Question 1

A client arrives in the emergency department with chest pain, shortness of breath, and hypotension. What is the priority nursing action?

Accepted Answer

Answer reason: Providing supplemental oxygen is a rapid, low-risk intervention that improves myocardial and systemic oxygen delivery while further evaluation is initiated. Starting an IV is important for fluids/medications, but it does not correct hypoxemia as quickly as oxygen in a dyspneic, hypotensive patient. A detailed history and analgesia are secondary to stabilizing airway/breathing and supporting circulation in a possible acute coronary syndrome or shock state.

Question 2

A 14 month-old child ingested half a bottle of aspirin tablets. Which of the following would the nurse expect to see in the child?

Accepted Answer

Answer reason: As poisoning progresses, a mixed respiratory alkalosis and metabolic acidosis develops, further increasing work of breathing and leading to shortness of breath. Hypothermia is not expected; fever and diaphoresis are more typical in significant toxicity, especially in children. Edema is not a characteristic finding, and epistaxis is not a hallmark acute sign compared with the prominent respiratory changes and acid–base derangements.

Question 3

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

Accepted Answer

Answer reason: This finding can indicate serious pathology such as pneumonia, bronchiolitis with fatigue, pulmonary edema, or impending respiratory failure and requires urgent evaluation and intervention. In contrast, abdominal breathing is commonly normal in young infants due to diaphragmatic predominance, and periodic/irregular breathing can be a benign infant pattern when brief and without color change or distress. A higher heart rate during crying is an expected sympathetic response rather than an emergency sign.

Question 4

In order to be effective in administering cardiopulmonary resuscitation to a 5 year-old, the nurse must

Accepted Answer

Answer reason: For a 5-year-old (child), two-handed chest compressions on the lower half of the sternum are typically needed to achieve the recommended depth (~1/3 of the chest, about 5 cm). The brachial pulse is the infant pulse check site; for children the carotid or femoral pulse is used. Compression rate should be about 100–120/min (not 80–90), and ventilation is not given as “once every 5 compressions” in standard single-rescuer pediatric CPR.

Question 5

The nurse is performing a physical assessment on a client with insulin dependent diabetes mellitus. Which client complaint calls for immediate nursing action?

Accepted Answer

Answer reason: Immediate nursing action is to check a bedside glucose and treat promptly with fast-acting carbohydrate (or glucagon/IV dextrose if unable to swallow) to prevent deterioration. Reduced lower leg sensation suggests chronic diabetic neuropathy and needs follow-up teaching and foot care but is not immediately life-threatening. Excessive thirst/hunger more often reflects hyperglycemia and dehydration risk, which is urgent but typically less immediately catastrophic than symptomatic hypoglycemia at the moment of assessment.

Question 6

The nurse is performing a neurological assessment on a client post right CVA. Which finding, if observed by the nurse, would warrant immediate attention?

Accepted Answer

Answer reason: This is a time-critical change because it can rapidly compromise airway protection and cerebral perfusion and requires urgent provider notification and escalation of care. The other findings can occur after a CVA but are typically not as immediately life-threatening as an acute mental status decline. Immediate attention focuses first on ABCs and detecting neurologic worsening early to prevent secondary brain injury.

Question 7

A client is brought to the emergency room following a motor vehicle accident. When assessing the client one-half hour after admission, the nurse notes several physical changes. Which changes would require the nurse's immediate attention?

Accepted Answer

Answer reason: This finding signals impending airway compromise and obstructive shock, requiring immediate emergency response (rapid assessment, oxygenation/ventilation support, and preparation for urgent decompression/chest tube). Tachycardia, tachypnea, and restlessness can reflect pain, anxiety, or early hypoxia/shock, but they are less specific and do not by themselves indicate an immediately reversible, fatal thoracic pressure problem. Prioritizing airway and breathing threats with clear red-flag indicators aligns with trauma ABC management.

Question 8

A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be?

Accepted Answer

Answer reason: Burns involving the face and neck raise concern for airway swelling and smoke exposure, so early signs like dyspnea and stridor must be identified immediately. This aligns with ABCs: secure/assess airway before moving to circulation or comfort measures. IV fluids and dressings are important but should follow confirmation that the airway is stable. Pain control is appropriate after emergent threats are addressed.

Question 9

While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?

Accepted Answer

Answer reason: A boggy uterus with increased vaginal bleeding in the immediate postpartum period most strongly indicates uterine atony, a leading cause of postpartum hemorrhage. The first nursing priority is to rapidly restore uterine tone to reduce bleeding. Firm fundal massage stimulates uterine contraction and is the fastest immediate bedside intervention before escalating to medications or additional evaluation. Checking vital signs is important but does not address the source of bleeding as quickly, and lacerations are more likely when the uterus is firm rather than boggy.

Question 10

The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the nurse?

Accepted Answer

Answer reason: An SpO2 of 88% indicates significant hypoxemia that can result from esophageal intubation, mainstem bronchus intubation, tube obstruction/kinking, dislodgement, or inadequate ventilation settings. The nurse should promptly verify tube placement and patency (ETCO2 if available, chest rise, auscultation, suction as needed) and support oxygenation/ventilation while notifying the provider/RT. By contrast, inability to speak is an expected finding with an endotracheal tube, and bilateral breath sounds plus visible mist are supportive but not definitive indicators of adequate oxygenation.

Question 11

While caring for a toddler with croup, which initial sign of croup requires the nurse's immediate attention?

Accepted Answer

Answer reason: With croup, worsening airway obstruction can rapidly progress; decreased responsiveness may indicate inadequate oxygenation/ventilation despite outward cough/stridor. A respiratory rate of 42 can be mild-to-moderate tachypnea for a toddler and must be interpreted with work of breathing and oxygenation, but it is less ominous than altered mentation. Copious secretions is not a classic early croup finding and is typically less immediately threatening than evidence of poor perfusion or hypoxemia.

Question 12

A pre-term baby develops nasal flaring, cyanosis and diminished breath sounds on one side. The provider's diagnosis is spontaneous pneumothorax. Which procedure should the nurse prepare for first?

Accepted Answer

Answer reason: Preparing for pleural decompression addresses the underlying problem by removing intrapleural air and allowing lung re-expansion, which is definitive management for a significant pneumothorax. Oxygen may temporarily improve saturation but does not correct the trapped air causing unilateral diminished breath sounds and worsening respiratory distress. Assisted ventilation without relieving the air leak can increase intrathoracic pressure and worsen the condition, while CPR is reserved for arrest rather than the first expected intervention here.

Question 13

The nurse is performing an assessment on a child with severe airway obstruction. Which finding would the nurse anticipate finding?

Accepted Answer

Answer reason: Cyanosis indicates significant deoxygenated hemoglobin, while mottling reflects compromised tissue perfusion often seen with worsening respiratory failure. Retractions and rapid, shallow breathing can occur with increased work of breathing, but they are not as specific for severe, late-stage oxygenation failure as cyanosis with mottling. Chest pain with breathing is more consistent with pleuritic processes than airway obstruction.

Question 14

The nurse is caring for a client with a myocardial infarction. Which finding requires the nurse's immediate action?

Accepted Answer

Answer reason: This finding signals impaired oxygenation/ventilation and requires immediate assessment of airway-breathing, oxygen support, vital signs, and prompt escalation of care. It can indicate left ventricular failure with fluid backing up into the lungs, which can deteriorate quickly without intervention. In contrast, periorbital edema and lethargy are typically less time-critical in this context and may reflect slower-developing fluid shifts or reduced perfusion rather than an immediate threat to oxygenation. Immediate action prioritizes preventing hypoxemia and further cardiac strain.

Question 15

A client was re-admitted to the hospital following a recent skull fracture. Which finding requires the nurse's immediate attention?

Accepted Answer

Answer reason: Lethargy can rapidly progress to obtundation and airway compromise, so it demands immediate assessment (neuro checks, vitals, pupil changes) and urgent provider notification. Agitation and ataxia can occur with concussion or focal injury but are less specific for impending herniation than a new decrease in arousal. Hearing loss may be associated with basilar skull fracture but is typically not as immediately life-threatening as an acute change in consciousness.

Question 16

The nurse is caring for a client with status epilepticus. The most important nursing assessment of this client is?

Accepted Answer

Answer reason: The priority assessment follows ABCs, so immediately evaluating breathing and circulation via respirations and pulse best identifies impending respiratory failure, hypoxia, or cardiopulmonary compromise. Level of consciousness is important but is secondary to ensuring oxygenation and perfusion are maintained. IV drip rate and extremity injuries do not detect the most immediate threat to life compared with monitoring cardiopulmonary status.

Question 17

A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the nurse do first?

Accepted Answer

Answer reason: Decontamination is the priority in a recent potentially toxic ingestion when the airway is stable and the patient presents within the effective time window. At 45 minutes after ingestion, activated charcoal can adsorb acetaminophen still in the gastrointestinal tract and reduce further absorption, making it the most time-sensitive first action. The antidote is important, but it is typically guided by timing and acetaminophen level (Rumack–Matthew nomogram) and is not as immediately time-critical as GI decontamination in the first hour. Gastric lavage is rarely indicated due to risk and limited benefit compared with charcoal, and starting a KVO IV is supportive but does not address ongoing toxin absorption.

Question 18

The nurse is teaching parents about accidental poisoning in children. Which point should be emphasized?

Accepted Answer

Answer reason: g., gasoline, kerosene, lighter fluid) poses a high aspiration risk due to low viscosity and volatility, so emesis markedly increases the chance of chemical pneumonitis. Emphasizing avoidance of induced vomiting aligns with emergency poisoning first-aid priorities: protect the airway and prevent aspiration-related respiratory failure. A common distractor is “empty the mouth in any case,” which is not universally safe because some exposures are caustic or risk further tissue injury or aspiration if manipulated improperly. While contacting Poison Control is important, the key safety teaching specific to hydrocarbon poisoning is to avoid inducing vomiting and seek urgent guidance/medical evaluation.

Question 19

The nurse is caring for a client with a distal tibia fracture. The client has had a closed reduction and application of a toe to groin cast. 36 hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 degrees Fahrenheit. The first assessment the nurse should perform is?

Accepted Answer

Answer reason: The priority in a sudden change with shortness of breath and acute confusion is to assess oxygenation and ventilation using the ABC framework. After a long-bone fracture and orthopedic immobilization, the combination of hypoxemia, neurologic changes, and fever is concerning for fat embolism syndrome, where early hypoxia is a key, rapidly treatable threat. Pulse oximetry provides an immediate, noninvasive assessment to guide urgent oxygen therapy and escalation. Checking distal circulation of the casted leg is important but does not address the immediate life-threatening respiratory compromise driving the current presentation.

Question 20

The nurse caring for a 9 year-old child with a fractured femur is told that a medication error occurred. The child received twice the ordered dose of morphine an hour ago. Which nursing diagnosis is a priority at this time?

Accepted Answer

Answer reason: One hour after receiving double-dose morphine, the highest immediate risk is hypoventilation with rising CO2, decreased level of consciousness, and potential apnea, making breathing the top ABC priority. The other choices describe expected but less immediately life-threatening opioid effects (e.g., decreased GI motility, nausea) or a less direct/less acute priority than compromised ventilation. Nursing priorities should focus on prompt assessment of respiratory rate, depth, oxygenation, sedation level, and readiness to initiate emergency interventions (e.g., supportive ventilation and antidote per protocol).

Question 21

A nurse is caring for a 2 year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to?

Accepted Answer

Answer reason: Children with Tetralogy of Fallot have a higher baseline risk of cerebrovascular complications due to chronic hypoxemia-related polycythemia and altered coagulation, and perioperative hemodynamic shifts can further increase risk. Postoperative meningitis typically presents with fever, irritability, neck stiffness, and more gradual neurologic change rather than an abrupt isolated seizure. Metabolic alkalosis is not a classic immediate cause of sudden seizures in this context, and medication reactions are less likely to be the primary explanation compared with an acute cerebrovascular complication.

Question 22

The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report?

Accepted Answer

Answer reason: Syncope indicates critically reduced cerebral oxygen delivery and can precede seizures, respiratory arrest, or cardiovascular collapse, making it an emergency that requires immediate evaluation and intervention. In contrast, feeding difficulty, poor weight gain, and fatigue with crying commonly reflect chronic decreased oxygenation/heart failure risk and warrant prompt follow-up but are not typically as immediately life-threatening as syncope. Teaching parents to recognize and urgently report signs of severe hypoxia helps prevent rapid decompensation while awaiting definitive surgical repair.

Question 23

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 notices 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: This is a potential hemorrhage/emergency change in status that requires immediate provider notification for rapid evaluation and possible operative or resuscitative intervention. Clamping the tube can worsen a developing hemothorax by preventing evacuation and increasing intrathoracic pressure, so it is unsafe unless specifically ordered for a brief purpose. Preparing for transfusion may be needed later, but the priority is urgent escalation and assessment orders; simply monitoring delays treatment of a potentially life-threatening bleed.

Question 24

The nurse is caring for a client with uncontrolled hypertension. Which findings require priority nursing action?

Accepted Answer

Answer reason: New arm weakness suggests impaired cerebral perfusion and potential time-sensitive treatment windows, so the nurse should initiate emergency response/rapid provider notification and focused neuro assessment. In contrast, edema, rales, and jugular venous distension suggest fluid overload/heart failure, which are serious but typically less immediately time-dependent than acute focal neurologic changes. Prioritizing potential stroke aligns with ABCs and neurologic emergency principles to prevent irreversible disability.

Question 25

A nurse who is reassigned to the emergency department needs to understand that gastric lavage is a priority in which situation?

Accepted Answer

Answer reason: Many powdered plant/yard fertilizers can contain corrosive salts and potentially toxic additives (e.g., nitrates, pesticides or metals), and ingestion may warrant urgent decontamination in the ED based on the product and amount. In contrast, ibuprofen overdose is typically managed with supportive care and activated charcoal when appropriate, and lavage is rarely indicated. Botulism is an infectious neurotoxin illness where lavage does not address the underlying pathology and priority care focuses on airway/respiratory support and antitoxin. Vitamin ingestions are usually low risk unless specific iron-containing preparations are involved, making lavage less routinely prioritized than a potentially caustic plant product ingestion.

Question 26

A 3 year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first?

Accepted Answer

Answer reason: The presentation is most consistent with acute epiglottitis with impending upper-airway obstruction, which is a life-threatening emergency requiring rapid airway management. The nurse’s priority is to escalate care immediately so the team can secure the airway and initiate appropriate therapy while minimizing agitation. Any manipulation of the airway (e.g., throat exam) can precipitate complete obstruction and respiratory arrest. Diagnostic testing like an x-ray or collecting sputum is not the first action when airway patency is threatened; stabilization and urgent provider notification come first.

Question 27

The nurse is caring for a 16 year-old client with femur fracture 14 hours after surgery. Assessment findings include tachycardia, increased shortness of breath, a temperature of 100.2 degrees Fahrenheit, complaints of feeling anxious, and oxygen saturation level of 88%. In immediately notify the provider of these findings, the nurse recognizes the client is at risk for?

Accepted Answer

Answer reason: The low SpO2 (88%) with tachycardia, shortness of breath, anxiety/restlessness, and low-grade fever reflects early hypoxia and an inflammatory response consistent with this emergency. Atelectasis can cause mild hypoxemia and low-grade fever post-op, but it is less specifically linked to femur fracture and typically improves with pulmonary hygiene rather than causing this classic post–long-bone-fracture pattern. Compartment syndrome would primarily cause severe limb pain, tense swelling, and neurovascular compromise rather than prominent respiratory findings.

Question 28

The nurse is assigned to a client who has heart failure. During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first?

Accepted Answer

Answer reason: Upright positioning with dependent legs decreases preload, improves diaphragmatic excursion, and can rapidly ease respiratory distress while additional therapies are arranged. Taking vital signs is important but should not delay a rapid, low-risk intervention that addresses the life-threatening breathing problem. Contacting the provider and giving a PRN anxiolytic are not first because they do not promptly correct the underlying cardiopulmonary compromise and the sedative effect could worsen respiratory status.

Question 29

A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to?

Accepted Answer

Answer reason: In emergency sequencing, airway and breathing are addressed before medication administration because hypoxia can occur rapidly from bronchospasm and laryngeal edema. Securing and supporting ventilation/oxygenation also prepares for escalation (e.g., rescue measures) if deterioration occurs. Epinephrine is the first-line drug for anaphylaxis, but it follows the immediate assessment and actions to ensure a patent airway and adequate breathing. Antihistamines are adjunctive and do not treat the critical airway component.

Question 30

The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority?

Accepted Answer

Answer reason: Airway patency and ventilation are the ABC priority, making airway clearance the most urgent nursing diagnosis. Newborns with TEF commonly have excessive drooling, choking, coughing, and cyanosis with feeds, reflecting an obstructed/contaminated airway that requires prompt suctioning and stabilization before other needs. Dehydration and nutrition problems are important but are secondary once the airway is protected and aspiration risk is controlled. Risk for injury is less specific and does not address the immediate life-threatening physiologic threat.

Question 31

A client who is 12 hour post-op becomes confused and says: "Giant sharks are swimming across the ceiling." Which assessment is necessary to adequately identify the source of this client's behavior?

Accepted Answer

Answer reason: Measuring oxygen saturation rapidly screens for inadequate ventilation/oxygenation from residual anesthesia, atelectasis, opioid effect, or pulmonary complications. This bedside assessment is immediate, noninvasive, and directly targets a common physiologic cause of sudden mental status change after surgery. While hypoglycemia is also possible, oxygenation is the most urgent ABC-related source to assess first in a 12-hour post-op patient with abrupt neurobehavioral changes. A cardiac rhythm strip or pupillary check does not as directly identify the likely systemic trigger for delirium in this context.

Question 32

An 8-year-old with a history of asthma is brought to the emergency department by his mother. The child tells the nurse that he was wheezing earlier and now feels worse. The nurse should be MOST concerned with which of the following findings?

Accepted Answer

Answer reason: Decreasing or “diminished” breath sounds during a worsening asthma episode suggest severely reduced airflow from critical bronchospasm and air trapping, which can precede respiratory failure (“silent chest”). Wheezing and chest tightness are common in asthma and do not by themselves indicate imminent decompensation. As obstruction becomes severe, wheeze may fade because little air is moving, making this finding more alarming than audible wheezing. This warrants immediate escalation (rapid bronchodilator therapy, oxygen, close monitoring, and preparation for advanced airway support if deterioration continues).

Question 33

The nurse is developing a plan of care for a client who is 30 weeks pregnant and experiencing new onset proteinuria, ≥3+ deep tendon reflexes, and sustained blood pressures > 140/90. Which of the following actions should the nurse take first?

Accepted Answer

Answer reason: The first priority is to prevent seizures with magnesium sulfate because it directly stabilizes neuromuscular excitability and reduces seizure risk quickly. Seizure precautions are important but are supportive measures and do not treat the underlying neurologic irritability. Delivery and antenatal corticosteroids may be indicated depending on maternal/fetal status and gestational age, but they do not address the immediate life-threatening complication as rapidly as magnesium therapy.

Question 34

A 15-year-old female who ingested 15 tablets of maximum strength acetaminophen 45 minutes ago is rushed to the emergency department. Which of these orders should the nurse do first?

Accepted Answer

Answer reason: At 45 minutes post-ingestion, activated charcoal can bind a substantial amount of the remaining drug in the gut and is a rapid, bedside intervention. Antidotal therapy with acetylcysteine is crucial for acetaminophen toxicity but typically follows initial stabilization/decontamination and is guided by timing and levels (e.g., at/after the 4-hour level) while not preventing ongoing absorption already in the stomach. Gastric lavage is rarely indicated due to risk and limited added benefit compared with charcoal in most ingestions, and starting a KVO IV does not address the immediate toxidrome risk.

Question 35

The nurse is caring for a client with scleroderma. Which assessment finding indicates the most serious complication of the disease and requires priority intervention?

Accepted Answer

Answer reason: Headache in this context is a red flag for hypertensive emergency with risk of encephalopathy, stroke, and rapid kidney failure, requiring immediate BP control and urgent evaluation. Raynaud phenomenon (blue/cold fingertips) and esophageal dysmotility (heartburn/dysphagia) are common but usually not immediately life-threatening. Dry cough and exertional dyspnea can suggest interstitial lung disease or pulmonary hypertension, which are serious, but the abrupt severe hypertension pattern is the most acute priority complication.

Question 36

The nurse is monitoring a female client with a diagnosis of peptic ulcer. Which assessment findings would most likely indicate perforation of the ulcer?

Accepted Answer

Answer reason: Peritonitis classically presents with sudden severe abdominal pain, guarding, and involuntary rigidity described as a “board-like” abdomen. This is an emergency finding that signals an acute abdomen and risk for shock, requiring rapid provider notification and preparation for surgical management. Nausea/vomiting can occur with uncomplicated peptic ulcer disease or obstruction and is not specific for perforation, and bradycardia is not the expected hemodynamic response to acute peritonitis.

Question 37

A parent brings a 6-month-old child to the primary health care provider after the child abruptly started crying and grabbing intermittently at the abdomen. The client's stool has a red, currant jelly appearance. What intervention does the nurse anticipate?

Accepted Answer

Answer reason: The combination of intermittent, severe crampy abdominal pain with “currant jelly” stools is classic for intussusception, a pediatric GI emergency due to telescoping of bowel that causes ischemia and bleeding. First-line nonoperative management in a stable infant is an air (or contrast) enema, which is both diagnostic and therapeutic by reducing the intussusception. Delaying definitive reduction risks bowel necrosis and perforation, so supportive or confirmatory measures are not the priority. Other options address anemia, constipation, or occult bleeding, none of which treat the underlying obstruction.

Question 38

A nurse is attending to a client undergoing hemodialysis. Which finding should the nurse report to the provider immediately?

Accepted Answer

Answer reason: During hemodialysis, glucose shifts and reduced intake can precipitate low serum glucose, so a value of 50 mg/dL requires urgent escalation and treatment. The other findings can occur in chronic kidney disease or during dialysis but are not typically immediately life-threatening in the same way. Prompt reporting ensures rapid orders for glucose replacement and evaluation of contributing dialysis-related factors.

Question 39

A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by nonrebreather mask, but arterial blood gas measurements continue to show poor oxygenation. Which action does the nurse anticipate that the health care provider will prescribe?

Accepted Answer

Answer reason: ARDS causes severe diffusion impairment and intrapulmonary shunting from noncardiogenic pulmonary edema, so oxygenation can remain poor despite high-FiO2 delivery by a nonrebreather. When hypoxemia persists, escalation to invasive ventilation allows delivery of precise FiO2 and application of PEEP to recruit alveoli and improve oxygenation. CPAP is noninvasive and may be inadequate in worsening ARDS and is often not tolerated or safe if rapid deterioration is occurring. High-dose IV furosemide is not the primary treatment for ARDS (not cardiogenic fluid overload) and could worsen perfusion, while calling a code is inappropriate unless the patient has arrested.

Question 40

A patient has meconium stained amniotic fluid. Fetal scalp sampling indicates a blood pH of 7.12 and fetal bradycardia is present. Based on these findings, the nurse should take which action?

Accepted Answer

Answer reason: 12 indicates significant fetal acidemia, and persistent fetal bradycardia is a nonreassuring sign of ongoing hypoxia that can rapidly progress to fetal decompensation. When objective evidence of fetal compromise is present, the priority is to expedite delivery rather than attempt slower, supportive measures alone. Amnioinfusion is used for variable decelerations from cord compression and to dilute thick meconium, but it does not correct established acidemia with bradycardia. Repositioning and IV fluids are initial intrauterine resuscitation steps, yet the pH result suggests these measures are unlikely to be sufficient without prompt operative delivery.

Question 41

A client presents to the emergency unit with an exacerbation of chronic obstructive airway disease (COPD). Which of the following findings is most concerning?

Accepted Answer

Answer reason: In COPD exacerbations, an SpO2 around 88% may be within an acceptable target range for some chronic CO2 retainers, whereas cyanosis indicates critical oxygen delivery impairment. Accessory muscle use and productive cough are common findings in exacerbations but do not, by themselves, signal imminent decompensation as strongly as central cyanosis. Central (tongue/lips) discoloration suggests systemic desaturation, making it the most concerning for impending respiratory arrest and need for urgent airway/ventilatory support.

Question 42

A client was admitted to PACU after prolonged surgery. The nurse assessment revealed O2SATS of 89%, and noisy breathing. What should the nurse do first?

Accepted Answer

Answer reason: The jaw-thrust is the preferred maneuver in an anesthetized or potentially cervical-spine-risk patient because it lifts the mandible and tongue off the posterior pharynx without requiring neck extension. Oxygen alone may improve saturation transiently but does not correct the obstruction, so ventilation can still be inadequate. Intubation and notifying the provider are escalation steps if basic airway maneuvers and supportive measures fail.

Question 43

A 32-week gestation client is seen by a primary HCP for reports of generalized illness. When assessing the client, the RN would immediately report what symptom to the HCP?

Accepted Answer

Answer reason: Visual disturbances in late pregnancy are a danger sign for severe preeclampsia and impending eclampsia due to cerebral vasospasm and end-organ involvement. At 32 weeks, new blurred vision signals high risk for seizure and stroke and requires urgent provider notification and rapid evaluation (BP, urine protein, labs) with escalation of care. This finding is more time-critical than nonspecific symptoms like nausea/vomiting. RUQ pain and severe headache are also concerning for preeclampsia/HELLP, but visual changes strongly indicate acute neurologic involvement requiring immediate action.

Question 44

A 32-year-old patient with sickle cell anemia is admitted to the hospital during a sickle cell crisis. Blood pressure is 104/62 mm Hg, oxygen saturation is 92%, and the patient reports pain at a level 8 (on a scale of 0 to 10). Which action prescribed by the health care provider will the nurse implement first?

Accepted Answer

Answer reason: Sickle cell crisis involves vaso-occlusion and tissue hypoxia, and immediate nursing priority follows ABCs to optimize oxygenation and prevent further sickling. An SpO2 of 92% indicates impaired oxygenation that should be corrected promptly with supplemental oxygen. Improving oxygen delivery helps limit ongoing ischemia while other therapies are initiated. IV opioids and fluids are important but do not take precedence over correcting oxygenation when saturation is low. Warm packs can support comfort but are adjunctive and not the first priority in this presentation.

Question 45

A patient's GRBS is 40 mg%. The immediate management is to administer?

Accepted Answer

Answer reason: The priority is rapid restoration of blood glucose with a concentrated IV glucose source to achieve a prompt rise. Concentrated dextrose is faster and more reliable for immediate correction than dilute maintenance fluids. Insulin would further lower glucose and worsen the emergency, while normal saline does not correct hypoglycemia.

Question 46

The physician has ordered oxygen to maintain an oxygen saturation above 92%. Your adult patient is on oxygen at 5 liters/minute via nasal prongs. You check the patient's oxygen saturation and find that it is 87%. To increase the oxygen saturation, you should?

Accepted Answer

Answer reason: A non-rebreather at 10–15 L/min provides the highest oxygen concentration among noninvasive devices and is appropriate for acute desaturation while further assessment and interventions occur. A simple mask increases FIO2 compared with a cannula but is typically insufficient for significant hypoxemia that persists at 5 L/min. An oxygen tent is not appropriate for adults, and proceeding directly to requesting intubation is premature without first escalating oxygen delivery and evaluating airway, work of breathing, and response.

Question 47

A nurse in the surgical unit receives a client who has just arrived from the post-anesthesia care unit (PACU) following an exploratory laparotomy. What actions should the nurse implement first?

Accepted Answer

Answer reason: Immediate post-anesthesia priorities follow ABCs because residual anesthetics and opioids can depress ventilation and compromise airway protection. Evaluating breathing first identifies hypoventilation, obstruction, or inadequate oxygenation that can rapidly become life-threatening if missed. Once respiratory stability is confirmed, the nurse can proceed to circulation-focused assessments such as vital signs trends and inspection for hemorrhage. Drains and tubes are important, but impaired ventilation is a more urgent threat than loss of patency.

Question 48

A nurse is caring for a client who is admitted for diabetic ketoacidosis (DKA)? Which of the following is the priority action the nurse should anticipate?

Accepted Answer

Answer reason: IV regular insulin is the standard initial therapy to reduce serum glucose and suppress lipolysis/ketone formation in a controlled, titratable way while other supportive measures proceed. Oral fluids are often unsafe or insufficient due to nausea, vomiting, and altered mental status, and fluid resuscitation is typically IV and coordinated with electrolyte management. Ambulation and dietary changes do not address the immediate life-threatening derangements of acidosis and hyperglycemia.

Question 49

A nurse is caring for a client who has suspected pulmonary embolism (PE). Which of the following is the priority action the nurse should take?

Accepted Answer

Answer reason: Anticoagulation (e.g., heparin per protocol/provider order) is the key initial therapy for suspected PE unless contraindicated, because it reduces morbidity and mortality by limiting new thrombus formation and embolization. Deep breathing may ease anxiety and support ventilation but does not treat the underlying thromboembolic process and is not the priority definitive action. Increasing fluids and a low-fat diet do not address the acute, life-threatening pathophysiology.

Question 50

An unresponsive patient arrives in the ER wearing a medic alert bracelet stating severe peanut allergy. Respiratory arrest and collapse occured after ingestion of a chocolate candy-topped ice cream dessert. Which immediate intervention is priority?

Accepted Answer

Answer reason: Anaphylaxis causes rapid airway edema and distributive shock from massive mediator release, so the definitive first-line medication is intramuscular epinephrine to reverse bronchospasm and vasodilation. This presentation (known severe peanut allergy with collapse and respiratory arrest after ingestion) is most consistent with life-threatening anaphylaxis where time-to-epinephrine is critical for survival. Oxygen and airway preparation are important supportive steps, but they do not halt the underlying pathophysiology and should not delay epinephrine. Antihistamines are adjuncts for cutaneous symptoms and do not treat shock or airway obstruction, but they are appropriately paired as ordered after the key therapy is initiated. A hypotonic fluid bolus is inappropriate in shock; if fluids are needed, isotonic crystalloids are used.

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