Question 1

The nurse is assessing the client following cardiac surgery. Which assessment findings should be of the greatest concern to the nurse?

Accepted Answer

Answer reason: Rising venous pressure (JVD) with hypotension indicates impaired cardiac filling and reduced stroke volume; muffled heart sounds suggest fluid/blood in the pericardial space. This condition can rapidly progress to obstructive shock and pulseless electrical activity without immediate intervention (notify provider/prepare for pericardiocentesis or surgical exploration). By contrast, mild hypothermia with shivering or expected postoperative pain/tachycardia is typically managed supportively and is less immediately fatal than tamponade physiology.

Question 2

The client who had an open thoracotomy for removal of a large tumor received fluid resuscitation during surgery due to an extensive blood loss. Upon postoperative assessment, the nurse finds that the client is cyanotic and dyspneic and has pink, frothy secretions drooling from the client’s mouth. Which intervention should the nurse implement immediately?

Accepted Answer

Answer reason: Pink, frothy secretions with cyanosis and severe dyspnea signal acute pulmonary edema with life-threatening hypoxemia requiring immediate emergency response and advanced airway/oxygenation support. Activating the respiratory code rapidly mobilizes personnel and equipment for high-flow oxygen, ventilatory support (e.g., CPAP/intubation), and urgent provider-directed therapy (e.g., diuretics/vasodilators as indicated). Positioning can help but is not sufficient as the first priority when the patient is actively decompensating with signs of impending respiratory failure. Additional fluid bolus would likely worsen pulmonary edema, and coughing/deep breathing is inappropriate and unsafe in this acute presentation.

Question 3

The parent of the 6-year—old brings the child to the clinic after being hit in the eye by a baseball. The nurse assesses gross hyphema (hemorrhage into the anterior chamber) and a visible fluid meniscus across the iris. Which intervention by the HCP should the nurse anticipate?

Accepted Answer

Answer reason: Emergency department evaluation enables urgent ophthalmology consultation, measurement and management of intraocular pressure, pain/nausea control, protective shielding, and monitoring for associated globe/orbital injuries. Waiting for outpatient referral can delay time-sensitive interventions and increases the chance of complications, especially in children. Home ice alone is inadequate for intraocular bleeding, and empiric patching can be unsafe if occult globe injury is present; topical steroids may be used but only after urgent specialist evaluation.

Question 4

The mother of the 2-year-old telephones the clinic nurse to ask advice. The child has a temperature of 104°F (40°C) and a sore throat and has been drooling for a few days. The child is now sleepy. Which is the best advice by the nurse?

Accepted Answer

Answer reason:  High fever with sore throat, drooling, and increasing sleepiness in a toddler raises concern for a potentially life-threatening upper-airway emergency (e.g., epiglottitis or deep neck infection) with risk of rapid airway obstruction and sepsis. Immediate ED evaluation is needed for airway assessment and prompt IV antibiotics and supportive care, rather than outpatient scheduling. Advising home care or simply clinic follow-up delays definitive airway-capable management. Attempting to visualize the throat can agitate the child and worsen obstruction, so it is unsafe to recommend.

Question 5

A client comes to the emergency department with acute shortness of breath and a cough that produces pink, frothy sputum. Admission assessment reveals crackles and wheezes, a blood pressure of 82/45 mm Hg, a heart rate of 120 beats/minute, and a respiratory rate of 38 breaths/minute. The client’s medical history includes diabetes mellitus, hypertension, and heart failure. Which disorder should the nurse suspect?

Accepted Answer

Answer reason: Severe tachypnea and hypoxemic distress fit rapid-onset pulmonary congestion, and the history of heart failure and hypertension strongly supports a cardiogenic cause. Hypotension and tachycardia suggest poor cardiac output and possible cardiogenic shock accompanying the pulmonary edema. Pneumothorax and pulmonary embolus more often present with sudden pleuritic chest pain and diminished/clear breath sounds rather than pink frothy sputum and widespread crackles, while tamponade would be expected to have muffled heart sounds and JVD rather than alveolar fluid findings.

Question 6

The nurse is caring for a 1-month-old infant with signs of increased intracranial pressure (ICP). The nurse is aware that a priority intervention will be necessary if the infant displays which of the following?

Accepted Answer

Answer reason: A bulging fontanel reflects elevated intracranial pressure in an infant with open sutures, and a high-pitched cry is a concerning neurologic sign of CNS irritation. Vomiting can occur from increased ICP and supports concern for worsening intracranial pathology rather than a benign feeding issue. In contrast, a sunken fontanel with tachycardia more strongly suggests dehydration, and blood-tinged emesis with legs drawn up points more toward gastrointestinal pathology (e.g., irritation/obstruction) than ICP.

Question 7

The nurse is one of many team members who respond to an infant in cardiopulmonary arrest. The nurse is directed to begin chest compressions while another maintains the infant’s airway. What action should the nurse perform next?

Accepted Answer

Answer reason: With another team member already managing the airway, the compressor should immediately use this technique on the lower half of the sternum to optimize circulation. Waiting for IO access delays high-quality CPR and worsens outcomes, so compressions should not be postponed for vascular access. The one-hand heel method is typically used for children or when rescuer size/infant size makes the encircling technique impractical, and the two-hand technique is inappropriate for an infant due to risk of excessive force.

Question 8

The 88-year-old client is admitted to the ED with numbness and weakness of the left arm and slurred speech. The computed tomography (CT) scan was negative for bleeding. Which nursing intervention is priority?

Accepted Answer

Answer reason: Acute focal neurologic deficits with a CT negative for hemorrhage suggest possible ischemic stroke, where eligibility for thrombolytic therapy is highly time-dependent. Establishing the last-known-well time is the key nursing priority because it determines whether the client is within the treatment window and guides immediate ED stroke protocols. Without an accurate onset time, thrombolytics may be unsafe or contraindicated even when imaging excludes bleeding. Other actions (exploring precipitating factors or arranging speech therapy) are secondary and should not delay time-critical stroke decision-making.

Question 9

A nurse caring for clients on a postpartal unit is aware that a condition requiring immediate intervention would be?

Accepted Answer

Answer reason: Bleeding occurring from 24 hours to 6 weeks postpartum is secondary postpartum hemorrhage, and a loss exceeding 500 mL meets the standard threshold for abnormal postpartum bleeding that requires urgent assessment and intervention. This level of blood loss should prompt evaluation for retained products, infection/subinvolution, or coagulation problems and immediate stabilization measures. Lower volumes listed are not the conventional cutoff used to define postpartum hemorrhage and are less likely to represent a life-threatening emergency on their own.

Question 10

A 59-year-old female client is experiencing chest pain at rest that is unresponsive to nitroglycerine. The physician diagnoses unstable angina and alerts the nurse that the client will require treatment with immediate surgical intervention. Which treatment is most appropriate?

Accepted Answer

Answer reason: PTCA provides rapid mechanical revascularization by opening the culprit coronary stenosis/occlusion and is an appropriate immediate invasive treatment when medical therapy fails. Cardiac catheterization is primarily a diagnostic step (often preceding intervention) rather than the definitive emergent treatment itself. Echocardiography evaluates cardiac structure/function but does not treat ischemia, and heart transplantation is reserved for end-stage heart failure, not acute coronary ischemia.

Question 11

A 60-year-old client was in a motor vehicle accident. He is brought to the emergency department by the paramedics. During the assessment, the client complains of difficulty breathing and chest pain. Auscultation of lung fields notes absent breath sounds in the left upper lobe. The nurse interprets this information as indicating which condition?

Accepted Answer

Answer reason: The acute presentation of dyspnea and chest pain in the setting of a motor vehicle accident fits a traumatic pneumothorax and is treated as an emergency because it can rapidly impair ventilation and oxygenation. Pneumonia and bronchitis typically cause adventitious sounds (crackles, wheezes/rhonchi) rather than a focal absence of breath sounds, and they are less likely to present immediately after trauma. Tuberculosis is a chronic infectious process and would not be expected to cause sudden unilateral absent breath sounds in this context.

Question 12

The nurse is completing the 1-minute Apgar assessment on the full-term newborn. The newborn's HR is 80 bpm. What should the nurse do next?

Accepted Answer

Answer reason: Neonatal resuscitation at 1 minute is driven by heart rate and effective ventilation. A heart rate of 80 bpm is below 100, indicating inadequate oxygenation/ventilation and the need to initiate assisted ventilation after initial steps. Providing positive pressure ventilation is the most effective intervention to rapidly improve heart rate and perfusion in this situation. Scoring the Apgar or providing routine warmth/skin-to-skin does not correct the underlying problem, and suctioning is only helpful when airway obstruction is suspected and should not delay ventilation when the heart rate is

Question 13

The laboring client suddenly experiences a dramatic drop in the FHR from the 150s to the 110. A vaginal exam reveals the presence of the fetal cord protruding through the cervix. What should be the nurse's first intervention?

Accepted Answer

Answer reason: The immediate priority is to relieve pressure on the cord by manually elevating the presenting part during a vaginal exam and maintaining that position until definitive delivery can occur. Positioning (e.g., Trendelenburg) can help reduce compression but is secondary and should be done after manual decompression is established. Simply monitoring delays lifesaving intervention and risks ongoing hypoxia and fetal demise.

Question 14

A home care aide notified the agency that she found a client lying on the floor. When the home health nurse arrives, she quickly assesses the newly diagnosed diabetic client. The assessment includes the following: client is semicomatose, apical heart rate is 102 beats/minute, blood pressure is 84/30 mm Hg, and skin is warm and dry. The nurse instructs the home care aide to call for an ambulance because these are signs of which condition?

Accepted Answer

Answer reason: Warm, dry skin and semicomatose presentation strongly support marked dehydration and hyperosmolarity rather than adrenergic diaphoresis. DKA more often presents with Kussmaul respirations, abdominal pain, and acetone/fruity breath from ketosis, and skin findings are not classically warm and dry as a key clue. Hypoglycemia typically causes cool, clammy sweating and neuroglycopenic symptoms, making it less consistent with the assessment findings. Immediate EMS activation is appropriate because the client is hemodynamically unstable and at risk for shock and coma.

Question 15

A client receiving hemodialysis treatments arrives at the hospital with a blood pressure of 200/100 mm Hg, a heart rate of 110 beats/minute, and a respiratory rate of 36 breaths/minute. Oxygen saturation on room air is 89%. He complains of shortness of breath, and plus 2 pedal edema is noted. His last hemodialysis treatment was yesterday. Which intervention should be done first?

Accepted Answer

Answer reason: The priority is immediate support of oxygenation and ventilation using ABCs when a patient is hypoxemic and in respiratory distress. An SpO2 of 89% on room air with tachypnea and dyspnea suggests acute pulmonary congestion/edema from fluid overload in a dialysis patient, creating an urgent gas-exchange problem. Supplemental oxygen is the fastest, safest first intervention to improve tissue oxygen delivery while the team evaluates and treats the underlying cause. Elevating the foot of the bed can worsen breathing by increasing venous return, and fluid restriction/hemodialysis address the cause but are not as immediate as correcting hypoxemia.

Question 16

Two hours after taking a regular morning dose of regular insulin, the client presents to a clinic with diaphoresis, tremors, palpitations, and tachycardia. Which nursing action is most appropriate?

Accepted Answer

Answer reason: Check blood glucose level; provide carbohydrates if less than 70 mg/dL (3.8 mmol/L). These adrenergic symptoms occurring about 2 hours after regular insulin strongly indicate acute hypoglycemia, which requires rapid assessment and treatment to prevent neuroglycopenia and seizure/coma. The immediate priority is to confirm the blood glucose and, if low, give fast-acting carbohydrate per hypoglycemia protocol. Oxygen or cardiac medications do not address the most likely time-linked cause and could delay definitive treatment. While chest pain would raise concern for ACS, the classic post-insulin timing with diaphoresis/tremor/palpitations makes hypoglycemia the safest first action to rule out and treat promptly.

Question 17

The nurse notes that the client has dyspnea and red blotches on the face and arms and appears anxious following exposure to latex. The nurse calls the ART, who initiates emergency treatment. Of all the emergency treatments available, which action should be taken first by ART?

Accepted Answer

Answer reason: Administer epinephrine hydrochloride 0.4 mL subcutaneously This presentation after latex exposure is consistent with an acute allergic reaction with respiratory involvement, where the immediate priority is reversing life-threatening airway edema and bronchospasm. Epinephrine is the first-line medication because it rapidly provides alpha- and beta-adrenergic effects that improve airway patency, reduce mucosal swelling, and support blood pressure. Oxygen and IV access are important supportive measures but do not treat the underlying anaphylactic physiology as quickly as epinephrine. Diphenhydramine is an adjunct for cutaneous symptoms and has a slower onset, so it should not delay definitive first-line therapy.

Question 18

The nurse is caring for a client with sickle cell disease who is reporting headache and blurred vision for the past 4 hours. The nurse should be most concerned that the client is experiencing?

Accepted Answer

Answer reason: Acute headache with blurred vision can represent evolving cerebral infarction or transient ischemic events from microvascular blockage. This diagnosis is immediately life-threatening and time-sensitive because prompt evaluation and disease-specific treatment (e.g., rapid imaging, possible exchange transfusion per protocol) can prevent progression and permanent deficits. A migraine is common but is a diagnosis of exclusion in this high-risk context, whereas meningitis would typically include fever/neck stiffness and retinal detachment more often presents with flashes/floaters or a “curtain” effect.

Question 19

The nurse received shift report on four assigned clients. The nurse should first assess the client?

Accepted Answer

Answer reason: This finding can precede rapid decompensation with hypoxemia, hypercapnia, and exhaustion, making it the highest-priority assessment using ABCs. In contrast, a nosebleed on high-flow nasal cannula is usually manageable and not immediately life-threatening if oxygenation is maintained. Tripod positioning after ambulation in chronic emphysema and pleuritic pain at a chest-tube site warrant assessment and intervention, but neither is as immediately ominous as near-silent lungs in acute asthma.

Question 20

A client who has an epidural hematoma suddenly becomes restless and agitated. What is the priority nursing action?

Accepted Answer

Answer reason: Sudden restlessness and agitation in a client with an epidural hematoma can be an early sign of rising intracranial pressure and impending neurologic deterioration, where preventing secondary brain injury from hypoxemia is critical. Immediate supplemental oxygen supports cerebral oxygen delivery while the team prepares for urgent evaluation and definitive management. A detailed neurologic assessment is important, but it should not delay rapid stabilization of oxygenation when acute decompensation is suspected. Starting an IV and auscultating lungs may be appropriate supportive steps, but they are not as time-sensitive for protecting the brain as promptly optimizing oxygenation.

Question 21

A patient with bleeding esophageal varices has had a Sengstaken-Blakemore tube placed to help prevent and control bleeding. What should the nurse do first if this tube becomes displaced?

Accepted Answer

Answer reason: The priority is protecting the airway and preventing asphyxiation when a balloon tamponade device migrates. A displaced Sengstaken-Blakemore tube can obstruct the upper airway if an inflated balloon shifts upward, creating an immediate life-threatening emergency. Deflating the balloon (and trimming/cutting as needed per emergency protocol) rapidly relieves obstruction risk while help is mobilized. Actions like raising the head of bed or calling a response team are supportive but do not immediately remove the airway hazard. Bowel sound assessment is unrelated to the emergent threat.

Question 22

A client is admitted with acute adrenal crisis. During the intake assessment the nurse can expect to find that the client has?

Accepted Answer

Answer reason: Reduced aldosterone causes sodium and water loss with intravascular volume depletion, producing hypotension that can progress to shock. Clients more typically develop tachycardia from hypovolemia rather than a slow regular pulse. Dehydration and volume depletion also make increased urination less likely (often oliguria), and warm flushed skin is not a hallmark finding compared with signs of hypovolemia and possible hyperpigmentation in chronic disease.

Question 23

A 79-year-old postoperative client (day 1 after hip fracture repair) who was oriented this morning is now acutely disoriented, pulling at lines, and saying, “I can’t breathe.” Vitals: BP 158/86, HR 112, RR 24, SpO₂ 88% on room air, T 37.1°C (98.8°F). Current meds include morphine PCA and diphenhydramine given 1 hour ago for itching. What is the nurse’s priority action?

Accepted Answer

Answer reason: Supplemental oxygen and head-of-bed elevation improve ventilation/perfusion and reduce work of breathing while further assessment is initiated. Sedating medications (diphenhydramine and opioids) can worsen respiratory status and delirium, so giving a benzodiazepine risks further hypoventilation and masking deterioration. Increasing opioid dosing could aggravate respiratory depression, while environmental measures like sleep do not treat the acute hypoxia driving the agitation.

Question 24

A provider asks the nurse which patient would benefit most from cardioversion. Which patient is the best candidate?

Accepted Answer

Answer reason: This rhythm is a common indication when the patient is symptomatic or hemodynamically unstable (e.g., hypotension, chest pain, acute heart failure) despite appropriate initial measures. Ventricular fibrillation is treated with unsynchronized defibrillation, not cardioversion, because there is no organized R wave to synchronize to. First-degree AV block is a conduction delay typically managed with observation and addressing causes rather than electrical cardioversion.

Question 25

Maximum oxygen delivers to patient by which route?

Accepted Answer

Answer reason: A non-rebreather mask uses a reservoir bag and one-way valves to minimize entrainment of room air and prevent re-inhalation of exhaled gas, allowing the highest FiO2 among the listed options when run at adequate flow (typically 10–15 L/min). A nasal cannula and simple face mask mix more room air and therefore deliver lower FiO2. An oxygen tent provides variable, less controlled oxygen concentration and is not a maximum-delivery device for emergent oxygenation.

Question 26

A patient who is currently in triage for probable thrombotic thrombocytopenic purpura (TTP) has a platelet count of 1,800/mm3 (1.8 x 10^9/L). Which assessment finding noted by the nurse is the highest priority?

Accepted Answer

Answer reason: In suspected TTP with profoundly low platelets, the most immediate threat is acute neurologic involvement from microthrombi causing cerebral ischemia, which can rapidly progress to seizures, stroke, and airway compromise. New disorientation represents a critical change in mental status and signals an evolving medical emergency requiring urgent escalation and definitive therapy (e.g., plasma exchange) rather than routine bleeding surveillance. Mucocutaneous bleeding findings such as petechiae and epistaxis are expected with severe thrombocytopenia but are not as immediately life-threatening unless there is evidence of major hemorrhage or hemodynamic instability. Hematuria can occur, but altered mental status indicates end-organ dysfunction and carries higher immediate risk.

Question 27

A client with hypothermia is brought to the emergency department. What treatment does the nurse anticipate?

Accepted Answer

Answer reason: Warmed IV fluids provide internal (core) rewarming and also support circulating volume, which may be reduced from cold diuresis. Ambulation is unsafe because exertion and movement can precipitate cardiovascular instability and afterdrop in moderate-to-severe hypothermia. Frequent oral temperatures are unreliable in hypothermia and do not treat the underlying problem, and gastric feedings are not an acute rewarming strategy and may increase aspiration risk in an unstable patient.

Question 28

Ms. S's condition is , and she has been transferred to the cardiac step-down unit. Which of the following should you instruct the nursing assistant to report immediately?

Accepted Answer

Answer reason: This finding can indicate unstable angina or an acute coronary syndrome, where delays in obtaining vital signs, ECG, oxygenation status, and provider notification can worsen outcomes. In contrast, a low-grade temperature of 99°F is commonly benign and does not suggest acute decompensation. Small increases in systolic BP after care and a mild HR rise after ambulation are expected physiologic responses to activity unless accompanied by symptoms, abnormal rhythm, or hemodynamic instability.

Question 29

The nurse is caring for the patient following removal of a large posterior oral lesion. The priority nursing measure would be to?

Accepted Answer

Answer reason: A posterior lesion site increases risk of tongue/base-of-tongue swelling and impaired swallowing, which can lead to aspiration or acute respiratory compromise. Ensuring a patent airway includes positioning, suction readiness, and close monitoring for stridor or increased work of breathing. Oral care and pain assessment are important but are secondary to preventing life-threatening airway obstruction. Keeping the incision “as dry as possible” is not realistic in the oral cavity and does not address the most immediate risk.

Question 30

An adult has a blood pressure of 150/92 mmHg, heart rate of 114 beats/min, respiratory rate of 24 breaths/min, and an oral temp of 99.1°F (37.3°C). The client reports severe shortness of breath. Which assessment does the nurse perform next?

Accepted Answer

Answer reason: Auscultating the lungs quickly identifies critical findings such as wheezes, crackles, diminished/absent air movement, or asymmetry that would drive immediate interventions (oxygen, bronchodilator, rapid response). Cardiac assessment is important but follows stabilization and rapid evaluation of ventilation/oxygenation when dyspnea is the dominant complaint. Neurologic and peripheral perfusion checks are lower priority because they do not address the most immediate threat to life in this presentation.

Question 31

The nurse should immediately report the development of which of the following symptoms in a client taking antipsychotic medication?

Accepted Answer

Answer reason: The combination of hyperthermia and autonomic instability with acute mental status change indicates systemic toxicity rather than a routine side effect. Immediate reporting is critical to enable prompt discontinuation of the offending drug and supportive/targeted therapy to prevent complications such as rhabdomyolysis and renal failure. In contrast, restlessness/pacing and bradykinesia reflect extrapyramidal symptoms that are concerning but typically not immediately life-threatening. Endocrine effects like sexual dysfunction or gynecomastia are usually nonemergent and monitored over time.

Question 32

The nurse is caring for a child who is lethargic and with a capillary blood glucose of 39 mg/dL (2.17 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]. The nurse should take which priority action?

Accepted Answer

Answer reason: Severe hypoglycemia with altered mental status is a medical emergency that requires immediate reversal of neuroglycopenia to prevent seizure, coma, or brain injury. With a glucose of 39 mg/dL and lethargy, the child may not be able to safely swallow, increasing aspiration risk if oral carbohydrates are attempted. Glucagon provides rapid hepatic glycogenolysis when IV dextrose is not the first available intervention, making it the fastest safe priority action among the options. Rechecking glucose or performing a GCS delays definitive treatment and does not address the immediate life-threatening problem.

Question 33

The nurse is caring for a client and upon initial evaluation the nurse suspects femoral artery occlusion. The nurse should take which action?

Accepted Answer

Answer reason: The priority nursing action is to escalate care immediately for urgent diagnostic evaluation and reperfusion therapy (e.g., anticoagulation/thrombolysis or surgical intervention). Elevating the extremity can further reduce arterial perfusion pressure and worsen ischemia, and cold application can promote vasoconstriction. Passive range of motion may dislodge a clot or increase pain and is not appropriate when arterial occlusion is suspected.

Question 34

The nurse is caring for a 7-year-old client who has a concussion from a head injury and is being observed overnight in the pediatric unit. When evaluating the client, it would be a priority for the nurse to report?

Accepted Answer

Answer reason: New or increasing drowsiness with difficulty speaking/being understood represents an acute change in level of consciousness/neurologic function and requires immediate provider notification and escalation of monitoring. In contrast, amnesia surrounding the event and a brief loss of consciousness can be consistent with concussion and are often expected historical findings once the child is stable. A localized forehead hematoma alone is not as concerning as an evolving mental-status change unless accompanied by neurologic deterioration.

Question 35

A client is brought to the emergency department after being found confused inside his home near a gas-powered space heater. The client reports headache, vision changes, dyspnea, nausea, vomiting, and his pulse oximetry reading is 100%. Which intervention should the nurse prioritize?

Accepted Answer

Answer reason: A normal pulse oximetry (SpO2) can be falsely reassuring because standard oximeters cannot differentiate oxyhemoglobin from carboxyhemoglobin, so hypoxia may be present despite a reading of 100%. High-flow 100% oxygen via non-rebreather is the immediate lifesaving intervention and also reduces the half-life of carboxyhemoglobin substantially. CT imaging and symptom-focused measures (antiemetic, vision testing) may be needed later but must not delay oxygen therapy in this time-sensitive toxic exposure.

Question 36

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 priority is rapid activation of the airway management team so the child can be kept calm and moved to a controlled setting for definitive airway support. Direct throat examination or any agitation can precipitate complete obstruction and respiratory arrest, so it is unsafe as an initial action. Imaging or sputum collection delays life-saving airway intervention and is not appropriate before urgent escalation of care.

Question 37

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: In suspected acute coronary syndrome with elevated troponin, the immediate priority is to limit ongoing myocardial ischemia by improving oxygen supply and decreasing oxygen demand. Interventions aimed at reducing preload/afterload, controlling heart rate/BP, and supporting oxygenation directly target the pathophysiology of infarction and can reduce infarct size. Pain and anxiety management are important but are secondary because they do not address the primary threat to perfusion as comprehensively as demand–supply optimization does. Confirming the diagnosis and monitoring for complications are necessary, but stabilizing myocardial oxygen balance is the urgent nursing priority in the ED setting.

Question 38

The nurse in the emergency department (ED) has a client with suspected septic shock. The priority intervention for this client is to?

Accepted Answer

Answer reason: Septic shock is a time-critical medical emergency where rapid restoration of perfusion and prompt delivery of resuscitation therapies reduce mortality. Establishing IV access is the immediate enabling step to administer large-volume isotonic fluids, obtain blood cultures/labs, and start broad-spectrum antibiotics and vasopressors if needed. A focused assessment for infection source is important but must not delay initiation of resuscitation and treatment. Infectious disease consult and frequent updates are supportive tasks that occur after life-saving stabilization measures are underway.

Question 39

The nurse is assessing a newborn client born vaginally 22 hours ago at 36 weeks gestation. Which of the following findings requires immediate follow-up?

Accepted Answer

Answer reason: Repeated episodes in a short period warrant immediate assessment of airway patency, work of breathing, oxygenation, and feeding tolerance, and may require suctioning or escalation of care. In contrast, soft occipital edema after vaginal birth is consistent with caput succedaneum and is typically benign and self-limited. A yellow tinge to the sclera and erythema toxicum-type rash are common transitional findings in the first days of life and usually do not require urgent intervention unless severe or accompanied by systemic signs.

Question 40

A 5-year-old child with acute asthma exacerbation is being treated in the emergency department. The child is sitting upright, is tachypneic, and has audible wheezing. After receiving a nebulized short-acting beta-agonist, the child's wheezing decreases, but breath sounds become markedly diminished. Oxygen saturation is 91% on room air. Which action should the nurse take next?

Accepted Answer

Answer reason: Diminished or absent breath sounds after bronchodilator therapy can indicate worsening airflow obstruction and impending respiratory failure (“silent chest”), which is an emergency. An SpO2 of 91% on room air also signals inadequate oxygenation requiring escalation (supplemental oxygen, additional bronchodilators, steroids, and possible advanced airway support). Waiting to reassess delays life-saving interventions when clinical signs suggest deterioration rather than improvement. Documentation or coaching breathing may be supportive, but they do not address the immediate risk of respiratory collapse.

Question 41

A telemetry unit nurse monitors the cardiac rhythms of several patients. Which rhythm requires immediate action by the nurse?

Accepted Answer

Answer reason: Disorganized ventricular electrical activity is consistent with ventricular fibrillation, a pulseless rhythm that produces no effective cardiac output and rapidly leads to sudden cardiac arrest. This requires immediate assessment of responsiveness/pulse and rapid activation of emergency response with defibrillation and CPR per ACLS. The other descriptions more closely match rhythms that may allow some perfusion (e.g., premature ventricular beats, atrial fibrillation, or ventricular tachycardia), where urgency depends on stability; none are as immediately lethal as ventricular fibrillation. Therefore, this rhythm demands the fastest, life-saving intervention.

Question 42

An emergency room nurse is caring for a patient. The patient goes into asystole. What should the nurse do?

Accepted Answer

Answer reason: Electrical therapies (defibrillation or synchronized cardioversion) are indicated for shockable rhythms (VF/pulseless VT) or unstable tachyarrhythmias, not for a flatline rhythm. Early CPR maintains minimal coronary and cerebral perfusion while reversible causes (Hs and Ts) are assessed and treated and epinephrine is administered per ACLS. Choosing no intervention would delay life-saving measures in a time-critical emergency.

Question 43

The nurse is working in the emergency department and is seeing a 5-year-old child who ingested 15 aspirin tablets 45 minutes ago. Which intervention should the nurse begin first?

Accepted Answer

Answer reason: This child is 45 minutes post-ingestion, making oral activated charcoal the fastest, least invasive, and most appropriate initial decontamination measure. Sodium bicarbonate is an important therapy for significant toxicity (e.g., acidemia, symptoms) because it alkalinizes serum/urine to enhance salicylate elimination, but it typically follows initial stabilization and decontamination. Gastric lavage has higher risk and limited benefit compared with charcoal and is generally reserved for life-threatening ingestions when done very early, while IV fluids are supportive but do not prevent ongoing absorption.

Question 44

A 32-year-old involved in a high-speed motor vehicle collision has chest bruising. He becomes short of breath and his blood pressure drops from 102/67 to 84/50. The nurse notes muffled heart tones. What action should the nurse take next?

Accepted Answer

Answer reason: The immediate priority is rapid definitive decompression of the pericardial space, so the nurse should urgently escalate care and prepare for pericardiocentesis. Nitroglycerin would worsen hypotension by reducing preload and is inappropriate in shock. While hemorrhage is a concern after MVC, the specific finding of muffled heart sounds points to tamponade rather than isolated hypovolemia, making decompression the most time-critical next step.

Question 45

A patient with a heart rate of 170 is diaphoretic and short of breath. His blood pressure has decreased from 129/70 to 90/50. P waves are not present on the EKG monitor and QRS complexes are regular and narrow. What is the nurse’s next course of action?

Accepted Answer

Answer reason: The rhythm description (regular narrow QRS, absent visible P waves) is consistent with SVT, and the BP drop to 90/50 indicates hemodynamic instability. Establishing IV access supports sedation/analgesia and emergency medication availability while preparing for synchronized shock delivery. Vagal maneuvers/adenosine are appropriate for stable SVT, but delaying cardioversion in an unstable patient increases risk of worsening shock and perfusion failure. Amiodarone is not first-line for unstable regular narrow-complex tachycardia in this context.

Question 46

Which of the following is most likely associated with cord prolapse?

Accepted Answer

Answer reason: The most common and most concerning fetal heart rate finding from this acute hypoxia is sudden, persistent fetal bradycardia (often with variable/prolonged decelerations). Vaginal bleeding and abdominal pain are not typical hallmark findings of cord compression and suggest other complications (e.g., placental abruption). Cord prolapse most often follows rupture of membranes rather than being associated with intact membranes.

Question 47

The nurse is assessing a client with infective endocarditis from a vegetation on the mitral valve. Which assessment finding is most concerning?

Accepted Answer

Answer reason: Infective endocarditis vegetations can embolize to the cerebral circulation, causing ischemic stroke, making this finding time-critical for emergent evaluation and intervention. Low-grade fever and splinter hemorrhages are common manifestations of endocarditis but are not as immediately life-threatening as acute stroke symptoms. A systolic murmur reflects valvular involvement but, in the absence of hemodynamic collapse, is less urgent than a new neurologic deficit. The priority is rapid stroke assessment/activation and provider notification to minimize irreversible neurologic injury.

Question 48

The nurse is performing a dressing change for a client recovering from lower abdominal surgery. After removing the old dressing, the nurse notices the edges of the surgical site are no longer approximated, and a small portion of the client’s intestines is protruding through the opening. Which action should the nurse take first?

Accepted Answer

Answer reason: Covering the protruding intestines with sterile gauze moistened with sterile saline maintains moisture, reduces infection risk, and minimizes further injury while awaiting definitive care. Other actions (vital signs, NPO status, calling the surgical team) are important but do not immediately protect the exposed bowel and therefore are not the first priority. After covering the organs, the nurse should place the client in low Fowler’s with knees flexed, monitor for shock, and urgently notify the provider/surgeon.

Question 49

You are caring for a patient with multiple trauma. Of all of these injuries and conditions, it the most serious?

Accepted Answer

Answer reason: Tracheal deviation is a classic late sign of tension pneumothorax, indicating rising intrathoracic pressure with mediastinal shift and impaired venous return, requiring immediate decompression. Decreased bowel sounds and hematuria can indicate significant injury but are typically less immediately life-threatening than an evolving airway/ventilation compromise. A grossly deformed extremity is important to assess for bleeding and neurovascular compromise, but it is usually addressed after stabilizing ABCs.

Question 50

The nurse is caring for the patient following removal of a large posterior oral lesion. The priority nursing measure would be to?

Accepted Answer

Answer reason: A large posterior oral lesion removal increases the risk of swelling and impaired protective reflexes, making obstruction a time-critical complication. Ensuring ventilation and oxygenation prevents rapid deterioration, whereas oral care and keeping the incision dry are supportive measures that do not address immediate life threats. Pain assessment is important but does not supersede airway management in the immediate post-op period.

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The nurse is caring for the patient following removal of a large posterior oral lesion. The priority nursing measure would be to?

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