Question 1

Heimlich maneuver technique is used to dislodge foreign bodies from?

Accepted Answer

Answer reason: The Heimlich maneuver (abdominal thrusts) generates a sudden upward pressure on the diaphragm, forcing air from the lungs to expel a foreign body lodged in the trachea.

Question 2

The Heimlich maneuver (abdominal thrust) is used for a client with which condition?

Accepted Answer

Answer reason: The Heimlich maneuver is a first-aid technique used to relieve foreign-body airway obstruction, i.e., a blocked airway caused by choking.

Question 3

A home health nurse finds the client lying unconscious in the doorway of her bathroom. The nurse checks for responsiveness by gently shaking her and calling her name. When it is determined that the client is nonresponsive, the nurse should?

Accepted Answer

Answer reason: After confirming unresponsiveness, the priority is to activate the emergency response system—call for help—before proceeding with airway, breathing, and compressions per adult BLS.

Question 4

What is the first step after finding an unresponsive patient who is not breathing?

Accepted Answer

Answer reason: Upon finding an unresponsive, apneic individual, the nurse should immediately activate the emergency response system and retrieve an AED. This ensures timely assistance and access to life-saving equipment. Pulse checks and compressions follow rapidly once help is secured.

Question 5

What is the recommended compression rate for adult CPR?

Accepted Answer

Answer reason: Current CPR guidelines recommend delivering chest compressions at a rate of 100–120 per minute for adults to optimize coronary and cerebral perfusion.

Question 6

What can be helpful during a person's accident?

Accepted Answer

Answer reason: Immediate first aid directly helps the injured person at the scene of an accident; the other options address non-immediate concerns.

Question 7

The nurse receives a report from the paramedic on four trauma victims. Which client would need to be treated first? A client with?

Accepted Answer

Answer reason: An open pneumothorax (“sucking chest wound”) allows air to enter the pleural space, collapsing the lung and impairing ventilation and oxygenation. Immediate stabilization with an occlusive dressing and chest tube insertion is life-saving. The other clients are either stable or already managed.

Question 8

What is the appropriate nursing action when triaging a client suspected of having inhalation anthrax in the emergency department?

Accepted Answer

Answer reason: Inhalation anthrax is not transmitted person-to-person, so airborne isolation or surgical masks are unnecessary. The priority in triage is to activate bioterrorism/emergency response by notifying hospital administration/public health. Urine sampling is not a priority diagnostic step.

Question 9

If a nurse discovers fire in a client's room, what is the first action the nurse should take?

Accepted Answer

Answer reason: Follow RACE for fire: Rescue first. Move the client to safety before sounding alarms or attempting other actions. Opening windows can fuel the fire.

Question 10

Which action is NOT included in cardiopulmonary resuscitation (CPR)?

Accepted Answer

Answer reason: CPR focuses on the ABCs—airway, breathing, and circulation. Treating abdominal pain is unrelated to resuscitation steps.

Question 11

A nurse is assigned to perform well child assessments at a day care center. A staff member interrupts the examinations to ask for assistance. They find a crying 3-year-old child on the floor with her mouth wide open and gums bleeding. Two unlabeled open bottles lie next to her. The nurse's FIRST action should be?

Accepted Answer

Answer reason: In suspected poisoning, the priority is to identify the ingested substance to guide appropriate actions. Calling poison control comes after identifying the agent. Ipecac and milk are not recommended.

Question 12

What is the correct compression to ventilation ratio during CPR for an adult?

Accepted Answer

Answer reason: According to current adult BLS guidelines, the chest compression to ventilation ratio is 30 compressions to 2 breaths for single- or two-rescuer CPR. Other ratios apply to pediatrics or are outdated.

Question 13

The nurse is making room assignments for four obstetrical clients. If only one private room is available, it should be assigned to?

Accepted Answer

Answer reason: The preeclamptic client requires a quiet, low-stimulus environment to prevent worsening hypertension and reduce seizure risk. A private room minimizes noise and external stimuli, making it the safest placement.

Question 14

What is the first aid required in case of a deep wound while playing?

Accepted Answer

Answer reason: First aid priorities for deep wounds focus on controlling hemorrhage; apply direct pressure to stop bleeding before other actions.

Question 15

The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40. The initial nurse's action should be to?

Accepted Answer

Answer reason: Sudden unresponsiveness with hypotension signals a medical emergency; the priority is to activate/code response and have resuscitation equipment immediately available. Bringing the emergency cart enables rapid airway, breathing, and circulation support. Trendelenburg and fluid increase are secondary, and atropine is not indicated without bradycardia.

Question 16

The nurse is working with parents to plan home care for a 2 year-old with a heart problem. A PRIORITY nursing intervention would be to?

Accepted Answer

Answer reason: Teaching caregivers CPR prepares them to respond to potential cardiac emergencies in a high-risk child, making it the priority intervention over other appropriate but less urgent measures.

Question 17

The nurse is assisting at a Poison Control Center telephone hotline. In which of the following cases of childhood poisoning would the nurse suggest that parents induce vomiting?

Accepted Answer

Answer reason: Inducing vomiting is contraindicated for caustic agents, hydrocarbons, and sedatives due to risk of aspiration, airway injury, or CNS depression. Philodendron is irritating but not caustic or sedating, making it the only option where vomiting may be considered.

Question 18

What is a consideration when you are using an AED?

Accepted Answer

Answer reason: Excess chest hair can prevent AED pads from adhering and delivering an effective shock; shave or remove hair if needed. The other statements are incorrect—remove medication patches, do not use AED while submerged, and AEDs can be used with pacemakers avoiding pad placement over the device.

Question 19

A victim with a foreign-body airway obstruction becomes unresponsive. What is your first course of action?

Accepted Answer

Answer reason: Per AHA/BLS, when a choking victim becomes unresponsive, activate help and begin CPR with chest compressions; do not perform back blows or blind finger sweeps, and abdominal thrusts are for responsive victims.

Question 20

The nurse is explaining the proper use of syrup of ipecac to a group of parents. For which of the following accidental poisonings is the treatment appropriate?

Accepted Answer

Answer reason: Syrup of ipecac is used to induce vomiting and is contraindicated with caustics (oven and drain cleaners) and hydrocarbons (kerosene) due to risk of further injury/aspiration. Of the choices, only vitamin ingestion is appropriate for induced emesis.

Question 21

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

Accepted Answer

Answer reason: First aid for suspected ingestion is to remove remaining substance from the mouth to prevent further absorption. Do not delay by starting unsupervised treatment, do not induce vomiting with hydrocarbons, and if inhaled toxins are involved the child should be moved to fresh air rather than kept in place.

Question 22

First nursing intervention while seeing a burn client is........?

Accepted Answer

Answer reason: The immediate priority in a burn is to stop the burning process and remove the client from the heat source to prevent ongoing tissue damage. Once flames are extinguished and exposure is halted, the nurse then assesses and secures airway, breathing, and circulation. Placing the client in a safe place and transport follow after the burning has been stopped.

Question 23

What is the ratio for chest compression: rescue breath for adults?

Accepted Answer

Answer reason: According to AHA BLS guidelines, adult CPR uses a compression-to-ventilation ratio of 30:2 for single rescuers (and also for two rescuers in adults). This maximizes coronary and cerebral perfusion while providing periodic ventilation. Ratios like 30:3 or 20:3 are not recommended for adult CPR.

Question 24

Burns caused by alkalis should be?

Accepted Answer

Answer reason: Alkali burns cause liquefaction necrosis and penetrate deeply; immediate and prolonged irrigation with copious running water is the primary treatment to dilute and remove the chemical. Attempting to neutralize with acids (e.g., acetic acid or lemon juice) can generate heat and worsen tissue injury. Strong acids are contraindicated and unsafe in first aid. Therefore, thorough water irrigation is the best initial management.

Question 25

Which pulse is palpated to see the effectiveness of CPR?

Accepted Answer

Answer reason: During adult CPR, the carotid pulse is checked to assess effectiveness and return of spontaneous circulation. It is a central pulse close to the heart and remains palpable even with low perfusion states, unlike the radial pulse. Temporal pulses are not used in resuscitation, and while the femoral is also central, the carotid is the recommended, most accessible site during CPR. Pulse checks should take no more than 10 seconds.

Question 26

For both one rescuer and two-rescuer CPR, what is the correct ratio of compressions to breaths?

Accepted Answer

Answer reason: Adult BLS guidelines specify a 30:2 compression-to-ventilation ratio for both single-rescuer and two-rescuer CPR. Pediatric ratios differ (30:2 for one rescuer, 15:2 for two), but the question asks for the ratio that applies to both formats, which is 30:2. This ensures high-quality compressions with minimal ventilation interruptions.

Question 27

A mass-casualty incident occurs after a stadium collapse, and the hospital initiates its emergency operations plan. Which action should the nurse take FIRST on the receiving unit?

Accepted Answer

Answer reason: The first priority upon activation of a mass-casualty plan is creating functional space for rapid triage flow. Clearing hallways and opening treatment zones ensures safe, immediate intake of high-acuity patients and prevents bottlenecking.

Question 28

A nurse is working during a hospital fire alarm activation on the pediatric unit. Smoke is reported two floors below. Which action is MOST appropriate at this time?

Accepted Answer

Answer reason: During early fire response, RACE protocol directs staff to contain the fire by closing doors. Horizontal evacuation is used only if smoke enters the area. Premature vertical or outdoor evacuation increases risk and violates fire-response sequencing.

Question 29

A train derailment involving hazardous materials has occurred near the hospital. Local authorities warn of potential airborne contamination. Which action should the emergency department nurse implement FIRST?

Accepted Answer

Answer reason: In airborne hazardous material events, preventing contaminated air from entering the facility is the immediate priority. Shutting down the HVAC system reduces internal exposure risk and maintains facility safety while further protective actions are implemented.

Question 30

A chemical tanker overturns near the hospital, releasing a chlorine-based gas. Several exposed clients arrive at the decontamination area. Which nursing action is the PRIORITY during gross decontamination?

Accepted Answer

Answer reason: Chlorine gas exposure requires immediate, continuous water irrigation to dilute and remove the chemical. Neutralizers are not recommended, and internal placement must wait until decontamination is complete. Water flushing is the critical first-line intervention.

Question 31

During an active shooter event inside the hospital, the nurse is caring for clients who cannot be evacuated. The shooter’s location is unknown. Which action should the nurse take FIRST?

Accepted Answer

Answer reason: When evacuation is impossible, shelter-in-place procedures take priority: lock/secure the room, reduce visibility, and conceal occupants. Hallway clustering increases exposure, and nonessential communication delays critical protective actions.

Question 32

A hurricane makes landfall earlier than predicted, and authorities advise immediate partial hospital evacuation. Which action should the nurse on a critical-care unit implement FIRST?

Accepted Answer

Answer reason: In urgent evacuation, the safest and fastest transfers begin with clients who are stable enough to move without destabilization. This maintains flow, frees resources, and allows later attention to high-acuity clients requiring complex transport coordination.

Question 33

During activation of the Hospital Incident Command System (HICS), the nurse receives conflicting instructions from two different departments about patient relocation. Which action should the nurse take FIRST?

Accepted Answer

Answer reason: HICS establishes a single, clearly defined chain of command to avoid conflicting orders. When discrepancies arise, the nurse must defer to the Incident Commander for authoritative direction, ensuring coordinated and safe disaster response operations.

Question 34

A regional power outage disrupts cellular networks and internet-based communication systems. The hospital’s emergency plan has been activated. Which nursing action is MOST appropriate to ensure continuous communication?

Accepted Answer

Answer reason: When electronic systems fail, emergency communication plans activate low-tech redundancy such as trained runners. This ensures reliable, continuous information flow between departments and maintains operational integrity during communications disruption.

Question 35

Heavy rainfall causes internal flooding on the first floor of the hospital, compromising the electrical system in several rooms. The emergency plan is activated. Which action should the nurse prioritize for client safety?

Accepted Answer

Answer reason: Internal flooding combined with compromised electrical infrastructure poses immediate electrocution and equipment failure risks. Horizontal relocation to a dry, safe zone is the priority to ensure immediate client protection without waiting for environmental remediation.

Question 36

After an explosion at a nearby manufacturing plant, the hospital activates its surge-capacity protocol. The ED is already full, and additional victims are expected within minutes. Which action should the triage nurse implement FIRST to maintain flow and prevent treatment delays?

Accepted Answer

Answer reason: In mass-casualty incidents, the priority is rapid throughput. Diverting low-acuity, ambulatory victims to an external alternate care site preserves ED resources for critical arrivals. This mirrors real surge-capacity and disaster triage practices.

Question 37

Flooding caused by a ruptured water main has compromised electrical systems on one wing of the hospital. Lights flicker, equipment alarms intermittently, and the smell of wet drywall is present. Which action should the nurse on that unit take FIRST?

Accepted Answer

Answer reason: Internal flooding with electrical compromise presents immediate risk of electrocution and equipment failure. The safest and most realistic first action is horizontal relocation to a dry, powered area—this aligns with real hospital disaster protocols.

Question 38

A nurse on a medical-surgical unit notices the overhead announcement: “Code Triage—Communication Failure.” Cellular service and hospital Wi-Fi drop simultaneously. The unit has two unstable clients requiring lab updates. Which action should the nurse implement FIRST?

Accepted Answer

Answer reason: When electronic communication fails, emergency plans activate preassigned runners to maintain critical information flow. This ensures immediate relay of time-sensitive clinical data to command, consistent with real-world disaster procedures.

Question 39

A radiological dispersal device (“dirty bomb”) detonates several blocks from the hospital. Authorities warn of potential external contamination. Several clients arrive panicked but stable, with powdery residue on clothing. Which action should the nurse implement FIRST to ensure facility safety?

Accepted Answer

Answer reason: Radiological events require strict contamination control. No potentially exposed client should enter the hospital until triage and decontamination occur outdoors. This prevents internal contamination and aligns with real-world radiation emergency protocols.

Question 40

A faint burning smell begins circulating through a surgical step-down unit. No alarms have sounded yet, but a patient reports seeing “a little smoke” coming from an unused supply room. Which action should the nurse take FIRST?

Accepted Answer

Answer reason: Early fire cues require immediate containment by closing the door to limit oxygen flow and smoke spread. The nurse then proceeds with RACE: Rescue, Alarm, Contain, Extinguish/Evacuate. Premature evacuation increases chaos and risk before containment is established.

Question 41

A major cyberattack disables electronic medication records and digital communication throughout the hospital. The command center instructs all units to shift to manual operations. Two units request assistance simultaneously due to staffing shortages. Which action should the charge nurse take FIRST?

Accepted Answer

Answer reason: During system-wide disruptions, the priority is immediate risk mitigation. Staffing resources must be directed first to the area where client harm is most imminent, consistent with triage-based resource allocation.

Question 42

A loud cracking noise is heard on a medical unit after an earlier earthquake tremor. Ceiling tiles near one support beam begin to sag, and fine dust is falling into the hallway. Which action should the nurse take FIRST?

Accepted Answer

Answer reason: Structural compromise after seismic activity represents immediate collapse risk. The priority is removing clients and staff from the danger zone without delay, using horizontal evacuation into structurally safer areas. Waiting for engineering or relying on fire doors is unsafe in a potential collapse scenario.

Question 43

A severe thunderstorm knocks out regional power. The hospital’s generators activate, but the ED becomes overcrowded with walk-in clients seeking shelter. Several nonurgent individuals are waiting in clinical chairs normally used for triage. Which action should the charge nurse implement FIRST to maintain safe flow?

Accepted Answer

Answer reason: When ED capacity is compromised by individuals seeking shelter rather than medical care, the priority is rapid separation of nonclinical sheltering from clinical operations. This preserves ED function, supports triage flow, and aligns with real severe-weather response plans.

Question 44

A nurse detects a sharp chemical odor near the central supply room. Several staff report eye irritation, and the ventilation system seems to be distributing the smell to adjacent hallways. No alarms have sounded yet. Which action should the nurse take FIRST?

Accepted Answer

Answer reason: In potential airborne chemical exposure, the priority is limiting spread by stopping airflow through the affected ventilation zone. Opening windows or delaying escalation increases exposure risk, and full outdoor evacuation is premature and unsafe without hazard confirmation.

Question 45

A small fire in the endoscopy suite has been extinguished, but smoke continues migrating through the ventilation into a nearby medical unit. Several clients begin coughing, and visibility is slightly hazy at the far end of the hallway. Which action should the nurse implement FIRST?

Accepted Answer

Answer reason: After a fire, smoke migration poses immediate respiratory and visibility hazards. The priority is containment—closing fire doors—and moving affected clients horizontally into a safer, clearer zone. Disrupting oxygen systems or ventilating rooms improperly increases risk.

Question 46

A chemical sterilization canister is dropped in the radiology department, releasing a sharp, acrid odor. Two staff report throat irritation, and an oily film is visible on the floor. No alarms have sounded yet. Which action should the nurse in that area take FIRST?

Accepted Answer

Answer reason: Chemical spills inside the hospital require immediate zone evacuation and securing the area to limit exposure. Water dilution can worsen chemical reactions, and hallway relocation spreads contamination risk. Securing the hot zone is the correct first step.

Question 47

A severe winter storm causes intermittent generator fluctuations. The hospital receives instruction from the command center to initiate a partial evacuation, prioritizing clients who are stable for transfer. One unit has a mix of high-acuity patients and several recovering post-op clients. Which action should the nurse implement FIRST?

Accepted Answer

Answer reason: During partial evacuation, sequencing is crucial. Stable clients are transferred first because they can be safely moved quickly, freeing resources and allowing later attention to complex, high-acuity transfers. This reflects real disaster evacuation workflow.

Question 48

A sudden electrical surge knocks out power to half of the step-down unit. Backup outlets activate, but several beds lose monitor function. Two clients are on vasoactive infusions, and one is being weaned from high-flow oxygen. Engineering is en route but not yet on the floor. Which action should the nurse implement FIRST?

Accepted Answer

Answer reason: When monitoring fails, immediate risk is highest for clients who depend on continuous cardiac/respiratory surveillance. Relocating them to a powered, safe zone ensures real-time monitoring and prevents deterioration during the outage. Manual vitals alone are insufficient for high-acuity clients.

Question 49

A courier accidentally drops a container containing a volatile laboratory reagent in a hospital corridor. The spill appears minor, but two nearby staff members develop mild dizziness several minutes later. No fumes are visibly present, and ventilation seems normal. Which action should the nurse take FIRST?

Accepted Answer

Answer reason: Delayed dizziness indicates possible inhalation exposure. Isolation and evacuation of the corridor prevent further exposure while the substance is identified. Premature containment attempts or informal relocation can worsen spread or create secondary contamination.

Question 50

A water line ruptures above a surgical step-down unit, causing steady dripping through ceiling tiles. The lights flicker, and one bed’s outlet begins sparking briefly before shutting off. Engineering is still several minutes away. Which action should the nurse implement FIRST?

Accepted Answer

Answer reason: Active water intrusion combined with electrical instability creates immediate electrocution and fire risk. The safest first action is horizontal relocation to a dry, powered zone. Power shutdown alone does not eliminate ceiling-collapse or ongoing water hazards.

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