Question 1

The nurse is to administer 100 mg phenytoin (Dilantin)intravenous (IV).Vital signs assessed by the nurse include blood pressure 90/60 mm Hg,heart rate 52 beats/min,respiratory rate 18 breaths/min,and oxygen saturation (SpO2)99% on supplemental oxygen at 3 L/min by cannula.To prevent complications,what is the best action by the nurse?

Accepted Answer

A)  Administer over 2 minutes. 
B)  Administer over 5 minutes. 
C)  Mix medication with 0.9% normal saline. 
D)  Administer via central line.

Question 2

The nurse admits a patient to the critical care unit following a motorcycle crash.Assessment findings by the nurse include blood pressure 100/50 mm Hg,heart rate 58 beats/min,respiratory rate 30 breaths/min,and temperature of 100.5°.The patient is lethargic,responds to voice but falls asleep readily when not stimulated.Which nursing action is most important to include in this patient's plan of care?

Accepted Answer

A)  Frequent neurological assessments 
B)  Side to side position changes 
C)  Range of motion to extremities 
D)  Frequent oropharyngeal suctioning

Question 3

The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level.The patient is in spinal shock.Following emergent intubation and mechanical ventilation,what is the priority nursing action?

Accepted Answer

A)  Maintain body temperature. 
B)  Monitor blood pressure. 
C)  Pad all bony prominences. 
D)  Use proper hand washing.

Question 4

The nurse is caring for a patient admitted with new onset of slurred speech,facial droop,and left-sided weakness 8 hours ago.Diagnostic computed tomography scan rules out the presence of an intracranial bleed.Which actions are most important to include in the patient's plan of care? (Select all that apply.)

Accepted Answer

A)  Make frequent neurological assessments. 
B)  Maintain CO2 level at 50 mm Hg. 
C)  Maintain MAP less than 130 mm Hg. 
D)  Prepare for thrombolytic administration. 
E)  Restrain affected limb to prevent injury.

Question 5

Which patient being cared for in the emergency department should the charge nurse evaluate first?

Accepted Answer

A)  A patient with a complete spinal injury at the C5 dermatome level 
B)  A patient with a Glasgow Coma Scale score of 15 on 3-L nasal cannula 
C)  An alert patient with a subdural bleed who is complaining of a headache 
D)  An ischemic stroke patient with a blood pressure of 190/100 mm Hg

Question 6

The nurse is caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm.Assessment by the nurse notes blood pressure 90/60 mm Hg,heart rate 115 beats/min,respiratory rate 28 breaths/min,oxygen saturation (SpO2)99% on supplemental oxygen at 3L/min by cannula,a Glasgow Coma Score of 4,and a central venous pressure (CVP)of 2 mm Hg.After reviewing the physician orders,which order is of the highest priority?

Accepted Answer

A)  Lasix 20 mg intravenous push as needed 
B)  500 mL albumin intravenous infusion 
C)  Decadron 10 mg intravenous push 
D)  Dilantin 50 mg intravenous push

Question 7

The nurse is preparing to administer 100 mg of phenytoin (Dilantin)to a patient in status epilepticus.To prevent patient complications,what is the best action by the nurse?

Accepted Answer

A)  Ensure patency of intravenous (IV) line. 
B)  Mix drug with 0.9% normal saline. 
C)  Evaluate serum K+ level. 
D)  Obtain an IV infusion pump.

Question 8

The physician orders fosphenytoin (Cerebyx),1.5 g intravenous (IV)loading dose for a 75-kg patient in status epilepticus.What is the most important action by the nurse?

Accepted Answer

A)  Contact the admitting physician. 
B)  Administer drug over 10 minutes. 
C)  Mix medication with 0.9% normal saline. 
D)  Administer via central line.

Question 9

The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated.While performing endotracheal suctioning,the patient reaches up in an attempt to grab the suction catheter.What is the best interpretation by the nurse?

Accepted Answer

A)  The patient is exhibiting extension posturing. 
B)  The patient is exhibiting flexion posturing. 
C)  The patient is exhibiting purposeful movement. 
D)  The patient is withdrawing to stimulation.

Question 10

The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis.To prevent the spread of nosocomial infections to other patients,what is the best action by the nurse?

Accepted Answer

A)  Implement droplet precautions upon admission. 
B)  Wash hands thoroughly before leaving the room. 
C)  Scrub the hub of all central line ports prior to use. 
D)  Dispose of all bloody dressings in biohazard bags.

Question 11

The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury.Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury?

Accepted Answer

A)  pH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO285 mm Hg 
B)  pH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg 
C)  pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg 
D)  pH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm Hg

Question 12

The nurse is caring for a patient admitted to the ED following a fall from a 10-foot ladder.Upon admission,the nurse assesses the patient to be awake,alert,and moving all four extremities.The nurse also notes bruising behind the left ear and straw-colored drainage from the left nare.What is the most appropriate nursing action?

Accepted Answer

A)  Insert bilateral ear plugs. 
B)  Monitor airway patency. 
C)  Maintain neutral head position. 
D)  Apply a small nasal drip pad.

Question 13

The nurse receives a patient from the emergency department following a closed head injury.After insertion of an ventriculostomy,the nurse assesses the following vital signs: blood pressure 100/60 mm Hg,heart rate 52 beats/min,respiratory rate 24 breaths/min,oxygen saturation (SpO2)97% on supplemental oxygen at 45% via Venturi mask,Glasgow Coma Scale score of 4,and intracranial pressure (ICP)of 18 mm Hg.Which physician order should the nurse institute first?

Accepted Answer

A)  Mannitol 1 g intravenous 
B)  Portable chest x-ray 
C)  Seizure precautions 
D)  Ancef 1 g intravenous

Question 14

The physician has opted to treat a patient with a complete spinal cord injury with glucocorticoids.The physician orders 30 mg/kg over 15 minutes followed in 45 minutes with an infusion of 5.4 mg/kg/min for 23 hours.What is the total 24-hour dose for the 70-kg patient?

Accepted Answer

A)  2478 mg 
B)  5000 mg 
C)  10,794 mg 
D)  12,750 mg

Question 15

The nurse is preparing to administer a routine dose of phenytoin (Dilantin).The physician orders phenytoin (Dilantin)500 mg intravenous every 6 hours.What is the best action by the nurse?

Accepted Answer

A)  Administer over 2 minutes. 
B)  Administer with 0.9% normal saline intravenous. 
C)  Contact the physician. 
D)  Assess cardiac rhythm.

Exam 13: Nervous System Alterations

The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level.The patient is in spinal shock.Following emergent intubation and mechanical ventilation,what is the priority nursing action?

Which patient being cared for in the emergency department should the charge nurse evaluate first?

The nurse is preparing to administer 100 mg of phenytoin (Dilantin) to a patient in status epilepticus.To prevent patient complications,what is the best action by the nurse?

The physician orders fosphenytoin (Cerebyx) ,1.5 g intravenous (IV) loading dose for a 75-kg patient in status epilepticus.What is the most important action by the nurse?

The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated.While performing endotracheal suctioning,the patient reaches up in an attempt to grab the suction catheter.What is the best interpretation by the nurse?

The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis.To prevent the spread of nosocomial infections to other patients,what is the best action by the nurse?

The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury.Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury?

The physician has opted to treat a patient with a complete spinal cord injury with glucocorticoids.The physician orders 30 mg/kg over 15 minutes followed in 45 minutes with an infusion of 5.4 mg/kg/min for 23 hours.What is the total 24-hour dose for the 70-kg patient?

The nurse is preparing to administer a routine dose of phenytoin (Dilantin) .The physician orders phenytoin (Dilantin) 500 mg intravenous every 6 hours.What is the best action by the nurse?