RPN Emergency Response 4 — Questions and Answers
Question 1: A patient is brought to the ED after being found unresponsive. The nurse notes a respiratory rate of 6 breaths/min and constricted pupils. Which medication should the nurse prepare FIRST?
- Flumazenil 0.2 mg IV
- Naloxone 0.4–2 mg IV/IM/IN (Correct answer)
- Dextrose 50% IV push
- Thiamine 100 mg IV
Correct answer: Naloxone 0.4–2 mg IV/IM/IN
Miosis and respiratory depression are hallmarks of opioid toxicity; naloxone rapidly reverses opioid-induced CNS and respiratory depression.
Question 2: A patient in the ED is diagnosed with hypertensive emergency with a blood pressure of 220/130 mmHg and confusion. The nurse should anticipate the blood pressure being lowered by no more than:
- 50% in the first hour
- 25% in the first hour (Correct answer)
- 10% in the first 15 minutes
- All the way to normal within 30 minutes
Correct answer: 25% in the first hour
Overly rapid blood pressure reduction in hypertensive emergency can cause cerebral ischemia; the goal is a maximum 25% reduction in the first hour.
Question 3: A patient with a penetrating abdominal wound has an evisceration. The nurse's CORRECT intervention is to:
- Attempt to gently reinsert the organs
- Cover the evisceration with dry sterile gauze
- Cover the evisceration with moist sterile saline gauze and do not reinsert (Correct answer)
- Apply an occlusive dressing and place the patient prone
Correct answer: Cover the evisceration with moist sterile saline gauze and do not reinsert
Eviscerated organs should be covered with moist sterile saline gauze to prevent drying and ischemia, and never pushed back in, as this risks contamination and vascular compromise.
Question 4: A nurse is performing a primary survey on a trauma patient. Using the ABCDE approach, which assessment occurs BEFORE evaluating breathing?
- Disability (neurological status)
- Circulation with hemorrhage control
- Airway with cervical spine protection (Correct answer)
- Exposure/environmental control
Correct answer: Airway with cervical spine protection
In the ABCDE trauma primary survey, Airway with simultaneous cervical spine protection is the very first assessment and intervention priority.
Question 5: A patient presents with a serum potassium of 6.8 mEq/L and peaked T-waves on ECG. The FIRST intervention to protect the heart is to administer:
- Sodium polystyrene sulfonate (Kayexalate) PO
- Furosemide IV
- Calcium gluconate IV (Correct answer)
- Regular insulin with dextrose IV
Correct answer: Calcium gluconate IV
Calcium gluconate IV is given first in severe hyperkalemia to stabilize the cardiac membrane and prevent lethal dysrhythmias before other measures lower serum potassium.
Question 6: An unresponsive adult patient is found with no pulse. Bystanders report the patient collapsed 8 minutes ago. The nurse correctly prioritizes:
- Immediate defibrillation before CPR
- Starting high-quality CPR while preparing the defibrillator (Correct answer)
- Establishing IV access before initiating CPR
- Obtaining a 12-lead ECG before any intervention
Correct answer: Starting high-quality CPR while preparing the defibrillator
After more than 4–5 minutes without CPR, myocardial oxygen depletion means CPR should be initiated first to improve the chance of successful defibrillation.
Question 7: A patient is admitted with heat stroke, a core temperature of 41.5°C (106.7°F), and altered mental status. The PRIORITY nursing intervention is:
- Administer antipyretic medication (acetaminophen)
- Begin rapid active external cooling immediately (Correct answer)
- Obtain a CT scan of the head
- Start oral hydration with cool fluids
Correct answer: Begin rapid active external cooling immediately
Heat stroke is a life-threatening emergency; rapid cooling (ice packs to groin/axilla/neck, cold water immersion) must begin immediately to prevent organ damage.
RPN Emergency Response 4
A patient is brought to the ED after being found unresponsive.
The nurse notes a respiratory rate of 6 breaths/min and constricted pupils.
Which medication should the nurse prepare FIRST?