Medical Emergencies practice questions

Answer: D) As soon as possible, and no later than 72 hours

• AIncorrect. It's effective.
• BIncorrect. That's too late.
• CIncorrect. Start early.
• DCorrect. Early treatment works best.

Answer: C) Give glucagon 1 mg IM while IV access efforts continue

For an unresponsive hypoglycemic patient without IV access, give IM or intranasal glucagon and nothing by mouth. Glucagon depends on liver glycogen stores, so IV dextrose is needed as soon as access is obtained if the patient does not respond.

• AIncorrect. Oral or buccal carbohydrate is for patients who are awake and can swallow safely. Giving it to an unresponsive patient risks aspiration and may not be absorbed reliably.
• BIncorrect. Thiamine is given with dextrose to malnourished or alcohol-dependent patients to prevent Wernicke encephalopathy, but it does not raise blood glucose.
• CCorrect. When a patient cannot swallow and IV dextrose cannot be given, IM (or intranasal) glucagon raises glucose by releasing the liver's glycogen stores. It may not work in patients whose glycogen is depleted, such as those with alcohol use, starvation, or liver failure, so IV dextrose should be given as soon as access is obtained if the patient does not respond.
• DIncorrect. Severe hypoglycemia with unresponsiveness is an emergency that can cause seizures and brain injury. Treatment should start right away based on the point-of-care result.

Answer: B) Stop the transfusion and keep the IV open with normal saline

With fever, chills, and back pain during a transfusion, assume an acute hemolytic reaction and stop the transfusion first. Keep the IV open with saline, monitor vital signs, notify the provider and blood bank, and return the product for testing.

• AIncorrect. Fever with chills and back or flank pain suggests an acute hemolytic reaction. Slowing the rate still lets incompatible blood reach the patient, and an antipyretic only hides the fever.
• BCorrect. Stopping the transfusion immediately comes first. Then keep the line open with 0.9% saline, check vital signs often, do a clerical check of the patient and the unit, notify the provider and blood bank, and send the bag, tubing, and post-transfusion samples for testing.
• CIncorrect. Antihistamines treat mild allergic (urticarial) reactions. They do not treat hemolysis, and resuming a suspect unit could be fatal.
• DIncorrect. Post-transfusion blood and urine samples are needed, but they are collected after the transfusion is stopped. Delaying the stop increases exposure to the incompatible product.

Answer: B) At least 30 mL/kg of IV crystalloid within the first 3 hours

For sepsis-induced hypotension or a lactate of 4 mmol/L or higher, the 2021 Surviving Sepsis Campaign guidelines suggest at least 30 mL/kg of IV crystalloid within the first 3 hours (a weak recommendation), with frequent reassessment. Starches should not be used, and albumin is reserved for patients who need large crystalloid volumes.

• AIncorrect. Crystalloid is the first-line resuscitation fluid. Albumin is suggested only as an add-on for patients who have already received large volumes of crystalloid.
• BCorrect. For sepsis-induced hypotension or a lactate of 4 mmol/L or higher, the 2021 guidelines suggest at least 30 mL/kg of IV crystalloid (balanced crystalloid preferred) within the first 3 hours. This is a weak recommendation, and the patient should be reassessed often for fluid responsiveness.
• CIncorrect. The guidelines recommend against starches for resuscitation because they are linked to kidney injury and the need for renal replacement therapy.
• DIncorrect. Prompt fluid resuscitation is part of initial management for sepsis-induced hypotension. Holding boluses delays restoring perfusion. Vasopressors are added to keep the MAP at 65 mm Hg or higher, not used to replace initial fluids.

Answer: D) Acute chest syndrome

In sickle cell disease, a new infiltrate on chest imaging with chest pain or fever defines acute chest syndrome. It is the leading cause of death in sickle cell disease and needs urgent treatment.

• AIncorrect. Splenic sequestration presents with sudden splenomegaly, a sharp drop in hemoglobin and hypovolemic shock. It is not characterized by chest pain and a new lung infiltrate.
• BIncorrect. Aplastic crisis, often triggered by parvovirus B19, causes severe anemia with a low reticulocyte count. It does not cause a new pulmonary infiltrate.
• CIncorrect. A pain crisis can cause chest pain, but a new infiltrate on imaging with fever goes beyond an uncomplicated pain crisis and meets the definition of acute chest syndrome.
• DCorrect. Acute chest syndrome is defined as a new pulmonary infiltrate plus symptoms such as chest pain, fever, cough, respiratory distress or hypoxemia. It is the most common cause of death in sickle cell disease and needs prompt oxygen, pain control, antibiotics and possibly transfusion.

Answer: A) Insulin moves potassium into cells and can cause dangerous hypokalemia

Insulin shifts potassium into cells. DKA patients have a total body potassium deficit, so potassium must be confirmed adequate (and replaced if low) before insulin is started to prevent life-threatening hypokalemia.

• ACorrect. Insulin drives potassium into the cells. Total body potassium is depleted in DKA, so insulin can cause hypokalemia, dysrhythmias and cardiac arrest. If potassium is low (below 3.5 mmol/L by current guidance; older guidance used 3.3 mEq/L), replace it before starting insulin.
• BIncorrect. This reverses the actual effect. Insulin lowers serum potassium by shifting it into cells.
• CIncorrect. In DKA, acidosis and lack of insulin shift potassium out of cells, so serum potassium is often high even though total body potassium is depleted.
• DIncorrect. Weight-based insulin dosing is not adjusted upward for high potassium. Potassium is checked to prevent insulin-induced hypokalemia.

Answer: A) Lyme disease

• ACorrect. It's treated with antibiotics.
• BIncorrect. The rash pattern suggests Lyme.
• CIncorrect. The rash pattern suggests Lyme.
• DIncorrect. The history suggests Lyme.

Answer: A) Pale skin and conjunctivae, tachycardia, and shortness of breath on exertion

Significant anemia lowers oxygen delivery, which causes fatigue, pallor, compensatory tachycardia, and shortness of breath on exertion. Chronic blood loss, such as heavy menstrual bleeding, is a common cause.

• ACorrect. Less oxygen-carrying capacity causes pallor, a compensatory fast heart rate, and shortness of breath with exertion. Check hemoglobin and hematocrit and assess for ongoing blood loss.
• BIncorrect. A ruddy complexion with a high hematocrit points to too many red cells (polycythemia), the opposite of anemia.
• CIncorrect. This cluster suggests hypothyroidism. Anemia usually causes a fast heart rate, not a slow one.
• DIncorrect. These findings suggest meningitis (possibly meningococcal), not anemia from chronic blood loss.

Answer: B) Octreotide

• AIncorrect. That worsens it.
• BCorrect. It reduces insulin release.
• CIncorrect. That's another sulfonylurea.
• DIncorrect. It doesn't treat this.

Answer: C) Draw blood cultures and promptly start broad-spectrum IV antibiotics

Febrile neutropenia after chemotherapy is a medical emergency. The nurse should expect blood cultures to be drawn, followed promptly by empiric broad-spectrum IV antibiotics, without waiting for antipyretic response or culture results.

• AIncorrect. Lowering the fever does not treat the possible underlying infection. Waiting to reassess delays care for a life-threatening emergency.
• BIncorrect. CDC advises that chemotherapy patients with fever should not wait long and should be seen quickly. Neutropenic patients should also be kept away from crowded waiting areas to limit exposure to infection.
• CCorrect. Fever during chemotherapy-related neutropenia is a medical emergency. Fever may be the only sign of a life-threatening infection, so cultures are drawn and empiric broad-spectrum IV antibiotics are started without delay.
• DIncorrect. Culture results take days. Neutropenic patients can worsen quickly from even minor infections, so empiric antibiotics are started right after cultures are drawn.