhythm is regular. From these data, the nurse calculates the patient’s heart rate to be
a. 60 beats/min.
b. 75 beats/min.
c. 100 beats/min.
d. 150 beats/min.
c. 100 beats/min.
Since each small block on the ECG paper represents 0.04 seconds, 1500 of these blocks represents 1 minute. By dividing the number of small blocks (15, in this case) into 1500, the nurse can calculate the heart rate in a patient whose rhythm is regular (in this case, 100).
Which statement best describes the electrical activity of the heart represented by measuring the PR interval on the ECG?
a. The length of time it takes to depolarize the atrium
b. The length of time it takes for the atria to depolarize and repolarize
c. The length of time for the electrical impulse to travel from the SA node to the Purkinje fibers
d. The length of time it takes for the electrical impulse to travel from the SA node to the AV node

c. The length of time for the electrical impulse to travel from the SA node to the Purkinje fibers

The electrical impulse in the heart must travel from the SA node through the AV node and into the Purkinje fibers in order for synchronous atrial and ventricular contraction to occur. When measuring the PR interval (the time from the beginning of the P wave to the beginning of the QRS), the nurse is identifying the length of time it takes for the electrical impulse to travel from the SA node to the Purkinje fibers. The P wave represents the length of time it takes for the impulse to travel from the SA node through the atrium causing depolarization of the atria (atrial contraction). Atrial repolarization occurs during ventricular depolarization and is hidden by the QRS complex. The length of time it takes for the electrical impulse to travel from the SA node to the AV node is the flat line between the end of the P wave and the beginning of the Q wave on the ECG and is not usually measured.

The nurse obtains a 6-second rhythm strip and charts the following analysis:
Tab 1
Atrial Data: Rate: 70, regular
Variable PR interval
Independent beats
Tab 2
Ventricular: Rate: 40, regular
Isolated escape beats
Tab 3
QRS: 0.04 sec
P wave and QRS complexes unrelatedWhat is the correct interpretation of this rhythm strip?
Sinus arrhythmias
a. Third-degree heart block
b. Wenckebach phenomenon
c. Premature ventricular contractions

a. Third-degree heart block

Third-degree heart block represents a loss of communication between the atrium and ventricles from AV node dissociation. This is depicted on the rhythm strip as no relationship between the P waves (representing atrial contraction) and QRS complexes (representing ventricular contraction). The atria are beating totally on their own at 70 beats/min, whereas the ventricles are pacing themselves at 40 beats/min. Sinus dysrhythmia is seen with a slower heart rate with exhalation and an increased heart rate with inhalation. In Wenckebach heart block, there is a gradual lengthening of the PR interval until an atrial impulse is nonconducted and a QRS complex is blocked or missing. Premature ventricular contractions (PVCs) are the early occurrence of a wide, distorted QRS complex.

The nurse is caring for a patient who is 24 hours postpacemaker insertion. Which nursing intervention is most appropriate at this time?
a. Reinforcing the pressure dressing as needed
b. Encouraging range-of-motion exercises of the involved arm
c. Assessing the incision for any redness, swelling, or discharge
d. Applying wet-to-dry dressings every 4 hours to the insertion site

c. Assessing the incision for any redness, swelling, or discharge

After pacemaker insertion, it is important for the nurse to observe signs of infection by assessing for any redness, swelling, or discharge from the incision site. The nonpressure dressing is kept dry until removed, usually 24 hours postoperatively. It is important for the patient to limit activity of the involved arm to minimize pacemaker lead displacement.

The nurse is watching the cardiac monitor, and a patient’s rhythm suddenly changes. There are no P waves. Instead there are fine, wavy lines between the QRS complexes. The QRS complexes measure 0.08 sec (narrow), but they occur irregularly with a rate of 120 beats/min. The nurse correctly interprets this rhythm as what?
a. Sinus tachycardia
b. Atrial fibrillation
c. Ventricular fibrillation
d. Ventricular tachycardia

b. Atrial fibrillation

Atrial fibrillation is represented on the cardiac monitor by irregular R-R intervals and small fibrillatory (f) waves. There are no normal P waves because the atria are not truly contracting, just fibrillating. Sinus tachycardia is a sinus rate above 100 beats/minute with normal P waves. Ventricular fibrillation is seen on the ECG without a visible P wave; an unmeasurable heart rate, PR or QRS; and the rhythm is irregular and chaotic. Ventricular tachycardia is seen as three or more premature ventricular contractions (PVCs) that have distorted QRS complexes with regular or irregular rhythm, and the P wave is usually buried in the QRS complex without a measurable PR interval.

A patient has sought care following a syncopal episode of unknown etiology. Which nursing action should the nurse prioritize in the patient’s subsequent diagnostic workup?
a. Preparing to assist with a head-up tilt-test
b. Preparing an IV dose of a β-adrenergic blocker
c. Assessing the patient’s knowledge of pacemakers
d. Teaching the patient about the role of antiplatelet aggregators

a. Preparing to assist with a head-up tilt-test

In patients without structural heart disease, the head-up tilt-test is a common component of the diagnostic workup following episodes of syncope. IV β-blockers are not indicated although an IV infusion of low-dose isoproterenol may be started in an attempt to provoke a response if the head-up tilt-test did not have a response. Addressing pacemakers is premature and inappropriate at this stage of diagnosis. Patient teaching surrounding antiplatelet aggregators is not directly relevant to the patient’s syncope at this time.

For which dysrhythmia is defibrillation primarily indicated?
a. Ventricular fibrillation
b. Third-degree AV block
c. Uncontrolled atrial fibrillation
d. Ventricular tachycardia with a pulse

a. Ventricular fibrillation

Defibrillation is always indicated in the treatment of ventricular fibrillation. Drug treatments are normally used in the treatment of uncontrolled atrial fibrillation and for ventricular tachycardia with a pulse (if the patient is stable). Otherwise, synchronized cardioversion is used (as long as the patient has a pulse). Pacemakers are the treatment of choice for third-degree heart block.

A patient in asystole is likely to receive which drug treatment?
a. Epinephrine and atropine
b. Lidocaine and amiodarone
c. Digoxin and procainamide
d. β-adrenergic blockers and dopamine

a.Epinephrine and atropine

Normally the patient in asystole cannot be successfully resuscitated. However, administration of epinephrine and atropine may prompt the return of depolarization and ventricular contraction. Lidocaine and amiodarone are used for PVCs. Digoxin and procainamide are used for ventricular rate control. β-adrenergic blockers are used to slow heart rate, and dopamine is used to increase heart rate.

Which ECG characteristic is consistent with a diagnosis of ventricular tachycardia (VT)?
a. Unmeasurable rate and rhythm
b. Rate 150 beats/min; inverted P wave
c. Rate 200 beats/min; P wave not visible
d. Rate 125 beats/min; normal QRS complex

c. Rate 200 beats/min; P wave not visible

VT is associated with a rate of 150 to 250 beats/min; the P wave is not normally visible. Rate and rhythm are not measurable in ventricular fibrillation. P wave inversion and a normal QRS complex are not associated with VT.

The patient has atrial fibrillation with a rapid ventricular response. The nurse knows to prepare for which treatment if an electrical treatment is planned for this patient?
a. Defibrillation
b. Synchronized cardioversion
c. Automatic external defibrillator (AED)
d. Implantable cardioverter-defibrillator (ICD)

b. Synchronized cardioversion

Synchronized cardioversion is planned for a patient with supraventricular tachydysrhythmias (atrial fibrillation with a rapid ventricular response). Defibrillation or AEDs are the treatment of choice to end ventricular fibrillation and pulseless ventricular tachycardia (VT). An ICD is used with patients who have survived sudden cardiac death (SCD), have spontaneous sustained VT, and are at high risk for future life-threatening dysrhythmias.

The nurse is doing discharge teaching with the patient and spouse of the patient who just received an implantable cardioverter-defibrillator (ICD) in the left side. Which statement by the patient indicates to the nurse that the patient needs more teaching?
a. “I will call the cardiologist if my ICD fires.”
b. “I cannot fly because it will damage the ICD.”
c. “I cannot move my left arm until it is approved.”
d. “I cannot drive until my cardiologist says it is okay.”

b. “I cannot fly because it will damage the ICD.”

The patient statement that flying will damage the ICD indicates misunderstanding about flying. The patient should be taught that informing TSA about the ICD can be done because it may set off the metal detector and if a hand-held screening wand is used, it should not be placed directly over the ICD. The other options indicate the patient understands the teaching.

The patient is admitted with acute coronary syndrome (ACS). The ECG shows ST-segment depression and T-wave inversion. What should the nurse know that this indicates?
a. Myocardia injury
b. Myocardial ischemia
c. Myocardial infarction
d. A pacemaker is present.
b. Myocardial ischemia
The ST depression and T wave inversion on the ECG of a patient diagnosed with ACS indicate myocardial ischemia from inadequate supply of blood and oxygen to the heart. Myocardial injury is identified with ST-segment elevation. Myocardial infarction is identified with ST-segment elevation and a widened and deep Q wave. A pacemaker’s presence is evident on the ECG by a spike leading to depolarization and contraction.
The nurse is seeing artifact on the telemetry monitor. Which factors could contribute to this artifact?
a. Disabled automaticity
b. Electrodes in the wrong lead
c. Too much hair under the electrodes
d. Stimulation of the vagus nerve fibers
c. Too much hair under the electrodes
Artifact is caused by muscle activity, electrical interference, or insecure leads and electrodes that could be caused by excessive chest wall hair. Disabled automaticity would cause an atrial dysrhythmia. Electrodes in the wrong lead will measure electricity in a different plane of the heart and may have a different wave form than expected. Stimulation of the vagus nerve fibers causes a decrease in heart rate, not artifact.
The patient has hypokalemia, and the nurse obtains the following measurements on the rhythm strip: Heart rate of 86 with a regular rhythm; the P wave is 0.06 seconds (sec) and normal shape; the PR interval is 0.24 sec; the QRS is 0.09 sec. How should the nurse document this rhythm?
a. First-degree AV block
b. Second-degree AV block
c. Premature atrial contraction (PAC)
d. Premature ventricular contraction (PVC)

a. First-degree AV block

In first-degree AV block there is prolonged duration of AV conduction that lengthens the PR interval above 0.20 sec. In type I second-degree AV block the PR interval continues to increase in duration until a QRS complex is blocked. In Type II the PR interval may be normal or prolonged, the ventricular rhythm may be irregular, and the QRS is usually greater than 0.12 sec. PACs cause an irregular rhythm with a different-shaped P wave than the rest of the beats, and the PR interval may be shorter or longer. PVCs cause an irregular rhythm, and the QRS complex is wide and distorted in shape.

The physician orders intracranial pressure (ICP) readings every hour for a 23-year-old male patient with a traumatic brain injury from a motor vehicle crash. The patient’s ICP reading is 21 mm Hg. It is most important for the nurse to take which action?
a. Document the ICP reading in the chart.
b. Determine if the patient has a headache.
c. Assess the patient’s level of consciousness.
d. Position the patient with head elevated 60 degrees

c. Assess the patient’s level of consciousness.

The patient has an increased ICP (normal ICP ranges from 5 to 15 mm Hg). The most sensitive and reliable indicator of neurologic status is level of consciousness. The Glasgow Coma Scale may be used to determine the degree of impaired consciousness.

A 19-year-old woman is hospitalized for a frontal skull fracture from a blunt force head injury. Clear fluid is draining from the patient’s nose. What action by the nurse is most appropriate?
a. Apply a loose gauze pad under the patient’s nose.
b. Place the patient in a modified Trendelenburg position.
c. Ask the patient to gently blow the nose to clear the drainage.
d. Gently insert a catheter in the nares and suction the drainage.

a. Apply a loose gauze pad under the patient’s nose.

Cerebrospinal fluid (CSF) rhinorrhea (clear or bloody drainage from the nose) may occur with a frontal skull fracture. If CSF rhinorrhea occurs, the nurse should inform the physician immediately. A loose collection pad may be placed under the nose. The head of the bed may be raised to decrease the CSF pressure so that a tear can seal. The nurse should not place a dressing or tube in the nasal cavity, and the patient should not sneeze or blow the nose.

The nurse prepares to administer temozolomide (Temodar) to a 59-year-old white male patient with a glioblastoma multiforme (GBM) brain tumor. What should the nurse assess before giving the medication?

a. Serum potassium and serum sodium levels
b. Urine osmolality and urine specific gravity
c. Absolute neutrophil count and platelet count
d. Cerebrosprinal fluid (CSF) pressure and cell count

c. Absolute neutrophil count and platelet count

Temozolomide causes myelosuppression. The nurse should assess the absolute neutrophil count and the platelet count. The absolute neutrophil count should be >1500/μL and platelet count >100,000/μL.

A 32-year-old female patient is diagnosed with diabetes insipidus after transsphenoidal resection of a pituitary adenoma. What should the nurse consider as a sign of improvement?
a. Serum sodium of 120 mEq/L
b. Urine specific gravity of 1.001
c. Fasting blood glucose of 80 mg/dL
d. Serum osmolality of 290 mOsm/kg
d. Serum osmolality of 290 mOsm/kg
Laboratory findings in diabetes insipidus include an elevation in serum osmolality and serum sodium and a decrease in urine specific gravity. Normal serum osmolality is 275 to 295 mOsm/kg, normal serum sodium is 135 to 145 mEq/L, and normal specific gravity is 1.003 to 1.030. Elevated blood glucose levels occur with diabetes mellitus.
A 68-year-old man with suspected bacterial meningitis has just had a lumbar puncture in which cerebrospinal fluid was obtained for culture. Which medication should the nurse administer first?
a. Codeine
b. Phenytoin (Dilantin) I
c. Ceftriaxone (Rocephin)
d. Acetaminophen (Tylenol)

c. Ceftriaxone (Rocephin)

Bacterial meningitis is a medical emergency. When meningitis is suspected, antibiotic therapy (e.g., ceftriaxone) is instituted immediately after the collection of specimens for cultures, and even before the diagnosis is confirmed. Dexamethasone may also be prescribed before or with the first dose of antibiotics. The nurse should collaborate with the health care provider to manage the headache (with codeine), fever (with acetaminophen), and seizures (with phenytoin).

A patient with a suspected traumatic brain injury has bloody nasal drainage. What observation should cause the nurse to suspect that this patient has a cerebrospinal fluid (CSF) leak?
a. A halo sign on the nasal drip pad
b. Decreased blood pressure and urinary output
c. A positive reading for glucose on a Test-tape strip
d. Clear nasal drainage along with the bloody discharge

a. A halo sign on the nasal drip pad.

When drainage containing both CSF and blood is allowed to drip onto a white pad, within a few minutes the blood will coalesce into the center, and a yellowish ring of CSF will encircle the blood, giving a halo effect. The presence of glucose would be unreliable for determining the presence of CSF because blood also contains glucose. Decreased blood pressure and urinary output would not be indicative of a CSF leak.

The nurse assesses a patient for signs of meningeal irritation and observes for nuchal rigidity. What indicates the presence of this sign of meningeal irritation?
a. Tonic spasms of the legs
b. Curling in a fetal position
c. Arching of the neck and back
d. Resistance to flexion of the neck

d. Resistance to flexion of the neck

Nuchal rigidity is a clinical manifestation of meningitis. During assessment, the patient will resist passive flexion of the neck by the health care provider. Tonic spasms of the legs, curling in a fetal position, and arching of the neck and back are not related to meningeal irritation.

The nurse is caring for a patient admitted with a subdural hematoma following a motor vehicle accident. Which change in vital signs would the nurse interpret as a manifestation of increased intracranial pressure (ICP)?
a. Tachypnea
b. Bradycardia
c. Hypotension
d. Narrowing pulse pressure

b. Bradycardia

Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing’s triad) occur with increased ICP. They consist of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations.

The nurse is providing care for a patient who has been admitted to the hospital with a head injury and who requires regular neurologic and vital sign assessment. Which assessments will be components of the patient’s score on the Glasgow Coma Scale (GCS) (select all that apply)?
a. Judgment
b. Eye opening
c. Abstract reasoning
d. Best verbal response
e. Best motor response
f. Cranial nerve function
b. Eye opening
d. Best verbal response
e. Best motor responseThe three dimensions of the GCS are eye opening, best verbal response, and best motor response. Judgment, abstract reasoning, and cranial nerve function are not components of the GCS.

What nursing intervention should be implemented in the care of a patient who is experiencing increased ICP?
a. Monitor fluid and electrolyte status carefully.
b. Position the patient in a high Fowler’s position.
c. Administer vasoconstrictors to maintain cerebral perfusion.
d. Maintain physical restraints to prevent episodes of agitation.

a. Monitor fluid and electrolyte status carefully.

Fluid and electrolyte disturbances can have an adverse effect on ICP and must be monitored vigilantly. The head of the patient’s bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors are not typically administered in the treatment of ICP.

A patient has a systemic blood pressure of 120/60 and an ICP of 24 mm Hg. After calculating the patient’s cerebral perfusion pressure (CPP), how does the nurse interpret the results?
A. High blood flow to the brain
B. Normal intracranial pressure
C. Impaired blood flow to the brain
D. Adequate autoregulation of blood flow

C. Impaired blood flow to the brain

Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP) minus ICP. MAP = SBP + 2 (DBP)/ 3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP – ICP: 80mm Hg – 24 mm Hg = 56 mm Hg CPP. The decreased CPP indicates that there is impaired cerebral blood flow and that autoregulation is impaired. Because the ICP is 24, it is elevated and requires treatment.

Decerebrate posture is documented in the chart of the patient that the nurse will be caring for. The nurse should know that the patient may have elevated ICP causing serious disruption of motor fibers in the midbrain and brainstem and will expect the patient’s posture to look like which posture represented below?
A
B
C
D

B

Decerebrate posture is all four extremities in rigid extension with hyperpronation of the forearms and plantar flexion of feet. Decorticate posture is internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers from interruption of voluntary motor tracts in the cerebral cortex. Decorticate response on one side of the body and decerebrate response on the other side of the body may occur depending on the damage to the brain. Opisthotonic posture is decerebrate posture with the neck and back arched posteriorly and may be seen with traumatic brain injury.

The patient with increased ICP from a brain tumor is being monitored with a ventriculostomy. What nursing intervention is the priority in caring for this patient?
a. Administer IV mannitol (Osmitrol).
b. Ventilator use to hyperoxygenate the patient
c. Use strict aseptic technique with dressing changes.
d. Be aware of changes in ICP related to leaking CSF.

c. Use strict aseptic technique with dressing changes.

The priority nursing intervention is to use strict aseptic technique with dressing changes and any handling of the insertion site to prevent the serious complication of infection. IV mannitol (Osmitrol) or hypertonic saline will be administered as ordered. Ventilators may be used to maintain oxygenation. CSF leaks may cause inaccurate ICP readings, or CSF may be drained to decrease ICP, but strict aseptic technique to prevent infection is the nurse’s priority of care.

A male patient suffered a diffuse axonal injury from a traumatic brain injury (TBI). He has been maintained on IV fluids for 2 days. The nurse seeks enteral feeding for this patient based on what rationale?
a. Free water should be avoided.
b. Sodium restrictions can be managed.
c. Dehydration can be better avoided with feedings.
d. Malnutrition promotes continued cerebral edema.

d. Malnutrition promotes continued cerebral edema.

A patient with diffuse axonal injury is unconscious and, with increased ICP, is in a hypermetabolic, hypercatabolic state that increases the need for fuel for healing. Malnutrition promotes continued cerebral edema, and early feeding may improve outcomes when begun within 3 days after injury. Fluid and electrolytes will be monitored to maintain balance with the enteral feedings.

In planning long-term care for a patient after a craniotomy, what must the nurse include when teaching the patient, family, and caregiver?
a. Seizure disorders may occur in weeks or months.
b. The family will be unable to cope with role reversals.
c. There are often residual changes in personality and cognition.
d. Referrals will be made to eliminate residual deficits from the damage.

c. There are often residual changes in personality and cognition.

In long-term care planning, the nurse must include the family and caregiver when teaching about potential residual changes in personality, emotions, and cognition as these changes are most difficult for the patient and family to accept. Seizures may or may not develop. The family and patient may or may not be able to cope with role reversals. Although residual deficits will not be eliminated with referrals, they may be improved.

The nurse in a primary care provider’s office is assessing several patients today. Which patient is most at risk for a stroke?
a. A 92-year-old female who takes warfarin (Coumadin) for atrial fibrillation.
b. A 28-year-old male who uses marijuana after chemotherapy to control nausea.
c. A 42-year-old female who takes oral contraceptives and has migraine headaches.
d. A 72-year-old male who has hypertension and diabetes mellitus and smokes tobacco.

d. A 72-year-old male who has hypertension and diabetes mellitus and smokes tobacco.

Stroke risk increases after 65 years of age. Strokes are more common in men. Hypertension is the single most important modifiable risk factor for stroke. Diabetes mellitus is a significant stroke risk factor; and smoking nearly doubles the risk of a stroke. Other risk factors include drug abuse (especially cocaine), high-dose oral contraception use, migraine headaches, and untreated heart disease such as atrial fibrillation

The nurse is teaching a senior citizen’s group about signs and symptoms of a stroke. Which statement by the nurse would provide accurate information?
a. “Take the person to the hospital if a headache lasts for more than 24 hours.”
b. “Stroke symptoms usually start when the person is awake and physically active.”
c. “A person with a transient ischemic attack has mild symptoms that will go away.”
d. “Call 911 immediately if a person develops slurred speech or difficulty speaking.”

d. “Call 911 immediately if a person develops slurred speech or difficulty speaking.”

Medical assistance should be obtained immediately for someone with signs and symptoms of a stroke such as sudden numbness; weakness; paralysis of the face, arm, or leg (especially on one side of the body); sudden confusion; trouble speaking or understanding; slurred speech; sudden trouble seeing in one or both eyes; sudden trouble walking; dizziness; loss of balance or coordination; or a sudden, severe headache with no known cause. A person with signs and symptoms of a transient ischemic attack should seek medical attention immediately because it is unknown if the symptoms will resolve or persist and progress to a stroke. Onset of signs and symptoms of a stroke vary depending on the type. Onset of an ischemic thrombotic stroke usually occurs at rest. Onset of an ischemic embolic stroke is not related to rest or activity, and onset of a hemorrhagic stroke usually occurs with activity.

The physician orders alteplase (Activase) for a 58-year-old man diagnosed with an acute ischemic stroke. Which nursing action is most appropriate?
a. Administer the medication by an IV route at 15 mL/hr for 24 hours.
b. Insert two or three large-bore IV catheters before administering the medication.
c. If gingival bleeding occurs, discontinue the medication and notify the physician.
d. Reduce the medication infusion rate for a systolic blood pressure above 180 mm Hg.

b. Insert two or three large-bore IV catheters before administering the medication.

Before giving alteplase, the nurse should start two or three large bore IVs. Bleeding is a major complication with fibrinolytic therapy, and venipunctures should not be attempted after alteplase is administered. Altepase is administered IV with an initial bolus dose followed by an infusion of the remaining medication within the next 60 minutes. Gingival bleeding is a minor complication and may be controlled with pressure or ice packs. Control of blood pressure is critical prior to altepase administration and for the following 24 hours. Before administering altepase, a systolic pressure above 180 mm Hg or diastolic pressure above 110 mm Hg requires aggressive blood pressure treatment to reduce the risk of cerebral hemorrhage.

The nurse observes a student nurse assigned to initiate oral feedings for a 68-year-old woman with an ischemic stroke. The nurse should intervene if she observes the student nurse
A. giving the patient 8 ounces of ice water to swallow.
B. telling the patient to perform a chin tuck before swallowing.
C. assisting the patient to sit in a chair before feeding the patient.
D. assessing cranial nerves IX and X before the patient attempts to eat.

A. giving the patient 8 ounces of ice water to swallow.

The majority of patients after a stroke have dysphagia. The gag reflex and swallowing ability (cranial nerves IX and X) should be assessed before the first oral feeding. To assess swallowing ability, the nurse should elevate the head of the bed to an upright position (unless contraindicated) and give the patient a very small amount (not 8 ounces) of crushed ice or ice water to swallow. The patient should remain in a high Fowler’s position, preferably in a chair with the head flexed forward, for the feeding and for 30 minutes following.

A 74-year-old man who has right-sided extremity paralysis related to a thrombotic stroke develops constipation. Which action should the nurse take first?
a. Assist the patient to the bathroom every 2 hours.
b. Provide incontinence briefs to wear during the day.
c. Administer a bisacodyl (Dulcolax) rectal suppository every day.
d. Arrange for several servings per day of cooked fruits and vegetables.

d. Arrange for several servings per day of cooked fruits and vegetables.

Patients after a stroke frequently have constipation. Dietary management includes the following: fluid intake of 2500 to 3000 mL daily, prune juice (120 mL) or stewed prunes daily, cooked fruit three times daily, cooked vegetables three times daily, and whole-grain cereal or bread three to five times daily. Patients with urinary incontinence should be assisted to the bathroom every 2 hours when appropriate. Suppositories may be ordered for short-term management if the patient does not respond to increased fluid and fiber. Incontinence briefs are indicated as a short-term intervention for urinary incontinence.

The nurse is providing emergent care for a 62-year-old man with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. Which action should the nurse take first?
a. Administer 100% humidified oxygen.
b. Teach the patient deep breathing exercises.
c. Encourage the patient to express his feelings.
d. Assist the patient to a high Fowler’s position.

a. Administer 100% humidified oxygen.

Carbon monoxide (CO) poisoning may occur in house fires. CO displaces oxygen on the hemoglobin molecule resulting in hypoxia. High levels of CO in the blood result in a skin color that is described as cherry red. Hypoxia may cause anxious behaviors and altered mental status. Emergency treatment for inhalation injury and CO poisoning includes the immediate administration of 100% humidified oxygen. The other interventions are appropriate for inhalation injury but are not as urgent as oxygen administration.

The nurse is caring for a 34-year-old male patient who sustained a deep partial thickness burn to the anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn?
a. Skin is hard with a dry, waxy white appearance.
b. Skin is shiny and red with clear, fluid-filled blisters.
c. Skin is red and blanches when slight pressure is applied.
d. Skin is leathery with visible muscles, tendons, and bones.

b. Skin is shiny and red with clear, fluid-filled blisters.

Deep partial thickness burns have fluid-filled vesicles that are red and shiny. They may appear wet (if vesicles have ruptured), and mild to moderate edema may be present. Superficial partial thickness burns are red and blanch with pressure vesicles that appear 24 hours after the burn injury. Full-thickness burns are dry, waxy white, leathery, or hard, and there may be involvement of muscles, tendons, and bones.

The nurse is planning to change the dressing that covers a deep partial-thickness burn of the right lower leg. Which prescribed medication should the nurse administer to the 70-year-old female patient 30 minutes before the scheduled dressing change?
a. Morphine sulfate
b. Sertraline (Zoloft)
c. Zolpidem (Ambien)
d. Enoxaparin (Lovenox)

a. Morphine sulfate

Deep partial-thickness burns result in severe pain related to nerve injury. The nurse should plan to administer analgesics before the dressing change to promote patient comfort. Morphine is a common opioid used for pain control. Sedative/hypnotics and antidepressant agents also can be given with analgesics to control the anxiety, insomnia, and/or depression that patients may experience. Zolpidem promotes sleep. Sertraline is an antidepressant. Enoxaparin is an anticoagulant.

Which patient should the nurse prepare to transfer to a regional burn center?
a. A 25-year-old pregnant patient with a carboxyhemoglobin level of 1.5%
b. A 39-year-old patient with a partial-thickness burn to the right upper arm
c. A 53-year-old patient with a chemical burn to the anterior chest and neck
d. A 42-year-old patient who is scheduled for skin grafting of a burn wound

c. A 53-year-old patient with a chemical burn to the anterior chest and neck

The American Burn Association (ABA) has established referral criteria to determine which burn injuries should be treated in burn centers where specialized facilities and personnel are available to handle this type of trauma (see Table 25-3). Patients with chemical burns should be referred to a burn center. A normal serum carboxyhemoglobin level for nonsmokers is 0% to 1.5% and for smokers is 4% to 9%. Skin grafting for burn wound management is not a criterion for a referral to a burn center. Partial-thickness burns greater than 10% total body surface area (TBSA) should be referred to a burn center. A burn to the right upper arm is 4% TBSA.

The nurse is caring for a 46-year-old female patient during the first 12 hours after a thermal burn injury. She weighed 71 kg on admission to the burn unit. Which outcomes if observed by the nurse would indicate adequate fluid resuscitation? (select all that apply)
a. Urine output is 80 mL/hour.
b. Heart rate is 86 beats/minute.
c. Urine specific gravity is 1.025.
d. Mean arterial pressure is 54 mm Hg.
e. Systolic blood pressure is 88 mm Hg.
a. Urine output is 80 mL/hour.
b. Heart rate is 86 beats/minute.
c. Urine specific gravity is 1.025.Assessment of the adequacy of fluid resuscitation is best made using either urine output or cardiac factors. Urine output should be at least 0.5 to 1 mL/kg/hr. Cardiac factors include a mean arterial pressure (MAP) > 65 mm Hg, systolic blood pressure (BP) > 90 mm Hg, heart rate < 120 beats/minute. Normal range for urine specific gravity is 1.003 to 1.030.

A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation?
a. The total 24-hour fluid requirement should be administered in the first 8 hours.
b. One half of the total 24-hour fluid requirement should be administered in the first 8 hours.
c. One third of the total 24-hour fluid requirement should be administered in the first 4 hours.
d. One half of the total 24-hour fluid requirement should be administered in the first 4 hours.

b. One half of the total 24-hour fluid requirement should be administered in the first 8 hours.

Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first 8 hours, one quarter of total fluid requirement should be administered in the second 8 hours, and one quarter of total fluid requirement should be administered in the third 8 hours.

The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment the nurse would expect to find which manifestation?
a. Blisters
b. Reddening of the skin
c. Destruction of all skin layers
d. Damage to sebaceous glands

b. Reddening of the skin Correct

The clinical appearance of superficial partial-thickness burns includes erythema, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours.

The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which interventions should the nurse expect to include in this patient’s care ()? (select all that apply)?

a. Escharotomy
b. Administration of diuretics
c. IV and oral pain medications
d. Daily cleansing and debridement
e. Application of topical antimicrobial

a. Escharotomy
c. IV and oral pain medications
d. Daily cleansing and debridement
e. Application of topical antimicrobial agentAn escharotomy (a scalpel incision through full-thickness eschar) is frequently required to restore circulation to compromised extremities. Daily cleansing and debridement as well as application of an antimicrobial ointment are expected interventions used to minimize infection and enhance wound healing. Pain control is essential in the care of a patient with a burn injury. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion.

The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement?
a. Full liquids only
b. Whatever the patient requests
c. High-protein and low-sodium foods
d. High-calorie and high-protein foods
d. High-calorie and high protein foods
A hypermetabolic state occurs proportional to the size of the burn area. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Caloric needs are often in the 5000-kcal range. Failure to supply adequate calories and protein leads to malnutrition and delayed healing.
A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert you to the presence of an inhalation injury? (select all that apply)?
a. Singed nasal hair
b. Generalized pallor
c. Painful swallowing
d. Burns on the upper extremities
e. History of being involved in a large fire
a. Singed nasal hair
b. Generalized pallor
c. Painful swallowing
e. History of being involved in a large fireReliable clues to the occurrence of inhalation injury is the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, altered mental status, and “cherry red” skin color.

When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question?
a. Mannitol 75 gm IV
b. Urine for myoglobulin
c. Lactated Ringer’s at 25 mL/hr
d. Sodium bicarbonate 24 mEq every 4 hours

c. Lactated Ringer’s at 25 mL/hr

Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute renal tubular necrosis (ATN). Treatment consists of infusing lactated Ringer’s at 2-4 mL/kg/%TBSA, a rate sufficient to maintain urinary output at 75 to 100 mL/hr. Mannitol can also be used to maintain urine output. Sodium bicarbonate may be given to alkalinize the urine. The urine would also be monitored for the presence of myoglobin. An infusion rate of 25 mL/hr is not sufficient to maintain adequate urine output in prevention and treatment of ATN.

A patient is admitted with second- and third-degree burns covering the face, entire right upper extremity, and the right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being?
a. 18%
b. 22.5%
c. 27%
d. 36%

b. 22.5%

Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Since the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore adding the three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient’s burns to cover approximately 22.5% of the total body surface area.

An 82-year-old patient is moving into an independent living facility. What is the best advice the nurse can give to the family to help prevent this patient from being accidentally burned in her new home?
a. Cook for her.
b. Stop her from smoking.
c. Install tap water anti-scald devices.
d. Be sure she uses an open space heater.
c. Install tap water anti-scald devices.
Installing tap water anti-scald devices will help prevent accidental scald burns that more easily occur in older people as their skin becomes drier and the dermis thinner. Cooking for her may be needed at times of illness or in the future, but she is moving to an independent living facility, so at this time she should not need this assistance. Stopping her from smoking may be helpful to prevent burns but may not be possible without the requirement by the facility. Using an open space heater would increase her risk of being burned and would not be encouraged.
The ambulance reports that they are transporting a patient to the ED who has experienced a full-thickness thermal burn from a grill. What manifestations should the nurse expect?
a. Severe pain, blisters, and blanching with pressure
b. Pain, minimal edema, and blanching with pressure
c. Redness, evidence of inhalation injury, and charred skin
d. No pain, waxy white skin, and no blanching with pressure

d. No pain, waxy white skin, and no blanching with pressure

With full-thickness burns, the nerves and vasculature in the dermis are destroyed so there is no pain, the tissue is dry and waxy-looking or may be charred, and there is no blanching with pressure. Severe pain, blisters, and blanching occur with partial-thickness (deep, second-degree) burns. Pain, minimal edema, blanching, and redness occur with partial-thickness (superficial, first-degree) burns.

In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what happens?
a. Serum sodium and potassium increase
b. Serum sodium and potassium decrease.
c. Edema and arterial blood gases improve.
d. Diuresis occurs and hematocrit decreases.

d. Diuresis occurs and hematocrit decreases.

In the emergent phase, the immediate, life-threatening problems from the burn, hypovolemic shock and edema, are treated and resolved. Toward the end of the emergent phase, fluid loss and edema formation end. Interstitial fluid returns to the vascular space and diuresis occurs. Urinary output is the most commonly used parameter to assess the adequacy of fluid resuscitation. The hemolysis of RBCs and thrombosis of burned capillaries also decreases circulating RBCs. When the fluid balance has been restored, dilution causes the hematocrit levels to drop. Initially sodium moves to the interstitial spaces and remains there until edema formation ceases, so sodium levels increase at the end of the emergent phase as the sodium moves back to the vasculature. Initially potassium level increases as it is released from injured cells and hemolyzed RBCs, so potassium levels decrease at the end of the emergent phase when fluid levels normalize.

When teaching the patient about the use of range-of-motion (ROM), what explanations should the nurse give to the patient? (select all that apply)?
A. The exercises are the only way to prevent contractures.
B. Active and passive ROM maintain function of body parts.
C. ROM will show the patient that movement is still possible.
D. Movement facilitates mobilization of leaked exudates back into the vascular bed.
E. Active and passive ROM can only be done while the dressings are being changed.
B. Active and passive ROM maintain function of body parts.
C. ROM will show the patient that movement is still possible.Active and passive ROM maintains function of body parts and reassures the patient that movement is still possible are the explanations that should be used. Contractures are prevented with ROM as well as splints. Movement facilitates mobilization of fluid in interstitial fluid back into the vascular bed. Although it is good to collaborate with physical therapy to perform ROM during dressing changes because the patient has already taken analgesics, ROM can and should be done throughout the day.

During the care of the patient with a burn in the acute phase, which new interventions should the nurse expect to do after the patient progressed from the emergent phase?
a. Begin IV fluid replacement.
b. Monitor for signs of complications.
c. Assess and manage pain and anxiety.
d. Discuss possible reconstructive surgery.

b. Monitor for signs of complications.

Monitoring for complications (e.g., wound infection, pneumonia, contractures) is needed in the acute phase. Fluid replacement occurs in the emergent phase. Assessing and managing pain and anxiety occurs in the emergent and the acute phases. Discussing possible reconstructive surgeries is done in the rehabilitation phase.

The patient in the acute phase of burn care has electrical burns on the left side of her body, type 2 diabetes mellitus, and a serum glucose level of 485 mg/dL. What should be the nurse’s priority intervention to prevent a life-threatening complication of hyperglycemia for this burned patient?
a. Replace the blood lost.
b. Maintain a neutral pH.
c. Maintain fluid balance.
d. Replace serum potassium.
c. Maintain fluid balance.
This patient is most likely experiencing hyperosmolar hyperglycemic syndrome (HHS). HHS dehydrates a patient rapidly. Thus HHS combined with the massive fluid losses of a burn tremendously increase this patient’s risk for hypovolemic shock and serious hypotension. This is clearly the nurse’s priority because the nurse must keep up with the patient’s fluid requirements to prevent circulatory collapse caused by low intravascular volume. There is no mention of blood loss. Fluid resuscitation will help to correct the pH and serum potassium abnormalities.
A patient with a burn inhalation injury is receiving albuterol (Ventolin) for bronchospasm. What is the most important adverse effect of this medication for the nurse to manage?
a. GI distress
b. Tachycardia
c. Restlessness
d. Hypokalemia

b. Tachycardia

Albuterol (Ventolin) stimulates β-adrenergic receptors in the lungs to cause bronchodilation. However, it is a non-cardioselective agent so it also stimulates the β-receptors in the heart to increase the heart rate. Restlessness and GI upset may occur but will decrease with use. Hypokalemia does not occur with albuterol.

The patient in the emergent phase of a burn injury is being treated for pain. What medication should the nurse anticipate using for this patient?
a. SQ tetanus toxoid
b. IV morphine sulfate
c. IM hydromorphone (Dilaudid)
d. PO oxycodone and acetaminophen (Percocet)
b. IV morphine sulfate
IV medications are used for burn injuries in the emergent phase to rapidly deliver relief and prevent unpredictable absorption as would occur with the IM route. The PO route is not used because GI function is slowed or impaired due to shock or paralytic ileus, although oxycodone and acetaminophen may be used later in the patient’s recovery. Tetanus toxoid may be administered but not for pain.
The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse include in the discharge teaching for this patient?
a. Sit or lay in the position of comfort.
b. Wear a pressure garment for 8 hours each day.
c. Refer the patient to a counselor for psychosocial support.
d. Use the sun to increase the skin color on the healed areas

c. Refer the patient to a counselor for psychosocial support.

In the rehabilitation phase, the patient will work toward resuming a functional role in society, but frequently there are body image concerns and grieving for the loss of the way they looked and functioned before the burn, so continued counseling helps the patient in this phase as well. Putting the leg in the position of comfort is more likely to lead to contractures than to help the patient. If a pressure garment is prescribed, it is used for 24 hours per day for as long as 12 to 18 months. Sunlight should be avoided to prevent injury, and sunscreen should always be worn when the patient is outside.

A client with partial- and full-thickness burns over 25% of the total body surface area (TBSA) is hospitalized in the burn unit. A large-bore central venous line is inserted to permit rapid administration of fluids and electrolytes. The large amounts of lactated Ringer’s solution and 5% dextrose in saline are administered to: 1. Prevent fluid shifts
2. Expand the plasma
3. Maintain blood volume
4. Replace electrolytes lost

3. Maintain blood volume

Fluids during the first 48 hours are given to replace fluid lost from the intravascular compartment to interstitial spaces.

1. Administration of fluids treats the fluid shifts, but does not prevent them.
2. Lactated Ringer’s solution and 5% dextrose in saline are not plasma expanders, as is albumin.
4. Electrolytes are specifically replaced based on serial assessments of serum electrolytes and arterial blood gases.

A patient with cardiogenic shock often requires vasopressor therapy. Select the most potent vasoconstrictor that could be administered:
a. Nitroprusside
b. Dopamine
c. Dobutamine
d. Epinephrine

d. Epinephrine

Epinephrine is an extremely potent vasoconstrictor. Nitroprusside is a vasodilator, and dopamine is a vasodilator at lower doses, requiring higher doses for vasoconstriction. Dobutamine is a beta-1 stimulant.

During deflation, the intra-aortic balloon pump (IABP) assists the heart by:
a. Increasing preload.
b. Decreasing afterload.
c. Increasing cardiac oxygen demand.
d. Decreasing preload.

b. Decreasing afterload

An IABP has very little effect on preload and should cause a decrease in the heart oxygen demand by decreasing workload. When the balloon deflates, it creates a dead space of several inches into which the left ventricle pushes blood with almost no resistance to flow.

A 76-year-old woman is admitted with a temperature of 102 ° F, mental confusion, HR 117, respirations 32, BP 64/40, and pulse oximeter reading 85%. What is your initial intervention?
a. Establish IV access.
b. Obtain cultures.
c. Supplement oxygen.
d. Provide patient comfort
c. Supply oxygen
Although fluid replacement is important, and isolating and identifying the causative agent are critical steps in the treatment of sepsis, respiratory status is always addressed first. Oxygen supplementation is important because the patient’s respiratory status is obviously compromised with the tachypnea and pulse oximetry. Patient comfort is always a consideration and should be incorporated, but it is not as important as respiratory status.

Sustained increased ICP can lead to brainstem herniation. The outcome of brainstem herniation is:

1 Cerebral stroke.
2 Seizure.
3 Death.
4 Migraine headache.

3. Death
Herniation of the brainstem causes immediate death. Although some of the late signs of increased ICP mimic stroke, stroke is not the outcome of brainstem herniation. Possible seizure activity is a possible late sign of increased ICP; however, stroke is not the outcome of brainstem herniation. Headache is a possible early sign of increased ICP and is not the outcome of brainstem herniation.
The appropriate drug for an agitated patient who requires a reduction in ICP based on reducing fluid on the brain is:
1 Mannitol (Osmitrol).
2 Morphine.
3 Midazolam (Versed).
4 Epinephrine (Adrenaline).

3. Versed

Is regularly used in TBI management to calm and/or sedate the agitated patient. This action helps reduce the patient’s ICP by eliminating or reducing the agitation and movement of the patient. Mannitol can reduce ICP by drawing fluid off the brain but offers no sedating qualities. Morphine and epinephrine can be harmful in TBI patients because the mechanisms of action can exacerbate ICP.

What is pulse pressure?
-The difference between the SBP and DBP
-Example- If BP = 120/80, pulse pressure 120-80= 40
-Increases in exercise
-Decreases with heart failure or hypovolemia
Mean arterial pressure (MAP)
-Mean arterial pressure (MAP) is the perfusion pressure felt by organs in the body
-MAP = (SBP+2DBP)/3
-Need a MAP > 60 to sustain vital organs or ischemia will result due to poor perfusion
-Normal MAP 70-105 mm Hg
Cardiac Output
CO is the volume of blood pumped by the heart in 1 minute
CO=SV x HR
Normal = 4-8L/min
Cardiac Index
Cardiac Index (CI) is the CO adjusted for body size (height and weight) and is a more precise measurement of the efficiency of the pumping action of the heart
CI=CO/Body surface area (BSA)
CI normal =2.2.- 4L/min/m2
Example- CO vs CI more accurate for ballet dancer vs football lineman
Stroke Volume
The volume ejected with each heartbeat
Normal SV = 60-150ml/beat
SV=CO/HR
Stroke volume index is adjusted for body size
SVI=CI/HR
SVI normal =30-65 ml/beat/min
Afterload (Resistance)
-The resistance to ventricular contraction
– Resistance = blood vessel tone
-The pressure the ventricle has to overcome to open the aortic or pulmonic valve and eject blood out of the ventricle into the systemic or pulmonary circulation
-Measurements:
-SVR=afterload to the L heart
-PVR=afterload to the R heart
-Higher the #, the more resistance and/or “clamped -down” the vasculature is
-Lower the #, the more loose or relaxed the vasculature is
* easier for heart to pump against less resistance
Stroke Volume (SV) & Systemic Vascular Resistance (SVR)
-SVR is opposition encountered by the left ventricle
-Pulmonary vascular resistance (PVR) is the opposition encountered by the right ventricle
-Both SVR and PVR reflect afterload
-CO and SVR or PVR determine our BP
*High afterload, decreased emptying, often results in decreased SV and CO
-When afterload is decreased, it is easier for the heart to pump the blood and the myocardial oxygenation needs are decreased
-When afterload is increased, it is more work for the heart to pump the blood against, and as a result the myocardial oxygen consumption is increased due to the increased effort to pump
Factors that Affect SVR
-HTN
-SNS stimulation
-Aortic stenosis- aortic impedance
-Cardiac failure
-Increased blood viscosity
-Pain
-Medications
-eVolume status
Factors that Affect PVR
-Pulmonary HTN
-COPD
-Pulmonary embolism
-Medications
Medications that Affect Afterload
Afterload can be reduced by:
Vasodilators nitroglycerine or nitroprussideAfterload can be increased by:
vasoconstrictors such as levophed, epinephrine or dopamine

Preload (Volume)
The amount of stretch of myocardial fibers at the end of diastole and can be thought of as the amount of blood within the ventricle at the end of diastole
Typically used as an indication of volume status. Too little preload results in inadequate stretch and too much preload will overstretch and result on lower CO
Measurements:
Pulmonary Artery Wedge Pressure (PAWP) reflects left ventricle end-diastolic pressure or the volume status of LV
Normal PAWP =6-12 mmHg
Central Venous Pressure (CVP) measures the right ventricular preload and reflects the right ventricular and end diastolic pressure or volume status of RV
Normal CVP = 2-8 mmHg
Normal PAWP
6-12
Normal CVP
2-8
Normal MAP
70-105
Normal Cardiac Output
4-8L
Normal Cardiac Index
2.2-4
Normal SVI
30-65 ml/beat/min
Frank Sterling’s Law
-Explains the effects of preload and describes that the more a myocardial fiber is stretched during filling, the more it shortens during systole and the greater the force of contraction
-As preload increased, SV and CO increase
-Preload can be increased by fluid administration or decreased by diuresis
Medications that Affect Preload
-Preload can be reduced by:
Diuretics (bumex, lasix, mannitol), vasodilators (nitroglycerin)-Preload can be increased by:
Crystalloids (NS, LR), colloids (blood, albumin)

Normal Ejection Fraction
50-75%
CO = _____________ ______________ × _____________________________________.
stroke volume x heart rate
Preload, afterload, and contractility are determinants of _____________________________.
Stroke volume.
Preload is defined as _________________________________.
Left ventricular end diastolic volume
Afterload is defined as ________________________________.
Resistance against which the left ventricle has to pump
PAWP measures
Preload
SVR measures
Afterload
The nurse reviews a client’s electrolyte results and notes that the potassium level is 5.4 mEq/L. Which should the nurse observe for on the cardiac monitor as a result of this laboratory value?
1. ST elevation
2. Peaked P waves
3. Prominent U waves
4. Narrow, peaked T waves

4. Narrow peaked T waves

Rationale: A serum potassium level of 5.4 mEq/L is indicative of hyperkalemia. Cardiac changes include a wide, flat P wave; a prolonged PR interval; a widened QRS complex; and narrow, peaked T waves.

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