Question 1

The nurse is caring for a client with severe chronic obstructive pulmonary disease (COPD). Which of the following findings would require immediate follow-up?

Accepted Answer

Answer reason: In advanced COPD this can indicate the patient is no longer able to maintain adequate ventilation and may rapidly decompensate to hypercapnic respiratory failure, requiring urgent assessment, ABGs, and possible ventilatory support. By contrast, an SpO2 of 88% may be near the target range for many COPD patients (often 88–92%) and is not automatically emergent if stable. Increased hemoglobin reflects chronic hypoxemia (secondary polycythemia), and dependent edema suggests possible cor pulmonale—important findings but typically not as immediately life-threatening as signs of imminent respiratory collapse.

Question 2

Which of the following is an intervention for postpartum hemorrhage?

Accepted Answer

Answer reason: Misoprostol is a prostaglandin analog that promotes uterine contractions and is used for prevention and treatment of postpartum hemorrhage, especially when other uterotonics are unavailable or as an adjunct. Magnesium sulfate is used for seizure prophylaxis in preeclampsia/eclampsia and can worsen uterine relaxation, making bleeding more likely. Insulin treats hyperglycemia, and heparin is an anticoagulant—both are inappropriate and potentially harmful in active hemorrhage.

Question 3

A nurse is caring for a client admitted with acute alcohol withdrawal who is prescribed lorazepam IV PRN. Which assessment finding would require the MOST immediate nursing action?

Accepted Answer

Answer reason: A low respiratory rate with decreased arousal suggests oversedation from IV benzodiazepine and requires immediate action such as stimulating the patient, assessing airway/oxygenation, holding further sedatives, and notifying the provider/activating rapid response as indicated. The other findings reflect expected autonomic hyperactivity or moderate withdrawal severity that warrants treatment and monitoring but is not as immediately life-threatening. The priority is preventing deterioration from impaired ventilation and reduced level of consciousness.

Question 4

The nurse is monitoring a client with hypokalemia. Which ECG finding is MOST concerning and requires immediate intervention?

Accepted Answer

Answer reason: A wide-complex tachycardia is an unstable rhythm risk that can rapidly deteriorate into ventricular fibrillation and cardiac arrest, so it demands immediate assessment and emergency treatment. While flattened T waves, ST depression, and prominent U waves are classic ECG manifestations of low potassium, they are typically warning signs rather than immediately life-threatening rhythms. The priority is to treat the dysrhythmia and correct potassium promptly while monitoring for hemodynamic instability.

Question 5

A nurse is assessing a client who has just been admitted with a suspected myocardial infarction (MI). Which assessment finding would be the nurse's priority to report to the healthcare provider?

Accepted Answer

Answer reason: g., nitrates, antiplatelet therapy, escalation to reperfusion pathway). This finding is a time-sensitive emergency symptom that directly guides immediate treatment decisions and monitoring intensity. By comparison, an SpO2 of 96% and BP 130/80 mmHg are not acutely unstable, and mild tachycardia can occur from pain/anxiety and is generally a secondary concern unless accompanied by hypotension, dysrhythmia, or hemodynamic compromise. Reporting the severity of pain promptly supports rapid therapy and evaluation of response to treatment.

Question 6

Your patient complains of sudden chest pain. What is the best way to obtain an image of the heart for this problem?

Accepted Answer

Answer reason: A 12-lead ECG provides a comprehensive electrical “map” (including ST elevation/depression and reciprocal changes) and is the standard first-line test obtained within minutes for sudden chest pain. A 3-lead ECG is primarily for rhythm monitoring and can miss regional ischemic changes because it does not sample enough leads. Echocardiography/TEE can evaluate structure and wall-motion but are not the fastest or most appropriate initial test to triage suspected MI.

Question 7

A patient in the emergency department has multiple fractured ribs and a right-sided tension pneumothorax. The nurse would expect to prepare the patient for which of the following procedures?

Accepted Answer

Answer reason: Definitive management is urgent pleural decompression and placement of a thoracostomy tube to continuously evacuate air and allow lung re-expansion. Multiple rib fractures commonly accompany traumatic pneumothorax and increase risk of respiratory compromise, further supporting immediate chest drainage preparation. An ECG or urinary catheter may be supportive monitoring measures, but they do not treat the primary lethal problem of intrathoracic pressure from a tension pneumothorax. Gastric lavage is unrelated to thoracic trauma management and would delay critical intervention.

Question 8

A client in sinus bradycardia, with a heart rate of 45 beats/minute, complains of dizziness and has a blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate will be prescribed?

Accepted Answer

Answer reason: Symptomatic bradycardia with hypotension and dizziness indicates poor cardiac output requiring immediate stabilization. Transcutaneous pacing is an indicated rapid intervention when bradycardia is causing hemodynamic instability or if medication therapy is ineffective/unavailable. Digoxin would worsen bradycardia by slowing AV conduction and is inappropriate in this unstable presentation. Defibrillation is used for pulseless VT/VF, and simple monitoring would be unsafe given ongoing signs of hypoperfusion.

Question 9

A patient with a history of epilepsy is found unresponsive and seizing for over 10 minutes. What is the most appropriate initial medication to administer?

Accepted Answer

Answer reason: An IV benzodiazepine is first-line because it quickly enhances GABA-A–mediated inhibition and can abort seizures within minutes. Phenytoin and levetiracetam are typically used as second-line agents to prevent recurrence after initial control rather than as the fastest initial abortive therapy. Oral valproate is inappropriate in an unresponsive actively seizing patient due to inability to safely swallow and delayed onset.

Question 10

A 3-year-old child is brought to the emergency department with a 2-day history of fever, sore throat, and difficulty swallowing. On examination, the child is sitting upright, leaning forward, drooling, and appears anxious. What is the priority nursing action?

Accepted Answer

Answer reason: This requires rapid escalation so advanced airway equipment and skilled personnel can be mobilized while minimizing agitation that can precipitate complete obstruction. Throat examination with a tongue depressor and routine throat cultures can trigger laryngospasm or sudden airway closure and are unsafe before the airway is secured. Encouraging oral fluids is inappropriate because swallowing is impaired and aspiration risk is high while the airway is threatened.

Question 11

The nurse in the emergency department (ED) is assessing a client who may have an acute myocardial infarction. Which of the following findings would support this diagnosis?

Accepted Answer

Answer reason: Acute myocardial infarction reflects acute myocardial ischemic injury that produces characteristic ECG changes. ST-segment elevation is the classic finding of transmural injury in STEMI and supports an acute MI diagnosis requiring emergent reperfusion evaluation. T-wave inversion can occur with ischemia and may be seen in NSTEMI/unstable angina, but it is less specific for an acute infarction than ST elevation. U-waves are more consistent with electrolyte abnormalities (e.g., hypokalemia), and a prolonged PR interval indicates AV conduction delay rather than acute infarction.

Question 12

The client is admitted with an ACS. Which should be the nurse’s priority assessment?

Accepted Answer

Answer reason: Tachypnea, hypoventilation, or increased work of breathing can signal hypoxemia, pulmonary edema, or impending respiratory failure, which require immediate intervention and can rapidly worsen myocardial ischemia. Respiratory status also guides urgent actions such as oxygen administration when indicated and escalation to rapid response if deterioration is present. Pain, blood pressure, and heart rate are important, but they are assessed after confirming that ventilation and oxygenation are adequate.

Question 13

A 10-month-old infant is found in respiratory arrest, and cardiopulmonary resuscitation is started. Which site is best to check for a pulse?

Accepted Answer

Answer reason: Carotid palpation in infants can be difficult and may risk excessive pressure on the airway/neck structures. Radial pulses are often weak or absent in low-flow states such as arrest and are not preferred for CPR decision-making. Femoral can be used, but brachial is typically easiest and most consistently found in a 10-month-old during an emergency.

Question 14

The nurse is caring for a child with epiglottitis. The child is at greatest risk of develop which condition?

Accepted Answer

Answer reason: This puts the child at immediate risk for sudden respiratory compromise and complete obstruction, especially if agitation or airway manipulation worsens swelling. Nursing priority is maintaining a patent airway and preparing for emergent airway management rather than focusing first on longer-term risks. Dehydration can occur from drooling and poor intake, but it is not as immediately life-threatening as loss of the airway.

Question 15

The child is hospitalized following renal trauma. The nurse should assess for signs of which complication first?

Accepted Answer

Answer reason: Assessment should focus on hemodynamic instability (tachycardia, hypotension, pallor, delayed capillary refill), abdominal/flank distention, and decreasing hematocrit. Urinary findings like decreased output may occur but are less immediately predictive of shock than ongoing internal hemorrhage. Hypertension and electrolyte disturbances are possible later complications but do not usually represent the most immediate threat to airway-breathing-circulation.

Question 16

A nurse would expect to prepare a client with ulcerative colitis for surgery if the client develops which condition?

Accepted Answer

Answer reason: A perforation represents an acute surgical emergency because ongoing leakage of bowel contents rapidly leads to sepsis and shock. Nursing priorities shift to rapid recognition, NPO status, IV fluids/antibiotics as ordered, and preparing for emergent operative management. By contrast, gastritis and outpouching/hernia are not classic UC-driven emergent indications for colectomy in the way perforation is.

Question 17

A client has experienced a brain stem infarction. It is most important for the nurse to assess the client for?

Accepted Answer

Answer reason: Brainstem infarctions can disrupt the medullary respiratory centers and cranial nerve function, creating an immediate threat to airway and ventilation. A decreased respiratory rate is an early sign of brainstem compromise that can rapidly progress to respiratory failure, making it the highest-priority assessment. Motor and sensory deficits can occur with many stroke locations, but they are generally less immediately life-threatening than impaired breathing. Aphasia more strongly suggests cortical (dominant hemisphere) involvement rather than primary brainstem injury.

Question 18

A preschooler is brought to the emergency department after ingesting kerosene. The nurse is aware the child is at risk for which condition?

Accepted Answer

Answer reason: g., kerosene) primarily threatens the airway because these low-viscosity substances are easily aspirated, especially if the child coughs or vomits. Aspiration causes a chemical injury to lung tissue leading to chemical pneumonitis, which can progress to respiratory distress and hypoxemia. This is why inducing emesis and routine gastric lavage are generally avoided due to increased aspiration risk. Carditis, uremia, and hepatitis are not the classic, highest-risk acute complications compared with aspiration-related lung injury.

Question 19

While examining a child with acute epiglottitis, a nurse should have which item available?

Accepted Answer

Answer reason: Having advanced airway supplies available supports rapid endotracheal intubation if stridor, drooling, tripod positioning, or deteriorating respiratory status occurs. Any action that could provoke agitation or laryngospasm and precipitate complete obstruction should be avoided during assessment, making airway backup essential. Cool mist may be supportive but does not address the imminent risk of airway occlusion, and using tongue blades can worsen obstruction by stimulating the inflamed epiglottis.

Question 20

A client is experiencing cardiac tamponade. The nurse reviews the physician’s orders and determines further intervention is not required when the orders include which intervention?

Accepted Answer

Answer reason: The definitive emergent treatment is to remove the compressing fluid to restore preload and hemodynamics. This intervention directly addresses the underlying cause rather than temporarily supporting blood pressure. Inotropes/vasopressors may be used as a bridge but do not relieve the mechanical obstruction, so their presence alone would still require further urgent action to decompress the pericardium.

Question 21

The nurse is assessing a 2-year-old child in the emergency department for epiglottitis. Which assessment finding would the nurse expect to document?

Accepted Answer

Answer reason: Sitting upright, leaning forward with the neck extended (tripod positioning) helps reduce airway obstruction and work of breathing and is a classic expected finding along with drooling and muffled voice. Mild fever is less characteristic because epiglottitis often presents with high fever and toxic appearance. Gradual onset is more consistent with croup, whereas epiglottitis typically has sudden, rapidly progressive symptoms requiring urgent airway management.

Question 22

A client with chronic alcohol abuse is admitted to the hospital for detoxification. Later that day, his blood pressure increases and he’s given lorazepam (Ativan) to prevent which complication?

Accepted Answer

Answer reason: g., hypertension, tachycardia) and can progress to withdrawal seizures and delirium tremens. Benzodiazepines like lorazepam are first-line because they enhance GABA activity, reducing neuronal firing and preventing withdrawal-related seizures. While they also reduce anxiety and agitation, the critical life-threatening complication being prevented is seizure activity. The other options do not represent the primary acute complication targeted by benzodiazepine prophylaxis in alcohol detox.

Question 23

A client with hyperthyroidism develops a high fever, extreme tachycardia, and systolic hypertension. The nurse suspects which of the following?

Accepted Answer

Answer reason: The classic presentation includes hyperpyrexia, marked tachycardia (often with dysrhythmias), and systolic hypertension with potential progression to heart failure and shock. This symptom cluster in a patient with hyperthyroidism is most consistent with an endocrine emergency requiring immediate recognition and escalation of care. Myxedema is the opposite extreme (severe hypothyroidism) and typically presents with hypothermia and bradycardia rather than fever and extreme tachycardia.

Question 24

The nurse is caring for the client admitted in Addisonian crisis. Which medication, if prescribed, should the nurse plan to administer?

Accepted Answer

Answer reason: Immediate treatment is stress-dose IV glucocorticoids to replace cortisol and support vascular tone and response to catecholamines. Hydrocortisone is preferred because it provides potent glucocorticoid effect and some mineralocorticoid activity, addressing both cortisol deficit and blood pressure instability. Regular insulin would worsen potential hypoglycemia risk, and ketoconazole suppresses steroid synthesis, which would exacerbate adrenal insufficiency. Sodium nitroprusside treats hypertensive emergencies, not the typical hypotensive presentation of adrenal crisis.

Question 25

A client with an impending myocardial infarction (MI) is experiencing angina. The nurse would document the angina as?

Accepted Answer

Answer reason: This type is characterized by new-onset, worsening (crescendo), or rest angina and signals high short-term risk for infarction, requiring urgent evaluation and treatment. Stable angina is predictable with exertion and relieved by rest or nitroglycerin, which does not fit an “impending MI” presentation. Variant (Prinzmetal) angina is primarily coronary vasospasm with transient ST elevation, not the typical documentation for pre-infarction ischemia described here.

Question 26

A client is experiencing acute pulmonary edema. What is the best position for the nurse to place the client in?

Accepted Answer

Answer reason: Upright positioning maximizes lung expansion, decreases work of breathing, and helps move fluid away from dependent lung regions, improving ventilation-perfusion. It also reduces venous return compared with supine positions, which can lessen pulmonary capillary congestion. Lying flat worsens dyspnea and oxygenation, and semi-Fowler’s is helpful but not as effective as the most upright position when severe distress is present.

Question 27

Which treatment goal is the nurse’s highest priority for a client with status asthmaticus?

Accepted Answer

Answer reason: A key treatment goal is rapid reversal of airflow obstruction with aggressive bronchodilation, systemic corticosteroids, and oxygen support so that invasive ventilation can be avoided. Intubation in severe asthma carries high risk (air trapping, barotrauma, hemodynamic compromise), so preventing deterioration to that point is the most urgent outcome-focused goal. Determining triggers and improving exercise tolerance are important later, but they do not address the immediate threat to airway and breathing. Reducing secretions is not the primary driver of the acute airflow obstruction in status asthmaticus compared with bronchospasm and mucosal edema.

Question 28

A client is experiencing status asthmaticus. What is the nurse’s priority intervention for this client?

Accepted Answer

Answer reason: Short-acting inhaled beta-2 agonists provide the fastest onset of bronchodilation and are first-line emergent therapy. Corticosteroids are important to reduce airway inflammation, but their effect is delayed and they are adjuncts rather than the first priority for acute relief. IV beta-adrenergic therapy is generally reserved for severe cases not responding to inhaled therapy and carries higher risk of systemic adverse effects, so it is not the initial priority.

Question 29

Which assessment finding indicates to a nurse that a neonate born with esophageal atresia needs suctioning?

Accepted Answer

Answer reason: A drop in oxygenation manifested by bluish discoloration is an urgent sign of airway obstruction/aspiration and indicates immediate need to clear secretions. Decreased saliva would be opposite of the typical finding (excessive drooling/foamy secretions) and does not signal urgent airway clearance. Swallowing difficulty is expected in this condition, but cyanosis specifically reflects impaired ventilation/oxygenation requiring prompt suctioning.

Question 30

What is the most important nursing intervention when dealing with a child who has been poisoned?

Accepted Answer

Answer reason: In suspected poisoning, immediate priorities follow ABCs to prevent hypoxia, aspiration, shock, and cardiac/respiratory arrest. Rapid stabilization (airway protection, breathing support, circulation assessment, vital signs, and rapid glucose/neurologic checks as indicated) addresses the most time-sensitive life threats. Identifying the substance and timing are important but are secondary assessments that should not delay resuscitative actions. Notifying parents is appropriate but does not directly treat the acute physiologic emergency and is not the first priority.

Question 31

The nurse is caring for a client with an extreme case of salicylate poisoning. The nurse anticipates the client will receive which treatment?

Accepted Answer

Answer reason: Dialysis is a definitive therapy because it directly clears salicylates from the blood and helps correct metabolic derangements. Among the options, only a dialysis modality accomplishes systemic toxin removal in an extreme poisoning scenario. Gastric lavage is time-limited to very early ingestions and does not address already-absorbed drug burden. Vitamin K targets coagulopathy from warfarin-type toxicity, and cooling blankets address hyperthermia but do not eliminate salicylates.

Question 32

A 12-year-old child with full-thickness, circumferential burns to the chest has difficulty breathing. The nurse is aware that which is the priority intervention?

Accepted Answer

Answer reason: The priority is to rapidly restore chest excursion by releasing the constricting eschar, which is achieved with an escharotomy. Interventions for pleural space problems (needle decompression for tension pneumothorax, chest tube for pneumothorax/hemothorax) do not address the primary mechanical restriction from the burn. Airway management may become necessary, but when the breathing difficulty is driven by circumferential chest constriction, immediate chest wall release is the most direct life-saving action.

Question 33

A nurse is caring for a 15-year old who sustained a fracture of the femur 24 hours ago. Which finding would alert the nurse to an early complication?

Accepted Answer

Answer reason: New-onset shortness of breath signals impaired gas exchange and potential hypoxemia, making it an urgent, systemic complication rather than an expected local response. Pain, local swelling, and loss of function are common, anticipated findings after a fracture and do not specifically indicate a developing life-threatening complication. Prompt recognition of respiratory symptoms is critical to initiate rapid assessment (oxygenation, vitals, mental status) and escalation of care.

Question 34

When performing chest compressions on a 2-year-old child, which depth is correct?

Accepted Answer

Answer reason: 2” to 2½” (5 to 6.5 cm) High-quality pediatric CPR requires compressing the chest to about one-third of the anterior-posterior diameter to generate adequate coronary and cerebral perfusion. For a 2-year-old child, this corresponds to approximately 2 inches (5 cm), aligning with pediatric BLS guidance. Shallower depths risk inadequate forward blood flow and lower chances of return of spontaneous circulation. Depths around 1–1.5 inches are more consistent with infants rather than children, making them insufficient for a typical toddler chest size. The listed range up to 2½ inches remains consistent with the one-third chest depth concept across varying child sizes.

Question 35

The nurse is assessing a child recently brought to the emergency department. Which observations would cause the nurse to suspect epiglottitis?

Accepted Answer

Answer reason: This presentation is a pediatric airway emergency and is classically associated with muffled voice, tripod positioning, and potential stridor, so recognizing signs that suggest imminent obstruction is critical. A low-grade fever is less typical because epiglottitis often presents with high fever and toxic appearance. Cough is usually minimal or absent (unlike croup), so a prominent cough would point away from this diagnosis.

Question 36

What is the most important goal for a child with ineffective airway clearance?

Accepted Answer

Answer reason: An “ineffective airway clearance” problem indicates the child cannot adequately remove mucus, so the primary outcome must be a clear, open airway with effective breath sounds and work of breathing. Measures like hydration and medications can support secretion thinning or bronchodilation, but they are secondary to ensuring the airway is open and gas exchange is protected. Anxiety reduction is beneficial but does not address the immediate physiologic threat of airway compromise. Prioritizing a patent airway aligns with ABCs and prevents respiratory failure.

Question 37

Using which part of the hands is appropriate when performing chest compressions on a child between ages 1 and 8?

Accepted Answer

Answer reason: For a child age 1 year to puberty, standard technique is compressions over the lower half of the sternum using the heel of one hand (or two hands only if needed for larger children). Using two fingers is the infant technique and typically does not generate adequate depth in a child. The two-thumb encircling method is also specific to infants with two rescuers, not to children.

Question 38

A client presents with a right tension pneumothorax. The nurse expects to find which sign and symptom?

Accepted Answer

Answer reason: A tension pneumothorax traps air under pressure, collapsing the affected lung and shifting mediastinal structures, which rapidly impairs ventilation and gas exchange. This creates a V/Q mismatch and reduced oxygenation, making low SpO2 and respiratory distress expected early findings. Tracheal deviation, when present, typically shifts away from the affected side (so a right tension pneumothorax would deviate left), making that distractor incorrect. Hemodynamic compromise is more often hypotension from decreased venous return rather than hypertension.

Question 39

The nurse is caring for a client who has been admitted with a diagnosis of addisonian crisis. In planning care for this client, which outcome should be priority?

Accepted Answer

Answer reason: The immediate priority is maintaining perfusion and preventing progression to refractory/irreversible shock through rapid IV fluids, IV glucocorticoids, and correction of electrolyte/glucose abnormalities. Infection prevention and anxiety relief are important but are secondary once airway, breathing, and circulation are stabilized. Lowering blood pressure is inappropriate because the key danger is dangerously low blood pressure and circulatory collapse.

Question 40

The nurse is admitting a client with the diagnosis of diabetic ketoacidosis (DKA). The nurse should anticipate administration of which of the following treatments?

Accepted Answer

Answer reason: Insulin and I.V. fluids DKA is a medical emergency caused by absolute/relative insulin deficiency leading to hyperglycemia, ketone production, metabolic acidosis, and severe osmotic diuresis with dehydration. Initial management prioritizes rapid intravascular volume repletion with isotonic IV fluids to restore perfusion and improve renal clearance of glucose/ketones. Regular insulin therapy is then used to stop ketogenesis and gradually reduce serum glucose while monitoring electrolytes closely, especially potassium, which can drop quickly once insulin is started. Glucagon is reserved for severe hypoglycemia, not hyperglycemic ketoacidosis, and steroids can worsen hyperglycemia and are not a primary DKA treatment.

Question 41

The nurse is caring for the client experiencing superior vena cava syndrome secondary to lung cancer. Which problem should be the nurse’s priority?

Accepted Answer

Answer reason: Using ABC priorities, breathing problems outweigh circulation, infection risk, or skin concerns because hypoxia and airway obstruction are immediately life-threatening. Early recognition focuses on respiratory status (dyspnea, stridor, decreased oxygen saturation) and positioning to optimize ventilation. Perfusion changes are important but are typically secondary to the more urgent threat of respiratory compromise in this syndrome.

Question 42

The nurse is assessing the client immediately following a C5–C6 anterior cervical discectomy. Which potential problem should be the nurse’s priority?

Accepted Answer

Answer reason: After an anterior cervical discectomy, postoperative neck swelling or hematoma can compress the trachea, and injury/irritation near the recurrent laryngeal nerve can contribute to stridor/airway obstruction, making respiratory status the most urgent assessment. A C5–C6 level also has potential to affect diaphragmatic function if high cervical cord issues occur, so detecting early hypoventilation is critical. The other choices are important postoperatively, but they generally evolve less abruptly and are addressed after ensuring adequate ventilation and oxygenation.

Question 43

The nurse is caring for the client experiencing Guillain-Barré syndrome (GBS). It is most important for the nurse to monitor the client for which complication?

Accepted Answer

Answer reason: Progressive loss of respiratory muscle strength can occur even when limb weakness seems only moderate, so trending vital capacity/negative inspiratory force and watching for shallow breathing and inability to clear secretions is critical. Autonomic instability and resultant dysrhythmias can occur, but airway and breathing take priority because decompensation can be sudden and fatal without timely ventilatory support. Septic emboli is not a typical primary complication of GBS.

Question 44

The 5-year-old with type 1 DM develops hypoglycemia during a preschool class. Which simple carbohydrate should the nurse give now?

Accepted Answer

Answer reason: Orange juice is rapidly absorbed and provides an appropriate quick sugar source in a measured amount suitable for the “15-15 rule.” Bread is a complex carbohydrate that digests more slowly, delaying correction. Peanuts are primarily fat/protein and will not correct hypoglycemia promptly, and chocolate milk contains fat/protein that can slow gastric emptying, making glucose rise less reliably than juice.

Question 45

The nurse is preparing to care for the infant newly diagnosed with esophageal atresia with tracheo-esophageal fistula. Which nursing action is priority?

Accepted Answer

Answer reason: The immediate priority is airway protection by making the infant NPO to prevent aspiration and subsequent respiratory compromise before surgical repair. Keeping suction available is important, but it is a secondary supportive measure after eliminating the source of aspiration (oral intake). Assessing lungs and monitoring vital signs are surveillance actions and do not prevent the life-threatening complication.

Question 46

If a gastric ulcer perforates, which action should be included in the management of the client?

Accepted Answer

Answer reason: Immediate management prioritizes circulation support with aggressive IV isotonic fluids and correction of electrolyte abnormalities while preparing for definitive surgical treatment. Acid-suppressing or antacid therapies do not address the acute hemodynamic instability created by perforation and contamination. Removing an NG tube is inappropriate; gastric decompression is often maintained/initiated to reduce further leakage and vomiting risk while the client is stabilized.

Question 47

A client has received an antibiotic infusion and is now experiencing an anaphylactic reaction. What is the most important intervention by the nurse?

Accepted Answer

Answer reason: Anaphylaxis is a time-critical emergency where airway edema and bronchospasm can rapidly cause hypoxia and respiratory arrest, so ABCs dictate securing ventilation/oxygenation first. The nurse’s priority action is to ensure the airway is open and that the client can be oxygenated while additional treatments are prepared and administered. Epinephrine is the first-line medication to reverse bronchoconstriction and vasodilation, but it is unsafe if the patient cannot be ventilated; airway support must occur immediately and concurrently with calling for help. A fluid bolus can treat distributive shock and vital sign monitoring provides data, but neither prevents imminent airway compromise.

Question 48

The nurse is caring for a client experiencing a stroke in evolution. What is the priority nursing intervention?

Accepted Answer

Answer reason: Acute stroke care prioritizes ABCs because evolving cerebral ischemia is worsened by hypoxemia. Supplemental oxygen is an immediately deployable intervention to optimize arterial oxygen content and support threatened brain tissue while definitive evaluation/treatment proceeds. Suction availability is important for airway protection if secretions or vomiting occur, but it is preparatory and not the most immediate action unless obstruction is present. Thickened liquids address aspiration risk during oral intake and is typically implemented after swallowing assessment, not as the first priority during an evolving stroke.

Question 49

A client with acute asthma is experiencing inspiratory and expiratory wheezes and a decreased forced expiratory volume. What is the priority intervention by the nurse?

Accepted Answer

Answer reason: The immediate priority is to rapidly reverse bronchospasm to improve ventilation and relieve obstruction, which is best achieved with short-acting bronchodilator therapy. Inhaled or oral steroids help reduce airway inflammation but have a delayed onset and are not the fastest intervention for acute symptom relief. Beta-adrenergic blockers can worsen bronchospasm by blocking beta-2 receptors and are contraindicated in uncontrolled asthma exacerbations.

Question 50

A client is experiencing an anaphylactic reaction to a drug. What is the most important intervention for the nurse to perform?

Accepted Answer

Answer reason: The immediate nursing priority follows ABCs—supporting airway and breathing while activating emergency response and preparing for epinephrine. Supplemental oxygen helps mitigate hypoxemia during acute respiratory compromise and buys time while definitive treatment is initiated. Starting an IV line is important for medication and fluid resuscitation, but it is secondary to ensuring adequate oxygenation in a patient who may be losing the airway. Labs and routine vital signs do not address the immediate threat and must not delay critical stabilization.

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