NCE PRACTICE EXAM

Fibrinolytic therapy is generally NOT recommended for patients whose symptoms began more than 12 hours before arrival. Fibrinolytics should not be given if the onset of symptoms was more than 24 hours before arrival UNLESS a posterior MI is diagnosed. In this case, the MI was anterior.

Preload is the volume of blood that enters the right side of the heart. This volume stretches the fibers in the heart prior to contraction. Preload is commonly measured as atrial pressure.

Ventricular fibrillation and pulseless ventricular tachycardia are the two rhythms that are considered to be "shockable" cardiac arrest rhythms. Although asystole and PEA are cardiac arrest rhythms, they will not respond to electrical shock.

According to the 2010 BLS and ACLS guidelines, suctioning for longer than 10 seconds may result in pulling too much oxygen out of the airways resulting in hypoxemia.

Common causes of cardiac arrest are known as the H's and T's and include: hypovolemia (NOT hypervolemia), hypoxia, hydrogen ion excess (acidosis), hypo or hyperkalemia, hypothermia, tension pneumothorax, tamponade, toxins, and thrombosis (pulmonary or coronary). Correction of these causes can often reverse a cardiac arrest.

The most likely cause of the failure of the chest to rise during ventilations is an airway obstruction. Although a faulty bag-mask device is a possibility, it is unlikely that it would fail in the middle of providing ventilations.

According to the most current AHA guidelines, cricoid pressure may delay or prevent placement of an advanced airway so is no longer recommended.

Latrogenic effects of hyperventilation through an ET tube include aspiration, stomach insufflation, and tension pneumothorax. Increasing waveform capnography readings are an indication of efficient CPR.

The AHA recommends continuous waveform capnography and clinical examination to confirm and maintain ET tube position.

Nasal flaring and retractions are signs of respiratory distress, not respiratory failure. In respiratory failure, you will see decreased respiratory effort with late bradypnea, diminished air movement, peripheral and central cyanosis, and decreased level of consciousness.

The gunshot wounds and symptoms would indicate that the young man has lost a significant amount of blood that has resulted in hypovolemia. The treatment of hypovolemia is a rapid infusion of a crystalloid intravenous solution.

Severity of shock is often characterized by its effect on the systolic blood pressure. When the compensatory mechanisms work and maintain the systolic blood pressure, the shock is defined as "compensated". When the mechanisms can no longer support the blood pressure, shock is classified as "hypotensive" (formally called "decompensated").

Congestive heart failure is a common cause of cardiogenic shock. Acute myocardial infarction and other heart conditions can also cause cardiogenic shock. Dehydration can be a cause of hypovolemic shock. Spinal cord injury can cause neurogenic shock. Infection can cause septic shock.

By all indications, the child is in hypovolemic shock and the first interventions should be a fluid bolus at 20 ml/kg of saline or lactated Ringer's solution.

Given the history of the recent MVA and these classic symptoms, the prudent nurse should have a high degree of suspicion of a subarachnoid hemorrhage. Assessment will show neurologic deficits and decreased eye movements. The nurse should prepare the patient for a CT scan of the brain.

The Epworth Scale is a measure of sleepiness and is not part of the standard evaluation of a child's neurological exam. The AVPU and Glasgow Coma scales can be used to evaluate a child's neuro status. Pupillary size and response should also be checked.

The goal for CT brain scan is 25 minutes after arrival to the Emergency Department. The assessment should occur within 10 minutes of arrival, diagnosis of ischemic stroke should be made within 45 minutes, and the administration of fibrinolytics should occur with 60 minutes.

The goal for general assessment by an ED or stroke team physician is within 10 minutes of arrival to the ED. Within the same 10 minutes, an urgent CT without contrast should also be ordered.

The nurse should recognize that these signs and symptoms in a teenage boy may be indicative of testicular torsion. Although all of the treatments may be used, surgery is the definitive treatment for this condition.

The symptoms of dysuria, urgency and frequency are classic indicators of a urinary tract infection. Urinary tract infections are very common in women and can almost always be treated on an outpatient basis with a course of antibiotics.

Given the patient symptoms, the nurse should suspect that the patient has pelvic inflammatory disease (PID). With early antibiotic treatment, this infection can be treated on an outpatient basis. Without treatment, the infection can continue and cause scar tissue that may lead to infertility and ectopic pregnancies.

ARF can be classified by using Risk, Injury, Failure, Loss and End-stage kidney disease. Risk is defined as an increased serum creatinine level at 1.5 times normal or decrease of glomerular filtration rate (GFR) by 25% or decrease in urine output less than 0.5 cc/kg/hr for more than 6 hours. AFR is defined as Injury when the serum creatinine level is increased more than 2 times, GFR is decreased by 50% or urine output is less than 0.5 cc/kg/hr for 12 hours. AFR is defined as Failure when the serum creatinine level is increased more than 3 times, GFR is decreased by 75% or urine output is less than 0.3 cc/kg/hr for 24 hours or anuria for 12 hours. AFR is classified as Loss if there is persistent ARF or if there is a complete loss of kidney function for more than 4 weeks. End-stage kidney disease is defined as a loss of kidney function for more than 3 months.

The symptoms described in the scenario are classic signs of fetal alcohol syndrome caused by maternal consumption of alcohol during pregnancy. The other vitamin deficiencies can result in defects and delays in growth and development, but the particular facial deformities in this scenario are unique to FAS.

The nurse should recognize that these signs and symptoms indicate possible anaphylaxis following the fire ant bites. Antibiotics are not indicated for the initial treatment of anaphylaxis. They may be necessary at a future time if the ant bites become infected. Adrenaline, oxygen, and antihistamines will help reduce some of the symptoms the patient is experiencing. The nurse should also be prepared for emergency intubation if the respiratory problems increase and result in respiratory distress.

The mechanism of injury and symptoms would indicate an anaphylactic reaction to the fire ant bites. Since the child has respiratory symptoms, immediate treatment must be instituted with attention to airway maintenance. Epinephrine will act rapidly and should be given as soon as possible and every 10 to 15 minutes as needed. Steroids and antihistamines may be given, but act much more slowly than epinephrine.

According to the CDC and infection control personnel, hand hygiene is the single most important precaution to take to prevent hospital-acquired infections. The other interventions may be necessary for specific circumstances. However, hand hygiene is the most important intervention to prevent nosocomial infections.

Isolation precautions should be based on all of these factors. In addition, ED personnel must consider risk factors for transmission of the agent in the infected patient. Room-sharing should only be considered if the patients have the same infection. Terminal clean should be instituted for any room that has been occupied by a potentially infectious patient.

Patients with hepatitis A rarely have pain so having scheduled pain medication would not be necessary. However, these patients do have nausea and fatigue necessitating medication and small meals for nausea and frequent rests for the fatigue.

Emergent endoscopy is indicated for any obstruction: when a patient is unable to manage secretions, when a patient swallows a sharp-pointed object, or when a patient swallows a disk battery. Any of these ingestions may constitute an emergency and the patient and family should be prepared for possible emergent endoscopy.

Respiratory distress as evidenced by increased respiratory rate is a potentially life-threatening complication of pancreatitis. The other symptoms are all common findings in the patient with pancreatitis. If the symptoms have not changed significantly, they should be noted but are not life-threatening.

Given the history of alcoholism and the presenting symptoms, this patient should be considered at very high risk for esophageal varices. As the disease progresses, one would expect to see bleeding from the varices. Ruptured esophageal varices should be considered a medical/surgical emergency.

The patient should be sitting up with his head leaning forward. This position helps to prevent blood from being swallowed by the patient. Swallowing blood can cause vomiting. Pinching the nose below the bridge of the nose may help stop bleeding.

The normal eardrum is pearly gray in color so this would rule out any of the ear infections. This patient has an extensive dental caries that should be referred to a dentist. The ED provider may prescribe antibiotics and/or pain medications for this patient to clear any infection that may be causing the ear pain.

A penetrating object should never be removed by the nurse since doing so can cause more injury to the eye. Instead, attempt to stabilize the object, patch the other eye to prevent eye movement, and call for an ophthalmology consult.

Many times, an avulsed tooth can be reimplanted if the tooth is out of the socket for less than 60 minutes. After that time, the periodontal ligaments begin to die. An avulsed tooth is best transported in the patient's own mouth if he is not at risk for swallowing the tooth and if there are no other injuries. Generally, the rule of thumb is that children under the age of six should not transport the tooth in their mouth.

The child and parent should understand that the hand must be elevated above the level of the heart (on a pillow, for example) when the child is sitting. When the child is up, the sling should be adjusted to keep the hand elevated as much as possible. Hanging the hand down will cause blood to collect in the hand causing swelling. The swelling under the cast may cause decreased venous return. The parents should be taught to check capillary refill, movement, and sensation of the hand as long as the cast is in place.

A comminuted fracture is one in which there are more than two portions of the fractured bone. In a comminuted fracture, you may see bone fragments at the site of the fracture. An open fracture is one in which the skin is broken. Since the skin is intact, this fracture is a closed, comminuted fracture of the femur.

The optimal position of the affected extremity is below the level of the heart to slow venom movement into central circulation. Tetanus vaccination and antivenom administration should be given as medically indicated. Cleaning the puncture wounds should be done gently.

Minor shallow or deep partial thickness burns on less than 15% of an adult's body less than 40 years of age can be treated on an outpatient basis. Because the burns are on his hands, the patient may be admitted as an observation patient since there is a functional risk to his hands.

The American Burn Association's guidelines are as follows:

• First Degree (partial thickness) - superficial, red, sometimes painful
• Second Degree (partial thickness) - red, blistered, swollen, very painful
• Third Degree (full thickness) - whitish, charred or translucent, no pin prick sensation

West Nile virus is caused by the bite of a mosquito. First discovered in the US in 1999, it is believed that the virus is actually carried by infected birds. The mosquito bites the bird and then bites a person. Mosquitoes carry the highest amount of virus in the early fall; typically, rates of the reported disease increases in late August and early September. As mosquitoes die off in the cold weather, the incidence of disease decreases.

Stamp stands for: Staring, Tone and volume of voice, Anxiety, Mumbling, and Pacing. Originally, a health researcher who spent 300 hours observing aggressive, violent behavior in the ED developed this framework. STAMP is a screening tool that triage nurses can use to identify potentially violent individuals in emergency rooms. 

Recommending that the family know where the patient is at all times may be counterproductive since this action can cause the patient to feel untrusted, trapped, and spied on. The other options should all be considered by the nurse.

Naloxone (Narcan) is the medication that is indicated for the treatment of an opioid overdose. If the patient's condition is due to opioids, the nurse should be prepared for rapid reversal of the narcotic effects of the drug.

The first action is to move the patient to a quiet room where the activity in the Emergency Department will not escalate the patient's abusive behavior. Locking the room is a form of restraint so rounds should be made every 15 minutes or more frequently as defined by hospital policy. Lorazepam is an appropriate medication to calm the patient and help prevent seizures. A magnesium level is appropriate since the risk of seizures increases if the magnesium level is low.

Regardless of the patient's age or gender, the Emergency Department nurse is required to report any suspected abuse or injury that might have resulted from abuse or neglect. The reporter is protected by statute from retaliatory actions as a result of their report to protective services or local law enforcement.

Although verbal and telephone orders are not ideal, the practice of emergency nursing often requires taking verbal orders. In those cases, the nurse must employ the practice of reading back the order to ensure that it was received and recorded accurately.

According to EMTALA, a pregnant woman cannot be transferred if delivery is imminent. However, in this scenario, the patient is stable, the fetus does not seem to be in distress, and the woman is not in active labor. Therefore, the discharge of the patient is not restricted by the EMTALA statute. The husband should transport the patient to the nearest hospital with a labor and delivery unit for further monitoring.

An integral part of being an effective ED nurse is knowing what tasks can or should be delegated to other roles. The ED nurse should not expect to perform all tasks for every patient but should know what tasks can be delegated.

The only task that the nurse should delegate to the unlicensed technician is the provision of oral care.

To reduce gender bias, nurses of both sexes need to ask all patients gender-neutral questions, not just those of the opposite sex. Ways to minimize gender bias overall include asking open-ended questions, imagining asking the same question to a patient of the opposite sex, and having a training coach work with staff to assist in identifying situations of gender bias.