Question 1

A chest tube accidentally disconnects from the drainage system. First action?

Accepted Answer

Answer reason: If a chest tube becomes disconnected from the drainage system, the priority is to quickly re-establish a one-way seal to prevent air from entering the pleural space and causing/worsening a pneumothorax. Placing the distal end of the tube into sterile water creates a temporary water seal so air can bubble out but cannot be sucked back in. Clamping can trap air and convert an air leak into a tension pneumothorax, and an occlusive dressing applies when the tube is pulled out, not merely disconnected. After stabilizing the system, the nurse can then replace the drainage unit and notify the provider as indicated.
Category reason: This is a nursing first-action/safety question about immediate emergency management of an accidental disconnection of a chest tube system, emphasizing rapid intervention to prevent respiratory compromise.

Question 2

Which pulse site is used during CPR in adults?

Accepted Answer

Answer reason:  Carotid pulse In adult CPR, the carotid artery is the recommended site to check for a pulse because it is a central pulse that remains palpable longer during low-flow states such as cardiac arrest. Peripheral pulses like the radial or dorsalis pedis may be absent even when some central perfusion exists. The brachial pulse is primarily used for infants, not adults, during resuscitation assessments.
Category reason: This question tests emergency response nursing action during CPR (selecting the correct pulse check site in an adult), which aligns with safety-focused emergency response planning rather than foundational anatomy alone.

Question 3

A patient with pneumonia develops confusion, HR 122, RR 28, BP 88/54, and temperature 39.4°C (103°F). Which intervention should the nurse perform first?

Accepted Answer

Answer reason:  Notify the rapid response team The patient shows signs of septic shock (suspected infection with hypotension, tachycardia, tachypnea, fever, and new confusion), which is a time-critical emergency requiring immediate escalation of care. Activating the rapid response team ensures rapid assessment, hemodynamic support, oxygenation, and initiation of sepsis bundle interventions without delay. While fluids, oxygen, cultures, and antibiotics are essential, the first nursing priority in an unstable, deteriorating patient is prompt emergency response activation to mobilize resources and prevent further decompensation.
Category reason: This item tests urgent nursing action and escalation for a rapidly deteriorating patient (suspected sepsis with shock), which falls under emergency response and patient safety decision-making rather than foundational biomedical knowledge.

Question 4

What is a tourniquet used for?

Accepted Answer

Answer reason:  Stop bleeding/find veins. A tourniquet is used to control severe extremity hemorrhage in emergencies by occluding arterial blood flow, and it is also commonly used to distend veins during venipuncture/IV cannulation. The other options (ear wash, eye exam, oxygen) are unrelated to the function of a tourniquet. Proper use requires appropriate placement and minimizing duration to reduce ischemic injury.
Category reason: This tests the nursing safety purpose of a common device used in emergencies to control bleeding and during procedures, aligning best with safety-focused emergency response.

Question 5

A client with a history of lung cancer is admitted with facial swelling, shortness of breath, and distended neck veins. The nurse suspects superior vena cava syndrome (SVCS). Which of the following is the priority nursing action?

Accepted Answer

Answer reason: Elevate the head of the bed. In suspected superior vena cava syndrome, immediate priority is to reduce venous congestion and improve airway/respiratory status. Elevating the head of the bed promotes venous drainage from the head/neck, decreases facial/airway edema, and can improve dyspnea. Supine positioning can worsen venous return obstruction and respiratory compromise, while diuretics may be ordered but are not the fastest first nursing action for stabilization.
Category reason: This question asks for the nurse’s priority immediate action to stabilize a client with signs of SVCS and respiratory compromise, which is a patient-safety and urgent response decision rather than testing foundational science.

Question 6

Child presents with sudden high fever, drooling, tripod position, muffled voice. Priority nursing action?

Accepted Answer

Answer reason: Keep child calm; prepare for controlled airway (intubation) Sudden high fever, drooling, muffled voice, and tripod positioning are classic for acute epiglottitis with imminent airway obstruction. The priority is maintaining a patent airway while minimizing agitation, because distress can precipitate complete obstruction. Preparing for controlled airway management (with expert personnel) is appropriate, while avoiding actions that could worsen swelling or trigger laryngospasm. Throat examination/culture with a tongue depressor is contraindicated in suspected epiglottitis.
Category reason: This is a priority nursing action question focused on emergency recognition and immediate safety interventions to prevent airway compromise, which fits NCLEX Safety and Infection Control (Emergency Response Plans).

Question 7

A paramedic calls ahead: “ETA five minutes.” ETA means?

Accepted Answer

Answer reason: Estimated Time of Arrival In emergency and healthcare communications, “ETA” is a standard abbreviation for the time until a patient/transport is expected to arrive. Knowing the ETA supports emergency response planning (e.g., preparing staff, equipment, and bed/room readiness). The other options are not standard, widely accepted meanings of ETA in clinical handoff or pre-arrival notification.
Category reason: This item tests understanding of a common prehospital-to-hospital communication used to coordinate preparedness for incoming emergencies, aligning with Emergency Response Plans in Safety and Infection Control.

Question 8

Your patient was brought to the emergency department by the police. He has serious lacerations on both wrists. What would the nurse’s first priority be?

Accepted Answer

Answer reason: Examine and treat both wounds. In the ED with serious bilateral wrist lacerations, the first priority is immediate assessment and management of potential life-threatening bleeding and neurovascular compromise (circulation) before psychosocial interventions. Stabilizing the patient includes inspecting the wounds, controlling hemorrhage, and initiating appropriate wound care and escalation for possible tendon/arterial injury. A complete history and discussion of feelings are important but come after urgent physical stabilization, and giving anxiolytics is not first-line prior to assessing airway/breathing/circulation and current clinical status.
Category reason: This is a prioritization question focused on the nurse’s first action in an emergency situation to maintain patient safety and physiologic stability, which aligns with NCLEX safety/emergency response decision-making.

Question 9

: What is the recommended depth for chest compressions during adult CPR?

Accepted Answer

Answer reason: 2-5.3 inches For adult CPR, the recommended compression depth is about 2 inches (5 cm), and not more than 2.4 inches (6 cm). Among the choices, this corresponds best to a range starting at 2 inches and extending to approximately 5.3 cm. Shallower depths (e.g., 1–1.5 inches or 1.5–2 inches) risk inadequate perfusion, while excessively deep compressions increase injury risk.
Category reason: This question tests a life-saving emergency intervention parameter (CPR compression depth), which falls under nursing safety and emergency response actions rather than foundational body science alone.

Question 10

A mother arrives at the emergency department with her child and a diagnosis of epiglottitis is documented. Which of the health care provider's prescription should the nurse question?

Accepted Answer

Answer reason: Obtain a throat culture. In suspected or documented epiglottitis, direct visualization of the throat or procedures that can agitate the airway (e.g., throat culture with tongue depressor/swab) can precipitate sudden airway obstruction and respiratory arrest. The priority is to maintain a patent airway and avoid unnecessary manipulation until the airway is secured by skilled personnel in a controlled setting. Humidified oxygen and fever control are supportive measures, and axillary temperature avoids oral instrumentation.
Category reason: This question tests nursing judgment about which provider order is unsafe in a high-risk airway emergency and should be questioned, aligning with safety-focused emergency management in acute care.

Question 11

The nurse notices the tracheostomy tube has been accidentally dislodged. What is the priority action?

Accepted Answer

Answer reason: Call for help and maintain airway with a manual resuscitation bag An accidentally dislodged tracheostomy is an airway emergency; the priority is to ensure oxygenation/ventilation and summon immediate assistance. Using a manual resuscitation bag to ventilate (via the stoma or mouth/nose as appropriate to patient anatomy) addresses ABCs while help and equipment arrive. Attempting reinsertion may be difficult/unsafe without appropriate support and can delay ventilation, while notifying the physician or applying a dressing does not immediately restore the airway.
Category reason: This is a nursing priority/emergency intervention question focused on immediate airway management after an acute device complication, which fits Safety and Infection Control (Emergency Response Plans).

Question 12

A client sustains a chemical eye injury from a splash of battery acid. The nurse should prepare the client for which immediate measure?

Accepted Answer

Answer reason: Irrigating the eye with sterile normal saline. Immediate, copious irrigation is the priority for chemical eye exposures to dilute and remove the caustic agent and limit ongoing tissue damage. Other actions (visual acuity checks, ointment, or patching) can delay decontamination and worsen outcomes. After irrigation begins, further assessment and treatment (including pH checks and ophthalmology evaluation) can follow, but irrigation should not be postponed.
Category reason: This item tests the nurse’s immediate emergency intervention to prevent further injury after a hazardous chemical exposure, which is a safety-focused patient-care decision under Safety and Infection Control.

Question 13

For CPR in adults, what is the recommended compression-to-ventilation ratio?

Accepted Answer

Answer reason: 30:2 Adult single-rescuer CPR uses a 30 compressions to 2 breaths ratio to maximize coronary and cerebral perfusion while still providing periodic ventilation. This is the standard BLS sequence for adults and applies whether using mouth-to-mouth or a barrier device when breaths are given. Ratios like 15:2 are used for pediatric two-rescuer CPR, and 5:1 is outdated and not recommended in current guidelines.
Category reason: This item tests a nursing emergency response action (performing CPR with the correct compression-to-ventilation ratio), which aligns with emergency preparedness and response in a safety-focused NCLEX category.

Question 14

The nurse is caring for a client with pneumonia receiving six liters a minute of nasal cannula oxygen. The client has a SpO2 of 81%, and the arterial blood gas (ABG) returns with a PaO2 of 68 mm Hg. Which immediate intervention should the nurse take?

Accepted Answer

Answer reason: Notify the rapid response team (RRT). An SpO2 of 81% indicates severe hypoxemia and potential impending respiratory failure requiring immediate escalation of care. Despite supplemental oxygen at 6 L/min via nasal cannula, the patient remains critically desaturated, so the priority is activating emergency response for rapid assessment and higher-level interventions (e.g., high-flow device, noninvasive ventilation, or intubation). Increasing nasal cannula flow beyond typical limits is not the safest immediate action and may delay definitive airway/oxygenation support. Additional diagnostics (chest radiograph) or further assessment (auscultation) are secondary once life-threatening hypoxia is identified.
Category reason: This question tests urgent nursing action/escalation for a dangerously low oxygen saturation, which is an emergency response and patient safety priority in the NCLEX Safety and Infection Control domain.

Question 15

The classic mnemonic FAST in stroke stands for?

Accepted Answer

Answer reason: Face, Arm, Speech, Time FAST is a rapid stroke recognition tool: facial droop, arm weakness, and speech difficulty are key warning signs. The “T” emphasizes time-sensitive action because early activation of emergency response enables timely evaluation and potential reperfusion therapy (e.g., thrombolysis/thrombectomy). The other options list nonstandard or incorrect components that do not reflect accepted stroke screening mnemonics.
Category reason: This item tests immediate recognition of stroke warning signs and the need to activate emergency response quickly, which aligns with emergency response planning and patient safety in NCLEX practice.

Question 16

Children with epiglottitis should be given throat exams immediately.?

Accepted Answer

Answer reason: False In suspected epiglottitis, inspecting the throat with a tongue depressor can precipitate sudden laryngospasm and complete airway obstruction. The priority is to keep the child calm, avoid unnecessary manipulation, and secure the airway in a controlled setting with appropriate personnel (e.g., anesthesia/ENT) available. Immediate throat exams increase risk and are contraindicated until the airway is protected.
Category reason: This question tests a safety-focused nursing action in an airway emergency (what to avoid to prevent rapid deterioration), which aligns with NCLEX Safety and Infection Control rather than foundational science.

Question 17

A client with a suspected hemorrhagic cerebrovascular accident (CVA) reports a sudden headache, rating the pain 10 on a 0 to 10 scale. Which intervention does the nurse perform first?

Accepted Answer

Answer reason: Call the rapid response team A sudden, severe “worst headache” with suspected hemorrhagic stroke suggests a possible life-threatening intracranial bleed requiring immediate emergency response and rapid stabilization/coordination of care. Activating the rapid response team prioritizes airway/breathing/circulation monitoring, rapid neurologic checks, and expedited diagnostics/treatment. A focused neuro assessment and notifying the provider are important but should occur within the emergency response pathway rather than delaying activation. Administering oral acetaminophen is inappropriate as a first action in an acute neurologic emergency and may delay definitive care.
Category reason: This is a priority-action question in an acute, potentially life-threatening neurologic emergency; the key nursing judgment is initiating the facility’s emergency response process.

Question 18

A 28-week pregnant woman has preeclampsia and experiences a seizure. What is the nurse's priority action?

Accepted Answer

Answer reason: During an eclamptic seizure, the immediate priority is ABCs—protect the airway and support breathing while preventing aspiration. Side-lying positioning promotes drainage of secretions and reduces the risk of aspiration and maternal hypoxia, which also protects fetal oxygenation. Cervical checks and oxytocin are not immediate life-saving interventions during an active seizure, and restraints increase injury risk and are not appropriate; instead, protect from harm and prepare for magnesium sulfate and emergency management.
Category reason: This is a nursing priority/action question during a maternal seizure requiring immediate safety-focused emergency intervention, which aligns with NCLEX safety and emergency response.

Question 19

A client with suspected aortic dissection complains of sudden, sharp chest pain radiating to the back. BP in the right arm is 180/90, and 100/60 in the left. What should the nurse do first?

Accepted Answer

Answer reason: Aortic dissection is a life-threatening emergency suggested by abrupt tearing chest/back pain and unequal arm blood pressures, requiring rapid medical/surgical management. The priority nursing action is to activate the emergency response by urgently notifying the provider/rapid response team while continuing close monitoring. Starting IV fluids can worsen hypertension and bleeding, Trendelenburg is not indicated, and nitroglycerin is not first-line because the key immediate goal is to rapidly control heart rate and blood pressure under provider direction (e.g., IV beta-blocker) and prepare for definitive intervention.
Category reason: This question tests immediate nursing action in response to a suspected life-threatening cardiovascular emergency, emphasizing rapid escalation/activation of emergency care rather than biomedical details.

Question 20

A nurse finds a client pulseless and unresponsive. ECG shows ventricular fibrillation. What is the priority?

Accepted Answer

Answer reason: Ventricular fibrillation is a shockable rhythm; early defibrillation is the intervention most likely to restore a perfusing rhythm and improve survival. While high-quality CPR should be started right away and continued between shocks, the key priority for VF specifically is rapid defibrillation as soon as a defibrillator is available. Epinephrine is given during the arrest algorithm after initial defibrillation/CPR cycles, and checking blood glucose is not an immediate priority during a witnessed pulseless VF arrest compared with restoring circulation.
Category reason: This is a nursing emergency response question focused on immediate life-saving actions during cardiac arrest, which aligns with NCLEX safety/emergency management content rather than foundational biomedical science.

Question 21

Which facility is the most appropriate EMS destination for a patient with sudden cardiac arrest who achieved return of spontaneous circulation in the field?

Accepted Answer

Answer reason: Post–cardiac arrest patients with ROSC are at high risk for acute coronary occlusion and recurrent malignant dysrhythmias, and outcomes improve when they are taken to a center that can provide immediate coronary angiography/PCI and comprehensive post–arrest care. Stroke centers and rehab/long-term care units lack the emergent cardiac catheterization capability needed for time-sensitive reperfusion therapy. EMS destination decisions should prioritize definitive treatment resources for likely underlying etiologies and prevention of secondary injury (hemodynamic optimization, targeted temperature management, critical care monitoring).
Category reason: This is a prehospital/EMS destination decision after a medical emergency (ROSC after cardiac arrest), requiring nursing/clinical judgment about the safest facility with appropriate emergency capabilities, which fits Emergency Response Plans.

Question 22

A post-op patient suddenly reports severe abdominal pain and their wound dressing is saturated with blood. What's your priority nursing action?

Accepted Answer

Answer reason: The findings suggest acute postoperative hemorrhage, which is an immediate threat to circulation and can rapidly progress to shock. The nurse’s first priority is to control bleeding with direct pressure and reinforce the dressing while rapidly assessing vital signs and overall perfusion. Calling the provider is important but follows immediate lifesaving intervention; pain medication and documentation do not address the urgent hemodynamic risk.
Category reason: This is a priority nursing action question focused on responding to an emergent postoperative complication and preventing deterioration, which fits NCLEX safety/emergency response decision-making.

Question 23

The nurse finds a 70-year-old client admitted with heart failure, unresponsive with agonal gasping respirations. Which action does the nurse take first?

Accepted Answer

Answer reason: Agonal gasps are not effective breathing and should be treated as cardiac arrest until proven otherwise. In BLS, once unresponsiveness and abnormal breathing are recognized, the priority is to initiate high-quality CPR immediately to restore perfusion; pulse checks should not delay compressions (limit to ≤10 seconds if performed). Rescue breaths and advanced airway placement are secondary and should occur after compressions have begun and additional help/defibrillation is being organized.
Category reason: This is a patient-care emergency requiring immediate recognition of cardiac arrest and initiation of appropriate resuscitation steps, which is a nursing safety/emergency response decision rather than foundational science.

Question 24

A nurse is caring for a postoperative patient who suddenly reports shortness of breath. The respiratory rate is 32/min and oxygen saturation is 88% on room air. What is the nurse’s priority action?

Accepted Answer

Answer reason: D. Place the patient in high Fowler’s position This patient has acute respiratory distress with tachypnea and hypoxemia, so the first priority is to improve airway patency and ventilation immediately. High Fowler’s maximizes chest expansion, decreases work of breathing, and can quickly improve oxygenation while additional interventions are prepared. Applying oxygen and calling rapid response may be needed next, but positioning is the fastest independent nursing action that can be initiated instantly. Assessment tasks (e.g., incision check/auscultation) should not delay immediate support of breathing.
Category reason: This is a prioritization question requiring immediate nursing action to stabilize breathing (ABCs) in an acutely decompensating postoperative patient, which aligns with emergency response and safety-focused clinical judgment.

Question 25

What is the correct compression-to-ventilation ratio during CPR for an adult when performed by a single rescuer?

Accepted Answer

Answer reason: Adult single-rescuer BLS follows current CPR guidelines recommending 30 chest compressions followed by 2 rescue breaths to balance circulation with oxygenation while minimizing interruptions in compressions. A higher compression count supports coronary and cerebral perfusion during cardiac arrest. Ratios like 15:2 are used for pediatric CPR with two rescuers, and the other ratios are not guideline-supported for adult single-rescuer CPR.
Category reason: This question tests the correct CPR procedure for emergency response (compression-to-ventilation ratio), which is a patient-safety skill within emergency response planning.

Question 26

What is the first-line treatment for anaphylaxis?

Accepted Answer

Answer reason: It is the lifesaving first-line medication because it rapidly reverses airway edema and bronchospasm via beta-adrenergic effects and counters hypotension/vasodilation via alpha-adrenergic vasoconstriction. Antihistamines and corticosteroids are adjuncts that do not act quickly enough to treat shock or airway compromise. Bronchodilators can help persistent wheeze but do not address the systemic vasodilation and laryngeal edema driving anaphylaxis, so they are not first-line.
Category reason: This is primarily a patient-safety emergency management question focused on immediate first-line intervention in a life-threatening reaction, aligning with NCLEX emergency response content.

Question 27

The compression to ventilation ratio in CPR in case of single rescuer is?

Accepted Answer

Answer reason: For adult basic life support with a single rescuer, current CPR guidelines recommend 30 chest compressions followed by 2 rescue breaths to optimize perfusion while still providing ventilation. This ratio balances minimizing interruptions in compressions with adequate oxygen delivery. The 15:2 ratio is used in specific situations (e.g., two-rescuer CPR for children/infants), not for a single rescuer adult sequence. Ratios like 5:2 or 2:30 are not standard recommended CPR sequences.
Category reason: This is a patient-care emergency intervention question focused on correct CPR performance during resuscitation, which aligns with nursing safety/emergency response responsibilities.

Question 28

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 the blood product, the priority is to maintain IV access with isotonic fluid using new tubing so emergency medications and supportive care can be given and to help support blood pressure. Normal saline is compatible with blood products and is the recommended solution to keep the line open during evaluation of a suspected reaction. Dextrose-containing solutions can cause RBC hemolysis or clotting and are avoided. The IV catheter should not be removed because access is needed for treatment and for collecting required specimens per protocol.
Category reason: This item tests immediate nursing actions and safety priorities in response to a transfusion reaction, which is an acute patient-care emergency requiring prompt intervention rather than foundational science knowledge.

Question 29

A patient arrives after a chemical burn to the eyes. What is the first action?

Accepted Answer

Answer reason: Immediate, copious irrigation is the priority because it dilutes and physically removes the chemical, limiting ongoing tissue damage and reducing risk of vision loss. Delaying irrigation to apply medications, cover the eye, or treat pain allows continued exposure and deeper injury. Irrigation should begin at once and continue until the ocular surface pH normalizes, with removal of contact lenses/particulate matter as able.
Category reason: This is an urgent patient-care decision focused on immediate safety interventions for an eye chemical exposure, aligning with emergency response actions in nursing practice.

Question 30

Which pediatric client requires immediate intervention?

Accepted Answer

Answer reason: B. A 2-year-old with epiglottitis who is drooling and sitting upright. Drooling with tripod/upright positioning signals impending upper-airway obstruction, and epiglottitis can rapidly progress to complete airway compromise. This is an airway emergency requiring immediate action (keep the child calm, avoid throat exam, and prepare for advanced airway management). The other presentations are more consistent with non-emergent illness or mild dehydration risk and do not pose an immediate threat to airway/breathing.
Category reason: This is a prioritization question requiring nursing judgment to identify the child at highest immediate risk (airway compromise) and initiate emergency response actions, which aligns with Safety and Infection Control.

Question 31

A training session on cardiopulmonary resuscitation (CPR) was conducted by the nurse. Which guideline in the session should the nurse incorporate?

Accepted Answer

Answer reason: Current CPR guidelines emphasize initiating high-quality chest compressions immediately for an unresponsive patient with absent/abnormal breathing, then addressing airway and ventilation (CAB) to maintain perfusion to vital organs. Checking for breathing should be rapid and not delay compressions, and the older “look, listen, feel” approach is de-emphasized. CPR should continue with rotating rescuers as needed rather than stopping simply due to fatigue. Cardiac arrest determination is not based on unresponsiveness alone; assessment includes breathing and pulse checks per training level.
Category reason: This item tests nursing response to a medical emergency and correct CPR sequence during resuscitation training, which fits emergency response and safety-focused patient care decision-making.

Question 32

The Heimlich manoeuvre (abdominal thrust) is used for a client who has?

Accepted Answer

Answer reason: The abdominal thrust (Heimlich maneuver) is an emergency intervention for a conscious person with severe airway obstruction from a foreign body (choking). It increases intrathoracic pressure to expel the object and restore airflow when the client cannot effectively cough, speak, or breathe. It is not indicated for epistaxis, falls/trauma without choking, or visual impairment, where different assessments and interventions are required.
Category reason: This item tests an immediate nursing emergency intervention for choking/airway obstruction, which falls under safety-focused emergency response actions in NCLEX.

Question 33

A postoperative patient suddenly develops signs of pulmonary embolism. What is the nurse’s priority action?

Accepted Answer

Answer reason: A pulmonary embolism causes sudden ventilation-perfusion mismatch and acute hypoxemia, so immediate support of oxygenation is the highest priority using the ABC approach. Supplemental oxygen increases alveolar oxygen tension and can improve oxygen delivery while further emergency measures are initiated. Trendelenburg is not recommended for PE and can worsen respiratory mechanics, coughing/deep breathing is insufficient for this acute event, and chest compressions are only indicated if the patient is pulseless.
Category reason: This item asks for the nurse’s immediate priority intervention during an acute, life-threatening event (suspected pulmonary embolism), emphasizing rapid emergency response and stabilization rather than underlying pathophysiology.

Question 34

The nurse hears the alarm sound on the telemetry monitor, quickly looks at the monitor, and notes that a client is in ventricular tachycardia. The nurse rushes to the client’s room, and upon reaching the client’s bedside, which action first should the nurse perform?

Accepted Answer

Answer reason: Immediate assessment of responsiveness is the first step in the BLS sequence when a potentially life-threatening rhythm is noted, because it determines whether to activate the emergency response and begin resuscitation actions. Ventricular tachycardia can be pulseless or perfusing; checking responsiveness rapidly helps distinguish clinical collapse from a patient who is still conscious and breathing. If unresponsive, the nurse then initiates the code response, assesses breathing/pulse per protocol, and proceeds to CPR/defibrillation as indicated to minimize time to definitive treatment.
Category reason: This item tests the nurse’s immediate action and sequence of response during a suspected cardiac emergency, emphasizing emergency assessment and activation of resuscitation procedures.

Question 35

You find an unresponsive adult patient. Your first action should be to begin CPR?

Accepted Answer

Answer reason: In an unresponsive adult, immediate assessment for normal breathing and pulse should occur quickly, and if absent, high-quality chest compressions should be started without delay to maintain perfusion to the heart and brain. Activating emergency response is important, but for a lone rescuer the sequence prioritizes starting compressions promptly while arranging for help/AED as soon as possible. Rescue breathing alone is insufficient in adult cardiac arrest because compressions are critical for circulation. Defibrillation is indicated for shockable rhythms, but an AED/defibrillator must be available and attached; it is not the first step at initial discovery.
Category reason: This is a nursing action/prioritization question about immediate response to an unresponsive adult and initiating life-saving interventions, which fits NCLEX safety/emergency response planning rather than foundational biomedical science.

Question 36

An adult patient is in cardiac arrest. The monitor shows ventricular fibrillation. You should immediately?

Accepted Answer

Answer reason: In pulseless ventricular fibrillation, the priority is immediate unsynchronized defibrillation because it is the definitive treatment to terminate the shockable rhythm. CPR should be started while the defibrillator is being prepared and resumed immediately after the shock, but it is not the first priority once VF is identified and a defibrillator is available. Epinephrine is given after initial shocks and CPR cycles per ACLS sequence, not before the first shock. Airway interventions such as intubation should not delay early defibrillation and high-quality chest compressions.
Category reason: This is an emergency nursing action/prioritization question focused on immediate resuscitation interventions during cardiac arrest, which aligns with NCLEX-level patient-care decision-making in emergency response.

Question 37

A patient is complaining of chest pain. He is dyspneic, and diaphoretic. The blood pressure is 70/50. The monitor shows ventricular tachycardia. You should immediately?

Accepted Answer

Answer reason: The patient is hemodynamically unstable (hypotension, chest pain, diaphoresis, dyspnea) with a pulse and ventricular tachycardia, which requires immediate synchronized cardioversion. Synchronization avoids delivering the shock during the vulnerable T wave and reduces the risk of precipitating ventricular fibrillation. Defibrillation is reserved for pulseless VT/VF or polymorphic VT where synchronization is not possible. Antiarrhythmics like lidocaine or epinephrine are not first-line when unstable VT with a pulse is present; delaying shock increases risk of deterioration.
Category reason: This question tests emergency nursing action in response to a life-threatening dysrhythmia (unstable ventricular tachycardia) and requires selecting the immediate intervention, which aligns with emergency response decision-making under Safety and Infection Control.

Question 38

Which pulse is palpated to see the effectiveness of CPR?

Accepted Answer

Answer reason: During adult CPR, a central pulse is assessed because peripheral perfusion may be absent even when there is some cardiac output. The carotid artery is a reliable, accessible central pulse in an unconscious adult and is recommended for pulse checks when evaluating return of spontaneous circulation. Radial and temporal pulses are more likely to be weak or absent during low-flow states, and femoral is central but typically less convenient and may be harder to locate quickly in many situations.
Category reason: This tests emergency nursing action during resuscitation—selecting the correct pulse site to assess CPR effectiveness—so it fits NCLEX content under emergency response.

Question 39

An activated AED does not promptly analyze the rhythm. What is your next action?

Accepted Answer

Answer reason: If an AED fails to analyze promptly, the priority is troubleshooting the device so it can correctly detect a shockable rhythm. Poor pad contact, loose cables, moisture, or patient movement can prevent analysis; ensuring secure connections and then reanalyzing addresses these common causes. Stopping resuscitation is unsafe, and moving pads is not the first step unless a placement/contact issue is identified. While CPR should be resumed when the AED is not analyzing, the question asks for the next action specifically to resolve the analysis failure.
Category reason: This question tests a nurse’s response during cardiopulmonary resuscitation with an AED, focusing on immediate actions in an emergency response situation.

Question 40

What is the first step after finding an unresponsive patient with no breathing?

Accepted Answer

Answer reason: Rapid activation ensures help is on the way and that a defibrillator and additional trained responders can arrive immediately, which is critical for survival in suspected cardiac arrest. After activating the response system, the nurse should start high-quality CPR promptly while another person retrieves the AED if available. Checking a pulse should not delay initiating the emergency response and lifesaving interventions, and AED attachment follows once it is available.
Category reason: This question tests immediate nursing actions in a suspected cardiac arrest scenario, emphasizing activating the emergency response system as part of emergency preparedness and response in patient care settings.

Question 41

After verifying unresponsiveness and abnormal breathing, you activate the emergency response team. What is your next action?

Accepted Answer

Answer reason: After confirming unresponsiveness with abnormal breathing and activating the response team, the next step in BLS is to assess circulation by checking for a carotid pulse for no more than 10 seconds. This determines whether to start chest compressions immediately versus providing ventilations for respiratory arrest with a pulse. Retrieving an AED is important but does not replace the immediate pulse check in the sequence. Rescue breaths are indicated only if a pulse is present but breathing is absent/inadequate, and a precordial thump is not a routine intervention in modern resuscitation algorithms.
Category reason: This question tests the nurse’s immediate actions during cardiopulmonary arrest response and adherence to BLS sequence, which fits emergency response within safety-focused patient care.

Question 42

What’s the first thing a nurse should do when they hear “Code Blue”?

Accepted Answer

Answer reason: Rapid assessment is essential to confirm unresponsiveness and initiate the emergency response system immediately. Activating help early ensures the code team and resuscitation equipment arrive without delay, enabling timely CPR/defibrillation per BLS/ACLS priorities. The other options are unsafe distractions and do not address immediate life-threatening deterioration.
Category reason: This question tests the nurse’s immediate action during a hospital emergency (code blue) and appropriate activation of emergency response, which fits Emergency Response Plans under Safety and Infection Control.

Question 43

Chest tube accidentally disconnects from drainage system—first action?

Accepted Answer

Answer reason: This immediately restores a temporary water seal (about 2 cm) to prevent air from being sucked back into the pleural space, reducing risk of an open pneumothorax/tension physiology. Clamping can trap air and worsen a pneumothorax, and increasing suction does not fix loss of the water-seal system connection. Removing the chest tube is not an initial nursing action and would require a provider order and sterile procedure.
Category reason: This is a priority, first-action nursing intervention for an accidental disconnection of a chest tube drainage system, emphasizing immediate safety actions to prevent respiratory compromise.

Question 44

In CPR, which step is done immediately after delivering a shock with AED?

Accepted Answer

Answer reason: After a shock, high-quality CPR should be resumed immediately to maintain coronary and cerebral perfusion, because even brief pauses in compressions reduce the chance of return of spontaneous circulation. Pulse checks are deferred until a rhythm check after about 2 minutes of CPR unless there are obvious signs of life. Breaths are delivered as part of CPR according to the compression-to-ventilation ratio, but the priority immediately post-shock is restarting compressions without delay. Rhythm reanalysis is performed after a CPR cycle, not immediately after defibrillation.
Category reason: This question tests the correct immediate action during a resuscitation sequence with an AED, requiring nursing judgment in an emergency response situation rather than foundational biomedical science.

Question 45

What is the ratio of compressions to breaths when performing Cardiopulmonary Resuscitation (CPR)?

Accepted Answer

Answer reason: Current BLS guidelines for single-rescuer CPR in adults (and also for children/infants when a lone rescuer is present) use a 30:2 compression-to-ventilation ratio to prioritize high-quality continuous chest compressions with minimal interruptions. The other options provide incorrect ratios and would lead to inadequate perfusion or inappropriate ventilation strategy. Pediatric CPR differs mainly when there are two rescuers (15:2), which is not what option D states.
Category reason: This question tests a nursing emergency response action (performing CPR) and the correct resuscitation protocol ratio, which fits within Safety and Infection Control as part of emergency response preparedness.

Question 46

A patient with COPD is on 2L/min oxygen via nasal cannula. They are drowsy, RR = 10/min, and SpO2 = 89%. What should the nurse do next?

Accepted Answer

Answer reason: This patient has signs of impending respiratory failure (depressed respiratory rate with decreased level of consciousness), which is an immediate threat to airway and ventilation. In COPD, excessive supplemental oxygen can worsen hypercapnia, but the priority is urgent assessment and escalation for potential ventilatory support and ABG evaluation rather than independently making large oxygen changes. Increasing oxygen to 5 L/min risks worsening CO2 retention, while turning off or lowering oxygen can worsen hypoxemia and does not address hypoventilation. Rapid response mobilizes advanced interventions (airway support, noninvasive ventilation, diagnostics) promptly.
Category reason: This question tests immediate nursing action and escalation in response to acute clinical deterioration (low RR and drowsiness), which is an emergency response/safety decision rather than foundational science knowledge.

Question 47

10 minutes after starting a blood transfusion, the patient develops chills, back pain, and shortness of breath. What's your priority nursing action?

Accepted Answer

Answer reason: These findings shortly after initiation of transfusion are concerning for an acute transfusion reaction (e.g., hemolytic or other severe reaction) that can rapidly progress to shock, respiratory compromise, and renal injury. The immediate priority is to stop exposure to the blood product while keeping venous access for supportive care using new tubing with normal saline. After stopping the transfusion, the nurse then assesses vital signs and notifies the provider and blood bank, but those are secondary to stopping the infusion. Giving antihistamine or checking temperature alone delays the life-saving first step and does not address a potentially life-threatening reaction.
Category reason: This is a patient-safety prioritization question requiring immediate nursing intervention during a suspected transfusion reaction, which aligns with emergency response actions under Safety and Infection Control.

Question 48

A patient with a nasogastric (NG) tube suddenly starts coughing and shows signs of respiratory distress during feeding. What is the priority nursing action?

Accepted Answer

Answer reason: Respiratory distress and coughing during tube feeding suggests possible aspiration or malposition of the tube into the airway, creating an immediate airway threat. The first priority is to remove the offending stimulus by stopping the feeding to prevent further aspiration and worsening hypoxia. After stopping the feed, the nurse would assess airway/breathing, verify tube placement, and implement additional interventions (e.g., suction, oxygen) and notify the provider as indicated.
Category reason: This item tests immediate nursing intervention to protect airway and prevent aspiration during enteral feeding, which is a patient-safety priority within Safety and Infection Control.

Question 49

The nurse in the emergency department received a call from emergency medical services and told that several victims who survived a plane crash and are suffering from cold exposure will be transported to the hospital. What should be the initial nursing action of the emergency department nurse?

Accepted Answer

Answer reason: The priority is to initiate the facility’s organized emergency response so staffing, triage flow, supplies, and communication are coordinated before patients arrive. A disaster plan establishes the incident command structure and mobilizes resources across departments, preventing duplicated or unsafe ad hoc actions. The other actions may be needed, but they are components that should occur after activating the formal emergency response system to ensure appropriate scope and coordination.
Category reason: This item tests the nurse’s first action in preparing the emergency department for an incoming mass-casualty event, which is a facility-level emergency preparedness and coordination task aligned with emergency response planning.

Question 50

A nurse is working in a hospital when a fire breaks out in a nearby patient room. What is the priority action the nurse should take?

Accepted Answer

Answer reason: C. Rescue patients in immediate danger This follows the RACE sequence for fire response, where the first priority is to remove anyone at immediate risk of harm. Life safety takes precedence over activating alarms, containing the fire, or attempting extinguishment. Once patients are moved to safety, the nurse should then activate the alarm, confine the fire, and extinguish only if trained and it is safe to do so.
Category reason: This question tests the nurse’s immediate actions during a hospital fire, focusing on emergency response procedures and safety priorities, which aligns with Emergency Response Plans.

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