26Question
An ICU charge nurse is assigning patients to a medical-surgical nurse floating to the unit. Which patient is most appropriate to assign to the floating nurse?
- A stable patient with a chest tube three days post-lobectomy
- A patient with ARDS on mechanical ventilation
- A patient with diabetic ketoacidosis on titrated insulin
- A patient twelve hours post-coronary artery bypass graft
Show the answer and explanation
Answer: A. A stable patient with a chest tube three days post-lobectomy
Topic: Float Nurse Assignments
A medical-surgical nurse floating to the ICU should be assigned stable patients with predictable outcomes. A patient who is three days post-lobectomy with a chest tube is stable and requires care that falls within the standard medical-surgical scope of practice.
Why the others are wrong
- B – Mechanical ventilation and ARDS require specialized ICU training and continuous, complex respiratory monitoring.
- C – Titrating insulin infusions for active diabetic ketoacidosis requires frequent monitoring and specialized ICU titration protocols.
- D – Early post-CABG patients are hemodynamically unstable and require advanced ICU monitoring and vasoactive titrations.
Remember: Float nurses get stable patients with predictable outcomes.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
27Question
A patient diagnosed with acute coronary syndrome insists on leaving the emergency department against medical advice (AMA). Which action should the nurse take first?
- Remove the patient's intravenous access line.
- Have the patient sign the standard AMA form.
- Assess the patient's decision-making capacity.
- Contact security to detain the patient.
Show the answer and explanation
Answer: C. Assess the patient's decision-making capacity.
Topic: Against Medical Advice Protocol
Before any patient can legally sign an AMA form or leave, the nurse must first assess their decision-making capacity to ensure they understand the risks of refusing treatment, especially in life-threatening conditions like acute coronary syndrome.
Why the others are wrong
- A – Removing the IV is done after establishing capacity and completing the AMA process.
- B – The AMA form cannot be signed until the patient's decision-making capacity is verified.
- D – Detaining a competent patient constitutes false imprisonment; security is only involved if they lack capacity.
Remember: Before they walk away, assess if they can think okay.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
28Question
A critically bleeding trauma patient refuses blood transfusions due to religious beliefs but consents to non-blood alternatives. Which action should the nurse prioritize to advocate for this patient?
- Ask the family to persuade the patient to accept blood.
- Delay volume resuscitation until a chaplain arrives.
- Confirm the signed refusal and coordinate bloodless therapies.
- Request an emergency court order to administer packed cells.
Show the answer and explanation
Answer: C. Confirm the signed refusal and coordinate bloodless therapies.
Topic: Blood Refusal and Autonomy
The nurse must respect the autonomous, competent patient's refusal of blood products. Prioritizing advocacy involves verifying the legally binding refusal document and immediately coordinating alternative bloodless resuscitation strategies to maintain perfusion.
Why the others are wrong
- A – Asking family to persuade the patient violates autonomy and breaches confidentiality.
- B – Delaying resuscitation in a critically bleeding patient causes life-threatening hypoperfusion.
- D – Competent adults have the legal right to refuse treatment; a court order is inappropriate.
Remember: Respect autonomy: confirm the refusal, then use bloodless alternatives.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
29Question
A patient on a medical unit becomes acutely confused. Vital signs are: BP 88/50 mmHg, HR 118/min, RR 28/min, and SpO2 89% on room air. After applying oxygen, which action should the nurse take first?
- Request an immediate chest radiograph.
- Activate the rapid response team.
- Page the primary care provider.
- Draw a set of arterial blood gases.
Show the answer and explanation
Answer: B. Activate the rapid response team.
Topic: Acute Clinical Deterioration
The patient exhibits signs of acute clinical deterioration, including altered mental status, hypotension, tachycardia, tachypnea, and hypoxia. Activating the rapid response team immediately brings critical care expertise to the bedside to stabilize the patient and prevent cardiac arrest.
Why the others are wrong
- A – A chest radiograph requires a provider's order and delays immediate life-saving stabilization.
- C – Paging the provider takes longer than activating the rapid response team for acute deterioration.
- D – Drawing arterial blood gases requires an order and delays immediate emergency intervention.
Remember: For acute deterioration, call the rapid response team first.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
30Question
An emergency department nurse is preparing to transfer an unstable, intubated patient to the ICU. Which information should the nurse include in the "Situation" portion of the SBAR hand-off report?
- Current ventilator settings and arterial blood gas results
- Patient's name, unit, and acute respiratory failure
- Plan to obtain a repeat chest X-ray in two hours
- History of severe asthma and previous intubations
Show the answer and explanation
Answer: B. Patient's name, unit, and acute respiratory failure
Topic: SBAR Hand-Off Communication
The "Situation" component of the SBAR tool focuses on the immediate, current issue. It includes the patient's identity, location, and the active, acute clinical problem or reason for the transfer.
Why the others are wrong
- A – Ventilator settings and lab results belong in the Assessment (A) section.
- C – Future plans and pending orders belong in the Recommendation (R) section.
- D – Past medical history and chronic conditions belong in the Background (B) section.
Remember: SBAR: Situation is the 'what and where' right now.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
31Question
The intensive care unit nurse receives report on four clients. Which client should the nurse assess first?
- Client with DKA whose blood glucose is 280 mg/dL
- Client with ARDS whose oxygen saturation dropped to 84%
- Client post-craniotomy with a urine output of 150 mL/hr
- Client post-CABG with 80 mL of chest tube output last hour
Show the answer and explanation
Answer: B. Client with ARDS whose oxygen saturation dropped to 84%
Topic: Client Care Prioritization
Using the ABC prioritization framework, the client with acute respiratory distress syndrome experiencing severe hypoxemia (oxygen saturation 84%) is the most unstable and requires immediate assessment and intervention to prevent life-threatening respiratory failure.
Why the others are wrong
- A – A blood glucose of 280 mg/dL is an expected, improving trend during DKA treatment.
- C – While high urine output may indicate diabetes insipidus, it is less urgent than severe hypoxemia.
- D – Chest tube drainage under 100 mL/hr is normal and expected during the post-CABG recovery period.
Remember: Airway and breathing come first; eighty-four percent oxygen demands immediate action.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
32Question
The intensive care unit nurse receives change-of-shift report on four clients. Which client should the nurse assess first?
- Client post-craniotomy with a new unilateral dilated pupil
- Client with a chest tube draining 70 mL of fluid hourly
- Client on mechanical ventilation requiring suctioning
- Client with acute pancreatitis and a pain score of 9 of 10
Show the answer and explanation
Answer: A. Client post-craniotomy with a new unilateral dilated pupil
Topic: ICU Client Prioritization
A new unilateral dilated pupil after a craniotomy indicates increased intracranial pressure and impending brain herniation. This is a life-threatening neurological emergency requiring immediate intervention to prevent irreversible brain damage or death.
Why the others are wrong
- B – Chest tube drainage under 100 mL/hr is expected and does not indicate active hemorrhage.
- C – Suctioning is a routine airway clearance intervention, not an immediate life-threatening emergency.
- D – Severe pain is expected with acute pancreatitis and is prioritized after life-threatening neurological changes.
Remember: A new blown pupil is a brain herniation emergency.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
33Question
An emergency department patient with a valid Out-of-Hospital Do Not Resuscitate (OOH-DNR) order goes into cardiac arrest. The spouse demands that the team perform CPR. Which action should the nurse take first?
- Contact the facility's legal counsel for guidance.
- Honor the DNR order and support the family.
- Initiate CPR until the attending physician arrives.
- Ask the spouse to sign a DNR revocation form.
Show the answer and explanation
Answer: B. Honor the DNR order and support the family.
Topic: Out-of-Hospital DNR Orders
A valid Out-of-Hospital DNR is a legally binding document representing the patient's autonomous wishes. The nurse must honor the order and withhold resuscitation, while providing compassionate emotional support to the grieving spouse.
Why the others are wrong
- A – Delaying action to contact legal counsel during a cardiac arrest is inappropriate.
- C – Initiating CPR directly violates the patient's legally documented autonomy and wishes.
- D – The spouse cannot unilaterally revoke the patient's valid, pre-existing DNR order.
Remember: Honor the patient's written wishes, not the family's panic.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
34Question
During a multi-casualty incident, a high-profile local official is admitted to the emergency department. A reporter calls the nursing station asking to confirm the official's admission and condition. Which action should the nurse take?
- Direct the caller to the public information officer.
- Provide a general condition update without names.
- Transfer the call directly to the client's room.
- Confirm the admission but withhold clinical details.
Show the answer and explanation
Answer: A. Direct the caller to the public information officer.
Topic: Disaster Media Relations
During a disaster or multi-casualty incident, the public information officer is the designated spokesperson for media inquiries. Directing reporters to this officer protects patient privacy under HIPAA and allows clinical staff to focus on patient care.
Why the others are wrong
- B – Sharing any patient information with the media without explicit consent violates HIPAA regulations.
- C – Disrupts patient care and violates privacy by exposing the patient to unauthorized media contact.
- D – Confirming a patient's admission status without consent is a direct violation of HIPAA.
Remember: Media in sight? Send to the PIO to keep privacy tight.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
35Question
A nurse is coordinating a home health safety assessment and occupational therapy referral for a geriatric client with macular degeneration and frequent falls. Which action should the nurse prioritize to ensure a safe transition?
- Postpone the home assessment until vision stabilizes.
- Instruct the family to purchase low-vision aids immediately.
- Request that the therapist perform a diagnostic eye exam.
- Share the client's specific visual deficits and fall history.
Show the answer and explanation
Answer: D. Share the client's specific visual deficits and fall history.
Topic: Home Safety Referral Collaboration
Sharing specific visual deficits and fall history with the occupational therapist ensures a targeted, safe home assessment. This interdisciplinary communication allows the therapist to customize interventions to the client's precise functional limitations and immediate safety hazards.
Why the others are wrong
- A – Macular degeneration is progressive, and delaying the assessment increases the immediate risk of falls.
- B – Aids should only be purchased after the occupational therapist assesses the client's specific needs.
- C – Diagnostic eye exams are outside the scope of practice for an occupational therapist.
Remember: Share the history to tailor the safety victory.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
36Question
An 82-year-old client with early-stage dementia, who is determined to have decision-making capacity, refuses a scheduled CT scan. Which action should the nurse take first?
- Explore the client's reasons for refusing the scan.
- Contact the client's designated power of attorney.
- Administer a prescribed PRN sedative before the scan.
- Reschedule the scan for when the client is cooperative.
Show the answer and explanation
Answer: A. Explore the client's reasons for refusing the scan.
Topic: Informed Refusal and Autonomy
Clients with decision-making capacity retain the right to refuse medical procedures, regardless of a dementia diagnosis. The nurse's priority is to assess the client's concerns and explore the reasons behind the refusal to ensure informed decision-making.
Why the others are wrong
- B – The power of attorney is inactive because the client retains decision-making capacity.
- C – Sedating a capable client to force a procedure violates autonomy and constitutes chemical restraint.
- D – Rescheduling delays care without addressing the underlying reason for the client's refusal.
Remember: Capacity intact? Autonomy rules. Always explore the refusal first.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
37Question
A nurse is planning care for an older adult patient who has severe dysphagia following an acute ischemic stroke. Which task is most appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
- Perform the initial bedside swallow screen.
- Feed the patient their first meal after the stroke.
- Record the percentage of the pureed meal consumed.
- Adjust the thickness of the liquids at the bedside.
Show the answer and explanation
Answer: C. Record the percentage of the pureed meal consumed.
Topic: Delegation of Dysphagia Care
Unlicensed assistive personnel can perform routine, non-invasive tasks such as documenting oral intake. Assessing swallowing ability, feeding a high-risk patient for the first time, and altering dietary prescriptions require clinical nursing judgment and cannot be delegated.
Why the others are wrong
- A – Initial swallow screening requires clinical assessment and judgment, which cannot be delegated to UAPs.
- B – Feeding a high-risk dysphagia patient for the first time requires professional nursing assessment and monitoring.
- D – Adjusting liquid consistency is a clinical intervention that requires a speech therapist's or nurse's evaluation.
Remember: UAPs document and assist; nurses assess, teach, and evaluate.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
38Question
During a norovirus outbreak on a long-term care unit, the nurse receives report on four geriatric patients. Which patient should the nurse assess first?
- An 85-year-old who is lethargic with a BP of 88/50 mmHg
- A 79-year-old with three watery stools and mild tenting
- An 82-year-old with dementia and dry mucous membranes
- A 74-year-old with nausea and a temperature of 99.8 F
Show the answer and explanation
Answer: A. An 85-year-old who is lethargic with a BP of 88/50 mmHg
Topic: Geriatric Dehydration Prioritization
This patient exhibits lethargy and hypotension, which are critical indicators of severe dehydration and impending hypovolemic shock. Immediate fluid resuscitation and assessment are required to prevent cardiovascular collapse in this vulnerable geriatric patient.
Why the others are wrong
- B – Mild skin tenting and three watery stools indicate moderate dehydration, which is currently stable.
- C – Dry mucous membranes indicate mild dehydration; this patient is hemodynamically stable compared to the hypotensive patient.
- D – Low-grade fever and nausea are expected norovirus symptoms and do not indicate immediate hemodynamic instability.
Remember: Lethargy and low blood pressure equal shock; assess them first!
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
39Question
A competent 82-year-old patient refuses further chemotherapy. However, the patient's adult child, who holds durable power of attorney (DPOA) for healthcare, demands that the oncologist continue the treatment. Which action should the nurse take first?
- Implement the DPOA's demands to continue treatment.
- Honor the patient's decision to refuse treatment.
- Request an immediate ethics committee consultation.
- Refer the family to the hospital's legal counsel.
Show the answer and explanation
Answer: B. Honor the patient's decision to refuse treatment.
Topic: Patient Autonomy and DPOA
A competent patient retains the absolute right to make their own healthcare decisions, including refusing treatment. A durable power of attorney for healthcare only takes effect when the patient is deemed incompetent or unable to make decisions.
Why the others are wrong
- A – The DPOA is inactive because the patient is currently competent to make decisions.
- C – An ethics consultation is unnecessary because the patient's competent refusal is legally and ethically clear.
- D – Legal counsel is not needed first; the nurse must immediately respect the competent patient's autonomy.
Remember: If the patient is competent, the DPOA has no power.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
40Question
A nurse is preparing a multidisciplinary telehealth consultation for a competent older adult patient. The patient's adult daughter requests to join the video call and view the medical records. Which action should the nurse take first?
- Allow access if the daughter provides the patient's SSN.
- Verify the patient's verbal or written consent.
- Share the records to promote family-centered care.
- Require proof of durable power of attorney.
Show the answer and explanation
Answer: B. Verify the patient's verbal or written consent.
Topic: Patient Information Confidentiality
For a competent adult patient, HIPAA regulations require explicit verbal or written consent before sharing confidential medical information or allowing family members to participate in consultations. The nurse must verify this consent first.
Why the others are wrong
- A – Providing a Social Security number does not bypass HIPAA consent requirements.
- C – Family-centered care does not override the patient's legal right to privacy and confidentiality.
- D – A durable power of attorney is only activated if the patient is deemed incompetent.
Remember: Competent patient? Consent first, even for family.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
41Question
An 82-year-old patient with presbycusis and expressive aphasia is preparing for discharge. To advocate for the patient's active participation in the discharge planning meeting, which action should the nurse take?
- Request written materials in a large, high-contrast font.
- Ensure the team faces the patient and allows time to point.
- Speak in a high-pitched, loud voice during the meeting.
- Ask the family to make all decisions to avoid fatigue.
Show the answer and explanation
Answer: B. Ensure the team faces the patient and allows time to point.
Topic: Aphasia and Presbycusis Communication
Facing the patient enhances communication for presbycusis by allowing lip-reading, while allowing time to point accommodates expressive aphasia. This combination directly promotes the patient's autonomy and active participation in their discharge planning.
Why the others are wrong
- A – This addresses visual deficits rather than presbycusis or expressive aphasia.
- C – High-pitched tones are harder to hear in presbycusis, and shouting distorts speech.
- D – This disempowers the patient instead of advocating for their active participation.
Remember: Face for hearing, wait for pointing, keep the patient participating.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
42Question
The ICU nurse receives report on four patients. Which patient should the nurse assess first?
- A patient with a chest tube draining 70 mL/hr of fluid
- A patient with an abdominal aortic aneurysm and back pain
- A patient on mechanical ventilation requiring suctioning
- A patient with pancreatitis and glucose of 220 mg/dL
Show the answer and explanation
Answer: B. A patient with an abdominal aortic aneurysm and back pain
Topic: Abdominal Aortic Aneurysm Rupture
New or worsening back pain in a patient with an abdominal aortic aneurysm is a classic sign of impending or active rupture. This is a catastrophic, life-threatening emergency requiring immediate surgical intervention to prevent hemorrhagic shock.
Why the others are wrong
- A – Chest tube drainage under 100 mL/hr is a stable, expected finding.
- C – Suctioning is a routine airway clearance intervention, not an immediate life-threatening emergency.
- D – Mild hyperglycemia is expected in acute pancreatitis and does not require immediate emergency assessment.
Remember: AAA plus back pain equals impending rupture; assess first!
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
43Question
A critically ill patient is brought to the emergency department with a valid, signed Out-of-Hospital Do Not Resuscitate (OOH-DNR) order. The patient's spouse demands that the team "do everything" to save them. Which action should the nurse take first?
- Honor the OOH-DNR and provide comfort care.
- Follow the spouse's instructions as the surrogate.
- Contact the attending physician to cancel the DNR.
- Initiate CPR until the ethics committee is consulted.
Show the answer and explanation
Answer: A. Honor the OOH-DNR and provide comfort care.
Topic: Advance Directives and DNR
A valid Out-of-Hospital Do Not Resuscitate (OOH-DNR) order legally represents the patient's autonomous wishes and supersedes family demands. The nurse must honor the directive and provide comfort care rather than initiating unwanted resuscitation.
Why the others are wrong
- B – A surrogate's demands cannot override a patient's own valid, documented advance directive.
- C – The nurse cannot request cancellation of a valid DNR based solely on family distress.
- D – Initiating CPR violates the active DNR order and the patient's legal right to refuse treatment.
Remember: A valid DNR is the patient's voice; family cannot silence it.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
44Question
An 80-year-old client with early-stage dementia retains decision-making capacity but refuses a scheduled colonoscopy. Which action should the nurse take first?
- Contact the designated healthcare proxy for consent.
- Request a psychiatric consultation for competency.
- Administer a mild sedative to help the client comply.
- Explore the reasons for refusal and discuss the risks.
Show the answer and explanation
Answer: D. Explore the reasons for refusal and discuss the risks.
Topic: Informed Refusal and Autonomy
Since the client retains decision-making capacity, their autonomy must be respected. The nurse's first step is to explore the reasons for refusal, ensure they understand the risks, and support informed decision-making.
Why the others are wrong
- A – Proxies only make decisions when the client lacks decision-making capacity.
- B – The client already retains decision-making capacity, making a competency evaluation unnecessary.
- C – Sedating a client to force compliance violates autonomy and constitutes chemical restraint.
Remember: Capacity intact? Respect the refusal and explore the "why" first.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
45Question
A nurse is caring for an older adult patient with severe dysphagia following an acute ischemic stroke. Which task is most appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
- Elevating the head of the bed to 90 degrees during meals
- Assessing the patient's swallowing ability before eating
- Performing the initial feeding with a new honey-thick liquid
- Instructing the patient to use the chin-tuck maneuver
Show the answer and explanation
Answer: A. Elevating the head of the bed to 90 degrees during meals
Topic: Delegation in Dysphagia Care
Elevating the head of the bed to 90 degrees is a standard, non-invasive positioning task that does not require clinical judgment, making it safe and appropriate to delegate to unlicensed assistive personnel.
Why the others are wrong
- B – Assessment of swallowing requires professional nursing judgment and cannot be delegated.
- C – Initial feeding of a high-risk dysphagia patient requires nursing assessment and monitoring.
- D – Patient education and instruction of therapeutic maneuvers must be performed by the nurse.
Remember: UAPs can position, but nurses must assess, teach, and evaluate (EAT).
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
46Question
The nurse in a long-term care facility manages care during a norovirus outbreak. Which geriatric patient should the nurse assess first?
- A 91-year-old who vomited once and is currently sleeping
- An 82-year-old with three loose stools asking for water
- An 88-year-old with dementia who is now lethargic
- An 80-year-old with a mild fever and slight nausea
Show the answer and explanation
Answer: C. An 88-year-old with dementia who is now lethargic
Topic: Geriatric Norovirus Prioritization
Lethargy in an older adult during a norovirus outbreak is a red flag for severe dehydration, electrolyte imbalance, or sepsis. This acute change in neurological status requires immediate intervention, whereas the other patients exhibit milder, stable, or compensating symptoms.
Why the others are wrong
- A – Vomiting once followed by sleep is stable and does not indicate acute distress.
- B – Asking for water shows the patient is alert, compensating, and hemodynamically stable.
- D – Mild fever and slight nausea are expected symptoms that do not require immediate intervention.
Remember: Lethargy in the elderly signals severe dehydration; prioritize acute mental status changes.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
47Question
A competent 82-year-old patient refuses further chemotherapy. The patient's adult child, who holds durable power of attorney (DPOA) for healthcare, demands that the oncology team continue the treatment. Which action should the nurse take first?
- Honor the patient's decision to refuse treatment.
- Refer the family to a medical social worker.
- Consult the ethics committee to resolve the conflict.
- Follow the DPOA's demands to continue treatment.
Show the answer and explanation
Answer: A. Honor the patient's decision to refuse treatment.
Topic: Patient Autonomy and DPOA
The competent patient has decision-making capacity; her autonomous choice to decline treatment supersedes the DPOA and family wishes, per informed consent and patient‑self‑determination principles legally.
Why the others are wrong
- B – Referral is helpful later but does not address immediate patient autonomy.
- C – Ethics committee can be consulted after respecting the patient’s decision.
- D – The DPOA’s authority is limited when the patient is competent and refuses treatment.
Remember: Competent patients decide; DPOA cannot override.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
48Question
A nurse is preparing for a multidisciplinary telehealth consultation with an 82-year-old client and their adult child. To maintain HIPAA compliance before sharing the client's health records during the call, which action must the nurse take first?
- Document the child's identity in the medical record.
- Confirm the child is the durable power of attorney.
- Verify the client's verbal or written consent.
- Password-protect the telehealth connection.
Show the answer and explanation
Answer: C. Verify the client's verbal or written consent.
Topic: HIPAA and Telehealth Consent
Under HIPAA regulations, the nurse must first verify the client's verbal or written consent before sharing protected health information with family members, assuming the client has decision-making capacity.
Why the others are wrong
- A – Documenting identity is necessary but does not authorize sharing confidential health information.
- B – Durable power of attorney is only utilized if the client lacks decision-making capacity.
- D – Securing the connection prevents external breaches but does not authorize sharing information with family.
Remember: Consent first: never share health information with family without the client's permission.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
49Question
The intensive care unit nurse is planning care for a group of patients. Which patients require immediate nursing assessment or intervention?
Select all that apply.
- A patient with a potassium level of 5.1 mEq/L receiving CRRT.
- A patient whose Glasgow Coma Scale score decreased from 11 to 8.
- A patient with chest tube drainage of 220 mL in the last hour.
- A patient with a MAP of 54 mmHg on norepinephrine.
- A patient with a blood glucose of 160 mg/dL on an insulin drip.
Show the answers and explanation
Answers: B, C and D.
- B – A patient whose Glasgow Coma Scale score decreased from 11 to 8.
- C – A patient with chest tube drainage of 220 mL in the last hour.
- D – A patient with a MAP of 54 mmHg on norepinephrine.
Immediate intervention is required for a mean arterial pressure below 65 mmHg to prevent organ hypoperfusion, chest tube output exceeding 100 to 200 mL/hr due to active hemorrhage risk, and a Glasgow Coma Scale score dropping to 8 or below, which indicates a compromised airway requiring urgent protection.
Why the others are wrong
- A – A potassium level of 5.1 mEq/L is only mildly elevated and is actively being cleared by continuous renal replacement therapy.
- E – A blood glucose level of 160 mg/dL is within the standard target range of 140 to 180 mg/dL for critically ill patients.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
50Question
An emergency department nurse is caring for a deteriorating patient with a valid Out-of-Hospital Do Not Resuscitate (OOH-DNR) order. The family demands that the team "do everything" and initiate CPR. Which actions should the nurse take?
Select all that apply.
- Provide comfort care and active symptom management.
- Honor the OOH-DNR and withhold CPR.
- Explain the patient's documented wishes to the family.
- Initiate CPR while waiting for an ethics consult.
- Request the provider immediately rescind the DNR.
Show the answers and explanation
Answers: A, B and C.
- A – Provide comfort care and active symptom management.
- B – Honor the OOH-DNR and withhold CPR.
- C – Explain the patient's documented wishes to the family.
The nurse must honor a legally valid out-of-hospital DNR order to respect patient autonomy, even when family members demand resuscitation. The nurse should continue providing comfort care and symptom management while using therapeutic communication to explain the patient's documented end-of-life wishes to the family, helping to resolve the conflict.
Why the others are wrong
- D – Initiating CPR directly violates a valid DNR order and breaches the patient's legal right to refuse life-sustaining treatment.
- E – The nurse cannot ask to rescind a valid DNR based solely on family distress, as this violates patient autonomy.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
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