Question 1

A nurse is performing an initial exam on a patient who presents for care of acute coronary syndrome. The patient is in cardiogenic shock and the physician has placed a central line. During the physical assessment, which sign or symptom would the nurse most likely expect to see?

Accepted Answer

Answer reason: Cardiogenic shock results from pump failure, most commonly due to myocardial ischemia, leading to decreased myocardial contractility and low cardiac output. Compensatory vasoconstriction increases systemic vascular resistance, and venous congestion raises filling pressures such as CVP; tachycardia is typical. Therefore, among the options, decreased cardiac contractility is the expected finding.

Question 2

A 36-year-old male patient is being seen in the emergency department after a spinal injury; the patient states that he cannot feel anything below the level of his shoulders. Which point best describes the time that this patient would need to be intubated with an endotracheal tube?

Accepted Answer

Answer reason: A GCS of 8 or less indicates the patient cannot adequately protect the airway and requires endotracheal intubation. A respiratory rate of 10/min is low but not an absolute indication for intubation if the patient is otherwise protecting the airway. An SpO2 of 88% on room air should be treated first with supplemental oxygen and reassessment. A pneumothorax requires chest decompression; intubation does not directly treat it and is not the immediate airway criterion.

Question 3

The nurse is caring for a 55-year-old male with a history of coronary artery disease, renal failure and hypertension. The client begins to complain of sharp chest pain radiating down the left arm. The nurse should first?

Accepted Answer

Answer reason: Acute chest pain radiating to the left arm suggests myocardial ischemia. The priority nursing action is to improve myocardial oxygen supply; applying supplemental oxygen is an immediate intervention while further evaluation and provider notification proceed. Calling to request nitroglycerin delays care and may be inappropriate without assessing hemodynamics, and morphine PO is not indicated in an acute event. Preparing for catheterization is premature before stabilization and diagnostics.

Question 4

A 58-year-old male presents to the emergency department with shortness of breath, altered level of consciousness, and a respiratory rate of 8 breaths per minute. He is using accessory muscles to breathe, and an oxygen saturation 82% on a non-mbreather mask. Arterial blood gases: pH: 7.28, PaCO2: 55 mmHg, PaO2: 60 mmHg. The physician prepares for intubation. What is the priority nursing action at this time?

Accepted Answer

Answer reason: The patient has impending respiratory failure with hypoxemia, hypercapnia, and depressed mental status despite high-flow oxygen. With intubation imminent, the nurse’s priority is to ensure airway equipment is ready, including functioning suction and a bag-valve-mask connected to oxygen to provide immediate ventilation/oxygenation if needed. Naloxone may be considered but should not delay airway management. A nasal cannula or encouraging deep breathing is inappropriate for this unstable, obtunded patient.

Question 5

The nurse enters a client's room and finds the client unresponsive, not breathing, and without a pulse. The nurse should first?

Accepted Answer

Answer reason: Per AHA BLS guidelines, when a client is unresponsive, apneic, and pulseless, the priority is to begin high-quality CPR immediately to maintain perfusion. After compressions are initiated, activate the emergency response system and obtain the defibrillator as soon as possible. A 12-lead ECG is obtained after return of spontaneous circulation, not during arrest. A sternal rub is for assessing responsiveness and is inappropriate once pulselessness is confirmed.

Question 6

Someone is having a diabetic emergency (Hypoglycemia – Low sugar), what should you do?

Accepted Answer

Answer reason: Hypoglycemia requires rapid administration of fast-acting carbohydrate (e.g., glucose tablets, juice, regular soda, candy) to quickly raise blood glucose and prevent neurologic deterioration. A low-calorie drink like diet cola contains little to no sugar and will not correct hypoglycemia. Bread or pasta are complex carbohydrates that take longer to digest and are not the best immediate treatment for a low-blood-sugar emergency.

Question 7

While caring for a patient with a diagnosis of heart failure, which of the following would require the nurse to notify the doctor immediately?

Accepted Answer

Answer reason: Pink, frothy sputum is a classic sign of acute pulmonary edema from left-sided heart failure and represents a medical emergency due to rapidly worsening gas exchange. This finding can precede severe hypoxia and respiratory failure, requiring immediate provider notification and urgent interventions (e.g., oxygen/ventilatory support, diuretics, vasodilators as ordered). The other findings (orthopnea, mild short-term weight gain, or an irregular heartbeat without instability described) can occur with heart failure but are typically less immediately life-threatening than pulmonary edema.

Question 8

Clear fluid draining from the nose and ear is indicative of?

Accepted Answer

Answer reason: Clear, watery drainage from the nose (CSF rhinorrhea) or ear (CSF otorrhea) after head trauma strongly suggests a basilar skull fracture with a dural tear. This finding is an emergency because it indicates a communication between the subarachnoid space and the outside environment, increasing risk for meningitis and other complications. Simple rhinorrhea or otitis media typically produces mucoid/purulent drainage rather than clear CSF, and cerebral edema does not cause clear fluid leakage from nose/ear.

Question 9

Cold and clammy skin is seen in?

Accepted Answer

Answer reason: Hypovolemic shock causes peripheral vasoconstriction as the body attempts to maintain blood pressure and perfusion to vital organs. This results in cool, pale, and clammy skin. Early septic shock typically presents with warm, flushed skin, neurogenic shock with warm and dry skin, and anaphylactic shock with flushing and edema rather than clamminess.

Question 10

Which of the following is the correct position of a newborn during resuscitation?

Accepted Answer

Answer reason: During neonatal resuscitation, the airway must be kept open to allow effective ventilation. Placing the newborn in a supine position with the neck slightly extended (the “sniffing” position) aligns the airway and optimizes airflow. Excessive flexion or extension can obstruct the airway and impair ventilation.

Question 11

A postpartum client develops shortness of breath, chest pain, and anxiety. The nurse notes tachycardia and decreased oxygen saturation. Which action is PRIORITY?

Accepted Answer

Answer reason: Sudden dyspnea, chest pain, tachycardia, and hypoxemia in the postpartum period strongly suggest a pulmonary embolism. Immediate escalation and rapid diagnostic evaluation are critical because this can rapidly progress to respiratory failure and hemodynamic collapse.

Question 12

What is the first link in the out-of-hospital cardiac arrest (OHCA) chain ofsurvival?

Accepted Answer

Answer reason: The first step is recognizing the emergency and activating the response system so that CPR/defibrillation and advanced care can occur as quickly as possible.

Question 13

A 55-year-old male presents with sudden chest pain, diaphoresis, and shortness of breath. Vital signs: BP 160/90 mmHg, HR 110 bpm, RR 24/min, SpO2 92%. What is the nurse’s first action?

Accepted Answer

Answer reason: The presentation is highly suspicious for acute coronary syndrome, where a rapid 12-lead ECG is a time-critical first step to identify STEMI/ischemia and guide emergent reperfusion decisions. While oxygen, nitroglycerin, and pain assessment are important, they do not replace immediate diagnostic confirmation that directs definitive emergency management. Obtaining an ECG promptly supports safe, evidence-based triage and treatment escalation in a potential myocardial infarction.

Question 14

In a trauma patient with ongoing hypotension and rigid, distended abdomen following penetrating abdominal injury, what is the best intervention?

Accepted Answer

Answer reason: Penetrating abdominal trauma with persistent hypotension and a rigid, distended abdomen suggests ongoing intra-abdominal hemorrhage and/or peritonitis with hemodynamic instability. In an unstable patient, definitive management is emergent exploratory laparotomy rather than delaying for CT imaging or waiting for labs. Bedside FAST may be used as a rapid adjunct, but it should not delay operative control of bleeding when clinical signs already indicate an acute surgical abdomen with shock. Continuing fluids alone without source control risks worsening hemorrhagic shock.

Question 15

Your patient is in cardiac arrest and has been intubated. To assess CPR quality, which should you do?

Accepted Answer

Answer reason: In an intubated patient in cardiac arrest, continuous waveform capnography (PETCO2/ETCO2) is the best bedside indicator of CPR quality because it reflects pulmonary blood flow generated by chest compressions. Higher ETCO2 values correlate with better compressions and perfusion, while persistently low ETCO2 suggests inadequate compressions or poor circulation. A sudden sustained rise in ETCO2 can also indicate return of spontaneous circulation (ROSC). A 12-lead ECG and chest X-ray do not assess compression quality, and pulse checks are intermittent and unreliable during ongoing CPR.

Question 16

Which facility is the most appropriate EMS destination for a patient with sudden cardiac arrest who achieved return of spontaneous circulation in the field?

Accepted Answer

Answer reason: After out-of-hospital cardiac arrest with ROSC, the priority is rapid evaluation and treatment of the likely underlying cause, commonly acute coronary occlusion. Transport to a coronary reperfusion-capable center enables immediate ECG interpretation, emergent cardiac catheterization/PCI when indicated, and post–cardiac arrest critical care (including targeted temperature management). Stroke, rehab, and long-term acute care facilities are not equipped for time-sensitive coronary reperfusion and advanced post-arrest management.

Question 17

You are caring for a patient with a suspected stroke whose symptoms started 2 hours ago. The CT was normal with no sign of hemorrhage. The patient does not have any contraindications for fibrinolytic therapy. Which treatment is best?

Accepted Answer

Answer reason: This presentation is consistent with an acute ischemic stroke within the treatment window (symptom onset 2 hours). A non-contrast CT showing no hemorrhage and no contraindications supports immediate IV fibrinolytic therapy to restore perfusion and improve neurologic outcomes. Delaying for MRI, echocardiography, or waiting 24 hours would unnecessarily postpone time-sensitive reperfusion therapy and worsen prognosis.

Question 18

A diabetic patient has the following presentation: unresponsive to voice or touch, tachycardia, diaphoresis, and pallor. Which of the following actions by the healthcare provider is the priority?

Accepted Answer

Answer reason: The symptoms (unresponsiveness, tachycardia, diaphoresis, pallor) are classic for severe hypoglycemia with neuroglycopenia, which is an immediate medical emergency. The priority is rapid correction of blood glucose; IV 50% dextrose provides the fastest definitive treatment when the patient cannot take oral carbohydrates. Sending labs delays life-saving therapy, oxygen does not address the primary problem, and giving insulin could worsen hypoglycemia and increase risk of seizures, coma, or death.

Question 19

Which of the following nursing action takes priority for a patient who is brought to emergency room complaining mid-sternal chest pain?

Accepted Answer

Answer reason: A patient presenting with acute mid-sternal chest pain must be evaluated immediately for myocardial ischemia or infarction. An electrocardiogram (ECG) is the highest-priority action because it rapidly identifies life-threatening cardiac events such as ST-elevation myocardial infarction and guides urgent treatment decisions. While vital signs and history are important, they must not delay obtaining an ECG in suspected acute coronary syndrome.

Question 20

Which client should the nurse see first?

Accepted Answer

Answer reason: A blood glucose level of 58 mg/dL indicates hypoglycemia, which is an immediate and potentially life-threatening condition. Symptoms such as dizziness signal neuroglycopenia and require prompt intervention to prevent seizures, loss of consciousness, or death. The other clients have psychosocial or non-urgent needs.

Question 21

What is the antidote for opioid overdose?

Accepted Answer

Answer reason: Naloxone is a competitive opioid receptor antagonist that rapidly reverses opioid-induced respiratory and CNS depression, making it the specific antidote for opioid overdose. Flumazenil reverses benzodiazepines, protamine reverses heparin, and atropine is used for symptomatic bradycardia and organophosphate poisoning. Because naloxone has a shorter half-life than many opioids, repeated dosing and close monitoring for recurrent respiratory depression are often required.

Question 22

The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?

Accepted Answer

Answer reason: After thoracentesis, a key priority is detecting and responding to acute respiratory compromise (e.g., pneumothorax, re-expansion pulmonary edema, bleeding). An SpO2 of 88% indicates clinically significant hypoxemia requiring immediate intervention and provider notification. The other findings are less urgent: mild hypertension, a slightly elevated respiratory rate when supine, and moderate pleuritic pain can be expected or managed but do not outweigh a low oxygen saturation.

Question 23

Which nursing diagnosis takes highest priority for a client with Parkinson’s crisis?

Accepted Answer

Answer reason: A Parkinsonian crisis (akinetic crisis) can involve severe rigidity, dysphagia, and impaired cough/gag reflex, creating an immediate threat to airway patency and ventilation. Using ABC priorities, airway clearance supersedes longer-term risks such as nutrition, urinary elimination, or injury. Secretions and aspiration risk can rapidly lead to hypoxia and respiratory failure, making ineffective airway clearance the highest-priority nursing diagnosis. Therefore, maintaining a patent airway and supporting breathing is the most urgent focus.

Question 24

A nurse is assessing the depth and extent of a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the first priority when assessing the severity of the burn?

Accepted Answer

Answer reason: Burn location is the first-priority severity factor because it immediately indicates risk to airway and vital functions. Burns of the face and neck raise concern for inhalation injury and rapidly developing airway edema, which can be life-threatening even before total body surface area or other factors are considered. Therefore, identifying where the burn is guides urgent airway assessment and early interventions. Age and past history affect prognosis, and cause can influence specific management, but neither supersedes immediate airway risk tied to location.

Question 25

A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

Accepted Answer

Answer reason: In type 1 diabetes, exercising when ketones are present indicates insufficient insulin and possible diabetic ketoacidosis risk; exercise can further increase counterregulatory hormones and worsen hyperglycemia/ketosis. Therefore, clients should avoid exercise if urine (or blood) ketones are positive and address hyperglycemia/ketones first. While carrying carbohydrates and avoiding injection into an exercising limb can be reasonable strategies, the ketone-positive restriction is the clearest safety-critical teaching point tested here.

Question 26

A patient with liver cirrhosis develops confusion and hand-flapping tremors. What should the nurse do first?

Accepted Answer

Answer reason: Confusion with asterixis (hand-flapping tremor) in a patient with cirrhosis strongly suggests hepatic encephalopathy, which can rapidly progress and threatens airway protection and neurologic status. The priority nursing action is to promptly notify the healthcare provider so urgent evaluation and treatment (e.g., lactulose/rifaximin and identification of triggers such as GI bleed or infection) can be initiated. Checking ammonia levels may help support the diagnosis but is not the first action because clinical status and timely treatment are more urgent. Monitoring I&O or offering water does not address the immediate risk of deterioration.

Question 27

A client with acute pancreatitis is experiencing severe abdominal pain and has a rigid, board-like abdomen. What is the nurse's priority action?

Accepted Answer

Answer reason: A rigid, board-like abdomen with severe pain suggests peritoneal irritation and possible complications such as perforation, hemorrhage, or worsening pancreatitis requiring urgent evaluation. This represents a potential acute abdomen/medical emergency where rapid provider notification is prioritized over comfort measures alone. Analgesics and positioning may be implemented after urgent assessment and orders, but they do not address the potential life-threatening cause. Reassessing in 30 minutes delays needed escalation of care.

Question 28

A multip at 38 weeks with placenta previa arrives in early labor with painless bright red bleeding. HR reassuring. What is the nurse's priority?

Accepted Answer

Answer reason: Placenta previa classically presents with painless, bright red third-trimester bleeding, and vaginal examination can precipitate massive hemorrhage, so it is contraindicated. The priority is to minimize bleeding risk with bed rest and preparation for cesarean birth, which is the definitive management at term with bleeding. Ambulation and oxytocin-induced labor increase uterine activity and bleeding risk and are not appropriate in active bleeding from previa. With a reassuring fetal heart rate, immediate focus remains maternal-fetal safety by preventing hemorrhagic deterioration and anticipating operative delivery.

Question 29

External fetal monitoring shows Category III tracing (absent variability, recurrent late decels). What is the priority sequence?

Accepted Answer

Answer reason: A Category III fetal heart rate tracing (absent variability with recurrent late decelerations) indicates probable fetal hypoxia/acidemia and requires immediate intrauterine resuscitation. Priority actions are to improve uteroplacental perfusion and reduce uterine activity: reposition the client (typically left lateral), administer oxygen per protocol, and discontinue oxytocin to decrease contractions. The provider must be notified promptly because escalation to operative delivery may be necessary if the tracing does not rapidly improve. The other options delay or worsen fetal compromise (continued monitoring only, ambulation/PO fluids, or pushing).

Question 30

A client with a long bone fracture suddenly becomes anxious, short of breath, and has chest pain. What should the nurse suspect?

Accepted Answer

Answer reason: After a long bone fracture, fat globules from bone marrow can enter the bloodstream and lodge in the pulmonary circulation, causing sudden respiratory distress, anxiety, and chest pain. Fat embolism syndrome classically occurs within 24–72 hours after injury and often includes hypoxemia and neurologic changes (e.g., confusion) and may include a petechial rash. Compartment syndrome presents with severe localized limb pain and neurovascular compromise, not acute dyspnea. Pulmonary embolism is possible but the long-bone-fracture association and classic sudden symptoms most strongly point to fat embolism syndrome.

Question 31

A nurse is caring for a postoperative client who is suddenly confused and has decreased oxygen saturation. What is the nurse's best initial action?

Accepted Answer

Answer reason: Sudden confusion with decreased oxygen saturation in a postoperative client is an acute change suggesting hypoxemia and possible respiratory compromise, which requires urgent escalation. Notifying the healthcare provider initiates rapid evaluation and potential interventions (e.g., oxygen therapy adjustments, assessment for atelectasis, pneumonia, opioid-induced respiratory depression, or pulmonary embolism). Reassurance or documentation alone delays care, and giving medications without assessing/clarifying the cause could worsen respiratory status. Therefore, the safest best initial action among the options is to notify the provider.

Question 32

A pregnant woman in her third trimester reports sudden upper abdominal pain and headache. What is the nurse’s priority?

Accepted Answer

Answer reason: Sudden upper abdominal (epigastric/RUQ) pain with headache in a third-trimester pregnant client is a warning sign of severe preeclampsia/HELLP, which can rapidly progress to eclampsia, stroke, liver complications, or placental abruption. The priority is immediate escalation of care to initiate urgent assessment and treatment (e.g., blood pressure management, magnesium sulfate, labs, fetal evaluation). Giving only analgesics, encouraging ambulation, or simply documenting delays potentially lifesaving interventions. Therefore, promptly notifying the healthcare provider is the safest and most appropriate priority action.

Question 33

A client with chest trauma has tracheal deviation and absent breath sounds on the left. What should the nurse do immediately?

Accepted Answer

Answer reason: Tracheal deviation with absent breath sounds after chest trauma is classic for a tension pneumothorax, which rapidly compromises ventilation and venous return. The immediate life-saving action is to prepare for emergent needle decompression to relieve intrathoracic pressure. Oxygen is supportive but does not correct the obstructive shock physiology. Chest X-ray would delay definitive emergency management.

Question 34

A postpartum woman has a boggy uterus and heavy bleeding. The nurse massages the fundus, which firms temporarily but remains boggy. What’s the next step?

Accepted Answer

Answer reason: A boggy uterus with heavy postpartum bleeding most commonly indicates uterine atony, a postpartum hemorrhage emergency. If fundal massage only provides temporary firming, the next priority intervention is to promote sustained uterine contraction with uterotonic medication such as oxytocin. IV fluids and leg elevation are supportive for shock, and a Foley can help empty the bladder, but neither directly treats the primary cause as effectively as uterotonics. Prompt uterotonic therapy reduces ongoing blood loss and helps prevent rapid hemodynamic decompensation.

Question 35

A nurse finds a client unconscious with signs of hypoglycemia. What is the nurse’s first action?

Accepted Answer

Answer reason: An unconscious client with signs of hypoglycemia requires immediate reversal of dangerously low blood glucose to prevent seizures and neurologic injury. If IV access is available, 50% dextrose IV is the fastest effective treatment for severe symptomatic hypoglycemia. Calling the physician delays life-saving care, and CPR is only indicated if the client is pulseless/apneic. Recovery position supports airway protection but does not treat the underlying emergency.

Question 36

A pt is in cardiac arrest. V fib has been refractory to an initial shock. If no pathway for medication administration is in place, which method is preferred?

Accepted Answer

Answer reason: In cardiac arrest with refractory ventricular fibrillation, ACLS prioritizes rapid vascular access to deliver epinephrine and antiarrhythmics; IV access is preferred, and if not immediately available, intraosseous (IO) access is the recommended alternative. Central venous access can delay drug delivery and interrupt CPR, and it is not the preferred initial route during active resuscitation. Endotracheal medication administration is less reliable and no longer preferred when IV/IO access can be obtained. External jugular access may be attempted but is generally less reliable and more interruptive than IV/IO during CPR.

Question 37

What is the indication for the use of Mg in cardiac arrest?

Accepted Answer

Answer reason: Magnesium sulfate is indicated for torsades de pointes (polymorphic ventricular tachycardia associated with prolonged QT), including when it occurs in cardiac arrest as pulseless VT. Mg helps stabilize cardiac myocyte repolarization and suppress early afterdepolarizations that trigger torsades. It is not the primary indicated therapy for shock-refractory VF or monomorphic VT, where defibrillation and antiarrhythmics like amiodarone are standard.

Question 38

You arrive on the scene with the code team. CPR is in progress. An AED previously advised "no shock indicated." A rhythm check now finds asystole. After resuming compressions, which action do you take next?

Accepted Answer

Answer reason: Asystole is a non-shockable rhythm; the priority is high-quality CPR and giving epinephrine as soon as possible. Establishing IV/IO access enables prompt administration of epinephrine while compressions continue. Advanced airway placement (laryngeal airway or endotracheal intubation) should not delay CPR and medication delivery. A pulse check is not indicated outside the scheduled rhythm checks and should not interrupt compressions.

Question 39

A client at 32 weeks with preeclampsia has BP 160/108, 3+ proteinuria, and visual changes. What is the nurse's priority action?

Accepted Answer

Answer reason: Severe features of preeclampsia are present (BP ≥160/110 with visual disturbances and significant proteinuria), placing the client at high risk for eclampsia (seizures) and stroke. The immediate nursing priority is seizure prophylaxis with magnesium sulfate per orders while closely monitoring maternal status. Preparing for delivery may be needed after stabilization, but it is not the first action over preventing imminent seizure. Encouraging oral fluids and delaying reassessment are unsafe and do not address the urgent risk.

Question 40

A woman at 36 weeks with placental abruption has abdominal pain, dark red vaginal bleeding, and uterine rigidity. What is the nursing priority?

Accepted Answer

Answer reason: Placental abruption is an obstetric emergency with risk for rapid maternal hemorrhage and fetal hypoxia. The immediate nursing priorities are to support maternal circulation (large-bore IV access/IV fluids, prepare for blood products as needed) and continuously assess fetal well-being with fetal heart rate monitoring. Fundal massage is for postpartum uterine atony, oral iron is not acute management, and ambulation is unsafe in active bleeding and suspected shock.

Question 41

A client reports chest pain at rest that radiates to the jaw and lasts longer than 20 minutes. ECG shows ST elevation. What is the nurse's priority?

Accepted Answer

Answer reason: ST-segment elevation with prolonged chest pain indicates an acute myocardial infarction requiring rapid reperfusion therapy. Immediate provider notification is essential to initiate emergency interventions such as PCI or thrombolytics.

Question 42

A patient is reporting chest pain and shortness of breath. What is your first action?

Accepted Answer

Answer reason: Chest pain with shortness of breath is a potential acute coronary syndrome or other cardiopulmonary emergency; the immediate nursing priority is to support oxygenation and reduce hypoxemia. Applying oxygen is a rapid, independent intervention that addresses airway/breathing while other assessments and treatments are initiated. Nitroglycerin and calling the provider can follow after quick stabilization and vital sign assessment, and an ECG should be obtained promptly but does not treat the immediate oxygenation problem.

Question 43

A nurse assesses a client post-seizure. What is the most important immediate action?

Accepted Answer

Answer reason: After a seizure, the priority is ABCs because compromised airway patency, hypoventilation, or aspiration can quickly become life-threatening. Immediate assessment of airway and breathing allows prompt positioning, suctioning, or oxygen support if needed. Once respiratory status is stabilized, the nurse can then evaluate for injuries, reorient the client, and document details of the event.

Question 44

A patient is admitted with acute pancreatitis. Which assessment finding requires immediate action?

Accepted Answer

Answer reason: A respiratory rate of 28 with crackles suggests acute respiratory compromise (e.g., pulmonary edema, atelectasis, or evolving ARDS), which can occur as a severe complication of acute pancreatitis and threatens oxygenation. Airway and breathing take priority, so this finding warrants immediate assessment and intervention (oxygen, positioning, rapid provider notification, and possible escalation of care). Nausea/vomiting and abdominal distension are common in pancreatitis but are not as immediately life-threatening as signs of respiratory failure. Cullen’s sign indicates hemorrhagic pancreatitis/retroperitoneal bleeding and is serious, but respiratory compromise requires the most urgent action due to imminent risk of hypoxia.

Question 45

A nurse is caring for a client with Addison's disease. Which finding should be reported to the provider?

Accepted Answer

Answer reason: Addison’s disease (primary adrenal insufficiency) can precipitate adrenal crisis, characterized by severe hypotension/shock due to cortisol and aldosterone deficiency. A blood pressure of 84/50 mmHg is an urgent, potentially life-threatening sign requiring prompt provider notification and intervention (e.g., IV fluids and stress-dose corticosteroids). The other values listed are within or near normal ranges (K 4.5, Na 135, glucose 80) and are not immediately alarming compared with marked hypotension.

Question 46

Preeclampsia Complications A client with preeclampsia suddenly develops seizures. What is the priority nursing action?

Accepted Answer

Answer reason: Seizures in a client with preeclampsia indicate eclampsia, a medical emergency requiring immediate seizure control and prevention of recurrence. Magnesium sulfate is the first-line medication for treating and preventing eclamptic seizures and is prioritized over antihypertensives. Trendelenburg positioning is not appropriate and can worsen respiratory status; a vaginal exam does not address the acute life-threatening problem. Antihypertensives may be needed for severe hypertension, but stabilizing seizures with magnesium is the priority action.

Question 47

A patient with a permanent pacemaker has an ECG showing wide bizarre QRS complexes at a rate of 30/min. What is the nurse's priority action?

Accepted Answer

Answer reason: A ventricular-paced rhythm typically produces wide, bizarre QRS complexes; with a rate of 30/min, the priority is to quickly determine if the pacemaker is capturing and pacing appropriately. Assessing for pacemaker spikes (and whether each spike is followed by a QRS) helps identify pacemaker malfunction such as failure to fire or failure to capture, which guides immediate escalation. Transcutaneous pacing is generally reserved for unstable bradycardia or confirmed ineffective pacing; atropine may be ineffective in high-grade conduction disease and does not address a pacemaker problem. Simply documenting/monitoring is unsafe given the severe bradycardia.

Question 48

A nurse is caring for a pregnant client diagnosed with gestational hypertension. Which finding requires immediate intervention?

Accepted Answer

Answer reason: In a pregnant client with gestational hypertension, significant proteinuria suggests progression to preeclampsia, which can rapidly worsen and lead to maternal and fetal complications (e.g., seizures, stroke, placental abruption). A 4+ dipstick finding indicates marked protein loss and end-organ involvement, requiring urgent evaluation and escalation of care. A BP of 140/90 mmHg meets the threshold for gestational hypertension but is not as immediately concerning as severe preeclampsia features. Mild edema and a headache that resolves with rest are common or less specific and are not the highest priority compared with heavy proteinuria.

Question 49

A client with a spinal cord injury at T6 develops a severe headache, flushed skin, and bradycardia. What should the nurse do first?

Accepted Answer

Answer reason: The symptoms in a client with a spinal cord injury at or above T6 (severe headache, flushing, and bradycardia) are classic for autonomic dysreflexia, a medical emergency. The first priority is to sit the client upright to reduce blood pressure and then assess for and remove the triggering stimulus, most commonly bladder distention from urinary retention or a kinked catheter. Administering analgesics or calling the provider delays immediate, life-saving interventions, and lowering the head of the bed can worsen hypertension and increase stroke risk.

Question 50

A post-operative patient develops hypoxia. What is the immediate nursing intervention?

Accepted Answer

Answer reason: Hypoxia is an acute, potentially life-threatening problem and the first nursing action is to improve ventilation and oxygenation. Raising the head of bed promotes lung expansion and reduces atelectasis risk common post-operatively, while applying supplemental oxygen increases oxygen delivery. The other options either worsen respiratory mechanics (lying flat/supine) or target a less likely immediate cause without first optimizing oxygenation (turning/suctioning unless obstruction/secretions are evident). After oxygen and positioning, reassess oxygen saturation and respiratory status and escalate care if not improving.

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