Question 1

The flight nurse assesses an alert and oriented client at an industrial accident scene who was impaled in the abdomen by a pair of scissors. Which nursing action is the immediate priority on arrival at the scene?

Accepted Answer

Answer reason: Securing the object with bulky dressings minimizes motion during assessment, packaging, and transport, which is the most time-critical immediate scene intervention for this mechanism. Starting IV fluids may be appropriate later, but rapid fluid infusion before controlling bleeding can worsen ongoing hemorrhage and does not address the immediate mechanical risk. Drawing blood for labs is not a scene priority and typically occurs after stabilization and rapid transport to definitive surgical care.

Question 2

A 2 year child is severely dehydrated and needs immediate fluid resuscitation. 4 attempts to gain IV access have failed. Which of the following access routes should be considered next?

Accepted Answer

Answer reason: The medullary cavity provides a fast, reliable route into the central circulation for fluids and emergency medications, with similar onset to IV delivery. After multiple failed IV attempts, delaying resuscitation to pursue central venous access increases risk and takes longer to establish in small children. Arterial routes are inappropriate for fluid resuscitation and carry high complication risk, while a venous cutdown is slower and more invasive than intraosseous access in this emergency context.

Question 3

A client with a mandibular fracture who has the upper and lower teeth wired together begins to choke on excessive oral secretions. What is the nurse's immediate action?

Accepted Answer

Answer reason: Removing pooled secretions with suction directly addresses the cause of obstruction and rapidly improves ventilation. Positioning (elevating the head of bed) can help but is secondary to actively clearing the airway when choking is already occurring. Cutting the wires is reserved for inability to maintain the airway (e.g., uncontrolled obstruction/vomiting) after immediate airway measures are attempted; notifying the provider delays a time-critical intervention.

Question 4

A cardiac client turns on his call light and tells the nurse he is experiencing chest pain. What is the first nursing action?

Accepted Answer

Answer reason: Suspected acute coronary syndrome requires immediate actions that improve myocardial oxygen supply-demand balance while further assessment and treatment are initiated. Supplemental oxygen is an urgent supportive intervention when chest pain suggests ischemia, because hypoxemia can worsen myocardial injury and dysrhythmias. The other options are assessments that can follow quickly, but they do not directly treat the immediate threat of ongoing ischemia. A focused history about preceding activity is helpful later, but it does not address the time-sensitive need to optimize oxygenation first.

Question 5

The nurse is assessing a 3-year-old client in the emergency department and finds dyspnea, high fever, irritability, and open-mouthed drooling with leaning forward. The parents report that the symptoms started rather abruptly. The client has not received age-appropriate vaccinations. Which set of actions should the nurse anticipate?

Accepted Answer

Answer reason: The priority is to secure the airway in a controlled setting with skilled personnel and equipment ready for a surgical airway if intubation fails. Attempts at agitation, oral examination, or noninvasive ventilation can worsen obstruction and precipitate complete airway closure. Racemic epinephrine is more consistent with viral croup (barking cough/stridor) and is not definitive management for epiglottitis. Pleural aspiration does not match the clinical picture.

Question 6

During morning assessment, the patient diagnosed with bipolar exhibits seizures and is extremely confused. The psychiatric nurse checks recent lab values and the lithium carbonate level is 4.6 mEq/L. The nurse should prepare the patient for immediate?

Accepted Answer

Answer reason: g., seizures, severe confusion) are present. A level of 4.6 mEq/L indicates severe toxicity with high risk of ongoing CNS injury and dysrhythmias. Because lithium is renally cleared and dialyzable, urgent extracorporeal removal is the definitive treatment to rapidly reduce serum concentration and symptom burden. Diagnostic testing like an EEG may document seizure activity but does not treat the cause, and the other options are unrelated to lithium poisoning management.

Question 7

A patient is admitted to the ICU for blunt trauma to the thorax and is placed on the ventilator. A nurse caring for the patient suspects left-sided tension pneumothorax. Which assessment finding is associated with this injury?

Accepted Answer

Answer reason: Tension pneumothorax occurs when air becomes trapped in the pleural space under pressure, collapsing the affected lung and pushing intrathoracic structures away from the injured side. With a left-sided tension pneumothorax, rising left pleural pressure shifts the mediastinum and trachea toward the right. This is a key bedside assessment clue of impending cardiovascular compromise due to reduced venous return. A common distractor is mediastinal shift toward the same (left) side, which is opposite of what occurs with a pressure-driven tension process.

Question 8

A pregnant client reports sharp pain, 9/10, high in the fundus. There is only minimal vaginal bleeding, but the abdomen is hard and her HR is 110. The nurse suspects?

Accepted Answer

Answer reason: Maternal tachycardia supports acute blood loss and evolving shock even when external bleeding is minimal. Couvelaire uterus (uteroplacental apoplexy) occurs when blood infiltrates the uterine myometrium in severe abruption, producing a firm, painful uterus and signs of hypovolemia. The other choices describe pelvic shape types rather than an acute obstetric hemorrhage complication.

Question 9

You are caring for a newly admitted client with increasing dyspnea, hypoxia, and dehydration who has possible avian influenza ("bird flu"). Which of these prescribed actions will you implement first?

Accepted Answer

Answer reason: Airway and breathing take priority in any patient with worsening dyspnea and documented hypoxia, because inadequate oxygenation is immediately life-threatening. A nonrebreather provides the highest fraction of inspired oxygen among simple devices and can rapidly improve oxygen delivery while further evaluation proceeds. IV fluids address dehydration but do not correct the urgent problem of impaired gas exchange, and D5W is not ideal initial resuscitation fluid if intravascular depletion is suspected. Antiviral therapy and obtaining specimens are important but can occur after stabilization, since they do not provide immediate physiologic support to prevent respiratory failure.

Question 10

The nurse teaches a client about exercise-induced angina occurring during exercise. Which steps does the nurse teach the client to take? (Place each option in order, from first priority to last.)?

Accepted Answer

Answer reason: Angina during exertion reflects myocardial ischemia from an oxygen supply–demand mismatch, so the first action is to immediately reduce cardiac workload by stopping activity. After stopping, the client should rest to lower heart rate and blood pressure and reassess whether symptoms resolve. If pain persists, nitroglycerin can be used to improve coronary perfusion via vasodilation, but it is not the very first step while the provoking activity continues. Ongoing or recurrent exercise-induced angina should be reported to the provider for medication/exercise-plan adjustment and evaluation of worsening coronary disease.

Question 11

A nurse is administering cefotetan via intermittent IV bolus to a client who suddenly develops dyspnea and widespread hives. Which of the following actions should the nurse take first?

Accepted Answer

Answer reason: Dyspnea with widespread hives during IV antibiotic administration indicates an acute hypersensitivity reaction with risk of anaphylaxis. The first priority is to stop exposure to the triggering agent by discontinuing the infusion to prevent further antigen delivery and worsening airway/vascular compromise. After stopping the drug, the nurse would maintain airway/oxygenation and prepare to administer emergency medications per protocol/prescriber order, including epinephrine as the first-line drug for anaphylaxis. Elevating the legs may support hypotension but does not remove the cause, and obtaining ABGs is not an immediate life-saving action.

Question 12

A client with a blood pressure (BP) of 250/145 mm Hg is admitted for hypertensive crisis. The health care provider prescribes a continuous IV infusion of nitroprusside sodium. Which of these is the priority goal in initial management of hypertensive crisis?

Accepted Answer

Answer reason: Titrated IV vasodilators like nitroprusside are used with close monitoring to lower MAP gradually, targeting no more than about a 25% reduction in the first hour. Driving BP rapidly to normal values risks stroke, myocardial ischemia, and acute kidney injury due to impaired autoregulation. Heart rate and urine output are important monitoring parameters, but they are not the primary initial BP-lowering goal that guides titration.

Question 13

The 4-year-old child is brought to the emergency department with a diagnosis of acute epiglottitis. Which assessment finding is most significant?

Accepted Answer

Answer reason: Acute epiglottitis is a life-threatening upper-airway emergency where rapid supraglottic swelling can suddenly obstruct airflow. Drooling indicates the child cannot swallow secretions due to severe oropharyngeal/epiglottic inflammation, signaling impending airway compromise and need for urgent airway management. Fever and tachycardia are common but nonspecific signs of infection and stress and do not best predict immediate obstruction. Cough is classically minimal/absent in epiglottitis (more typical of croup), making this finding less discriminating for the most critical risk.

Question 14

A Female patient, 32 years of age, was admitted to hospital with severe hemorrhagic shock due to polytrauma with hip fracture, who developed acidosis, coagulopathy, and hypothermia. The first line of therapy in this patient of trauma is?

Accepted Answer

Answer reason: In a severely bleeding trauma patient with the lethal triad (acidosis, coagulopathy, hypothermia), damage-control resuscitation prioritizes early balanced blood products (PRBCs with plasma and platelets) to restore perfusion while addressing coagulopathy. Large-volume crystalloids can dilute clotting factors, worsen hypothermia, and exacerbate coagulopathy, making them inferior as the key initial strategy in this setting. Inotropes do not correct the underlying hypovolemia and may worsen tissue perfusion if used before adequate volume and hemostasis. Colloids have not shown benefit over blood products in exsanguinating trauma and can contribute to coagulopathy depending on type and dose.

Question 15

A client received as needed (PRN) morphine, lorazepam, and cyclobenzaprine. The unlicensed assistive personnel (UAP) reports that the client has a respiratory rate of 10 breaths/min. What is the priority action?

Accepted Answer

Answer reason: The core priority is to rapidly verify and quantify potential CNS/respiratory depression after administration of multiple sedating medications. A respiratory rate of 10/min may indicate opioid/benzodiazepine-related hypoventilation, but the nurse must first assess airway patency, level of consciousness, work of breathing, oxygenation, and adequacy of ventilation to determine severity and immediate needs. This assessment guides whether supportive measures (stimulation, oxygen, ventilation) and/or reversal agents are indicated and can be initiated with appropriate urgency. Calling for naloxone may be needed, but without assessment you may miss impending arrest or an alternative cause of bradypnea. Immediate bag-valve ventilation at a fixed rate is not the first step when the patient may still be ventilating adequately and requires rapid assessment-driven escalation.

Question 16

Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action?

Accepted Answer

Answer reason: Fetal distress indicates compromised fetal oxygenation, so the priority is to optimize maternal oxygen delivery and uteroplacental perfusion while definitive management (cesarean birth) is arranged. High-flow oxygen by face mask increases maternal PaO2 and the oxygen gradient across the placenta, supporting fetal oxygenation in the interim. Continuing oxytocin can worsen uterine tachysystole and further reduce placental blood flow, making it unsafe. Slowing the IV rate and placing the client in high Fowler’s do not directly and reliably improve fetal oxygenation during an acute compromise and may be counterproductive to hemodynamic support.

Question 17

The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next?

Accepted Answer

Answer reason: After stopping blood, the priority is to maintain IV access for emergency medications and fluid support while preventing any further infusion of the blood product. Isotonic normal saline is compatible with blood tubing and helps support circulating volume without causing hemolysis. Removing the IV line would eliminate immediate access needed for rapid treatment of hypotension, bronchospasm, or shock. Dextrose solutions are not used in this setting because they are incompatible with blood products and can contribute to red cell hemolysis; culturing a catheter tip is not the immediate next action for an acute transfusion reaction.

Question 18

You are caring for several children with cancer and are reviewing morning laboratory results for all of your patients. Which of these patient conditions combined with the indicated laboratory result causes you the greatest immediate concern? 1. Nausea and vomiting with a potassium level of 3.3 mEq/L 2. A nosebleed with a platelet count of 100,000/mm3 3. Fever with an absolute neutrophil count of 450/mm3 4. Fatigue with a hemoglobin level of 8 g/dL?

Accepted Answer

Answer reason: An ANC

Question 19

The nurse cares for a client who gave birth an hour ago to a 9-lb (4.1-kg) newborn. The client's lochia is heavy with large clots, and the fundus remains boggy after fundal massage and an oxytocin bolus. Which prescription from the health care provider should the nurse question? Click on the exhibit button for additional information?

Accepted Answer

Answer reason: Persistent heavy lochia with large clots and a boggy fundus after massage and oxytocin indicates postpartum hemorrhage from uterine atony, which requires rapid escalation of uterotonic therapy and hemorrhage readiness measures. Methylergonovine is a uterotonic but is contraindicated in clients with hypertension or preeclampsia due to potent vasoconstriction and risk of hypertensive crisis, so this order should be questioned until contraindications are ruled out. Misoprostol rectally is an appropriate alternative uterotonic when bleeding persists. STAT hemoglobin/hematocrit and establishing large-bore secondary IV access are appropriate to assess blood loss impact and enable rapid fluid/blood product resuscitation.

Question 20

The nurse is caring for a client that is 3 days post tonsillectomy and reports a 2 pound (0.91 kg) weight loss, lethargy, and frequent swallowing. What is the nurse's priority assessment?

Accepted Answer

Answer reason: The priority is to rapidly identify hemodynamic compromise from bleeding, and blood pressure is a key indicator of worsening hypovolemia/shock (often after early tachycardia). Weight loss and lethargy can reflect dehydration or occult blood loss, both requiring assessment of circulatory stability first. Breath sounds may become relevant if aspiration is suspected, but circulation assessment for possible hemorrhage is more urgent at this stage.

Question 21

A patient with pre-eclampsia is admitted to the unit with an order for magnesium sulfate. The nurse will understand that the therapy is effective if?

Accepted Answer

Answer reason: Effectiveness is demonstrated by the absence of eclamptic seizures and reduction of hyperreflexia/neuromuscular excitability. Increased ankle clonus and scotomas are signs of worsening disease and increased risk of seizure rather than therapeutic success. Blood pressure reduction is not the main therapeutic goal of magnesium (antihypertensives address BP), and a BP drop alone does not confirm adequate seizure prophylaxis.

Question 22

You are caring for a newborn with a myelomeningocele who is awaiting surgical closure of the defect. Which assessment finding is of most concern?

Accepted Answer

Answer reason: Temperature of 101.8° F (38.8° C) Fever in a newborn with an open neural tube defect is an urgent red flag for infection, including meningitis, because exposed tissues provide a portal for pathogens. A temperature of 38.8°C indicates a potentially serious systemic process requiring rapid evaluation and intervention before surgical closure. Neurologic and bowel/bladder deficits (e.g., flaccid legs, stool leakage) are common baseline sequelae of myelomeningocele and are not as immediately life-threatening as suspected infection. Bulging of the sac with crying can occur with increased pressure, but fever most strongly signals an acute complication that can rapidly deteriorate.

Question 23

The healthcare provider is caring for a patient who has septic shock. Which of these should the healthcare provider administer to the patient first?

Accepted Answer

Answer reason: Septic shock causes distributive vasodilation and capillary leak, leading to relative hypovolemia and inadequate tissue perfusion. Immediate isotonic crystalloid resuscitation is the first-line intervention to restore circulating volume, improve preload, and support cardiac output while other therapies are arranged. Vasopressors are typically started after adequate fluid resuscitation if hypotension persists to achieve a target MAP. Antibiotics are urgent and should be given early, but initial hemodynamic stabilization with fluids is prioritized to prevent rapid deterioration and organ hypoperfusion.

Question 24

A nurse is providing morning care for a patient in the ICU. Suddenly, the bedside monitor shows ventricular fibrillation and the patient becomes unresponsive. After calling for assistance, what action should the nurse take next?

Accepted Answer

Answer reason: Ventricular fibrillation with unresponsiveness is treated as a pulseless, shockable cardiac arrest until proven otherwise, so immediate high-quality chest compressions are the priority after activating help. Early CPR maintains minimal coronary and cerebral perfusion while the defibrillator is brought to the bedside and prepared. Epinephrine is given during the arrest algorithm but not before initiating compressions in the first moments of a witnessed collapse. Electrical cardioversion is for unstable tachyarrhythmias with a pulse, whereas pulseless VF requires defibrillation (unsynchronized), not cardioversion.

Question 25

The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding?

Accepted Answer

Answer reason: Umbilical cord prolapse is an obstetric emergency because the presenting part can compress the cord and rapidly impair fetal oxygenation. The immediate priority is to reduce pressure on the cord by positioning the client head-down to shift the fetus off the cord and improve perfusion while definitive interventions are arranged. Attempting to push the cord back can cause vasospasm or further compression and is unsafe. After positioning, the nurse should activate the emergency response/notify the provider and prepare for expedited delivery.

Question 26

The nurse is caring for a client who is experiencing a heroin overdose. The client's arterial blood gas (ABG) results are pH, 7.20; PaO2, 82 mm Hg; PaCO2, 60 mm Hg; HCO3, 22 mEq/L (22 mmol/L). Which of the following actions should the nurse take first?

Accepted Answer

Answer reason: Heroin overdose causes opioid-induced respiratory depression leading to hypoventilation and acute respiratory acidosis, reflected here by low pH with elevated PaCO2 and a non-elevated HCO3. The priority is to rapidly reverse the opioid effect on ventilatory drive to restore adequate ventilation and CO2 clearance. Naloxone is a fast-acting opioid antagonist that directly addresses the life-threatening cause, whereas oxygen alone may improve oxygenation but does not correct hypoventilation or hypercapnia. Pupil assessment and ECG are secondary assessments and should not delay definitive reversal of the overdose.

Question 27

The nurse is caring for a hospitalized client with a diagnosis of heart failure who suddenly complains of shortness of breath and dyspnea. The nurse should take which immediate action?

Accepted Answer

Answer reason: Upright/high-Fowler positioning rapidly decreases preload and improves lung expansion, often relieving shortness of breath within minutes and requiring no provider order. Oxygen may be needed, but positioning is the fastest first action while the nurse simultaneously assesses oxygenation and prepares additional interventions. Calling the provider or preparing diuretics delays an essential, immediately available measure and does not address the urgent breathing difficulty as quickly.

Question 28

A client in the intensive care unit who is on the ventilator, suddenly exhibits signs of decreased cardiac output. A quick assessment reveals that the client has cyanosis, absence of breath sounds on the right side, neck vein distention, and the trachea is deviating to the left. What initial emergency measure should the nurse expect to be performed? Choose One?

Accepted Answer

Answer reason: The immediate life-saving priority is rapid pleural decompression to relieve intrathoracic pressure and restore venous return and ventilation. Needle decompression is the fastest initial intervention and is performed on the affected side, followed by definitive chest tube placement. Removing the client from the ventilator does not resolve trapped pleural air, and thoracentesis is aimed at fluid removal rather than emergent decompression of a tension pneumothorax.

Question 29

While changing the tapes on a tracheostomy tube, the client coughs and the tube is dislodged. The initial nursing action is to?

Accepted Answer

Answer reason: Airway patency is the immediate priority when a tracheostomy tube becomes dislodged, because the stoma can rapidly narrow and obstruct ventilation. Using the retention sutures helps keep the tract open to facilitate rapid reinsertion and oxygenation while minimizing time without a secure airway. Calling the physician or respiratory therapy delays the urgent step needed to maintain access to the airway. Covering the site prioritizes infection prevention over a potentially life-threatening loss of airway.

Question 30

The nurse is ambulating a cardiac surgery client whose heart rate suddenly increases to 146 beats/min. In which order will the nurse take the following actions? 1. Call the client’s health care provider. 2. Have the client sit down. 3. Check the client’s blood pressure. 4. Administer as needed (PRN) oxygen by nasal cannula.?

Accepted Answer

Answer reason: Stopping the activity and seating the client reduces myocardial oxygen demand and prevents syncope or falls. Next, assessing blood pressure helps determine perfusion status and whether the tachycardia is associated with hypotension, bleeding, or decreased cardiac output. Providing PRN oxygen then supports oxygen delivery and decreases cardiac workload while further evaluation is underway. Notifying the provider is appropriate after initial stabilization and focused assessment data are obtained to report the situation accurately and guide further orders.

Question 31

The nurse is assessing a client after a car accident. Partial airway obstruction is suspected. Which clinical manifestation is a late sign of airway obstruction?

Accepted Answer

Answer reason: Peripheral cyanosis (e.g., ear lobes) indicates low oxygen saturation and poor oxygen delivery that typically occurs after earlier symptoms have progressed. Earlier findings include restlessness from mild hypoxia and inspiratory stridor from turbulent airflow through a narrowed upper airway. Rales are more consistent with fluid in alveoli/small airways (e.g., pulmonary edema) rather than a hallmark progression of upper airway obstruction.

Question 32

A nurse is completing a shift assessment on a patient admitted to the telemetry unit with a diagnosis of syncope. The patient's heart rate is 55 bpm with a blood pressure of 90/66 mm Hg. The patient is also experiencing dizziness and shortness of breath. Which of the following medications will the nurse anticipate administering to the patient based on these clinical findings?

Accepted Answer

Answer reason: Symptomatic bradycardia with hypotension and signs of poor perfusion (dizziness, shortness of breath, syncope risk) is treated first-line with an anticholinergic that increases SA/AV nodal firing. This medication blocks vagal tone, raising heart rate and often improving cardiac output and blood pressure quickly in unstable bradycardia. The other options are antiarrhythmics or rate-slowing drugs more appropriate for tachyarrhythmias; one would further decrease AV conduction and worsen bradycardia and hypotension. Therefore the anticipated medication aligns with ACLS management of unstable/symptomatic bradycardia.

Question 33

Client is complaining of chest pain. Nursing assessment reveals a BP of 78/40, shortness of breath, and third-degree block on the heart monitor. What medication would the nurse prepare for initial administration?

Accepted Answer

Answer reason: This medication is the first-line ACLS drug to block vagal tone at the SA/AV nodes and can increase heart rate and improve cardiac output, which is critical with a BP of 78/40. Verapamil would worsen AV nodal conduction and further drop blood pressure, making it unsafe here. Lidocaine and procainamide treat ventricular dysrhythmias rather than an unstable complete heart block, so they do not address the primary life-threatening problem.

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Medical Emergencies Practice Test 17

Medical Emergencies NCLEX Practice Test

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