Answering CEN Practice Questions under timed conditions can improve your time management skills.
Question 1.
Which of the following assessment parameters should be accomplished last?
[a] Auscultation
[b] Percussion
[c] Palpation
[d] Inspection
Answer:
[c] Palpation
Nursing Process: Assessment
Rationale:
Palpation should occur after inspection and auscultation in the assessment of a patient with abdominal pain. False bowel sounds can occur due to the mechanism of palpation. Inspection of the abdomen is done first and can provide much information, including visible pulsations, masses, symmetry, and scars which can then open the door for the attainment of history an important piece of information! Auscultation should be done second and should involve all four quadrants. Percussion is third on the list and the normal finding would be tympany.
The proper sequence of assessment should be an easy question, but it is often the easy questions that stump the test taker. Another important aspect of inspection is the The proper sequence of assessment should be an easy question, but it is often the easy questions that stump the test taker. Another important aspect of inspection is the position of the patient that is, pancreatitis patients tend to lie in curled up or fetal position because it is too painful to lie totally supine. And look at facial grimacing! That can tell you so much about their pain level!
Question 2.
Which of the following medications would the emergency nurse anticipate to be prescribed for a patient presenting with a potential esophageal foreign body?
[a] Maalox
[b] Cimetidine (Zantac)
[c] Omeprazole (Prilosec)
[d] Glucagon
Answer:
[d] Glucagon
Nursing Process: Intervention
Rationale:
Glucagon is the medication of choice for an esophageal foreign body as it can relax smooth muscle and allow the foreign body to pass. Maalox is utilized to reduce acidity in the stomach. Cimetidine (Zantac) can help reduce secretions and is used primarily for GERD (Gastro-Esophageal Reflux Disease) and omeprazole (Prilosec) is a proton pump inhibitor also utilized in treating GERD. They work by reducing the production of stomach acids over a longer period of time.
Question 3.
A patient presents with acute onset of right upper quadrant pain and severe nausea after eating at a local fast food restaurant. The patient also has pain to the right subclavicular area. The pain rating is 8 out of 10. Which of the following medications would the emergency nurse anticipate to NOT be prescribed for this patient?
[a] Hydromorphone (Dilaudid)
[b] Morphine sulfate
[c] Fentanyl (Sublimaze)
[d] Meperidine (Demerol)
Answer:
[b] Morphine sulfate
Nursing Process: Intervention
Rationale:
This patient presents with manifestations of cholecystitis. Although there is some controversy regarding this, it is thought that morphine sulfate can cause spasm of the sphincter of Oddi and increase pain. Hydromorphone (Dilaudid) and fentanyl (Sublimaze) are other common narcotic medications that are used to treat this type of pain. Meperidine (Demerol) is not used as much in health care today and should not be utilized for chronic pain; however, it can be used to treat acute situations such as cholecystitis.
Question 4.
Which of the following laboratory values would most likely be decreased in a patient diagnosed with pancreatitis?
[a] Lipase
[b] Amylase
[c] Calcium
[d] Glucose
Answer:
[c] Calcium
Nursing Process: Analysis
Rationale:
Pancreatitis can cause a systemic hypocalcemia due to the available calcium in the body binding with free fatty acids that are formed from the release of lipase. This would render the calcium unable to perform its duties. In pancreatitis, lipase and amylase values are typically elevated and are diagnostic for this disease process. Hypoglycemia would not be suspected, although an elevated blood glucose value might be present in a patient with a history of diabetes mellitus due to the stress incurred with an acute disease process.
Other laboratory values that might be present include a decreased hemoglobin and hematocrit if the pancreatitis is hemorrhagic in nature, and a decreased potassium from vomiting. Hemoglobin and hematocrit could also be elevated slightly if dehydration from vomiting is present.
Question 5.
A finding of free air under the diaphragm in a patient complaining of abdominal pain and fever would most likely correlate with which of the following diagnoses?
[a] Intestinal obstruction
[b] Acute appendicitis
[c] Intestinal perforation
[d] Acute cholelithiasis
Answer:
[c] Intestinal perforation
Nursing Process: Analysis
Rationale:
A finding of free air under the diaphragm is associated with a diagnosis of an intestinal perforation. An obstruction would most likely demonstrate visible air-fluid levels with dilated bowel. An ultrasound or computed tomography (CT) scan would best show an inflamed appendix. Cholelithiasis would be diagnosed with ultrasonography.
This is also known as a pneumoperitoneum. What a cool word! Free air is the presence of air or another type of gas that is not normally found in the abdomen and radiographically is best seen on an upright chest radiograph. It can also be noted on a computerized tomography (CT) scan. Surgical practices, which utilize the introduction of carbon dioxide into the abdomen in order to perform laparoscopic surgical procedures, can cause pain that is associated with pneumoperitoneum.
Question 6.
A patient is being treated for an acute ruptured diverticulum. Which of the following interventions would NOT be appropriate?
[a] Inserting a nasogastric (NG) tube
[b] Offering oral clear liquids
[c] Administering intravenous antibiotics
[d] Preparation of patient for surgery
Answer:
[b] Offering oral clear liquids
Nursing Process: Intervention
Rationale:
The patient with an acute abdominal emergency would not be given liquids of any kind due to the imminence of surgical repair. A nasogastric (NG) tube would be appropriate to decompress the gastrointestinal (GI) tract and decrease vomiting of the patient. Antibiotics should be provided intravenously as this situation is a clear setup for sepsis. Surgery is the mainstay of treatment of this kind of process, especially with an acute onset.
Question 7.
A diagnostic peritoneal lavage is being performed on a patient with blunt injury to the abdomen. Which of the following must be in place before this procedure?
[a] Urinary catheter
[b] Endotracheal tube
[c] Intravenous access
[d] Oxygen cannula
Answer:
[a] Urinary catheter
Nursing Process: Intervention
Rationale:
When a diagnostic peritoneal lavage is being performed, both a urinary catheter and nasogastric (NG) tube should be in place to decompress both the bladder and the stomach before the insertion of the lavage catheter. Patients are not always unresponsive and unable to maintain their own airway when the need arises for this test. Intravenous access is important for any critical patient, but is not mandatory for a diagnostic peritoneal lavage. Oxygen is not a necessity for this procedure. The administration of oxygen would be dependent on the patient.
Diagnostic Peritoneal Lavage (also known as a “belly tap”) is not performed as often as before the advent of the computed tomography (CT) examination. However, it might be utilized in situations in which the patient is too ill to travel to the CT scanner or if the scanner were not working. It is easy, fast, and has a high level of predictability for accuracy. It is often, also, used as an incorrect answer on questions for abdominal trauma questions, so be aware of some of these "older” procedures!
Question 8.
Which of the following statements made by the emergency nurse assisting with a diagnostic peritoneal lavage (DPL) would indicate an understanding of the procedure?
[a] “If we hear a ‘whoosh’ of air when it’s put in that means it’s positive.”
[b] “If blood is coming out of the catheter then that is a positive test.”
[c] “If nothing comes out then it must mean it’s negative for sure.”
[d] “If gastric contents are detected, that is a good sign of no injury.”
Answer:
[b] “If blood is coming out of the catheter then that is a positive test.”
Nursing Process: Evaluation
Rationale:
When a peritoneal catheter is inserted into the abdominal cavity, a positive test would be indicated if blood were to be aspirated or it flowed freely from the catheter. Hearing a “whoosh” of air would not occur with this procedure. (That would be great to hear with attempting to treat a tension pneumothorax in the chest!) If no blood comes out of the catheter, it would not necessarily mean the test was negative as retroperitoneal blood may not manifest itself with this procedure. Organs such as the pancreas and kidneys are retroperitoneal organs. Fluid from the lavage is sent to laboratory, and if gastric contents as well as fecal material, bile, food, or bacteria are noted, the test is positive. Red and white cells are also counted in this process.
Sometimes, blood will actually spurt out of the catheter when performing a DPL and aim for the ceiling! That is a positive test! If blood does not “shoot” out of the abdomen—yes that does happen!—it’s quite dramatic!—then 1 liter of warm normal saline is introduced into the peritoneal cavity and then the bag is turned upside down on the floor with the damp open—make sure to not use tubing that has a check valve on it!—and the returned contents are sent to the laboratory.
Question 9.
A patient is being evaluated for abdominal pain and multiple episodes of coffee ground emesis. Which of the following would be the most important piece of history provided by the patient?
[a] Recent intake of fried food
[b] Nonsteroidal antiinflammatory drug (NSAID) use
[c] Oral iron supplements ingestion
[d] Diagnosis of alcoholic hepatic disease
Answer:
[b] Nonsteroidal antiinflammatory drug (NSAID) use
Nursing Process: Assessment
Rationale:
Ingestion of NSAIDs (nonsteroidal anti-inflammatory drugs) can cause inflammatory reactions in the stomach contributing to an active GI bleed. Coffee ground emesis occurs when bleeding has slowed or stopped and has been converted to a brownish color— known as hematin—by the gastric acids. Intake of fried foods usually is associated with attacks of cholecystitis.
Oral iron supplements can cause patients to have black-looking stools, but, of course, they will be guaiac negative for occult blood. This would be a good piece of history if the stools were black in color but not coffee ground emesis. A history of liver disease, especially associated with alcoholism, would cause one to suspect bleeding varices if the bleeding was bright red, spontaneous, and painless.
Question 10.
A patient with a past history of intravenous substance abuse presents with confusion, abdominal distension, and bilateral icteric conjunctiva. Lactulose (Cholac) is prescribed for this patient. Which of the following laboratory values would be monitored to determine the effect of the lactulose?
[a] Ammonia
[b] Magnesium
[c] Potassium
[d] Sodium
Answer:
[a] Ammonia
Nursing Process: Evaluation
Rationale:
High ammonia levels are found in patients who are experiencing hepatic encephalopathy, which is treated with lactulose (Cholac). This patient, with a prior history of intravenous substance abuse, is presenting with manifestations of this disease process. Other electrolytes including potassium, sodium, and magnesium are noted to be deficient in liver failure; however, lactulose (Cholac) is not utilized to treat these deficiencies.
Lactulose (Cholac) is given orally or rectally. Do not draw this up to give intravenously!!! It works in the colon to pull out the ammonia before excretion. This can improve mentation. It is also used as a laxative in the treatment of constipation.
Question 11.
Which of the following would be a possible indicator of an underlying primary diagnosis of pancreatitis?
[a] Amylase in thoracentesis fluid
[b] Hypoglycemic event
[c] Increased calcium
[d] Coffee ground emesis
Answer:
[a] Amylase in thoracentesis fluid
Nursing Process: Analysis
Rationale:
One of the possible complications of pancreatitis is a pleural effusion. This is thought to occur due to increased vascular permeability and possible fistula formation. Amylase in thoracentesis fluid should create a suspicion for this. Hyperglycemia would most likely occur with a malfunctioning pancreas, not hypoglycemia, due to lack of insulin production. Low calcium levels can occur due to the binding of calcium to free fatty acids produced by the release of lipase. The most common concern with coffee ground emesis is gastrointestinal bleeding.
Question 12.
All of the following medications could be utilized to treat pancreatitis EXCEPT:
[a] dicyclomine (Bentyl).
[b] fentanyl (Sublimaze).
[c] octreotide (Sandostatin).
[d] famotidine (Pepcid).
Answer:
[c] octreotide (Sandostatin).
Nursing Process: Intervention
Rationale:
Octreotide (Sandostatin) is used to treat esophageal varices associated with liver disease. Dicyclomine (Bentyl) is an anticholinergic medication that hinders the release of pancreatic secretions by preventing nerve impulses from stimulating the cells. Fentanyl (Sublimaze) can be used to treat the pain associated with pancreatitis. Histamine H2 inhibitors such as famotidine (Pepcid) prevents histamine release, which increases the pancreatic secretions.
Remember that morphine is not the drug of choice for pancreatitis. Morphine can cause spasm of the sphincter of Oddi, Increasing pain. Hydromorphone (Dilaudid) and fenlanyl along with the older medication, meperidine (Demerol), are more useful in this disease process. And—contrary to what many people believe—alcohol consumption is not always the primary cause of pancreatitis. Biliary problems—gallstones—is another major etiology!
Question 13.
Which of the following is a nonmechanical cause of a bowel obstruction?
[a] Foreign body
[b] Ileus
[c] Intussusception
[d] Volvulus
Answer:
[b] Ileus
Nursing Process: Assessment
Rationale:
An ileus is caused by decreased muscle activity, which then reduces the movement of the intestines. Mechanical etiologies involve some type of blockage either inside or outside the intestinal tract that causes an actual obstruction. Examples of this are foreign bodies, intussusception (a telescoping of the intestinal tract into itself), and volvulus (twisting of the colon on itself).
Question 14.
Which of the following is most symptomatic for appendicitis?
[a] Presence of ecchymosis to the periumbilical area
[b] Right lower abdominal pain during palpation of left lower abdomen
[c] Reddish discoloration to the right flank area
[d] Tympany noted to palpation of generalized abdominal area
Answer:
[b] Right lower abdominal pain during palpation of left lower abdomen
Nursing Process: Assessment
Rationale:
Pain that increases in the right lower quadrant of the abdomen when the left side of the abdomen is palpated can be indicative of appendicitis. This is known as Rovsing’s sign. The presence of a reddened area (ecchymosis) to the periumbilical area of the abdomen is usually a sign of a retroperitoneal or intraperitoneal bleed or hematoma. This known as Cullen’s sign. Grey-Turner’s sign is indicated by ecchymosis to the flank area that can occur later in retroperitoneal bleeds. Tympany would be a normal finding on percussion of the abdomen as it is present with gas-filled areas.
Other indications of appendicitis are generalized abdominal pain (early stages) that then localizes to the right lower quadrant, nausea, vomiting, and low-grade fever. A good question to ask patients who are suspicious for appendicitis is “Did the pain increase when the car hit a rut in the road or you went over railroad tracks?” Jumping up and down in place should also create pain in the right lower quadrant.
Question 15.
A patient is being assessed for possible intraperitoneal bleeding after a motor vehicle crash (MVC). Which of the following would be the most sensitive for the diagnosis of pancreatic injury?
[a] Focused Assessment with Sonography for Trauma (FAST) examination
[b] Flat plate of abdomen and chest radiograph
[c] Computerized Tomography (CT) of the abdomen
[d] Diagnostic Peritoneal Lavage (DPL)
Answer:
[c] Computerized Tomography (CT) of the abdomen
Nursing Process: Analysis
Rationale:
The computed tomography (CT) test is the most sensitive of those listed for pancreatic injury because the pancreas is a retroperitoneal organ. The FAST (Focused Assessment with Sonography for Trauma) examination is a valuable tool, but its sensitivity for the presence of retroperitoneal bleeding is not good. An upright chest may indicate free air, which might supply. valuable information; however, a flat plate of the abdomen/chest does not usually afford positive data regarding retroperitoneal hemorrhages. The diagnostic peritoneal lavage (DPL), though a useful tool to determine bleeding in the abdominal cavity, can provide a false-negative response with retroperitoneal injuries.
Other retroperitoneal organs include the duodenum and the kidneys. The advent of the CT examination has become a great tool in the care of the trauma patient.
Question 16.
A patient presents to the emergency department following a fall from a porch 3 days before. He is pale and diaphoretic and states that he feels short of breath. On assessment, he has tenderness to the right lower anterior .'ribs. Bilateral, clear, equal breath sounds are present.
Vital signs are as follows:
Blood pressure—88/62 mm Hg
Pulse—134 beats/minute
Respirations—32 breaths/minute
Pulse oximetry—92 % on room air
Temperature—98.4° F (36.8° C)
Which of the following diagnoses should the emergency nurse anticipate?
[a] Splenic injury
[b] Colon injury
[c] Cardiac injury
[d] Liver injury
Answer:
[d] Liver injury
Nursing Process: Assessment
Rationale:
Right lower rib fractures can cause liver injury, especially with fractures from the eighth rib down. Emergency personnel should be aware of this as a mechanism of injury and be alert to the possibility. This patient is demonstrating signs of hypovolemic shock and a major clue should be the tenderness to the right lower rib area along with the vital signs and the fall from the porch. Splenic injuries can occur with left lower rib fractures. Colonic injuries are hot associated with rib fractures. Blunt cardiac injury can happen with sternal fractures.
Always remember that both the liver and the spleen can be lacerated, but the capsule surrounding it can encapsulate the injury and “tamponade" it off until it eventually breaks through and then becomes a major problem. Patients can bleed out from these injuries and they may not show up until several days later. Ears should perk up when patients say they were involved in motor vehicle crashes or other traumatic events days earlier. This is one time that orthostatic vital signs (OSVS) can be a good test when the patient does not present with altered vital signs. And yes, sitting and standing OSVS can be done in the triage area!
Question 17.
Which of the following patients would be at highest risk for dehydration?
[a] A 30-year-old with vomiting three times in past 12 hours
[b] A 6-month-old with report of two wet diapers in 24 hours
[c] An 80-year-old with noted tented skin on forearms for 48 hours
[d] A 15-year-old with 220 mL urine output in 4 hours
Answer:
[b] A 6-month-old with report of two wet diapers in 24 hours
Nursing Process: Evaluation
Rationale:
Infants contain a large amount of water and are therefore at very high risk for dehydration. An infant who is not producing enough urine for normal diaper changes should be considered at risk. An adult who has vomited three times over the past 12 hours does not present an urgent suspicion for dehydration. Elder patients should not have their skin turgor checked on their forearms. Loss of collagen as part of the normal aging process causes this assessment finding. Skin turgor is best checked on the forehead, the sternum, or the thigh in the older patient. It is not a good tool in the older adult. A teenager who is producing at least 30 to 50 mL of urine per hour can be considered to be maintaining their body fluid normal.
Question 18.
A 14-month-old infant with vomiting and diarrhea has been prescribed a fluid bolus for treatment of dehydration. The child weighs 20 pounds. Which of the following is the correct bolus amount?
[a] 900 ml
[b] 180 ml
[c] 200 ml
[d] 400 ml
Answer:
[a] 900 ml
Nursing Process: Intervention
Rationale:
Fluid bolus rehydration for infants and children is based on 20 mL/kg of body weight. For this patient weighing 20 pounds, the first step in the mathematical equation is to change the pounds to kilograms. This is the most common error in calculations. Therefore, 20 pounds is equal to 9 kg (20 divided by 2.2), 9 kg x 20 mL =180 mL bolus. If the pounds are not changed to kilograms, then the incorrect mathematical outcome would be 400 mL. If an incorrect formula is used and 10 mL/kg is considered to be correct, then the outcome utilizing pounds is 200 mL or 900 mL if the correct conversion is made to kilograms but the incorrect formula is used.
Children who have underlying congenital heart problems may need 10 mL/kg of fluid bolus instead of the standard 20 mL/kg.
Question 19.
Which of the following would be considered to be a normal finding in an abdominal assessment?
[a] Low-pitched regular bowel sounds
[b] Tympany on percussion
[c] Bruit heard on auscultation
[d] Pulsations noted on inspection
Answer:
[b] Tympany on percussion
Nursing Process: Assessment
Rationale:
Air masses provide for tympany when the abdomen is percussed. Since the abdomen has many air-filled organs, tympany would be the normal. Dullness to percussion is indicative of solid organs. Normal bowel sounds are irregular and high-pitched. A bruit would be present as an indication of a vascular abnormality. Pulsations, when inspecting the abdomen, could suggest a disease process such as an aortic aneurysm.
Question 20.
Which of the following is the correct type of pain that is associated with pancreatitis?
[a] Primary
[b] Secondary
[c] Referred
[d] Somatic
Answer:
[a] Primary
Nursing Process: Assessment
Rationale:
Primary pain is also known as “visceral” pain. This originates within the organ itself. Appendicitis is another example of this type of pain. Secondary or somatic pain occurs because of irritation from a bacterial or chemical etiology. Disease processes that fall into this category are peritonitis and gastroenteritis. Referred pain occurs in an area different than the organ that is affected. Cholecystitis would fall into this category as pain is referred to the subclavicular area with this problem.
Question 21.
Proton pump inhibitors are used in patients with gastroesophageal reflux disease (GERD) because of which of the following actions?
[a] Increases lower esophageal sphincter pressure
[b] Reduces secretions in the stomach
[c] Lowers acid present in the stomach
[d] Decreases the production of acid
Answer:
[d] Decreases the production of acid
Nursing Process: Analysis
Rationale:
Proton pump inhibitors such as omeprazole (Prilosec) and pantoprazole (Prevacid) decrease the production of acid in the stomach and cause a reduction of irritation of the lining of the stomach. These also help to kill the organism Helicobacter pylori when used in combination with antibiotics. Medications such as metoclopramide (Reglan) help to increase lower esophageal sphincter pressure. Ranitidine (Zantac) and famotidine (Pepcid) reduce secretions and Maalox and Mylanta lowers the acid content that is present in the stomach.
Question 22.
Which of the following is an important landmark for the diagnosis of appendicitis?
[a] McBurney’s point
[b] Ligament of Treitz
[c] Cardioesophageal juncture
[d] Sphincter of Oddi
Answer:
[a] McBurney’s point
Nursing Process: Analysis
Rationale:
McBurney’s point lies within the iliac crest and is the point of tenderness for patients diagnosed with appendicitis. The ligament of Treitz is a muscle that helps to suspend the stomach and is the separating point between the upper gastrointestinal (GI) tract and the lower GI tract. The cardioesophageal juncture occurs at the terminal end of the esophagus and the beginning of the stomach where they meet. The sphincter of Oddi is located between the pancreas and small intestine and functions as a valve to control the flow of bile and pancreatic secretions.
Question 23.
Glucagon can be used for all of the following disease processes EXCEPT:
[a] foreign body of the esophagus.
[b] anaphylactic shock.
[c] beta-blocker toxicity.
[d] pulmonary embolism.
Answer:
[d] pulmonary embolism.
Nursing Process: Analysis
Rationale:
Of the disease processes presented as options, pulmonary embolism is the only one that does not have a use for glucagon. Glucagon is used in foreign body of the esophagus in an attempt to relax smooth muscle and allow the foreign body to pass. In beta-blocker toxicity, glucagon can increase cardiac contractility (inotropic response) as well as heart rate (chronotropic response) and can affect electrical conduction through the atrioventricular node. In anaphylaxis, glucagon might be used if epinephrine does not work due to the patient being on beta-blockers. Epinephrine works on the beta-cells, so if they are blocked, the epinephrine may not work whereas, the glucagon can assist with positive chronotropic and inotropic effects.
Question 24.
A patient is bought to the emergency department with a past history of hepatitis C, cardiac stents, and hypertension. He is vomiting large amounts of bright red blood and is nauseated. No pain is present. Based on this patient’s presentation and his present symptoms, which of the following medications should the emergency nurse expect to utilize?
[a] Octreotide (Sandostatin)
[b] Nitroprusside (Nipride)
[c] Amiodarone (Cordarone)
[d] Flumazenil (Romazicon)
Answer:
[a] Octreotide (Sandostatin)
Nursing Process: Intervention
Rationale:
This patient is experiencing symptoms consistent with esophageal varices, which also matches his past history of hepatitis C. Cirrhosis is a complicating factor of hepatitis C. The medication used for this is octreotide (Sandostatin). Nitroprusside (Nipride) is an antihypertensive, which is used for emergencies in which blood pressures must be dropped. Amiodarone (Cordarone) is used for dysrhythmias, which would not match with this scenario. Flumazenil (Romazicon) is the antidote for benzodiazepine overdose.
Nitroprusside is a good drug to use because it has such a short half-life, and if the blood pressure is dropping too fast, it can easily be recovered by slowing or turning off the drip. Another interesting tidbit about this medication is that it can cause cyanide poisoning! Patients who are on high doses or for long periods of time can actually die from the administration of this medication!
Question 25.
Patients with a diagnosis of pancreatitis prefer which of the following positions?
[a] Prone
[b] Supine
[c] Fowler’s
[d] Fetal
Answer:
[d] Fetal
Nursing Process: Assessment
Rationale:
Pancreatitis pain is severe and unrelenting. It is sharp and knifelike and patients prefer to curl up on their sides in a fetal position. The supine position increases the pain level in these patients. A prone position would place the patient on their abdomens and Fowler’s is sitting upright in the bed.
Remember that pancreatitis can be hemorrhagic or non-hemorrhagic. The hemorrhagic type affects the vascular compartment and the non-hemorrhagic type causes an "autolysis” where the digestive enzymes are causing the organ to “eat itself. ”
Question 26.
Which of the following is NOT a side effect of the medication octreotide (Sandostatin)?
[a] Hypoglycemia
[b] Hyperglycemia
[c] Bradycardia
[d] Tachycardia
Answer:
[d] Tachycardia
Nursing Process: Analysis
Rationale:
Octreotide (Sandostatin) does not cause tachycardias. Rather it is known to cause bradycardias as well as QT prolongation. Interestingly enough, this medication can cause both hypo and hyperglycemia! Type I diabetic patients are prone to hypoglycemia and type II diabetics tend to have hyperglycemia. This is due to its action with insulin and glucagon.
Question 27.
Which of the following is a true statement regarding a bowel obstruction?
[a] Hyperactive bowel sounds can be heard in a bowel obstruction in certain situations.
[b] Large bowel obstructions usually present with a moderate amount of abdominal swelling.
[c] All bowel obstructions will have a fecal smell to the emesis.
[d] A small bowel obstruction usually has a lesser amount of vomiting.
Answer:
[a] Hyperactive bowel sounds can be heard in a bowel obstruction in certain situations.
Nursing Process: Assessment
Rationale:
Bowel obstructions that are in the early stages or are partial obstructions can have hyperactive bowel sounds. These sounds are usually high pitched. In the later stages and if there is a complete obstruction, the bowel sounds will be absent. In the early phases, the bowel is attempting to overcome the obstruction. A large bowel obstruction will present with a great deal of abdominal swelling, whereas a small bowel obstruction will carry a smaller amount of swelling. Fecal odor to the emesis is a good clue for a bowel obstruction, but it is not always present. Small bowel obstructions usually have a much greater amount of vomiting.
There is hardly ever a situation in which the word "all” is true! If you see the word “all” dr “none” in a potential answer, it is probably a wrong answer.
Question 28.
Which of the following is NOT a cause of ischemic bowel disease?
[a] Gastroenteritis
[b] Incarcerated hernia
[c] Volvulus
[d] Vasospasm
Answer:
[a] Gastroenteritis
Nursing Process: Analysis
Rationale:
There are many causes for ischemic bowel disease, but gastroenteritis is not one of them. This disease process will cause intestinal symptoms such as nausea, vomiting, and diarrhea, but does not contribute to ischemia. An incarcerated hernia could cause the bowel to become ischemic. Another example of an etiology for ischemic bowel is a volvulus when the bowel twists on itself. Vasospasms of the vessels feeding the bowel is also a cause for this malady, as well as a thrombus that travels to the colonic vessels or a build-up of plaque. All of these can cause a decrease in the blood flow, causing an ischemic reaction. This makes those with cardiovascular disease, hypertension, and increased lipid levels at risk.
Question 29.
A patient with a history of diverticula noted on prior colonoscopies is in the emergency department with acute onset of left-sided abdominal pain. Occult blood is noted in the stool. The patient relates a subjective fever at home with chilling occurring during that day. The emergency nurse caring for this patient is aware that all of the following are potential complications for this patient EXCEPT:
[a] intestinal obstruction.
[b] perforation.
[c] abscess.
[d] ulcerative colitis.
Answer:
[d] ulcerative colitis.
Nursing Process: Analysis
Rationale:
Ulcerative colitis is not a complication of diverticulitis. This patient has manifestations and history conducive to a diagnosis of diverticulitis. Ulcerative colitis occurs as an inflammatory reaction, causing “sores” on the innermost layer of the colon. This is a disease process all its own. Diverticulitis can cause intestinal obstruction, perforation, and abscesses as well as strictures and fistulas.
Question 30.
Which of the following statements made by a patient would indicate to the emergency nurse that the “melena” stools are most likely NOT caused by a true gastrointestinal bleed?
[a] “1 bought some black licorice and have been eating it like crazy.”
[b] “I have been taking iron tablets for some anemia for the past 2 weeks.”
[c] “My stools are black and tarry looking and they have a different odor.”
[d] “This stuff I am vomiting up looks just like my grandpa’s chew!”
Answer:
[b] “I have been taking iron tablets for some anemia for the past 2 weeks.”
Nursing Process: Analysis
Rationale:
Iron tablets and bismuth-containing compounds such as Pepto-Bismol will cause stools to appear black. Black licorice consumption can cause hypo-kalemia, but will not create the appearance of a gastrointestinal bleed. Black, tarry-looking stools with a distinctive odor is a good definition of melena. Coffee ground emesis correlates with bleeding that has slowed or stopped for a period of time and has converted from the red hemoglobin to brown hematin by coming into contact with the gastric acid. This emesis looks very much like tobacco “chew”! A patient could have both an upper and lower gastrointestinal bleed at the same time.
Question 31.
Which of the following indicates the location of the tears that occur in Boerhaave’s syndrome?
[a] Cardioesophageal juncture
[b] Duodenojejunal flexure
[c] Sigmoid mesocolon
[d] Esophageal wall
Answer:
[d] Esophageal wall
Nursing Process: Assessment
Rationale:
In Boerhaave’s syndrome, the patient vomits with great force and the tears that occur are in the esophagus itself. In Mallory-Weiss syndrome, the patient vomits with normal emptying and the tear occurs at the cardio esophageal (also known as gastroesophageal) juncture. The duodenojejunal flexure and sigmoid mesocolon are anatomical features and landmarks but do have anything to do with Boerhaave’s syndrome.
Boerhaave’s syndrome can actually rupture the esophagus! This would be a medical emergency!
Question 32.
A patient presents to the emergency department with chief complaint of feeling weak and generalized fatigue. The patient is diaphoretic with cool skin. He states persistent nausea without vomiting. Vital signs are as follows:
Blood pressure—92/64 mm Hg
Pulse—122 beats/minute
Respirations—32 breaths/minute
Pulse oximetry—91 % on room air
Temperature: 98.8° F (37.1° C)
Past history reveals hypertension, chronic bronchitis, recent history of fracture of the left 11th to 12th ribs, and hypercholesteremia. Which of the following diagnoses would the emergency nurse suspect?
[a] Pneumonia
[b] Pancreatitis
[c] Splenic injury
[d] Lacerated liver
Answer:
[c] Splenic injury
Nursing Process: Analysis
Rationale:
This patient’s recent fall has probably contributed to the development of a splenic injury. Fractures of the left lower ribs can lead to spleen lacerations that become evident several days after initial injury. Fractures of the lower right ribs are prone to cause liver injuries. This patient is not demonstrating any manifestations that should make the nurse consider pneumonia or pancreatitis. A fever and usually a cough should be present with pneumonia and pancreatitis would present with severe pain to left mid-quadrant.
Remember that both the liver and the spleen have a capsule surrounding them making them prone to manifestations several days after injury. Bleeding can occur within the capsule with subsequent tampotiading at that time. When the capsule finally breaks through, the patient can develop hypovolemic shock. This is a good use of orthostatic vital signs, which would most likely (but not 100% of the time!) be positive.
Question 33.
Which of the following situations would cause the emergency nurse to be concerned about an increased potential severity of injury?
[a] A 13-month-old who falls when trying to walk at home.
[b] A 2-year-old who falls off of a dressing table at home.
[c] A 15-year-old who falls down five rungs on a ladder.
[d] A 25-year-old who falls off the bed of a nonmoving truck.
Answer:
[b] A 2-year-old who falls off of a dressing table at home.
Nursing Process: Analysis
Rationale:
The 2-year-old who fell off of a dressing table is most at risk because he was probably three times his height. This should raise a red flag as to the potential severity of a fall for a child. For adults, an increased concern for severity usually occurs when they fall 12 to 20 feet. Consider the need for transfer to a tertiary trauma center for these patients.
Question 34.
A FAST (Focused Assessment with Sonography for Trauma) examination is performed on a patient involved in a motor vehicle crash. Which of the following statements made by the emergency nurse indicates an understanding of this evaluation tool?
[a] “I heard that this tool is great and has a 90% to 100% accuracy rating for all patients.”
[b] “This is great to use! We will have our answer for sure in a few minutes!”
[c] “This diagnostic tool is so much better for small bowel and stomach injuries.”
[d] “This test only checks for large amounts of blood in the abdomen.”
Answer:
[d] “This test only checks for large amounts of blood in the abdomen.”
Nursing Process: Evaluation
Rationale:
The FAST (Focused Assessment with Sonography for Trauma) examination is sensitive for large amounts of blood in the abdomen. If there is less than 400 mL fluid in the abdomen, it is not usually identified. It is most sensitive (90% to 100% of the time) if there is at least 1,000 mL present hi the abdomen. This test does not work as well as the diagnostic peritoneal lavage or the computed tomography (CT) for injuries of the stomach or small bowel. If the FAST examination is negative, it does not mean there are no injuries.
The great thing about the FAST examination is that it is not invasive and can also cut down on the amount of radiation that patients receive. A positive FAST examination would assist in obtaining prompt treatment but does not assess well for retroperitoneal bleeding or injuries to hollow organs. Unfortunately, the FAST examination also has only a moderate level of sensitivity in the child. If it is negative in a child, further investigation with computed tomography (CT) should be performed.
Question 35.
Which of the following would decrease the chances of abdominal organ injury in children involved in motor vehicle crashes (MVC)?
[a] Use of a booster seat in the older child
[b] Seat belts that lie across the abdomen
[c] Rearfacing restrained car seats for infants
[d] Allowing the older child to sit in the front seat
Answer:
[a] Use of a booster seat in the older child
Nursing Process: Analysis
Rationale:
The use of booster seats in older children (up to age 12 or 36 (g in the United States) allows for proper fit of the seat belt. When children sit in the seat and use a seat belt, the lap portion is usually sitting at the abdomen instead of proper placement across the hips. With the lap belt across the abdomen, this creates a situation in which the abdominal organs are; compressed increasing potential for injury. The booster seat also allows for better positioning of the shoulder harness as well. A rear-facing restrained car seat for infants helps prevent all types of injuries in the child but mostly decreases the risk of cervical fracture at C1 to C3, which is seen at greater levels with front-sitting car seats due to the infant’s head being thrown forward. Children should not be in the front seat due to potential damage from the airbag.
Question 36.
Which of the following would be the treatment of choice for a hemodynamically stable child who has sustained a splenic injury?
[a] Immediate surgical intervention and repair
[b] Removal of the spleen within 4 hours of injury
[c] Admission and careful monitoring of the child
[d] Discharge with instructions to return for any changes
Answer:
[c] Admission and careful monitoring of the child
Nursing Process: Intervention
Rationale:
In the hemodynamically stable pediatric patient with a splenic injury, 90% to 98% of these patients are able to heal spontaneously. If the patient was unstable or if there was a substantial disruption, then surgical intervention with possible removal would be in order. It would not be appropriate to discharge this child to home.
Question 37.
A patient arrives in the emergency department after a motorcycle crash and loops of bowel are noted to be emerging from the abdominal wall. Which of the following would be the correct intervention for the emergency nurse to perform?
[a] Place a towel over it to keep it from coming into contact with possible organisms.
[b] Cover the organ with sterile, saline-soaked abdominal pads and keep the area moist.
[c] Gently replace the organs back into the abdominal cavity with a tight sterile dressing.
[d] Leave the area open to the air and dp not manipulate or cover it with any type of dressing.
Answer:
[b] Cover the organ with sterile, saline-soaked abdominal pads and keep the area moist.
Nursing Process: Intervention
Rationale:
The loops of bowel should be covered immediately with a large sterile dressing such as abdominal pads that are saline-soaked. Keep the area moist until surgical repair can occur. An unsterile towel would not maintain the sterility of the area and would increase the potential of bacterial contamination. Do not attempt to replace the organs or create a tight dressing over the area. Leaving the area open would also increase the potential for contamination of the wound leading to peritonitis and would also dry out the eviscerated organs.
Question 38.
Which of the following laboratory values would be present that would necessitate the administration of N-acetylcysteine (Mucomyst) to a patient who is undergoing a contrast-enhanced computed tomography (CT) examination?
[a] Elevated serum creatinine
[b] Decreased blood urea nitrogen (BUN)
[c] Elevated hemoglobin
[d] Decreased potassium
Answer:
[a] Elevated serum creatinine
Nursing Process: Intervention
Rationale:
Utilizing a contrast-enhanced computed tomography (CT) with elevated serum creatinine level above 1.2 mg/dL could cause renal problems posttest. The addition of prophylactic N-acetylcysteine (Mucomyst) can decrease the potential of this process. The blood urea nitrogen (BUN), hemoglobin level, and potassium reading would not be indicators for the use of this medication in this situation.
Question 39.
Which of the following procedures should be delayed in a patient undergoing a FAST (Focused Assessment with Sonography for Trauma) examination?
[a] Nasogastric tube insertion
[b] Intravenous line insertion
[c] Urinary catheter placement
[d] Oxygen per nasal cannula
Answer:
[c] Urinary catheter placement
Nursing Process: Intervention
Rationale:
When performing a Focused Assessment with Sonography for Trauma (FAST) examination, a distended bladder increases the sensitivity of the examination by allowing for better visualization. If possible, delay this procedure until the FAST examination is completed. Intravenous line placement is of high priority in the trauma patient, so make sure this is completed quickly. Oxygen in the early stages of trauma care is also a priority. If a nasogastric or orogastric tube needs to be inserted, it does not interfere with the FAST examination.
Question 40.
Contrast is provided to patients in different ways in order to clearly identify different organs during computed tomography (CT) examinations. Oral contrast would be necessary to visualize which of the following organs during this type of test?
[a] Stomach
[b] Liver
[c] Spleen
[d] Pancreas
Answer:
[a] Stomach
Nursing Process: Analysis
Rationale:
Oral contrast assists in the visualization of hollow organs; therefore, the stomach would be one of these types of organs as well as the bladder and small intestine. One of the downsides of this type of contrast is that the patient must drink it and then wait for at least 30 minutes for the examination (time requirement to coat the small bowel). If the patient is hesitant to drink the contrast, that can delay the entire process even more. Intravenous contrast is essential for solid organ injury discovery. These organs include the liver, spleen, and pancreas.
In order to accurately diagnose injuries to the colon, a triple contrast approach is recommended—oral, intravenous, and rectal.
Question 41.
Which of the following injuries should the emergency nurse suspect in combination with the diagnosis of lumbar region Chance fractures (also known as seatbelt fractures)?
[a] Colon
[b] Stomach
[c] Spleen
[d] Small intestine
Answer:
[d] Small intestine
Nursing Process: Analysis
Rationale:
The small intestine is often injured when Chance fractures are present because of the amount of force and energy necessary to create these vertebral fractures. Injuries to the small bowel are often insidious and so there is a delay in diagnosis. Injuries to the colon, stomach, or spleen are not necessarily associated with Chance fractures.
Always be aware of possible concomitant injuries in trauma-related events. Remember mechanism of injury to make sure that injuries are not missed!
Question 42.
Patients who have undergone splenectomies are known to be at risk for which of the following problems?
[a] Ulcerative colitis
[b] Immune system deficiencies
[c] Cholelithiasis
[d] Pancreatic cancer
Answer:
[b] Immune system deficiencies
Nursing Process: Analysis
Rationale:
When injuries to the spleen are extreme or the patient is unable to be stabilized, splenectomies do occur. When this happens, patients are at risk for infectious disease processes because of lowered immunity and must receive appropriate immunizations at proper times for different bacteria. These include Streptococcus pneumoniae, Neisseria meningitides, and Hemophilus influenzae. The patients are not at any higher risk for ulcerative colitis, cholelithiasis, or pancreatic cancer.
Question 43.
A patient has been in the emergency department for 4 hours following a four-wheeler crash and is now complaining of severe abdominal pain. The provider caring for her states that she has a positive Cullen’s sign. This sign can occur in concert with another sign known as Grey-Turner’s sign. Which of the following is true regarding the similarities in these two signs?
[a] Both occur in the periumbilical area.
[b] Both are ecchymotic areas.
[c] Both indicate bladder injury.
[d] Both are present within 1 hour of injury.
Answer:
[b] Both are ecchymotic areas.
Nursing Process: Assessment
Rationale:
Cullen’s and Grey-TYirner’s signs are ecchymotic areas and both indicate a retroperitoneal hemorrhage. Cullen’s sign presents as ecchymosis to the periumbilical area and Grey-Hirner’s sign is ecchymosis to the flank area. These usually occur well after the initial injury and may not be present for up to 24 hours.
CEN test questions may not ask outright "What is Cullen’s sign?,” but it is always good to know what signs are present with different disease processes and what they mean—just in case!
Question 44.
Which of the following findings regarding bowel sounds would the emergency nurse expect to find on auscultation of the abdomen in the trauma patient with an intra abdominal injury?
[a] Normal
[b] Hyperactive
[c] Hypoactive
[d] Shrill
Answer:
[c] Hypoactive
Nursing Process: Assessment
Rationale:
With an intra-abdominal injury, the bowel sounds are absent or hypoactive. This may be due to the irritation from the blood in the abdomen and should at the least be cause for concern. Normal bowel sounds would be present if there was no injury. Hyperactive and shrill bowel sounds would not be expected in this situation.
Question 45.
A patient is undergoing measurement for the possibility of abdominal compartment syndrome. Which of the following would be a necessary component to complete this procedure?
[a] Nasogastric tube
[b] Chest tube
[c] Intravenous line
[d] Urinary catheter
Answer:
[d] Urinary catheter
Nursing Process: Assessment
Rationale:
In order to perform a measurement for the diagnosis of compartment syndrome of the abdomen, the patient must have a urinary catheter in place. The side port that is normally used for specimen sampling is accessed with a needle that is set up with a manometer hooked to it. Some of these may hook into the monitor for waveforms. Saline is introduced and then the reading is taken when the fluid level balances out or the reading appears on the screen. A nasogastric tube, chest tube, and intravenous lines may be necessary to care for the trauma patient, but they are not necessary for this procedure.
Yes, the abdomen can be a focus of compartment syndrome—just like the extremities! Readings below 10 cm H20 are considered normal. The patient may have elevated lactate levels with this process and end-organ damage.
Question 46.
When assisting with a paracentesis for a patient with cirrhosis, which of the following parameters would decrease indicating that the procedure was successful as an interventional option?
[a] Respiratory effort
[b] Blood pressure
[c] Temperature
[d] Heart rate
Answer:
[a] Respiratory effort
Nursing Process: Evaluation
Rationale:
When ascites is removed from the peritoneal cavity, the patient will usually have relief related to their respiratory effort. When the intra-abdominal pressure is relieved, the patient is able to breathe better and so the effort and rate will decrease. Blood pressure and temperature will not be affected. The heart rate may decrease because the patient is no longer struggling to breath, but the main parameter affected is the work of the respiratory system.
Question 47.
A patient is seen in the emergency department following a motor vehicle crash. He is diagnosed with a perforated stomach, a pelvic fracture, upper left arm fracture, and a mild closed head injury. Which of the following complications would the emergency nurse understand to be the highest probability to occur for this patient due to the injuries sustained?
[a] Cardiogenic shock
[b] Pulmonary edema
[c] Peritonitis
[d] Paralysis
Answer:
[c] Peritonitis
Nursing Process: Analysis
Rationale:
When the stomach is torn or perforated, hydrochloric acid and enzymes escape that then causes peritonitis. There is a very high probability that peritonitis will follow for this patient. The patient is at much higher risk for hypovolemic shock rather than cardiogenic. Pulmonary edema and paralysis would not occur in this scenario. There is no chest or spinal cord injury.
It is also important to remember that patients involved in traumatic events can be susceptible to sepsis even though we usually think about that shock situation with more medical types of patients. When the integrity of the skin is compromised, infectious processes can also enter in that way as well.
Question 48.
A trauma patient is being seen in the emergency department and has the following values reported 30 minutes after arrival—serum lactate: 1.4 mmol/L, base deficit: —2, pH: 7.36, hemoglobin: 10.4 g/dL, and urine output: 28 mL. Which of the following reported levels received 1 hour later would indicate adequate resuscitation in an adult trauma patient?
[a] Serum lactate level of 3.2 mmol/L
[b] Urine output of 75 mL/hour
[c] Base deficit of -5
[d] Hemoglobin level of 9.6 g/dL
Answer:
[b] Urine output of 75 mL/hour
Nursing Process: Evaluation
Rationale:
Urine output is a sensitive indicator for systemic perfusion. The increase or adequacy of the urine output in this patient would be a good indication that adequate perfusion and thus resuscitation of the patient was occurring. The increased base deficit demonstrates a greater amount of cellular hypoxia. The patient arrived with a base deficit in the normal range of -2 to +2 and with a base deficit of -5 this would indicate a worsening situation for the patient. The serum lactate in this question is also increasing, which would indicate inadequate perfusion. A drop in the hemoglobin level would also not indicate good progress for the patient, but rather that bleeding was occurring and the source would need to be explored.
“The kidney is the window to the viscera” is an old saying that simply means the urine output tells us a lot about how the organs in the "gut” or abdominal cavity are being perfused. (Sorry! My “old nurse” is showing!) Watch urine output closely in your patients it will tell you a great deal!
Question 49.
Which of the following would be the best manner to check for proper gastric tube placement?
[a] Listen for instilled air over the epigastrium
[b] Radiograph or computed tomography (CT) to confirm placement
[c] pH testing of gastric aspirate
[d] Use of carbon dioxide detector
Answer:
[b] Radiograph or computed tomography (CT) to confirm placement
Nursing Process: Evaluation
Rationale:
The method now recommended to achieve the highest level of certainty of proper placement of a nasogastric tube is to have radiograph or computed tomography (CT) evidence. The next recommended method is to utilize pH testing of the gastric aspirate. The use of a carbon dioxide detector to determine it is not in the lungs is the third highest recommendation, although it is considered to be weak. The common practice of listening over the stomach area for the sound of instilled air is not recommended anymore. This is an unreliable method.
Question 50.
When utilizing the pH method of confirmation of gastric tube placement, which of the following numbers would indicate that the tube is in the stomach?
[a] 4.0
[b] 8.5
[c] 10.0
[d] 14.5
Answer:
[a] 4.0
Nursing Process: Evaluation
Rationale:
The pH of gastric contents should be acidic, which would correlate with an acid pH of 1 to 5.5. Any number above 5.5 must have a radiograph to confirm placement. (Radiograph is the preferred method.)
Question 51.
An 82-year-old patient presents to the emergency department with 10 episodes of watery diarrhea starting the day prior. The patient is weak and also complains of some nausea without vomiting and subjective fever. The patient is taken to a bed and placed on which of the following types of isolation?
[a] Droplet
[b] Reverse
[c] Contact
[d] Airborne
Answer:
[c] Contact
Nursing Process: Intervention
Rationale:
Patients with the potential of infection with Clostridium difficile should be placed in contact isolation. Clostridium difficile is passed in the stool but has the potential to be acquired from any surface that might have come in contact with the spores of the infecting agent such as surfaces in rooms, toilet seats, and medical equipment that might have been used on the patient.
Question 52.
Which of the following is a true statement regarding caring for individuals who are diagnosed with Clostridium difficile infection?
[a] The use of alcohol-based hand cleansers is extremely useful and recommended.
[b] Patients should remain in isolation for at least 48 hours after the last diarrhea stool.
[c] Gowns and masks are not necessary to wear when caring for these patients.
[d] Private rooms are not necessary when these patients are admitted for inpatient care.
Answer:
[b] Patients should remain in isolation for at least 48 hours after the last diarrhea stool.
Nursing Process: Intervention
Rationale:
Patients can continue to shed the Clostridium difficile spores for several days after the last diarrheal stool. Therefore, it would be advantageous for them to remain in isolation even after their diarrhea has stopped. Clostridium difficile is not killed by alcohol. Alcohol-based hand cleansers are not adequate for the health care providers to use during the care of these patients. Soap and water are the best hand cleanser agents to use. Gloves are actually best as even hand washing cannot always adequately prevent the spread of this organism. Gowns should be worn when caring for these individuals. Private rooms are necessary or at least room the patient with another patient who is diagnosed with Clostridium difficile. This is known as “cohorting. ”
Question 53.
A nurse working in the cruise industry is aware that norovirus is a particularly virulent problem in their environment for all the following reasons EXCEPT that:
[a] It has a very low dose that can adequately cause infection.
[b] It transmits very easily and is able to live in both hot and cold environments.
[c] The average incubation time for infection passage is 6 to 8 hours.
[d] There is no vaccine available for this viral agent to assist in containment.
Answer:
[c] The average incubation time for infection passage is 6 to 8 hours.
Nursing Process: Analysis
Rationale:
The average incubation time of norovirus is 12 to 48 hours. So, it is short, but not as short as 6 to 8 hours. The dose that can actually transmit this virus to another person is as low 18 virus particles. The virus is very stable in all types of hot or cold situations, being able to survive both freezing and high temperatures. There is presently no vaccine available.
Norovirus is an extreme problem in areas where large groups of people are in a confined space. This is why cruise ships are particularly at high
risk for an outbreak of epidemic proportions. It is taken very seriously on board the ships. Other areas of high risk include tour buses, daycare centers, and long-term care facilities. This virus can also be passed in the vomitus as well as the fecal-oral route.
Question 54.
Treatment for norovirus includes all of the following EXCEPT:
[a] antibiotic therapy.
[b] rehydration.
[c] bed rest.
[d] strict hand washing.
Answer:
[a] antibiotic therapy.
Nursing Process: Intervention
Rationale:
Viruses are not treated with antibiotics. Treatment for norovirus is supportive care, which includes rehydration through intravenous fluids if necessary, rest which usually includes bed rest for a day or two, and strict hand washing to prevent further contamination.
Question 55.
Which of the following would be a concern for a patient involved in a major motor vehicle crash who presents with right upper quadrant pain and has a past history of hepatitis C, COPD, and hypertension?
[a] Respiratory distress
[b] Uncontrolled bleeding
[c] Hypertensive crisis
[d] Pneumonia
Answer:
[b] Uncontrolled bleeding
Nursing Process: Analysis
Rationale:
The liver is the major involved organ in hepatitis C, and in a motor vehicle crash the emergency nurse should be concerned about the patient’s ability to clot. The liver is extremely involved in the clotting process as most of the necessary clotting factors are produced here. In these traumatic situations, the clotting cascade may not work appropriately. The liver is located in the right upper quadrant and the liver also receives a large amount of cardiac output and has the potential to bleed copiously if damaged. Respiratory distress would be a concern, but the lack of ability to clot would take precedence. There were no symptoms of respiratory distress noted in the stem of the question. Hypertensive crisis is not a concern in this scenario. The emergency nurse should be most concerned about hypotension with the strong possibility of hypovolemic shock being present. Pneumonia may occur later but would not be a primary concern in this case.
Remember to read the question carefully and do not “add-in” information! This is a pitfall for many of us! If the question had mentioned something about respiratory distress or provided information that might lead the test taker to respiratory distress, hypertension, or pneumonia, then those might be a concern. Everything you need to know to answer the question is in the stem!
Question 56.
A 3-month-old infant is brought to the emergency department by his parents with complaints of diarrhea stools for the past 2 days. The child is lethargic, pale, is noted to have retractions, and does not cry during the assessment or weight process. Which of the following acid-base disturbances would the emergency nurse suspect with this patient?
[a] Respiratory acidosis
[b] Respiratory alkalosis
[c] Metabolic acidosis
[d] Metabolic alkalosis
Answer:
[c] Metabolic acidosis
Nursing Process: Analysis
Rationale:
Diarrhea causes loss of bicarbonate in the stools. With the loss of bicarbonate, metabolic acidosis quickly occurs. This can be a major complication especially in a child of this age. It does not take very long for an infant to develop acidosis, which can take a deadly turn very fast.
Question 57.
A 7-month-old infant is brought to the emergency department by her parents with a 3-day history of diarrhea. The patient is cyanotic but does not appear to be in any respiratory distress. No retractions are present. Pulse oximetry is 92 % on room air, and respiratory rate is 24 breaths/minute. She is slightly lethargic but responsive and cries appropriately when the emergency nurse is examining her. Blood is drawn, which appears to have the coloration of chocolate. Oxygen is applied at 15 L/minute per blow, but this does not clear the cyanosis. Which of the following medications would the emergency nurse ' expect to administer to this child?
[a] Adrenaline (Epinephrine)
[b] Atropine
[c] Ceftriaxone (Rocephin)
[d] Methylene blue
Answer:
[d] Methylene blue
Nursing Process: Intervention
Rationale:
Methylene blue is the treatment for methemoglobinemia. The fact that this child is cyanotic appearing but has no respiratory distress and applied oxygen does not help the cyanosis are two big hints that the child may be suffering from this disease process. In an infant, diarrhea can cause metabolic acidosis, which then can create the methemoglobinemia. The other clues were the 3-day history of diarrhea and the fact that the blood draw appeared to look like “chocolate.” Methylene blue will reverse the process. Nothing in the scenario would lead the emergency nurse to administer epinephrine or atropine and there are no signs of infection listed such as a fever to warrant an antibiotic.
Question 58.
Which of the following is NOT a risk factor for the development of peptic ulcers?
[a] Long-term and high-use smoking
[b] Frequent intake of alcohol
[c] Nonsteroidal anti-inflammatory drugs
[d] Thyroid supplemental medications
Answer:
[d] Thyroid supplemental medications
Nursing Process: Analysis
Rationale:
The use of thyroid supplements is not a risk factor for the development of peptic ulcers. Smoking, alcohol intake, and the use of NSAIDs (non-steroidal anti-inflammatory drugs) are risk factors as well as some other medications such as anticoagulants, steroids, and medications like alendronate (Fosamax). Stress and eating spicy foods are also factors in peptic ulcer disease.
Question 59.
Which of the following organisms is the cause of the majority of peptic ulcer disease?
[a] Bordetella pertussis
[b] Varicella-zoster virus
[c] Helicobacter pylori
[d] Human papillomavirus
Answer:
[c] Helicobacter pylori
Nursing Process: Analysis
Rationale:
Peptic ulcer disease is caused by the virus Helicobacter pylori. Bordetella pertussis causes whooping cough (pertussis), varicella-zoster virus is the causative agent for chickenpox, and human papillomavirus causes cervical cancer.
Helicobacter pylori is found in up to 90% of duodenal and gastric ulcers. It is treated with antibiotic therapy.
Question 60.
A patient is seen in the emergency department with pain to the left upper quadrant and says he often wakes up at night with the pain. He was recently in the hospital for an extended recovery from a diagnosis of sepsis secondary to open fractures of both lower legs. He has been home for 1 week. Which of the following types of peptic ulcers does this patient most likely have?
[a] Duodenal
[b] Stress
[c] Gastric
[d] Mucosal
Answer:
[b] Stress
Nursing Process: Assessment
Rationale:
Stress ulcers occur after long hospitalizations with severe illness, injury, or physical stress. The cause of this is the actual stress response of the body, which shunts blood away from some areas in order to conserve the blood flow for more important areas. This ischemia to the mucosal lining causes ulcerations to form in the stomach. The most common type of ulcer is the duodenal ulcer that forms due to an increase in parietal cells in the stomach thus causing an increase in acid and gastrin. Gastric ulcers are in the antral area of the stomach close to the parietal cells and tend to become a chronic issue for the patient. All ulcers are caused by problems in the mucosal layer.
Gastric ulcers often progress to gastric cancer. The pain associated with gastric ulcers occurs after eating. Duodenal ulcers cause pain before eating and are relieved by eating or by using antacids. Be sure to get a good history from your patients!!
Question 61.
A patient arrives in the emergency department with bright red, bloody emesis. He is vomiting on arrival and continues as he is placed into a room. He is pale and diaphoretic with cold extremities. Vital signs are as follows:
Blood pressure—82/46 mm Hg
Pulse—146 beats/minute
Respirations—36 breaths/minute
Pulse oximetry—89% on room air
Temperature—99.4° F (37.4° C)
The team starts two large-bore intravenous lines and crystalloids are begun at a rapid rate. All of the following would be anticipated by the emergency nurse EXCEPT:
[a] type and screen.
[b] gastric tube placement.
[c] contact endoscopy.
[d] cardiac monitoring.
Answer:
[a] type and screen.
Nursing Process: Intervention
Rationale:
This patient is actively bleeding. A type and crossmatch is needed, not a type and screen. Blood needs to be set up immediately and the patient may need type-specific or universal donor (0 negative) blood products before the crossmatch can be completed. Gastric tube placement, contacting the endoscopy department for a potential emergent procedure, and cardiac monitoring are all important treatment interventions for this patient. The patient needs close monitoring of vital signs and cardiac rhythms.
Ice water or room temperature lavage is no longer performed for these patients. This can actually destroy clot formations and increase the amount of bleeding. Also, this question is another good example of reading the information and options closely—paying attention to detail. It would have been very easy to think that option A was an appropriate action if the reader did not pick up on the nuances and the vital signs.
Question 62.
Which of the following hemoglobin readings indicates the point at which blood replacement is recommended?
[a] 10.2 g/dL
[b] 9.6 g/dL
[c] 8.4 g/dL
[d] 7.0 g/dL
Answer:
[d] 7.0 g/dL
Nursing Process: Analysis
Rationale:
The newer accepted hemoglobin level for administering blood products is 7.0 g/dL and below.
Question 63.
Which of the following is the correct action for the medication Sandostatin (octreotide) used to treat bleeding esophageal varices?
[a] Decreases portal pressure through relaxation of mesenteric vascular smooth muscle.
[b] Causes vasodilation of the bleeding vessels to clamp down.
[c] Improves blood supply to the gastric mucosa to heal ulcerated areas.
[d] Assists in production of red blood cells to replace lost blood volume.
Answer:
[a] Decreases portal pressure through relaxation of mesenteric vascular smooth muscle.
Nursing Process: Intervention
Rationale:
The correct action for the medication Sandostatin (Octreotide) is that it decreases portal pressure through the relaxation of the mesenteric vascular smooth muscle. Vasodilation would not cause vessels to clamp down. This medication does not help improve blood supply to the ulcerated areas or assist in erythropoiesis.
Question 64.
Which of the following is NOT a risk factor for the development of cholecystitis?
[a] Pregnancy
[b] Caucasian
[c] Obesity
[d] Male
Answer:
[d] Male
Nursing Process: Analysis
Rationale:
Females are at higher risk of developing cholecystitis and pregnancy increases the chances. It is more frequent in the Caucasian population, and obesity also increases the likelihood of developing this problem.
There is a classic mnemonic to help remember these risk factors: Fat/Female/Forties/Fertile/Fair/ Flatulent—a little “non-classy” but it works to help remember!
Question 65.
One of the diagnostic signs of cholecystitis is a gasp or indication of pain from the patient when the right costal arch is palpated. This occurs because the fingers of the examiner have made contact with the enlarged, inflamed gallbladder. This is known as which of the following signs?
[a] Kehr’s
[b] Murphy’s
[c] Cullen’s
[d] Rovsing’s
Answer:
[b] Murphy’s
Nursing Process: Assessment
Rationale:
Murphy’s sign is indicative of cholecystitis and occurs during palpation of the gallbladder area, Kehr’s sign occurs with splenic rupture or tear and creates pain in the left subclavicular/subscapular area. Cullen’s sign is an indication of retroperitoneal hemorrhage and is noted as an ecchymotic area to the periumbilical area. Rovsing’s sign is present in appendicitis when the left lower quadrant is palpated, causing pain to the right lower quadrant.
Question 66.
Which of the following would NOT be appropriate care in a patient with a diagnosis of appendicitis?
[a] Prepare the patient for emergency surgery.
[b] Administer broad-spectrum antibiotics.
[c] Administer H2 inhibitors.
[d] Institute nothing by mouth (NPO).
Answer:
[c] Administer H2 inhibitors.
Nursing Process: Intervention
Rationale:
H2 inhibitors would be used in a patient with a diagnosis of gastroesophageal reflux disease (GERD), not appendicitis. Proper management of the patient with a diagnosis of appendicitis would be to maintain NPO (nothing by mouth) status, prepare the patient for surgery, and administer broad-spectrum antibiotics as well as pain and nausea control before surgery.
Question 67.
Which of the following is NOT part of the elixir known as the GI Cocktail?
[a] Antacid
[b] Viscous lidocaine
[c] Milk of magnesia
[d] Anticholinergic
Answer:
[c] Milk of magnesia
Nursing Process: Intervention
Rationale:
Milk of magnesia is a laxative. The “GI Cock tail” is administered to treat reflux disease. It contains a combination of an antacid such as Maalox, viscous lidocaine, and an anticholinergic such as Donnatal.
Some institutions do not use the anticholinergic portion of the GI Cocktail. Be aware that this is the “accepted” version of the GI Cocktail. Remember that questions will focus on “classic textbook" and not “the way we do it. ”
Question 68.
A Sengstaken-Blakemore tube is used for which of the following disease processes?
[a] Cholecystitis
[b] Diverticulitis
[c] Pancreatitis
[d] Esophageal varices
Answer:
[d] Esophageal varices
Nursing Process: Intervention
Rationale:
The Sengstaken-Blakemore tube is a last option for the treatment of esophageal varices. It is a form of esophagogastric tamponade to compress the bleeding varices and control bleeding. It has a triple lumen and two balloons. Other types of balloon tubes that can be used are the Minnesota and the Linton-Nachlas tubes. These tubes are not necessary in cholecystitis, diverticulitis, or pancreatitis.
Question 69.
A patient presents with a large amount of abdominal distention, vomiting, and generalized abdominal pain. On assessment, the emergency nurse notes that no bowel sounds are present. The patient has a history of a temporary colostomy for a ruptured colon 5 years prior, a cholecystectomy, and appendectomy. Medical history includes hypothyroidism and hypertension. The emergency nurse realizes that this patient will be prone to all of the following potential complications EXCEPT:
[a] sepsis.
[b] pneumonia.
[c] dehydration.
[d] perforation.
Answer:
[b] pneumonia.
Nursing Process: Analysis
Rationale:
Pneumonia would not be a possible complication. The description of this patient in the scenario is that of bowel obstruction. Patients with bowel obstruction will have generalized abdominal pain, vomiting, and abdominal distention. In this case, the large amount of distention would point toward a large bowel obstruction. The past history of the repair for a ruptured colon and the appendectomy could create a situation in which adhesions are present that could cause a bowel obstruction. Complications for this disease process include sepsis, dehydration due to a third spacing that occurs and the vomiting and possible perforation.
Question 70.
A 4-month-old is brought to the emergency department by his father with symptoms of crying and drawing up his legs intermittently. The father states that the baby has been having strange stools, “They look like jelly or something like that.” The emergency nurse should do which of the following regarding this child’s care?
[a] Send the patient to the waiting room.
[b] Immediately take this patient to a room.
[c] Reassure the father that the child is fine.
[d] Have the father check with urgent care to be seen.
Answer:
[b] Immediately take this patient to a room.
Nursing Process: Intervention
Rationale:
This child has manifestations of intussusception, which is an emergent condition. No child with this suspicion should be sent to the waiting room. It would also be inappropriate to tell the father that the child is “fine” because that might encourage him to leave and not be seen. Urgent care would not be an appropriate place for this child to be assessed and treated.
Intussusception can cause necrosis and rupture the bowel. These patients need to be seen immediately. This is usually a diagnosis for young children up to the age of 5 years; however, though rare, it can be seen in older children and young adults. This occurs as a result of one portion of the intestine telescoping into another and can move in and out thus causing the intermittent symptoms.
Question 71.
A mother brings her 9-week-old infant to the emergency department with abdominal distention and a 1-week history of forceful vomiting that is increasingly worse. On examination, the emergency nurse notes that the child appears dehydrated and notes a palpable mass to the right of the umbilicus. The baby has not gained weight and seems to be hungry all the time. Waves of peristalsis are noted, which move from left to right. Which of the following processes should the nurse suspect?
[a] Reflux disease
[b] Failure to thrive
[c] Intussusception
[d] Pyloric stenosis
Answer:
[d] Pyloric stenosis
Nursing Process: Assessment
Rationale:
The manifestations in the stem of this question are significant for pyloric stenosis. This is a congenital anomaly that causes an obstruction at the pyloric sphincter arising from hypertrophy of the circular pylorus. This usually occurs in infants aged 2 to 5 months. Failure to thrive would be indicated by dehydration and a decrease in the physical growth of the infant. Intussusception is manifested by crying and pulling the legs upward intermittently and the presence of .“red currant” jelly-like stools. Reflux in an infant would be noted as “colic.”
Question 72.
A 2-year-old female child is brought to the emergency department with a distended abdomen and vomiting. Assessment reveals a lethargic toddler who does not cry when examined. The child’s skin is cool and slightly diaphoretic. No bowel sounds are heard. Breath sounds are clear to auscultation. Vital signs are as follows:
Blood pressure—76/42 mm Hg
Pulse—164 beats/minute
Respirations—44 breaths/minute
Pulse oximetry—84% on room air
Temperature—99.8° F (37.6° C) rectal
A KUB (kidney, ureter, and bladder) radiograph is obtained which shows air-fluid levels. Which of the following would be the highest priority for this child?
[a] Oxygen by mask or flow by
[b] Intravenous line
[c] Fluid administration
[d] Urinary catheter
Answer:
[a] Oxygen by mask or flow by
Nursing Process: Intervention
Rationale:
This child is in distress, most likely with a bowel obstruction, and needs to have oxygen started immediately. She obviously needs an intravenous line and fluid administration, but these will take time, and therefore, the fastest intervention that can be done is to start high-flow oxygen. The urinary catheter also is important but again will take time and can be done after the airway is maintained and the fluid boluses are started.
Bowel obstruction in children can often be missed and can have fatal outcomes. One of the items that children have been known to ingest over the past several years are magnets. These can attach to each other in the intestines and cause a blockage. These magnets can also cause necrosis, perforation, and the creation of fistulas. Be suspicious for objects being ingested, inhaled, or placect in orifices with children. And remember! Airway is always the first priority unless uncontrolled bleeding is present.
Question 73.
A 3-year-old child is brought to the emergency department after his parents saw him put a button battery in his mouth and swallow it. He is not in respiratory distress but cannot seem to swallow anything. Which of the following is a true statement regarding this ingestion?
[a] Button batteries are not a danger when swallowed and will pass through without problems.
[b] Button batteries must always be removed immediately by endoscopy or surgical procedure.
[c] Button batteries that have passed beyond the esophagus can be allowed to pass on their own.
[d] Button batteries can be removed by administering ipecac to the child and having them vomit.
Answer:
[c] Button batteries that have passed beyond the esophagus can be allowed to pass on their own.
Nursing Process: Analysis
Rationale:
Button batteries are a major danger to children. If the ingested battery has passed through the esophagus, the child can be watched with serial radiographs to monitor its progress. If it is in the esophagus, it must be removed. These batteries can cause permanent injuries to tissues whether it is ingested or placed as a foreign body in orifices such as the ears or nose. Never have a child attempt to vomit if they have swallowed one of these batteries. This can actually cause movement of the battery back up into the esophagus.
Burns occur from the electrical current that is present in the button batteries. This electrical current also creates sodium hydroxide, which contributes to the injury. Perforation ) has been known to occur within 6 hours of ingestion of the foreign body. The stronger the voltage, the more damage is done due to the creation of stronger currents. If the battery was successful in moving through the esophagus, it should be able to pass through the rest of the digestive system without difficulty. However, if it is in the esophagus, endoscopy must be done to retrieve it before it causes major damage to these tissues.
Question 74.
Which of the following is a manifestation of an esophageal obstruction?
[a] Abdominal pain
[b] Drooling
[c] Nausea
[d] Abdominal distention
Answer:
[b] Drooling
Nursing Process: Assessment
Rationale:
Patients who have an esophageal obstruction will not be able to swallow. Drooling is a common manifestation with this process. Abdominal pain, distention and nausea are not usually part of the assessment picture.
Any patient who is drooling and cannot swallow their sputum must be seen immediately. Never put these patients back in the waiting room!
Question 75.
Which of the following gastrointestinal disease processes is one in which surgery is NOT able to correct the underlying problem?
[a] Crohn’s disease
[b] Cholecystitis
[c] Incarcerated hernia
[d] Ulcerative colitis
Answer:
[a] Crohn’s disease
Nursing Process: Analysis
Rationale:
A patient with Crohn’s disease can have surgical repair of complications from the disease (strictures/fistulas) but there is no surgical procedure that is curable. Crohn’s disease affects all parts of the entire GI tract. Cholecystitis is most often managed surgically. An incarcerated hernia can be repaired surgically if manual reduction is not successful. Ulcerative colitis is a colonic problem, and there are surgical procedures that are curative for this disease process.