Question 1

A laboring client on oxytocin infusion has uterine contractions q 1–1.5 min lasting 90 sec with resting tone not returning to baseline; fetal heart tracing shows recurrent late decelerations. What is the nurse’s priority?

Accepted Answer

Answer reason: The pattern describes uterine tachysystole/hyperstimulation with impaired uteroplacental perfusion (late decelerations and no return of resting tone), which is an urgent fetal oxygenation problem. The first priority is to remove the causative agent by discontinuing oxytocin and improve uterine blood flow and maternal-fetal oxygen delivery by left lateral positioning. Continuing oxytocin worsens hypoxia; checking dilation or addressing pain does not treat the immediate fetal compromise. Additional measures (as ordered per protocol) can include IV fluid bolus and oxygen, but stopping oxytocin is the key initial action.
Category reason: This is a labor-and-delivery patient-care scenario requiring immediate nursing intervention to address fetal distress and uterine tachysystole, aligning with urgent physiologic stabilization.

Question 2

After spontaneous rupture of membranes (SROM) in active labor, fetal heart rate drops to 80 bpm. What should the nurse do first?

Accepted Answer

Answer reason: An abrupt severe fetal bradycardia immediately after membrane rupture is a red flag for umbilical cord prolapse or cord compression, which requires rapid confirmation and immediate interventions to relieve pressure. A prompt sterile vaginal examination can identify a prolapsed cord so the nurse can elevate the presenting part and initiate emergency response for expedited delivery. Increasing oxytocin could worsen uterine activity and reduce placental perfusion, and terbutaline is not first-line until a cause such as cord prolapse is assessed. Applying a fetal scalp electrode may improve monitoring but delays addressing a time-critical, potentially life-threatening cause.
Category reason: This is a labor-and-delivery emergency requiring immediate nursing assessment and action to protect fetal oxygenation, which aligns with managing acute clinical emergencies.

Question 3

A client with suspected DVT reports sudden chest pain and shortness of breath. What is the nurse’s priority action?

Accepted Answer

Answer reason: Sudden chest pain and dyspnea in a client with suspected DVT is highly concerning for an acute pulmonary embolism, an immediate threat to airway/breathing/oxygenation. The nurse should implement the most urgent supportive measure first to improve oxygen delivery while additional emergency actions are initiated. After oxygen is started, the nurse should rapidly escalate care (notify the provider/activate emergency response) and prepare for definitive evaluation and treatment.
Category reason: This is a patient-care prioritization question requiring immediate nursing action for a suspected life-threatening complication (pulmonary embolism), which fits Medical Emergencies under Physiological Adaptation.

Question 4

Which assessment finding is most concerning in a patient with diabetic ketoacidosis (DKA)?

Accepted Answer

Answer reason: These are deep, rapid breaths indicating significant metabolic acidosis with respiratory compensation, which is a hallmark of severe DKA and signals physiologic decompensation requiring urgent treatment. The other findings are either expected in hyperglycemia/dehydration (polyuria) or are not consistent with severe DKA (pH 7.35 is normal-low, and glucose 200 mg/dL is only mildly elevated and can occur after partial treatment). Kussmaul breathing also raises concern for worsening acid-base status and impending fatigue/respiratory failure if the underlying acidosis is not corrected promptly.
Category reason: This item asks the nurse to identify the most worrisome clinical assessment finding in an acute, life-threatening condition (DKA), emphasizing recognition of deterioration and urgency of response, which fits Medical Emergencies under Physiological Adaptation.

Question 5

A 32 year-old patient who is 39 weeks pregnant reports a “crushing headache” that has brought her to the emergency room. Shortly after, she begins having a seizure and the RN calls a rapid response, is ordered to administer magnesium sulfate IV, and the patient is sent for an emergency C-section. The goal of the chosen drug therapy is to?

Accepted Answer

Answer reason: D. Halt seizure activity This presentation is consistent with eclampsia (seizure in a patient with severe preeclampsia features such as severe headache). Magnesium sulfate is administered as first-line therapy to prevent and treat eclamptic seizures by reducing neuromuscular excitability. It is not primarily an antihypertensive; blood pressure control is typically managed with agents like labetalol or hydralazine. Cervical ripening or delaying labor are not the purpose in this emergency stabilization scenario.
Category reason: This item tests urgent nursing management of a pregnant patient with seizure activity and the purpose of an emergency medication in a critical event, which aligns with Medical Emergencies under Physiological Adaptation.

Question 6

A patient presents with sudden right-sided weakness, slurred speech, and facial droop. Which intervention should the nurse implement first?

Accepted Answer

Answer reason: Hypoglycemia can mimic acute stroke with focal neurologic deficits and requires rapid bedside confirmation because treatment is immediate and time-sensitive. A point-of-care glucose check is a fast, low-risk action that can identify a reversible cause before proceeding with stroke protocols. If glucose is low, prompt dextrose can quickly improve symptoms and prevent harm; if normal, the team proceeds urgently to imaging and thrombolysis evaluation within the stroke time window.
Category reason: This is an acute neurologic presentation requiring rapid nursing prioritization and immediate emergency assessment to rule out reversible life-threatening causes, which aligns with nursing care in medical emergencies.

Question 7

You are the pediatric RN receiving morning report. Which child do you assess first?

Accepted Answer

Answer reason: Drowsiness and vomiting following a head injury are red-flag signs of increased intracranial pressure or intracranial bleeding. This represents an immediate, potentially life-threatening neurologic emergency requiring urgent assessment and intervention.
Category reason: The question focuses on rapid identification and prioritization of a life-threatening condition requiring immediate action, which aligns with the Medical Emergencies leaf category.

Question 8

A client with a fractured femur develops sudden chest pain and dyspnea. What should the nurse suspect?

Accepted Answer

Answer reason: B. fat embolism A long-bone fracture (such as the femur) can release fat droplets from bone marrow into the bloodstream, leading to acute respiratory distress with sudden dyspnea and chest pain. This presentation is a classic early warning for fat embolism syndrome and requires rapid recognition and escalation of care. Pneumothorax is more associated with chest trauma or procedures, cardiac tamponade with penetrating/blunt cardiac injury, and pulmonary edema is typically related to heart failure or fluid overload rather than an isolated femur fracture.
Category reason: This is a nursing clinical judgment question focused on recognizing an acute complication (a medical emergency) after a long-bone fracture, which aligns with Physiological Adaptation—Medical Emergencies.

Question 9

For a child with epiglottitis, which position is safest until airway is secured?

Accepted Answer

Answer reason: This posture helps maintain airway patency by maximizing airflow and reducing obstruction from the swollen epiglottis, which can rapidly worsen in epiglottitis. Keeping the child calm and upright decreases the risk of sudden airway collapse that can occur with agitation or forced positioning. Supine positioning can increase airway obstruction and respiratory distress, and other positions do not reliably optimize airway mechanics in this emergency while awaiting definitive airway management.
Category reason: This question tests an immediate, safety-focused nursing intervention for a life-threatening airway emergency, which aligns with medical emergency management in Physiological Adaptation.

Question 10

A client is being treated for suspected air embolism. What is the proper position for treatment?

Accepted Answer

Answer reason: This positioning helps trap the air in the right atrium/ventricle apex and reduces the chance it will move into the pulmonary outflow tract, which can worsen obstructive shock. It is an immediate supportive maneuver used while definitive actions (e.g., stopping the source of air, administering 100% oxygen, and notifying the provider/rapid response) are initiated. The left lateral position also promotes venous return patterns that keep the air away from the pulmonary circulation as much as possible.
Category reason: This question tests an urgent nursing intervention for a life-threatening complication (air embolism), focusing on immediate positioning in an emergency situation, which fits Medical Emergencies under Physiological Adaptation.

Question 11

A 10-month-old infant presents with irritability, vomiting, and a bulging fontanel. What is the nurse's initial action?

Accepted Answer

Answer reason: A bulging fontanel with vomiting and irritability is a red-flag constellation suggesting increased intracranial pressure (e.g., meningitis, intracranial hemorrhage, hydrocephalus), which requires urgent evaluation and intervention. The nurse’s priority is rapid escalation to prevent neurologic deterioration and potential herniation. Supportive measures like fluids or antipyretics do not address the life-threatening cause and could delay definitive care. Elevating the legs can worsen venous return from the head and is not appropriate in suspected increased intracranial pressure.
Category reason: This item tests immediate nursing action in a potentially life-threatening pediatric presentation requiring urgent escalation, which aligns with recognizing and responding to a medical emergency in Physiological Adaptation.

Question 12

What is the priority nursing diagnosis for a client with a pelvic fracture?

Accepted Answer

Answer reason: D. Risk for hemorrhage Pelvic fractures can disrupt major pelvic vessels and lead to rapid, life-threatening internal bleeding, making circulation and perfusion the immediate priority. Early nursing focus is on recognizing signs of shock (tachycardia, hypotension, cool clammy skin, decreasing level of consciousness) and initiating/emphasizing urgent hemorrhage control and resuscitation support. Pain, urinary complications, and infection are important but are secondary to stabilizing hemodynamics and preventing death from exsanguination.
Category reason: This is a patient-care prioritization question centered on the most life-threatening complication of a pelvic fracture and the nurse’s immediate clinical judgment, fitting NCLEX Medical Emergencies under Physiological Adaptation.

Question 13

A patient is 2 hours post-thyroidectomy and begins showing signs of respiratory distress. What should the nurse do?

Accepted Answer

Answer reason: B. Place the client in Fowler's and call physician Respiratory distress shortly after thyroidectomy suggests a potential airway-compromising complication such as neck hematoma, laryngeal edema, or laryngospasm from hypocalcemia. Positioning upright (Fowler’s) optimizes airway patency and ventilation while urgent provider notification initiates rapid evaluation and possible intervention (e.g., airway management or wound decompression). Lying flat can worsen airway obstruction, and elevating the legs does not address the primary threat. Turning the head toward the incision is not an airway-preserving intervention and can delay emergent management.
Category reason: This is a postoperative nursing emergency requiring immediate airway-focused intervention and escalation of care, which aligns with Medical Emergencies under Physiological Adaptation.

Question 14

During a central line dressing change, the patient begins to cough and reports chest pain. The nurse suspects air embolism. What is the priority position?

Accepted Answer

Answer reason: Air embolism is an acute medical emergency most commonly related to central venous access; positioning aims to trap air in the right atrium/ventricle and prevent it from entering the pulmonary circulation. Placing the client in left lateral decubitus with Trendelenburg (Durant maneuver) helps keep the air in the apex of the right ventricle where it is less likely to obstruct outflow. This position is prioritized while activating emergency response, administering high-flow oxygen, and preparing for further interventions such as aspiration via the central line if ordered.
Category reason: This item tests immediate nursing action in response to a suspected life-threatening complication of a central line (air embolism), which is a medical emergency requiring rapid positioning and stabilization—best mapped to NCLEX Physiological Adaptation: Medical Emergencies.

Question 15

A nurse notes a prolapsed umbilical cord during a vaginal exam. What is the priority nursing action?

Accepted Answer

Answer reason: These positions use gravity to reduce fetal pressure on the prolapsed cord, improving umbilical blood flow and fetal oxygenation while preparations are made for urgent delivery. This is the fastest, safest initial nursing action to decrease cord compression. Pushing the cord back increases vasospasm and trauma risk, and covering with dry gauze can dry and injure the cord (it should be kept warm and moist if needed). Fundal pressure can worsen cord compression and fetal compromise.
Category reason: This is an obstetric emergency requiring immediate nursing interventions to prevent fetal hypoxia, which fits Physiological Adaptation → Medical Emergencies.

Question 16

A client diagnosed with ectopic pregnancy has sudden shoulder pain and dizziness. What is the nurse’s priority?

Accepted Answer

Answer reason: A. Prepare for emergency surgery Sudden shoulder pain with dizziness in a client with ectopic pregnancy suggests intraperitoneal bleeding causing diaphragmatic irritation and possible hypovolemic shock from rupture. This is an immediate, life-threatening emergency requiring rapid escalation and definitive surgical management to control hemorrhage. The other options do not address the underlying hemorrhage and would delay life-saving treatment.
Category reason: This is a time-critical nursing priority in a suspected ruptured ectopic pregnancy requiring emergency response and escalation of care, which aligns with Medical Emergencies under Physiological Adaptation.

Question 17

Which symptom in a client with atrial fibrillation requires immediate intervention?

Accepted Answer

Answer reason: Acute confusion can indicate decreased cerebral perfusion or an acute thromboembolic stroke, which is a life-threatening complication of atrial fibrillation. This represents a sudden change in neurologic status and requires rapid assessment and emergency response to preserve brain function. In contrast, an irregular pulse and palpitations are expected findings in atrial fibrillation, and fatigue is common but not typically immediately life-threatening without other signs.
Category reason: This is a priority clinical judgment question about recognizing an emergent complication (possible stroke/poor perfusion) in a client with atrial fibrillation, which fits NCLEX Medical Emergencies rather than foundational science.

Question 18

A nurse is caring for a client with thyroid storm. Which order should the nurse question?

Accepted Answer

Answer reason: A. Administer aspirin for fever Aspirin is avoided in thyroid storm because salicylates can displace thyroid hormone from binding proteins, increasing free T3/T4 levels and potentially worsening thyrotoxicosis. Fever management should instead use acetaminophen and external cooling. Continuous cardiac monitoring and beta-blockade are appropriate due to high risk of tachyarrhythmias and cardiovascular collapse. Cooling measures are supportive care to reduce hyperthermia and metabolic demand.
Category reason: This item tests nursing judgment in responding to an acute endocrine crisis (thyroid storm) by identifying an unsafe provider order and appropriate emergency supportive measures, which aligns with Medical Emergencies under Physiological Adaptation.

Question 19

A pregnant woman at 36 weeks with preeclampsia has a sudden onset of severe epigastric pain and nausea. What should the nurse do first?

Accepted Answer

Answer reason: C. Notify the provider immediately Severe epigastric/RUQ pain with nausea in a client with preeclampsia can signal hepatic involvement (e.g., HELLP syndrome or impending eclampsia), which is an obstetric emergency. The priority is rapid escalation for immediate evaluation and potential urgent interventions (labs, magnesium sulfate, stabilization, and planning for delivery as indicated). Antacids or diet changes risk delaying care, and preparing for delivery may be necessary but should follow immediate provider notification to coordinate emergent management.
Category reason: This question tests the nurse’s urgent action and escalation in a high-risk obstetric complication, emphasizing emergency recognition and immediate provider notification rather than foundational physiology.

Question 20

Respiratory Distress Syndrome (RDS) in Preterm Newborn A preterm newborn is in respiratory distress. What is the priority nursing action?

Accepted Answer

Answer reason: B) Administer surfactant Surfactant deficiency is the primary cause of RDS in preterm newborns, leading to alveolar collapse, decreased lung compliance, and impaired gas exchange. Early surfactant therapy (along with appropriate respiratory support) addresses the underlying pathophysiology and rapidly improves oxygenation and ventilation. IV fluids and breastfeeding do not correct the immediate respiratory failure, and thermoregulation is important but secondary to stabilizing breathing and oxygenation in acute distress.
Category reason: This item asks for the priority nursing action in an acute neonatal respiratory crisis, requiring immediate patient-care decision-making and stabilization rather than testing basic pulmonary science alone.

Question 21

A client with left-sided heart failure suddenly becomes anxious and develops pink frothy sputum. What is the priority?

Accepted Answer

Answer reason: C. Administer oxygen and raise head of bed The presentation suggests acute pulmonary edema with severe impaired gas exchange, so immediate airway/breathing support is the priority. High-flow oxygen and positioning upright reduce work of breathing and improve oxygenation by decreasing venous return and improving ventilation. Other actions (provider notification, diuretics, morphine) are important but are secondary to stabilizing oxygenation first and should follow once the client is supported and monitored. Foley placement does not address the life-threatening hypoxia.
Category reason: This is a nursing priority question requiring immediate emergency interventions to stabilize a client with suspected acute pulmonary edema, which fits Medical Emergencies under Physiological Adaptation.

Question 22

A nurse is caring for a client with Addisonian crisis. What is the priority intervention?

Accepted Answer

Answer reason: Addisonian crisis is an acute adrenal insufficiency that can rapidly progress to shock due to severe cortisol deficiency and volume depletion. Priority care is rapid IV glucocorticoid replacement (hydrocortisone) plus aggressive isotonic fluid resuscitation to restore perfusion and support blood pressure. Oral prednisone is too slow and unreliable in an emergency, and simply encouraging oral fluids is inadequate given potential hypotension and vomiting. Dialysis is not a standard immediate intervention for this condition.
Category reason: This is an acute, life-threatening endocrine emergency requiring immediate nursing intervention to prevent cardiovascular collapse, fitting Physiological Adaptation → Medical Emergencies.

Question 23

Postpartum Hemorrhage Priority Intervention A client is experiencing postpartum hemorrhage. What is the priority nursing action?

Accepted Answer

Answer reason: B) Massage the fundus Postpartum hemorrhage is most commonly caused by uterine atony, and immediate uterine fundal massage helps stimulate uterine contraction to reduce bleeding at the source. This is a rapid, independent nursing intervention that can be initiated while calling for help and preparing additional therapies. Checking blood pressure is important for assessment but does not treat the bleeding, and medications or transfusion preparation are subsequent actions that typically require provider orders and additional time.
Category reason: This is an acute obstetric emergency requiring immediate nursing intervention to control hemorrhage and prevent shock, aligning with Physiological Adaptation—Medical Emergencies.

Question 24

The nurse is monitoring a client after a thyroidectomy. Which symptom is most concerning?

Accepted Answer

Answer reason: These findings suggest acute airway compromise after thyroid surgery, commonly from laryngeal edema, hematoma compressing the trachea, or recurrent laryngeal nerve injury. Stridor is an emergency sign of upper-airway obstruction and can rapidly progress to respiratory failure. This requires immediate assessment of airway patency, inspection for neck swelling, and rapid activation of emergency response with preparation for airway management. The other options are common, less urgent postoperative symptoms that do not indicate imminent airway obstruction.
Category reason: This question tests recognition of a potentially life-threatening postoperative complication (airway obstruction) and the need for urgent nursing response, which fits Physiological Adaptation—Medical Emergencies.

Question 25

A client is admitted to the emergency department by emergency medical services after having seriously lacerated both wrists. Which action should the nurse perform first?

Accepted Answer

Answer reason: Life-threatening problems are addressed first using ABCs and physiologic stabilization, especially with serious bilateral wrist lacerations where hemorrhage and shock are immediate risks. Rapid assessment and intervention (bleeding control, neurovascular checks, IV access as indicated) prevents deterioration before moving to longer assessments. Psychosocial support and crisis resources are essential but come after urgent medical stabilization to ensure safety.
Category reason: This is a prioritization question requiring immediate nursing action in an acute self-harm presentation, emphasizing emergent physiologic stabilization rather than foundational science knowledge.

Question 26

A 22-year-old client with a closed head injury becomes more drowsy, has sluggish pupillary response, and begins vomiting without nausea. BP 182/60, HR 48, irregular respirations. Which order should the nurse question?

Accepted Answer

Answer reason: The assessment findings indicate increased intracranial pressure with possible herniation risk (Cushing response: widened pulse pressure, bradycardia, irregular respirations) requiring emergent stabilization. Targeting a specific PaCO₂ is a ventilator/ABG-driven intervention and can be unsafe if it delays immediate airway and neurologic emergency management; intentional hyperventilation is generally reserved for acute deterioration as a short-term temporizing measure under close monitoring. In contrast, head-of-bed elevation with neutral neck alignment promotes venous drainage and is appropriate, and mannitol is a standard hyperosmolar therapy when ordered and not contraindicated (e.g., severe hypotension/renal failure). Therefore this order is the one the nurse should question in this context.
Category reason: This item tests urgent nursing judgment in a neurologic emergency (recognizing increased ICP/Cushing’s triad and evaluating the safety/appropriateness of ordered interventions), which fits NCLEX patient-care decision making under Medical Emergencies.

Question 27

The nurse is caring for a client with type 1 Diabetes Mellitus who is obtunded and responding only to painful stimuli. A STAT blood sample reveals a blood glucose level of 38 mg/dL (2.11 mmol/L). Which initial action by the nurse is best?

Accepted Answer

Answer reason: The client has severe symptomatic hypoglycemia (BG 38 mg/dL) with depressed level of consciousness, so oral carbohydrates are unsafe due to aspiration risk. Immediate treatment is needed to raise serum glucose; if IV dextrose is not offered as an option, IM glucagon is the appropriate emergent intervention. Further assessments (vital signs, observing symptoms) should not delay definitive treatment. After glucose is corrected and the client is awake, follow-up with oral carbohydrate and evaluation of the cause are appropriate.
Category reason: This is a patient-care priority question requiring urgent nursing action for a life-threatening hypoglycemic episode, which fits NCLEX medical emergency management under Physiological Adaptation.

Question 28

A client with type 1 diabetes has a blood glucose of 55 mg/dL and is confused. Which action is most appropriate?

Accepted Answer

Answer reason: A blood glucose of 55 mg/dL with confusion indicates symptomatic hypoglycemia requiring immediate rapid glucose to prevent progression to seizure or coma. The 15-15 rule (15 g rapid carbohydrate, recheck in 15 minutes) is first-line when the client is conscious and can safely take oral intake. Glucagon is typically reserved for severe hypoglycemia when the client cannot safely swallow or is unconscious. Protein alone is too slow to correct acute hypoglycemia, and waiting without treatment is unsafe.
Category reason: This item tests urgent nursing action for symptomatic hypoglycemia (a time-sensitive complication), which is managed as a medical emergency requiring immediate intervention and reassessment.

Question 29

A nurse notes nasal flaring, grunting, and intercostal retractions in a newborn. What is the nurse’s first priority?

Accepted Answer

Answer reason: These are classic signs of neonatal respiratory distress, so airway/breathing support is the immediate priority to prevent hypoxemia and deterioration. Providing supplemental oxygen is a rapid, nurse-initiated intervention that directly treats impaired gas exchange while further assessment and escalation occur. Suctioning may be appropriate if secretions are obstructing, but without evidence of obstruction it does not address the primary problem as reliably as oxygenation. Notifying the provider and thermoregulation are important, but they follow immediate stabilization of breathing.
Category reason: This item tests urgent nursing action in response to newborn respiratory distress (prioritization and immediate stabilization), which aligns with NCLEX Physiological Adaptation—Medical Emergencies.

Question 30

A nurse is reviewing the electronic fetal monitor (EFM) tracing of a client who is in labor and has ruptured membranes. Which of the following findings should alert the nurse to the possibility of a cord prolapse?

Accepted Answer

Answer reason: After rupture of membranes, cord prolapse can lead to acute umbilical cord compression, causing abrupt decreases in fetal oxygenation. This typically presents as severe variable decelerations and can be accompanied by fetal bradycardia due to compromised perfusion. This pattern is an obstetric emergency requiring immediate interventions to relieve pressure on the cord and expedite delivery if not rapidly corrected.
Category reason: This question tests recognition of an acute intrapartum complication on fetal monitoring and the need to respond to a potential obstetric emergency, which aligns with Physiological Adaptation—Medical Emergencies.

Question 31

Ana's postoperative vital signs are a blood pressure of 80/50 mm Hg, a pulse of 140, and respirations of 32. Suspecting shock, which of the following orders would the nurse question?

Accepted Answer

Answer reason: D. Administer Demerol 50mg IM q4h In suspected shock, immediate priorities are airway/oxygenation, circulation support, and close monitoring of organ perfusion. An IM opioid can worsen hypotension via vasodilation and may further depress ventilation in a patient already tachypneic, and IM absorption can be unreliable with poor peripheral perfusion. The other orders support stabilization: positioning to improve venous return, high-flow oxygen, and hourly urine output to assess renal perfusion and response to treatment.
Category reason: This question tests nursing judgment in an acute hemodynamic instability scenario (suspected shock) and asks which provider order to question for patient safety, which aligns with managing medical emergencies.

Question 32

A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notes 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action?

Accepted Answer

Answer reason: A sudden output of 200 mL of dark red drainage after repositioning in a post-lobectomy trauma patient can indicate active intrathoracic bleeding or disruption of a vessel/surgical site, which requires urgent provider evaluation. Clamping can precipitate a tension pneumothorax and may worsen respiratory/hemodynamic compromise. Preparing for transfusion is not the first independent action without immediate escalation and assessment of ongoing bleeding and instability. Continued monitoring alone delays intervention when the amount and appearance suggest a potentially emergent complication.
Category reason: This item tests urgent nursing recognition and escalation for potentially life-threatening postoperative/trauma chest tube drainage, which is a patient-care emergency response decision.

Question 33

A pre-school age child is admitted with a febrile seizure. The practical nurse (PN) obtains an oral temperature of 104.2° F (40.1° C) during the morning assessment. Which action should the PN prepare to implement?

Accepted Answer

Answer reason: A very high fever in a child with febrile seizure history requires prompt, safe cooling measures while avoiding interventions that increase metabolic demand. Tepid sponging can help lower temperature without triggering intense peripheral vasoconstriction and shivering that may occur with cold exposure. Removing blankets during shivering or using a fan can worsen shivering and raise heat production. Diaphoresis is a natural cooling response and does not indicate a need to add blankets.
Category reason: This item tests nursing actions to manage hyperthermia in an acute pediatric seizure-related situation, focusing on immediate interventions and safety rather than underlying biomedical mechanisms.

Question 34

A child with asthma presents with severe wheezing, tachypnea, and use of accessory muscles. What's your priority nursing action?

Accepted Answer

Answer reason: The presentation suggests an acute asthma exacerbation with increased work of breathing, so the immediate priority is to relieve bronchospasm and improve ventilation. A short-acting beta2-agonist via nebulizer provides rapid bronchodilation and is first-line for acute symptoms. Notifying the provider can occur concurrently/after initial stabilization, but treatment should not be delayed. Peak flow measurement and deep breathing exercises are not priority in severe distress and may be unreliable or worsen fatigue.
Category reason: This is a priority patient-care decision in an acute respiratory situation requiring immediate nursing intervention, which fits NCLEX Physiological Adaptation focusing on medical emergencies.

Question 35

A nurse is assisting with the delivery of a client who has a breech presentation. The nurse notices that the umbilical cord is protruding from the vagina. Which of the following actions should the nurse take first?

Accepted Answer

Answer reason: Cord prolapse is an obstetric emergency because the presenting part can compress the cord, rapidly reducing fetal oxygenation. The immediate priority is to manually elevate the presenting part off the cord to relieve compression while maintaining that position until definitive delivery (often emergent cesarean) is possible. Maternal positioning and supplemental oxygen are supportive but do not directly and immediately relieve the cord occlusion. Clamping/cutting the prolapsed cord would worsen fetal hypoxia and is contraindicated.
Category reason: This item tests urgent nursing actions to manage an obstetric emergency (umbilical cord prolapse) to prevent fetal compromise, which is a patient-care emergency response scenario.

Question 36

You find an unresponsive patient who is not breathing. After activating the emergency response system, you determine that there is no pulse. What is your next action?

Accepted Answer

Answer reason: In a pulseless, apneic adult, the priority is immediate high-quality CPR to generate minimal circulation and improve survival. Current BLS sequence emphasizes starting compressions promptly after confirming no pulse, then integrating ventilation and AED/defibrillation as available. Airway maneuvers and rescue breaths are secondary once cardiac arrest is identified, and the epinephrine dose listed is incorrect for adult cardiac arrest.
Category reason: This question tests the nurse’s immediate action in a cardiac arrest scenario (BLS sequence and prioritization of CPR), which is an emergency response decision under Medical Emergencies.

Question 37

You are evaluating a 58-year-old man with chest pain. The blood pressure is 92/50 mm Hg, the heart rate is 92/min, the nonlabored respiratory rate is 14 breaths/min, and the pulse oximeter reading is 97%. What assessment step is most important now?

Accepted Answer

Answer reason: This presentation suggests possible acute coronary syndrome, and the most time-critical assessment is a 12-lead ECG to detect STEMI or ischemia and guide immediate reperfusion decisions. Hypotension increases concern for cardiogenic compromise, making rapid cardiac rhythm/ischemia assessment essential. Chest x-ray and labs can be obtained after the ECG because they do not as directly and immediately determine emergent cardiac management. PETCO2 is not the priority in a spontaneously breathing patient with normal oxygenation and no ventilation concern.
Category reason: This question tests urgent assessment and decision-making for suspected acute coronary syndrome, which is an emergency condition requiring rapid nursing/clinical prioritization and fits Medical Emergencies.

Question 38

Mother at 36 weeks present in labor cervix 5 cm open cord prolapsed baby is at -1 station what is the best option?

Accepted Answer

Answer reason: A. C section Umbilical cord prolapse is an obstetric emergency because cord compression can rapidly cause fetal hypoxia. With the cervix only 5 cm dilated and the presenting part at -1 station, an operative vaginal delivery is not feasible or safe, and waiting risks worsening compression. The definitive management is urgent delivery by cesarean while simultaneously relieving pressure on the cord (e.g., elevating the presenting part, knee-chest position, oxygen as indicated).
Category reason: This item tests urgent nursing/clinical decision-making for an intrapartum obstetric emergency (cord prolapse) requiring rapid, safe delivery planning, fitting Medical Emergencies under Physiological Adaptation.

Question 39

The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. Which action should receive priority?

Accepted Answer

Answer reason: Severe burns involving the face and neck raise immediate concern for inhalation injury and rapidly progressive airway edema, making airway and breathing the first priority (ABCs). High-flow oxygen supports oxygenation and treats potential carbon monoxide exposure while preparations for airway management are made. IV access, labs such as ABGs, and analgesia are important but should follow initial stabilization of airway and ventilation.
Category reason: This is an emergency nursing prioritization question using ABCs to determine the first intervention for a patient with burns and suspected inhalation injury, which fits Medical Emergencies under Physiological Adaptation.

Question 40

A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons?

Accepted Answer

Answer reason: Mannitol is an osmotic diuretic used in acute neurologic deterioration from increased intracranial pressure by raising serum osmolality and shifting water out of cerebral tissue, reducing cerebral edema and ICP. The client’s restlessness, confusion, and ipsilateral pupil dilation suggest rising ICP with possible herniation risk, making rapid ICP reduction the priority. Intraocular pressure reduction is a separate indication (e.g., acute glaucoma), not the primary goal here. Preventing acute tubular necrosis or raising blood pressure are not the therapeutic intent of mannitol in this context and can be unsafe if it causes intravascular volume shifts or renal strain.
Category reason: This question centers on an urgent intervention for suspected increased intracranial pressure in a neurologic emergency, requiring nursing understanding of the treatment goal and patient safety monitoring, which aligns with Physiological Adaptation—Medical Emergencies.

Question 41

A nurse is caring for a preterm newborn immediately after delivery. Which of the following actions should the nurse take first?

Accepted Answer

Answer reason: Preterm newborns are at high risk for heat loss due to a large surface-area-to-weight ratio, thin skin, and limited brown fat stores. Immediate drying and providing external heat helps prevent cold stress, which increases oxygen consumption and can precipitate hypoglycemia and respiratory compromise. Temperature, weight, and glucose assessment are important but should occur after initial thermoregulation is established.
Category reason: This item tests immediate priority nursing actions for stabilizing a vulnerable newborn after birth, emphasizing emergency physiologic support rather than recall of foundational science.

Question 42

What should be done to minimize interruptions in chest compressions during CPR?

Accepted Answer

Answer reason: High-quality CPR emphasizes minimizing pauses in compressions because interruptions reduce coronary and cerebral perfusion pressure and worsen outcomes. Charging the defibrillator can be done while compressions continue, then compressions are paused only briefly for rhythm check and shock delivery when indicated. This approach decreases hands-off time and supports more effective resuscitation compared with strategies that add unnecessary pauses.
Category reason: This question tests immediate resuscitation actions to optimize CPR performance during a cardiac arrest, which is a medical emergency requiring nursing clinical judgment and intervention.

Question 43

A client has a chest tube inserted for the treatment of a pneumothorax. While turning in the bed, the client dislodges the tube and it is found on the bed. As the registered nurse is directing the health care team, place the actions of the registered nurse in the correct order. All options must be used.?

Accepted Answer

Answer reason: This is a chest-tube dislodgement emergency where immediate action is needed to prevent air entry and worsening pneumothorax. The first priority is to seal the open chest wound with an occlusive dressing to reduce intrathoracic air movement and stabilize breathing. After immediate containment, the nurse should rapidly assess respiratory status and vital signs, notify the provider, and follow further orders based on the client’s stability.
Category reason: This tests urgent nursing actions and prioritization during an acute complication of therapy (dislodged chest tube), which is managed as a medical emergency under Physiological Adaptation.

Question 44

WHAT IS THE NURSE'S PRIORITY INTERVENTION FOR A CHILD EXPERIENCING A CYANOTIC SPELL?

Accepted Answer

Answer reason: This is the immediate action for a hypercyanotic (tet) spell because it increases systemic vascular resistance, which reduces right-to-left shunting and improves pulmonary blood flow and oxygenation. It is a rapid, bedside maneuver that can be initiated while preparing additional supportive measures such as calming the child and administering oxygen as ordered. The other options do not address the acute pathophysiology of sudden hypoxemia during a cyanotic spell and may delay life-saving stabilization.
Category reason: This is a priority nursing intervention during an acute, potentially life-threatening episode of hypoxemia, which fits emergency clinical management and physiologic adaptation rather than foundational science.

Question 45

A client who delivered vaginally 2 hours ago has saturated two perineal pads in 30 minutes. What is the next step?

Accepted Answer

Answer reason: Heavy bleeding (soaking two pads in 30 minutes) at 2 hours postpartum is abnormal and suggests early postpartum hemorrhage, most commonly due to uterine atony. The immediate nursing priority is to assess uterine tone and intervene by massaging the uterus to promote contraction and reduce bleeding while quickly escalating care if bleeding persists. Pain medication, ambulation/fluids, or documenting as normal would delay recognition and treatment of a potentially life-threatening hemorrhage.
Category reason: This is a postpartum patient-care emergency requiring immediate nursing assessment and intervention to manage acute hemorrhage risk, which aligns with NCLEX Physiological Adaptation focusing on medical emergencies.

Question 46

A 54-year-old patient with pneumonia is febrile (39.2°C), HR 112, BP 98/60, and RR 24. The nurse notes cold, clammy skin and confusion. What is the most appropriate action?

Accepted Answer

Answer reason: The presentation (fever, tachycardia, hypotension, tachypnea, cold clammy skin, and confusion) is concerning for sepsis with evolving shock, where immediate support of oxygenation and perfusion is the priority (ABCs). Supplemental oxygen helps correct or prevent hypoxemia from pneumonia and improves tissue oxygen delivery while escalation of care (rapid response/IV access/fluids/antibiotics per protocol) is initiated. Antipyretics and oral fluids do not address the immediate threat, and Trendelenburg is not recommended for shock due to limited benefit and potential to worsen respiratory mechanics.
Category reason: This is a time-sensitive clinical deterioration scenario requiring immediate nursing action based on ABCs and recognition of sepsis/shock, which fits Medical Emergencies under Physiological Adaptation.

Question 47

A diabetic client has a blood glucose of 48 mg/dL. What is the nurse’s first action?

Accepted Answer

Answer reason: A blood glucose of 48 mg/dL is clinically significant hypoglycemia and requires immediate treatment to prevent neurologic injury and seizures. If the client is conscious and able to swallow, the priority first action is the “15-15 rule”: provide 15 g of rapid-acting carbohydrate and recheck glucose in about 15 minutes, repeating as needed. Administering insulin would worsen hypoglycemia, and notifying the provider or starting an IV can follow after stabilization or if the patient cannot take oral glucose (then IV dextrose or glucagon is indicated).
Category reason: This item tests urgent nursing prioritization and immediate intervention for a life-threatening hypoglycemic event, which aligns with emergency physiologic management rather than foundational science content.

Question 48

In which clinical scenario should bag-and-mask ventilation be avoided or used with extra caution in a neonate? (AIIMS NORCET 2025 Mains)?

Accepted Answer

Answer reason: Positive-pressure bag-mask ventilation can insufflate the stomach and intestines, worsening distension in the thorax and further compressing the hypoplastic lungs in this condition. This can rapidly deteriorate ventilation and oxygenation and increase the risk of barotrauma. Initial management prioritizes endotracheal intubation with gastric decompression (orogastric tube) rather than mask ventilation.
Category reason: This item tests a high-stakes neonatal resuscitation intervention decision (when to avoid bag-mask ventilation for safety), which is a patient-care emergency response scenario under Physiological Adaptation/Medical Emergencies.

Question 49

A nurse is assessing a patient’s vital signs. Which of the following findings should be reported to the healthcare provider immediately?

Accepted Answer

Answer reason: B. Respiratory rate of 8 breaths per minute This is significant bradypnea and can indicate impending respiratory failure, opioid/sedative effect, or neurologic depression, placing the patient at immediate risk for hypoxia and arrest. It requires prompt assessment of airway and breathing, pulse oximetry, level of consciousness, and rapid escalation to the provider/rapid response per facility policy. The other findings listed are within normal adult ranges and are not typically urgent.
Category reason: This question tests nursing recognition of an acutely dangerous vital-sign abnormality requiring immediate escalation, which is a patient-safety and emergency response judgment under Physiological Adaptation.

Question 50

Which of the following artificial ventilation mode is best suitable for a patient with respiratory arrest?

Accepted Answer

Answer reason: In respiratory arrest the patient has absent or ineffective spontaneous breathing, so full ventilatory support with a set rate and tidal volume/pressure is required. This mode ensures adequate minute ventilation regardless of patient effort, which is essential during apnea. CPAP and other noninvasive positive pressure options rely on spontaneous respirations and are therefore inappropriate in true respiratory arrest. Assist-control can provide full support as well, but controlled mandatory ventilation is the most direct match when there is no spontaneous effort.
Category reason: This item tests appropriate ventilator mode selection in an acute life-threatening clinical condition (respiratory arrest), which is a patient-care emergency management decision under Physiological Adaptation.

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