Question 1

Scenario: A patient receiving IV antibiotics suddenly develops wheezing and facial swelling. What is the nurse's priority action?

Accepted Answer

Answer reason: This presentation suggests an acute anaphylactic reaction with airway compromise risk. The first priority is to remove the trigger by stopping the IV antibiotic and support/secure the airway using ABCs, because respiratory obstruction can progress rapidly. Antihistamines and oxygen can be adjuncts, but they do not address the ongoing exposure and are not sufficient if the airway is threatened. Notifying the provider is important after immediate life-saving actions are initiated.
Category reason: This question tests immediate nursing actions in response to a suspected anaphylactic emergency, requiring ABC prioritization and rapid intervention rather than foundational biomedical knowledge, fitting NCLEX Medical Emergencies.

Question 2

A client with infective endocarditis suddenly develops left leg pain, pallor, and no pedal pulse. What should the nurse do first?

Accepted Answer

Answer reason: The sudden onset of limb pain, pallor, and absent distal pulse in a client with infective endocarditis strongly suggests an acute arterial occlusion from septic embolization, which is limb-threatening. This is a time-sensitive emergency requiring immediate medical/surgical evaluation for reperfusion (e.g., anticoagulation and/or embolectomy) and to prevent tissue necrosis. Interventions like elevation, warming, or massage can worsen ischemia or potentially dislodge embolic material and delay definitive care.
Category reason: This question tests immediate nursing action in response to signs of acute arterial occlusion and potential embolic complication, emphasizing urgent escalation and emergency management rather than underlying biomedical facts.

Question 3

Which sign indicates sepsis in a neonate?

Accepted Answer

Answer reason: Neonatal sepsis often presents with nonspecific systemic signs such as decreased feeding, lethargy, temperature instability, and poor perfusion. A well-appearing pink color and stable temperature suggest physiologic stability rather than systemic infection. A present startle reflex is a normal neurologic finding and does not indicate sepsis. Therefore, reduced feeding with lethargy is the most concerning sign for neonatal sepsis among the options.
Category reason: This item tests recognition of an acute, potentially life-threatening condition (neonatal sepsis) requiring urgent nursing assessment and response, aligning with Physiological Adaptation and medical emergencies.

Question 4

A client with myasthenia gravis is having difficulty breathing and swallowing. What is the priority nursing action?

Accepted Answer

Answer reason: Myasthenia gravis can rapidly progress to myasthenic crisis with respiratory muscle weakness and impaired airway protection from dysphagia. Airway and breathing take priority because hypoventilation and aspiration can quickly become life-threatening. Immediate assessment of respiratory status (e.g., work of breathing, oxygenation, ability to handle secretions) and readiness for ventilatory support is the safest action. Oral medications are unsafe when swallowing is compromised and are not the first priority when ventilation may fail.
Category reason: This item tests immediate nursing prioritization and emergency airway/respiratory management in an unstable client, which aligns with Medical Emergencies under Physiological Adaptation.

Question 5

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 to fibrinolytic therapy. Which treatment is best?

Accepted Answer

Answer reason: Within the treatment window for acute ischemic stroke, rapid thrombolysis improves neurologic outcomes when intracranial hemorrhage has been excluded and there are no contraindications. A non-contrast CT ruling out bleeding is the key precondition to proceed without delay. Waiting for additional testing or delaying 24 hours risks loss of salvageable brain tissue and worsened functional recovery. An echocardiogram may be useful later to evaluate embolic sources but should not postpone time-sensitive reperfusion therapy.
Category reason: This item tests urgent nursing/clinical decision-making for an acute stroke scenario, focusing on time-sensitive emergency treatment after ruling out hemorrhage, which aligns with Medical Emergencies under Physiological Adaptation.

Question 6

A client with severe burns over the face and chest is having difficulty breathing. What is the most appropriate position?

Accepted Answer

Answer reason: This presentation suggests potential inhalation injury and/or chest wall restriction from burns, making airway and ventilation the priority. Upright positioning maximizes chest expansion, decreases work of breathing, and helps maintain airway patency. Supine or prone positions can worsen ventilation and make airway management more difficult, while side-lying is not the best position for optimizing oxygenation in acute respiratory distress.
Category reason: This question tests an immediate nursing intervention (positioning) to support breathing in an acute, potentially life-threatening burn/inhalation scenario, which fits Medical Emergencies.

Question 7

During a vaginal delivery, the client's umbilical cord prolapses. What is the emergency position?

Accepted Answer

Answer reason: C. Knee-chest or extreme Trendelenburg Umbilical cord prolapse is an obstetric emergency because the presenting part can compress the cord, rapidly reducing fetal oxygenation. Positions that use gravity to elevate the presenting part off the cord help restore/maintain cord blood flow while preparing for definitive management (often urgent cesarean birth). Knee-chest and extreme Trendelenburg are specifically used to relieve cord compression and improve fetal perfusion. Other listed positions do not effectively offload the presenting part and can worsen compression.
Category reason: This item tests immediate nursing action during an acute intrapartum emergency to reduce fetal hypoxia risk, which fits Medical Emergencies under Physiological Adaptation.

Question 8

A 32-week pregnant client with sickle cell disease presents in pain crisis. What is the first nursing intervention?

Accepted Answer

Answer reason: Sickle cell pain crisis involves vaso-occlusion that worsens with dehydration and hypoxemia, so immediate supportive care targets perfusion and oxygen delivery. Isotonic IV fluids help reduce blood viscosity and improve microcirculatory flow, while supplemental oxygen addresses any hypoxia and decreases further sickling risk. Tocolytics are only indicated if preterm labor is confirmed, oral iron does not treat acute crisis, and cesarean preparation is not a first-line response without obstetric indications or fetal/maternal instability.
Category reason: This is a patient-care priority question asking for the first nursing intervention in an acute complication (sickle cell crisis) during pregnancy, which requires urgent clinical judgment and stabilization actions.

Question 9

A nurse is caring for a patient with hypoglycemia who is unconscious. What is the next step?

Accepted Answer

Answer reason: An unconscious patient cannot safely swallow, so oral glucose risks aspiration and will not reliably correct the emergency. Severe hypoglycemia is an immediate threat to the brain and requires rapid IV correction with dextrose (or glucagon if IV access is not available). Insulin infusion would worsen hypoglycemia, and delaying treatment to monitor is unsafe.
Category reason: This question tests immediate nursing action for an acute, life-threatening condition requiring rapid stabilization, which aligns with Medical Emergencies under Physiological Adaptation.

Question 10

Scenario: During labor, the nurse notices a prolapsed umbilical cord. Q. What is the priority intervention?

Accepted Answer

Answer reason: A prolapsed cord is an obstetric emergency because cord compression rapidly reduces fetal oxygenation. The immediate nursing action is to relieve pressure on the cord by manually elevating the presenting part while activating the emergency response for expedited birth. This intervention directly addresses the life-threatening pathophysiology (impaired fetal perfusion) and is prioritized over additional monitoring or maternal pushing. Positioning can help, but without immediate decompression and urgent assistance it is insufficient.
Category reason: This item tests urgent nursing actions to manage an intrapartum obstetric emergency and prevent fetal compromise, which aligns with Physiological Adaptation—Medical Emergencies.

Question 11

A client with a fractured femur develops sudden shortness of breath, restlessness, and petechiae on the chest. What should the nurse suspect?

Accepted Answer

Answer reason: B. Fat embolism A long-bone fracture can release fat droplets from bone marrow into the circulation, leading to acute respiratory distress and neurologic changes such as restlessness. The presence of a petechial rash on the chest is a classic distinguishing finding of fat embolism syndrome. This triad (respiratory compromise, neurologic symptoms, petechiae) makes this diagnosis more likely than thrombotic pulmonary embolism, myocardial infarction, or pneumothorax.
Category reason: This is a patient-care recognition question requiring nursing judgment to identify an acute, life-threatening complication (fat embolism syndrome) after a femur fracture, which fits Physiological Adaptation—Medical Emergencies.

Question 12

A diabetic client presents with cold, clammy skin, and confusion. What is the immediate nursing intervention?

Accepted Answer

Answer reason: Cold, clammy skin and confusion are classic signs of hypoglycemia, which requires rapid glucose administration to prevent seizure, loss of consciousness, or neurologic injury. The immediate action for a conscious client who can swallow is the 15-15 rule: give 15 g of rapid-acting carbohydrate and reassess blood glucose in about 15 minutes. Administering insulin would worsen the condition, while calling the provider or giving an IV fluid bolus delays definitive treatment.
Category reason: This is an urgent patient-care decision requiring immediate nursing action for a suspected hypoglycemic emergency, which falls under management of acute physiologic emergencies.

Question 13

During delivery, the baby's head delivers, but the shoulders remain stuck. The priority nursing action is.?

Accepted Answer

Answer reason: This presentation is classic for shoulder dystocia, an obstetric emergency requiring immediate maneuvers to free the impacted anterior shoulder. The McRoberts maneuver (hyperflexing the maternal hips) increases the anteroposterior diameter of the pelvis and often resolves the obstruction quickly with minimal risk. Fundal pressure is contraindicated because it can worsen impaction and increase the risk of uterine rupture or neonatal injury. Episiotomy may be considered as an adjunct to facilitate internal maneuvers but is not the first priority, and oxytocin would not address the mechanical obstruction.
Category reason: This item tests the nurse’s immediate emergency response during an obstetric complication (shoulder dystocia) requiring prompt, correct intervention, which aligns with Physiological Adaptation—Medical Emergencies.

Question 14

A nurse finds the uterus protruding from the vagina after a forceful fundal massage. What is the priority intervention?

Accepted Answer

Answer reason: Uterine inversion is an obstetric emergency that can rapidly cause massive postpartum hemorrhage and shock, and uterotonics can worsen the inversion by maintaining a constriction ring. The immediate nursing action is to stop agents that promote uterine contraction, call for emergency assistance, and prepare for prompt reduction by an experienced provider while supporting circulation (oxygen, large-bore IV access, fluids/blood as indicated). Oxytocin is given only after the uterus is successfully repositioned to maintain tone and reduce bleeding risk. Attempting replacement without appropriate support and coordination can delay definitive management and increase maternal risk.
Category reason: This question tests urgent nursing recognition and immediate actions for a life-threatening postpartum complication, which fits Medical Emergencies within Physiological Adaptation.

Question 15

Which newborn assessment finding is most concerning for sepsis?

Accepted Answer

Answer reason: A) Hypothermia Newborns with sepsis commonly present with temperature instability, and hypothermia is a particularly concerning early sign due to immature thermoregulation and systemic infection. It often occurs alongside other subtle findings (e.g., poor feeding, lethargy, respiratory distress) and warrants urgent evaluation. The other options can occur with normal neonatal adjustment or noninfectious issues and are less specific for neonatal sepsis than temperature instability.
Category reason: This question tests recognition of an urgent, potentially life-threatening newborn condition requiring prompt nursing action and escalation, which aligns with Medical Emergencies.

Question 16

A nurse is assessing a client with pulmonary edema. What finding requires immediate action?

Accepted Answer

Answer reason: This indicates significant hypoxemia despite supplemental oxygen, signaling inadequate oxygenation and potential impending respiratory failure. In acute pulmonary edema, airway and breathing take priority, and persistent low saturation requires rapid escalation (e.g., higher-flow oxygen, noninvasive ventilation, rapid provider/rapid response notification). Pink frothy sputum and crackles are classic findings of pulmonary edema but are less immediately actionable than refractory hypoxemia. Elevated blood pressure can worsen edema, but it is not as immediately life-threatening as inadequate oxygenation.
Category reason: This item tests urgent nursing judgment and prioritization of immediate actions for a potentially unstable respiratory condition, which aligns with Physiological Adaptation—Medical Emergencies.

Question 17

A trial of labor after cesarean (TOLAC) patient at 6 cm suddenly reports sharp tearing abdominal pain, contractions stop; fetal parts palpated easily; FHR decels to 70. What is the priority?

Accepted Answer

Answer reason: These findings in a TOLAC patient (sudden tearing pain, cessation of contractions, easily palpable fetal parts, and profound fetal bradycardia) are classic for uterine rupture, a life-threatening obstetric emergency. The priority is immediate activation of emergency response and preparation for emergent cesarean birth to prevent fetal hypoxia and maternal hemorrhage. Increasing oxytocin could worsen the rupture, and applying a monitor or encouraging ambulation delays definitive, time-critical intervention.
Category reason: This question requires rapid recognition of an acute, life-threatening obstetric complication and the immediate nursing action to initiate emergency care and surgical response, which fits Medical Emergencies under Physiological Adaptation.

Question 18

A pregnant client at 35 weeks reports severe headache and visual changes. What is the most concerning finding?

Accepted Answer

Answer reason: Hyperreflexia in a late-term pregnant client with severe headache and visual changes indicates significant CNS irritability consistent with severe preeclampsia and impending eclampsia (seizure risk). This is a more urgent warning sign than mild-range hypertension, minimal proteinuria, or dependent edema, which can be less specific in pregnancy. The finding warrants immediate escalation of care and seizure precautions (e.g., magnesium sulfate per protocol) and close maternal-fetal monitoring.
Category reason: This is a patient-care judgment question requiring recognition of an obstetric emergency (severe preeclampsia/impending eclampsia) and identification of the most dangerous assessment finding, which aligns with NCLEX medical emergencies.

Question 19

A 6-week pregnant client has severe unilateral abdominal pain, shoulder pain, and dizziness. What is the priority nursing action?

Accepted Answer

Answer reason: The findings strongly suggest a ruptured ectopic pregnancy with intra-abdominal bleeding (referred shoulder pain from diaphragmatic irritation plus dizziness consistent with hypovolemia). This is a time-critical emergency where rapid escalation for surgical management is the safest priority to control hemorrhage and prevent shock. Waiting for confirmatory testing or providing outpatient-type measures delays definitive treatment and increases mortality risk. Methotrexate is for stable, unruptured ectopic pregnancy without signs of rupture or hemodynamic compromise.
Category reason: This question centers on immediate nursing prioritization in a life-threatening obstetric emergency (suspected ruptured ectopic pregnancy), which aligns with rapid recognition and response to medical emergencies in Physiological Adaptation.

Question 20

The first step in clinical intervention for patient with diabetes coma:

Accepted Answer

Answer reason: In an unconscious or altered patient with suspected diabetic coma, the immediate principle is to rapidly identify and correct life-threatening, reversible causes—especially hypoglycemia. A bedside glucose check is fast, noninvasive, and directly determines whether dextrose is urgently needed versus insulin/fluids for hyperglycemic crises. Starting dextrose without confirming can worsen hyperglycemia in DKA/HHS, while delaying confirmation risks missing severe hypoglycemia. Oxygen and urinary catheterization may be appropriate supportive steps, but they do not direct definitive, cause-specific treatment as quickly as point-of-care glucose does.

Question 21

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: B. Applying oxygen Airway and breathing take priority in the ABC approach, especially with facial and neck burns that can rapidly cause airway edema and obstruction. Immediate high-flow oxygen supports oxygenation and buys time while preparing for possible advanced airway management. Starting an IV and obtaining ABGs are important for resuscitation and monitoring but should not delay stabilizing ventilation/oxygenation. Pain control is necessary, yet it is addressed after life-threatening airway and respiratory risks are managed.

Question 22

A nurse is caring for a client after a bronchoscopy and biopsy. Which of the following signs if noted in the client should be reported immediately to the physician?

Accepted Answer

Answer reason: Bronchoscopy can precipitate acute airway compromise from airway irritation, edema, or a hypersensitivity response, making sudden respiratory deterioration an emergency. New-onset wheezing, increased work of breathing, hypoxia, or stridor indicates bronchospasm and requires immediate medical evaluation and prompt airway/bronchodilator management. In contrast, small amounts of blood-streaked sputum and a mild dry cough can occur after bronchoscopy/biopsy due to minor mucosal trauma and usually resolve with monitoring. Hematuria is not an expected post-bronchoscopy finding and warrants follow-up, but it does not directly signal imminent airway obstruction like bronchospasm does.

Question 23

Which acronym would BTST describe the procedure for assessing a patient that appears unconscious?

Accepted Answer

Answer reason: Initial assessment of an unconscious patient follows the airway, breathing, circulation priority because these are the most immediate life-sustaining functions. This structured approach rapidly identifies and treats threats to oxygenation and perfusion before moving to secondary assessments. Using this sequence helps prevent missing reversible causes of collapse and guides urgent interventions such as opening the airway, supporting ventilation, and checking pulse/initiating CPR as indicated. The other acronyms listed are not a standard primary assessment framework for an unconscious patient.

Question 24

While assessing a 1-month-old infant, which finding should the nurse report immediately?

Accepted Answer

Answer reason: This finding can indicate serious conditions such as pneumonia, bronchiolitis, sepsis, or evolving respiratory failure and therefore warrants immediate provider notification and escalation of assessment (work of breathing, oxygen saturation, perfusion). In contrast, abdominal breathing is typical in young infants due to diaphragmatic predominance. Periodic irregular respirations can be normal in infants, and tachycardia with crying is a common physiologic response to agitation.

Question 25

A nurse at an urgent care clinic is caring for a child who hit her head on the playground at school 30 min ago. Which of the following findings is the nurse's priority?

Accepted Answer

Answer reason: This finding reflects acute neurologic deterioration and takes priority over localized injury care using ABCs/neurologic red-flag prioritization. A small scalp laceration may bleed and needs treatment but is not as immediately dangerous as signs of increased ICP. Nasal discharge that is negative for glucose suggests CSF leak is less likely, and a negative Babinski is a reassuring neurologic sign rather than a priority concern.

Question 26

The nurse is caring for a post-op client receiving IV morphine. Which finding requires immediate action?

Accepted Answer

Answer reason: A respiratory rate of 8/min is severe bradypnea and signals impending respiratory failure, requiring rapid intervention such as stimulation, stopping/holding the opioid infusion, oxygen support, and preparing to administer naloxone per protocol. Constipation, nausea, and drowsiness are common expected side effects that are typically managed with supportive care rather than emergent reversal. The priority is airway and breathing, so the markedly low respiratory rate demands immediate action.

Question 27

The nurse observes a client have a tonic clonic seizure lasting about 90 seconds, followed by a period of decreased consciousness lasting 2 minutes. Then the client begins to have another seizure. It is MOST important for the nurse to take which of the following actions?

Accepted Answer

Answer reason: Recurrent tonic-clonic seizures with only a brief postictal period suggest evolving status epilepticus, where immediate seizure termination is the priority to prevent hypoxia, acidosis, hyperthermia, and neuronal injury. A benzodiazepine is the first-line emergent medication because it rapidly enhances GABA-mediated inhibition and can stop ongoing seizure activity. Checking glucose and vital signs are important assessments, but they do not treat the active life-threatening problem when the patient is seizing again. Removing clothing may help with comfort/temperature later, but it is not the most time-critical intervention compared with aborting the seizure.

Question 28

A client experiencing cocaine toxicity is brought to the emergency department. The nurse should prepare to take which initial action?

Accepted Answer

Answer reason: Cocaine toxicity can rapidly progress to life-threatening emergencies (seizures, hyperthermia, dysrhythmias, myocardial ischemia) and the first priority is stabilization using the ABCs. Securing the airway and supporting breathing prevents hypoxia and aspiration, especially if the patient has altered mental status or seizures. Actions like IV access and a 12-lead ECG are important for treatment and evaluation but come after immediate airway stabilization. Naloxone is an opioid antagonist and is not an initial intervention for isolated cocaine toxicity unless opioid co-ingestion is suspected with respiratory depression.

Question 29

A nurse is caring for a client diagnosed with pneumonia. Which assessment finding requires immediate intervention?

Accepted Answer

Answer reason: Marked tachypnea plus accessory muscle use suggests hypoxemia and fatigue of respiratory muscles, which can rapidly deteriorate without prompt support (e.g., oxygen, positioning, rapid provider/RT notification). The other findings are common in pneumonia and usually managed after ABCs are addressed. Fever and purulent sputum support infection but are not as immediately life-threatening as signs of decompensating ventilation.

Question 30

A client is admitted with right-sided weakness and slurred speech. Which action is the nurse’s priority?

Accepted Answer

Answer reason: Establishing the last-known-well time immediately determines eligibility for thrombolysis and/or thrombectomy and guides the urgency of activating the stroke protocol. This action directly impacts potentially reversible neurologic injury and must occur before downstream interventions. Comfort measures and rehabilitation planning do not address the immediate emergency, and elevating the bed to 90 degrees can reduce cerebral perfusion and is not the priority in suspected acute stroke.

Question 31

Your patient complains of chest pain and shortness of breath after a PICC insertion. You note hypotension and tachycardia. These symptoms are indicative of?

Accepted Answer

Answer reason: Air obstructing pulmonary blood flow leads to abrupt chest pain and dyspnea with reflex tachycardia and can produce hypotension from reduced left-sided preload. This time course and symptom cluster is more consistent with an embolic event than infection, which typically presents later with fever and local/systemic inflammatory signs. Phlebitis more often causes localized erythema, warmth, tenderness along the vein rather than sudden hypotension and respiratory distress. Catheter malposition may cause arrhythmias or infusion issues but does not classically cause this acute shock-like presentation.

Question 32

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: Burns involving the face and neck raise immediate concern for inhalation injury and rapidly progressing airway edema that can compromise ventilation and oxygenation. Providing supplemental oxygen is an immediate, low-risk intervention that supports tissue oxygen delivery while further airway assessment and preparation for advanced airway management occur. Starting an IV and drawing labs are important but do not address the most time-critical threat. Pain control is necessary but must not delay stabilization of respiratory status.

Question 33

During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions?

Accepted Answer

Answer reason: Sitting the client upright promotes venous pooling in the lower extremities and decreases venous return, which helps lower systemic blood pressure quickly while the trigger is identified and removed. Positions that increase venous return (lying flat, Trendelenburg, or elevating legs) can worsen hypertension and increase the risk of stroke. After positioning, the nurse should promptly assess for and relieve common noxious stimuli (e.g., bladder distention, bowel impaction, tight clothing) and monitor blood pressure closely.

Question 34

A 45-year-old man is rushed to the ER with reports of substernal chest pain and diaphoresis. Cardiac troponin levels were taken and found to be elevated. The ER nurse understands that nursing interventions would focus on which priority?

Accepted Answer

Answer reason: This priority is addressed by rapid assessment and interventions such as oxygen if hypoxemic, positioning, minimizing activity, and administering ordered anti-ischemic therapies (e.g., nitrates) to reduce preload/afterload and myocardial workload. Elevated troponin supports myocardial injury, so focusing first on stabilizing perfusion and oxygenation is more urgent than diagnostic confirmation steps. Pain control and anxiety reduction are important but are secondary because they primarily support comfort and can be incorporated after initiating the life-preserving ischemia-reducing measures. Preventing complications is ongoing, but it depends on first stabilizing the acute emergency physiology.

Question 35

The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?

Accepted Answer

Answer reason:  A sudden severe headache in a client with a known cerebral aneurysm is a red-flag symptom for impending or actual rupture with risk of subarachnoid hemorrhage and rapid neurologic deterioration. The priority nursing action is immediate escalation for urgent medical evaluation and intervention to prevent death or permanent neurologic injury. Comfort measures or routine analgesics can mask worsening symptoms and delay definitive treatment. Informing a nurse manager does not address the time-critical nature of this potential intracranial emergency.

Question 36

The nurse is assessing a 3-year-old with a diagnosis of Tetralogy of Fallot. The child becomes short of breath with ambulation. Which action will the nurse perform next?

Accepted Answer

Answer reason: Tet spells in Tetralogy of Fallot are acute hypoxic episodes caused by increased right-to-left shunting, often triggered by exertion. The immediate nursing action is to increase systemic vascular resistance to reduce shunting and improve pulmonary blood flow, which the knee-chest position accomplishes by kinking femoral arteries and increasing afterload. Supplemental oxygen can be added, but positioning is the fastest first intervention to correct the physiology. Laying supine can worsen ventilation and does not address shunting, and a crash cart is not the next step unless the child is decompensating despite initial measures.

Question 37

A nurse is caring for a pregnant patient who is 37 weeks gestation and reports severe abdominal pain, dark red vaginal bleeding, and a firm, board-like abdomen. What is the nurse’s priority intervention?

Accepted Answer

Answer reason:  The presentation is classic for placental abruption, where uterine bleeding and myometrial irritation lead to a rigid, tender uterus and severe pain, creating an obstetric emergency with high risk of maternal hemorrhage and fetal hypoxia. At 37 weeks, definitive management is rapid stabilization and expedited birth, commonly by emergent cesarean if fetal distress or ongoing bleeding is present. Continuous fetal monitoring is important for assessment, but it does not treat the life-threatening cause and must not delay definitive action. Oxytocin can worsen uterine hypertonus and bleeding in abruption, and Trendelenburg does not address hemorrhage or fetal compromise and is not a priority intervention.

Question 38

A 3-year-old has ingested bleach. The emergency room nurse is aware that the priority nursing action is to?

Accepted Answer

Answer reason: Caustic ingestions can rapidly cause airway and GI burns with edema, bleeding, and systemic compromise, so early recognition of deterioration is the immediate priority. Ongoing assessment of perfusion (vital signs, capillary refill, mental status, urine output) helps detect shock early so resuscitation and airway management can be initiated promptly. Inducing emesis with ipecac is contraindicated because it re-exposes the esophagus and airway to the caustic agent and increases aspiration risk. Placing an NG tube can worsen mucosal injury or precipitate perforation and is not a first-line nursing action.

Question 39

Which of the following additional assessment data should immediately be gathered to determine the status of a client with a respiratory rate of 4 breaths/minute?

Accepted Answer

Answer reason: A respiratory rate of 4/min indicates severe hypoventilation with imminent risk of hypoxemia and hypercapnic respiratory failure, requiring immediate bedside assessment of oxygenation and neurologic status. Pulse oximetry provides a rapid, noninvasive estimate of oxygen saturation to gauge severity and need for urgent oxygen/ventilatory support. Level of consciousness reflects adequacy of cerebral oxygen delivery and CO2 retention (CO2 narcosis), helping identify life-threatening deterioration. ABGs and auscultation are useful but take longer and do not supersede the fastest indicators of oxygenation and ventilatory compromise in this emergency.

Question 40

Nurse Oliver is caring for a client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client?

Accepted Answer

Answer reason: This is an airway emergency requiring immediate notification and prompt intervention (e.g., high-flow oxygen, racemic epinephrine, corticosteroids, and possible reintubation). Mild tachypnea can occur transiently after extubation and is less specific for impending obstruction. Small amounts of pink-tinged sputum or a few basilar crackles may reflect minor airway irritation or atelectasis and are typically monitored rather than treated as an immediate airway threat unless worsening.

Question 41

Nurse Joy is caring for a client after a bronchoscopy and biopsy. Which of the following signs, if noticed in the client, should be reported immediately to the physician?

Accepted Answer

Answer reason: This finding indicates acute lower-airway reactivity and requires immediate provider notification and intervention (e.g., oxygen, bronchodilator therapy, possible escalation of airway support). In contrast, mild dry cough and small amounts of blood-streaked sputum can occur after biopsy from mucosal irritation and are often self-limited. Hematuria is not an expected bronchoscopy complication and would be assessed, but it is less immediately life-threatening than a developing airway obstruction.

Question 42

A 19-year-old comes into the emergency department with acute asthma. His respiratory rate is 44 breaths/minute, and he appears to be in acute respiratory distress. Which of the following actions should be taken first?

Accepted Answer

Answer reason: A nebulized short-acting bronchodilator provides the fastest, most direct treatment to improve airflow, reduce work of breathing, and prevent progression to respiratory failure. Interventions like obtaining a full medication history or providing emotional support are appropriate but must not delay definitive treatment of hypoxia/bronchoconstriction. A cardiac monitor may be useful due to beta-agonist effects and physiologic stress, but it is not as time-critical as restoring ventilation.

Question 43

Emergency treatment of a client in status asthmaticus includes which of the following medications?

Accepted Answer

Answer reason: Rapid-acting inhaled short-acting beta2-agonists provide the fastest, targeted bronchodilation with a favorable onset compared with anti-inflammatory therapies. Corticosteroids (inhaled or oral) are important adjuncts to reduce airway inflammation but have slower onset and are not the primary immediate rescue medication. IV beta-adrenergic agents are not first-line for routine emergency management due to greater systemic adverse effects and are generally reserved for refractory cases under close monitoring.

Question 44

Which of the following treatment goals is best for the client with status asthmaticus?

Accepted Answer

Answer reason: Avoiding invasive mechanical ventilation is a key target because intubation in severe asthma can be difficult and carries risks such as barotrauma, dynamic hyperinflation, and hypotension. Rapid bronchodilation, systemic corticosteroids, oxygen, and close monitoring are aimed at reversing airflow obstruction early enough to avert respiratory fatigue and arrest. Determining the trigger and improving exercise tolerance are longer-term objectives and do not address the acute emergency priority. Reducing secretions is not the primary therapeutic focus compared with relieving bronchoconstriction and preventing ventilatory failure.

Question 45

Emergency treatment for a client with impending anaphylaxis secondary to hypersensitivity to a drug should include which of the following actions first?

Accepted Answer

Answer reason: Early high-flow oxygen helps counter hypoxemia from bronchospasm, airway edema, and ventilation–perfusion mismatch while other definitive therapies are prepared. Starting an IV line is important for rapid medication and fluid delivery, but it does not address imminent respiratory compromise as quickly as oxygen does. Labs like a CBC and routine vital signs are secondary and should not delay immediate stabilization of airway and breathing.

Question 46

Following the initial care of a client with asthma and impending anaphylaxis from hypersensitivity to a drug, the nurse should take which of the following steps next?

Accepted Answer

Answer reason: After the initial emergency measures, giving a bronchodilator helps reverse bronchoconstriction and improves airflow and oxygenation. Beta-adrenergic blockers can worsen bronchospasm and blunt the response to epinephrine, making them unsafe in this context. Electrolyte labs are not time-critical during evolving anaphylaxis, and positioning flat can compromise ventilation; respiratory support takes precedence over nonessential diagnostics and less targeted measures.

Question 47

A glucagon emergency kit is prescribed for a client with type 1 diabetes mellitus. When should the nurse instruct the client to use the glucagon?

Accepted Answer

Answer reason: g., confusion, seizure, or unconsciousness). In type 1 diabetes, glucagon works by stimulating hepatic glycogenolysis and gluconeogenesis to increase serum glucose. Using it routinely after meals or after insulin is inappropriate because it is not a preventive medication and can contribute to rebound hyperglycemia and delayed proper treatment. During sick days with reduced intake, mild hypoglycemia is usually managed first with oral glucose if the client is awake and able to swallow, while glucagon is reserved for severe episodes or inability to take oral carbs.

Question 48

Following involvement in a motor vehicle collision, a middle aged adult client is admitted to the hospital with multiple facial fractures. The client is blood alcohol level is high on admission. Which PRN prescription should be administered if the client begins to exhibit signs and symptoms of DT (tremens (DT)?

Accepted Answer

Answer reason: Benzodiazepines are first-line therapy because they enhance GABAergic inhibition, directly treating the pathophysiology and reducing seizure risk. The other options do not treat withdrawal and can worsen safety: antipsychotics (e.g., chlorpromazine) may lower seizure threshold, antiemetics (prochlorperazine) are unrelated to withdrawal control, and opioids address pain but can add respiratory depression and obscure neurologic assessment in a trauma patient. Therefore, a benzodiazepine PRN is the most appropriate order to give when DT symptoms appear.

Question 49

The nurse is caring for a client with status epilepticus. What medication should the nurse anticipate administering to stop the seizures immediately?

Accepted Answer

Answer reason:  Ongoing generalized seizure activity is a neurologic emergency requiring a rapidly acting IV medication to abort seizures and prevent hypoxia, acidosis, and neuronal injury. Benzodiazepines are first-line for immediate seizure termination because they enhance GABA-A–mediated inhibition and act within minutes when given IV. An oral option is inappropriate because it is too slow and may be unsafe or impossible in an actively seizing patient with impaired airway protective reflexes. While other antiepileptics may be used after initial control for longer-term suppression, the immediate priority is fast IV benzodiazepine therapy to stop the seizure now.

Question 50

A 37-yr old female was admitted to the hospital with a Myasthenic crisis. The most important nursing action is to?

Accepted Answer

Answer reason: In this setting, the nurse’s highest priority is frequent assessment of vital signs and cardiopulmonary status to detect decompensation early and trigger urgent escalation of care. Among the options, monitoring pulse on a scheduled basis is the only direct physiologic surveillance action aligned with emergency management; the other choices address comfort, social needs, or routine care. Although respiratory assessment is typically the most critical focus, this option best matches immediate life-preserving monitoring compared with intake/output or meal timing.

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