Question 1

A patient with chest pain has ST elevation on ECG. What's MOST critical?

Accepted Answer

Answer reason: ST elevation with ischemic chest pain indicates an acute STEMI requiring immediate reperfusion workflows (rapid activation of cath lab/PCI pathway). Time-to-treatment is the priority; initiating the STEMI protocol mobilizes the team, secures rapid access, and reduces delay to definitive therapy. Aspirin and nitroglycerin can be important, but they should not postpone system activation, and nitroglycerin may be contraindicated (e.g., hypotension, RV infarct, recent PDE-5 inhibitor use). Troponin is not required to start emergent STEMI management when the ECG is diagnostic.
Category reason: This question tests the nurse’s urgent action/activation of emergency systems for a life-threatening condition (STEMI), which is an emergency response and coordination-of-care decision.

Question 2

WHAT SHOULD BE THE RATE OF CHEST COMPRESSIONS PER MINUTE WHILE PROVIDING CHEST COMPRESSIONS IN CPR FOR ADULTS?

Accepted Answer

Answer reason: High-quality adult CPR recommends a chest compression rate of 100–120/min to optimize coronary and cerebral perfusion. A rate below this range can reduce cardiac output during compressions, while significantly faster rates can lead to inadequate chest recoil and shallow depth. Among the choices, this option best matches the evidence-based target range used in adult BLS guidelines.
Category reason: This question tests a nursing emergency intervention standard (adult CPR compression rate), which is part of safe emergency response actions in patient care rather than foundational biomedical science.

Question 3

IN CASE OF CARDIAC ARREST IN OT, THE IMMEDIATE STEP IS?

Accepted Answer

Answer reason: Immediate management of cardiac arrest is to initiate high-quality chest compressions and basic life support while activating the resuscitation response and preparing for defibrillation if indicated. This maintains minimal perfusion to the brain and myocardium and is time-critical; delays markedly worsen outcomes. IV fluids, calling a surgeon, or wound dressing do not address the absent circulation and are secondary tasks during a code.
Category reason: This question tests the nurse’s immediate emergency action in a life-threatening event (cardiac arrest) in the operating theater, which aligns with emergency response procedures within Safety and Infection Control.

Question 4

A nurse is monitoring a patient on telemetry and notes a sudden onset of ventricular tachycardia (VT) with a pulse. The patient is alert but reports feeling dizzy and lightheaded. What is the nurse’s priority action?

Accepted Answer

Answer reason: The patient has VT with a pulse and symptoms suggesting hemodynamic instability may be developing, so immediate escalation for advanced assessment and treatment is the safest priority. Defibrillation and CPR are indicated for pulseless rhythms; in VT with a pulse, care focuses on prompt evaluation, continuous monitoring, and preparation for synchronized cardioversion/antiarrhythmic therapy based on stability. Calling the rapid response team mobilizes critical resources quickly while the nurse maintains monitoring, obtains vital signs, ensures IV access/oxygen as needed, and prepares emergency equipment.
Category reason: This item tests a nurse’s immediate clinical decision-making and escalation of care for a potentially unstable dysrhythmia, which aligns with emergency response actions in the NCLEX safety domain.

Question 5

Time to put that clinical judgment to the test A 4-year-old with a known peanut allergy accidentally eats a cookie at daycare. He's scratching his throat and has wheezing. What do you do first?

Accepted Answer

Answer reason: B. Administer epinephrine Throat itching and wheezing after known peanut exposure indicate probable anaphylaxis with impending airway compromise. Intramuscular epinephrine is the first-line, time-critical treatment that reverses bronchospasm and reduces mucosal edema; delaying it increases risk of rapid deterioration. Calling EMS is important but should occur after or concurrently with epinephrine if available, while antihistamines are adjunctive only. CPR is only indicated if the child becomes pulseless or apneic.
Category reason: This item tests the nurse’s immediate emergency intervention and prioritization in suspected anaphylaxis, which is a safety-focused clinical judgment scenario under emergency response.

Question 6

A nurse on a telemetry unit is caring for a client who becomes unconscious and whose monitor displays ventricular tachycardia. Which of the following actions should the nurse take first after determining the client does not have a palpable pulse?

Accepted Answer

Answer reason: Pulseless ventricular tachycardia is a shockable cardiac arrest rhythm, so the priority intervention is immediate unsynchronized shock to attempt to restore a perfusing rhythm. Delays for additional assessment or IV access reduce chances of successful defibrillation and survival. After shock delivery, high-quality CPR is resumed and medications such as epinephrine are given during subsequent cycles per ACLS algorithms.
Category reason: This question tests immediate nursing action during a life-threatening cardiac arrest rhythm and requires rapid emergency response prioritization, which aligns with Emergency Response Plans under Safety and Infection Control.

Question 7

A patient with chest pain is admitted to the emergency department. What is the priority nursing assessment?

Accepted Answer

Answer reason: Chest pain can indicate life-threatening conditions (e.g., acute coronary syndrome, dysrhythmias, pulmonary embolism) that may rapidly compromise oxygenation and perfusion. The initial assessment follows the ABC approach to identify and treat immediate threats to life before collecting less urgent history. Dietary and social histories are important but do not address imminent instability. A focused neurologic exam is secondary unless there are signs of altered mental status or stroke.
Category reason: This question tests prioritization of immediate life-saving nursing assessment actions in an emergency presentation, which aligns with emergency response and safety-focused care.

Question 8

What is the first action a nurse should take when entering a patient's room and noticing the patient is unresponsive?

Accepted Answer

Answer reason: Immediate activation of the emergency response ensures additional trained staff and a crash cart/AED arrive quickly, which improves survival and allows simultaneous assessment and interventions. In an unresponsive patient, the nurse should not delay emergency activation by performing prolonged assessments alone. Once help is summoned, the nurse can rapidly assess breathing and pulse and begin CPR/AED use as indicated per BLS sequence for in-hospital arrest.
Category reason: This item tests the nurse’s first safety-focused action in a suspected cardiac/respiratory arrest situation, emphasizing emergency response activation and rapid team-based intervention, which aligns with Emergency Response Plans.

Question 9

While performing high-quality CPR on an adult, what action should you ensure is being accomplished?

Accepted Answer

Answer reason: High-quality adult CPR requires adequate compression depth to generate sufficient coronary and cerebral perfusion pressure. Current BLS guidance is to compress at least 2 inches (about 5 cm) while avoiding excessive depth. A rate of 100–120/min is recommended, making the lower end of 90/min incorrect. Hand placement should be on the lower half of the sternum, and recoil is allowing the chest to return fully (not “recoil at least 2 inches”).
Category reason: This question tests correct performance of CPR during an emergency response, which is a nursing safety intervention in resuscitation situations.

Question 10

What should you do if you need to use an AED on someone who has been submerged in water?

Accepted Answer

Answer reason: An AED should never be used while the person is in water because moisture can conduct electricity and interfere with shock delivery, increasing risk to rescuers and reducing effectiveness. The patient must be moved to a dry, safe surface, and the chest quickly dried to ensure good pad adhesion and accurate rhythm analysis. After drying, apply pads and follow AED prompts while continuing high-quality CPR as indicated. These steps align with standard BLS safety principles for defibrillation in wet environments.
Category reason: This item tests emergency response actions and safety precautions during resuscitation with an AED, which is a nursing/patient-care safety decision in an acute scenario.

Question 11

The nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is dazed and tries to get up, and the leg appears fractured. The nurse should plan to perform which action?

Accepted Answer

Answer reason: A suspected fracture with possible associated head/neck injury requires minimizing movement to prevent worsening bleeding, displacement, or spinal injury. The nurse should provide immediate first-aid support, keep the person calm and still, and enlist bystanders to call emergency services rather than leaving the injured person unattended. Attempting reduction or walking the person increases risk of neurovascular compromise and further trauma.
Category reason: This is primarily about immediate safety-focused nursing actions at the scene of an injury (first response and preventing further harm), which fits Safety and Infection Control under emergency response.

Question 12

A newborn with apnea is being discharged from the hospital with home monitoring. What information concerning the infant's care should the practical nurse review with the parents?

Accepted Answer

Answer reason: Because apnea can recur at home, caregivers must be prepared to provide immediate lifesaving measures while awaiting emergency services. Teaching CPR is a key safety intervention that reduces risk of hypoxic injury or death if the monitor alarms or the infant is found apneic. The other options are inappropriate: IV antibiotics are not a routine home-monitoring teaching point, electrocution reassurance is not the priority compared with emergency readiness, and caregivers can be used if they are trained on monitoring and emergency response.
Category reason: This question focuses on discharge teaching and preparation for managing a potential emergency event (apnea) at home, which is a patient-safety and emergency response nursing responsibility.

Question 13

For CPR, what is the correct compression depth in adults?

Accepted Answer

Answer reason: High-quality adult CPR requires a chest compression depth of at least 5 cm but not more than 6 cm to generate adequate coronary and cerebral perfusion while minimizing injury risk. Shallower compressions reduce forward blood flow and lower the chance of ROSC. Excessive depth increases the likelihood of rib and sternal fractures and potential organ injury. Maintaining full recoil and an appropriate rate alongside correct depth optimizes perfusion.
Category reason: This item tests emergency response actions during resuscitation (CPR technique), which is a safety-focused clinical intervention under emergency response.

Question 14

A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?

Accepted Answer

Answer reason: This is an acute, significant drop in blood pressure in a postoperative patient, raising concern for hemorrhage, sepsis, or other shock states requiring immediate assessment and intervention. Rapid response activation ensures urgent evaluation, hemodynamic support, and escalation of care without delay. Simply documenting, waiting, or rechecking later risks missing time-sensitive deterioration; notifying the provider alone may be slower than activating the emergency response pathway.
Category reason: This item tests the nurse’s immediate safety-focused action for sudden hemodynamic instability, which is an emergency escalation decision within nursing care.

Question 15

A nurse of the telemetry unit is caring for a client who has had a MI and is now attached to a cardiac monitor. The nurse is monitoring the client's cardiac rhythm and notes ventricular fibrillation. Which nursing intervention should the nurse take first?

Accepted Answer

Answer reason: a. Calling the rapid response team Ventricular fibrillation is a pulseless, life-threatening rhythm requiring immediate activation of emergency response and rapid defibrillation with CPR. The nurse’s first priority is to summon help and initiate the unit’s emergency protocol to get the defibrillator and resuscitation team to the bedside without delay. Cardioversion is for unstable tachyarrhythmias with a pulse, vagal maneuvers are for SVT, and diltiazem is used for rate control in atrial arrhythmias—not for ventricular fibrillation.
Category reason: This question tests the nurse’s immediate priority action in response to a lethal rhythm on telemetry, emphasizing rapid activation of emergency response systems and resuscitation protocols.

Question 16

A client in ventricular fibrillation is receiving ACLS. Which intervention should the nurse prioritize?

Accepted Answer

Answer reason: Ventricular fibrillation is a shockable cardiac arrest rhythm, and early defibrillation is the highest-priority intervention to restore a perfusing rhythm. Actions such as starting oxygen, inserting an IV, and giving fluids are important but should not delay defibrillation. ACLS algorithms emphasize immediate unsynchronized shock with ongoing high-quality CPR and rapid rhythm reassessment.
Category reason: This question focuses on urgent nursing actions during a life-threatening cardiac arrest scenario and prioritizing ACLS interventions, which aligns with emergency response within patient safety.

Question 17

Scenario: A nurse finds an unconscious adult with no pulse. What is the first nursing action?

Accepted Answer

Answer reason: For an unresponsive adult with no pulse, the priority is to activate the emergency response system and immediately start high-quality chest compressions to restore perfusion to the brain and heart. Rescue breaths are not the initial step for an adult in presumed cardiac arrest; compressions take priority, with breaths added per CPR sequence once compressions are underway. Defibrillation is indicated for shockable rhythms but requires an AED/defibrillator and should occur as soon as available while CPR continues. Checking blood pressure delays life-saving interventions and is inappropriate when pulselessness is already identified.
Category reason: This item tests immediate nursing actions during cardiac arrest, requiring emergency response activation and initiation of CPR, which fits NCLEX safety-focused emergency management.

Question 18

Which item is not typically found on a hospital crash cart?

Accepted Answer

Answer reason: Crash carts are stocked for immediate resuscitation during cardiopulmonary emergencies, prioritizing airway management, defibrillation, and rapid-access ACLS medications. Defibrillators, suction, and drugs such as epinephrine are core components needed within seconds to minutes. A bedside blood glucose check may be useful in some scenarios, but glucometers are typically kept on units/medication rooms rather than being a standard crash cart item.
Category reason: This question tests knowledge of emergency preparedness equipment used during hospital resuscitation, which aligns with nursing safety practices and emergency response planning.

Question 19

During CPR, the nurse must give compressions at what depth for an adult?

Accepted Answer

Answer reason: Effective adult chest compressions require a depth of about 5–6 cm to generate adequate intrathoracic pressure and forward blood flow to vital organs. Shallower compressions reduce coronary and cerebral perfusion and lower the chance of return of spontaneous circulation. Excessively deep compressions increase the risk of injury without improving perfusion. High-quality CPR also includes a rate of 100–120/min, full chest recoil, and minimizing interruptions.
Category reason: This question tests a nursing emergency intervention parameter (proper CPR compression depth) used during resuscitation, which aligns with emergency response in patient care.

Question 20

The bleeding room should be equipped with the following injections ............. except?

Accepted Answer

Answer reason: In an acute bleeding/emergency room setup, commonly stocked rescue medications focus on anaphylaxis/shock management and reversal of specific toxicities or metabolic disturbances. Adrenaline and dexamethasone are typical emergency drugs for severe allergic reactions and airway edema, and calcium gluconate is a key antidote for citrate toxicity (e.g., massive transfusion) and for life-threatening hyperkalemia. Atropine is primarily used for symptomatic bradycardia and certain poisonings, and it is not a standard “bleeding room” essential compared with the other listed agents.
Category reason: This item tests emergency preparedness for a clinical care area (what medications should be stocked for acute bleeding/emergencies), which is a patient-safety and emergency response planning topic rather than foundational biomedical science.

Question 21

A postoperative client reports chest pain and shortness of breath. What is the nurse’s first action?

Accepted Answer

Answer reason: B. Elevate head of bed and apply oxygen This client has acute respiratory symptoms postoperatively, so the priority is to support airway and breathing immediately. Raising the head of the bed optimizes lung expansion, and supplemental oxygen treats hypoxemia while further assessment occurs. Calling a rapid response may be needed, but initiating immediate, low-risk oxygenation measures is the first nursing action. Analgesia or checking chest tube output can follow after stabilizing oxygenation and ventilation.
Category reason: This is a nursing priority/action question focused on immediate response to a potential postoperative respiratory emergency, fitting NCLEX patient-safety/emergency response decision-making.

Question 22

Scenario: A 2-year-old is choking on a small toy and cannot cry or breathe. What is the appropriate immediate action?

Accepted Answer

Answer reason: A 2-year-old with inability to cry or breathe has a severe foreign-body airway obstruction and is not an infant, so abdominal thrusts are indicated to generate an expiratory force to dislodge the object. Back slaps and chest thrusts are the recommended technique for infants (

Question 23

A nurse notes the ECG rhythm below (Ventricular Asystole). What is the nurse’s priority action? (ECG shows flatline/asystole)?

Accepted Answer

Answer reason: Asystole is a non-shockable cardiac arrest rhythm, so immediate high-quality chest compressions with prompt activation of the code/ALS response is the priority to maintain minimal perfusion. Defibrillation is not indicated because there is no organized ventricular electrical activity to reset. Atropine is not recommended for routine management of asystolic cardiac arrest in current ACLS algorithms; epinephrine and CPR are the key initial interventions. Providing oxygen without compressions delays definitive life-saving measures and worsens outcomes.
Category reason: This question tests the nurse’s immediate emergency response to a lethal rhythm and the correct initial resuscitation action, which aligns with emergency response planning and basic life support priorities in patient care.

Question 24

Scenario: A post-op patient becomes pale, diaphoretic, and hypotensive with a rapid pulse. What action should the nurse take first?

Accepted Answer

Answer reason: These findings suggest acute shock (e.g., hemorrhage) with poor perfusion, requiring immediate support of circulation and rapid escalation. Elevating the legs can transiently improve venous return and cardiac output while awaiting urgent evaluation and interventions. Calling for help activates rapid response/medical team for assessment of bleeding, fluid resuscitation, oxygen, and potential return to OR. Delaying care, giving oral fluids, or focusing on analgesia risks worsening instability and aspiration.
Category reason: This question tests the nurse’s immediate first action in an acute deterioration scenario requiring rapid escalation and stabilization, which aligns with emergency response and patient safety decision-making in NCLEX.

Question 25

A client on a cardiac monitor suddenly has a flatline (asystole). What is the nurse’s first action?

Accepted Answer

Answer reason: A flatline on the monitor can be due to artifact such as disconnected leads, poor electrode contact, or monitor malfunction, so the nurse must rapidly verify the rhythm and assess the patient before initiating interventions meant for true cardiac arrest rhythms. Confirming asystole includes checking the patient for responsiveness/pulse and ensuring the monitor is reading correctly (leads, gain, another lead). Once true asystole is confirmed, immediate CPR is initiated and epinephrine is given per ACLS, while defibrillation is not indicated for asystole.
Category reason: This question tests immediate nursing actions during a suspected cardiac emergency, emphasizing verification of monitoring accuracy and rapid response steps, which fits emergency response planning and safety-focused patient care.

Question 26

A woman has been rushed to the hospital with ruptured membrane. Which of the following should the nurse check first?

Accepted Answer

Answer reason: Rupture of membranes creates an immediate risk of umbilical cord prolapse, which can rapidly compress the cord and cause acute fetal hypoxia and bradycardia. This is a time-critical emergency where rapid assessment and intervention (e.g., relieving pressure, positioning, urgent provider notification) can prevent fetal compromise. Other checks like infection risk, maternal pulse, or fluid color are important but are not as immediately life-threatening as potential cord compression.
Category reason: This question tests urgent nursing assessment and prioritization in an obstetric emergency (ruptured membranes) to prevent fetal harm, aligning with safety-focused emergency response in NCLEX practice.

Question 27

Priorities when caring for the elderly trauma patient?

Accepted Answer

Answer reason: Initial trauma care follows the ABC approach to rapidly address immediately life-threatening problems and stabilize the patient. Airway protection is prioritized first, then assessment and support of breathing/ventilation, followed by circulation with hemorrhage control and perfusion support. In older adults, reduced physiologic reserve and atypical shock signs make early airway/oxygenation and prompt circulation management especially critical. Neurologic assessment (disability) is performed after ABCs are secured because it is rarely the first correctable cause of imminent death in trauma.
Category reason: This question tests emergency prioritization during trauma care, focusing on immediate nursing actions to stabilize life-threatening conditions, which aligns with emergency response planning and safety.

Question 28

A parent calls you and frantically reports that her child has gotten into her famous ferrous sulfate pills and ingested a number of these pills. Her child is now vomiting, has bloody diarrhea, and is complaining of abdominal pain. You will tell the mother to?

Accepted Answer

Answer reason: A. Call emergency medical services (EMS) and get the child to the emergency room Iron overdose in children can rapidly cause severe GI hemorrhage, metabolic acidosis, shock, and later hepatic failure, so it is a time-critical emergency. The presence of vomiting, bloody diarrhea, and abdominal pain indicates significant toxicity and requires immediate ED evaluation and likely chelation/supportive care. Syrup of ipecac is no longer recommended due to poor benefit and risk of aspiration/delayed definitive care. Poison control can be contacted, but the safest priority with severe symptoms is immediate transport via EMS for urgent treatment.
Category reason: This question tests urgent nursing triage and safety actions in a poisoning emergency (what the nurse should instruct a caregiver to do immediately), which aligns with emergency response planning in the Safety and Infection Control category.

Question 29

A mother reports her 3-year-old child ingested half a bottle of iron tablets. What is the nurse's first action?

Accepted Answer

Answer reason: Iron overdose in young children is a life-threatening poisoning that requires immediate expert guidance and rapid escalation of care. Poison control provides time-critical, evidence-based instructions (e.g., need for emergency evaluation, decontamination choices, and antidotal therapy such as deferoxamine) based on dose and symptoms. Activated charcoal does not reliably bind iron, inducing vomiting is unsafe and not recommended, and giving oral fluids can delay definitive management and does not address systemic toxicity.
Category reason: This item tests the nurse’s immediate response to a pediatric poisoning emergency, emphasizing rapid, safe triage and appropriate use of emergency resources.

Question 30

A nurse observes an umbilical cord prolapse. What is the most appropriate nursing action?

Accepted Answer

Answer reason: B) Place the client in knee-chest or Trendelenburg position This obstetric emergency requires immediate actions that relieve pressure on the cord to preserve fetal oxygenation. Maternal positioning with knee-chest or Trendelenburg uses gravity to reduce cord compression while preparations are made for urgent delivery and continuous fetal monitoring. Attempting to push the cord back can cause vasospasm and further compromise perfusion, while bearing down or fundal pressure increases compression and worsens hypoxia.
Category reason: This question tests urgent nursing interventions and safety actions during an obstetric emergency to prevent fetal compromise, fitting NCLEX patient-care emergency response decision-making.

Question 31

A patient with a prolapsed umbilical cord during labor should be placed in?

Accepted Answer

Answer reason: These positions use gravity to shift the presenting fetal part away from the prolapsed cord, reducing cord compression and improving fetal oxygenation while definitive management is arranged. Immediate relief of pressure on the cord is the key priority because ongoing compression can quickly cause fetal hypoxia and bradycardia. Supine, lithotomy, and High Fowler’s can worsen compression by increasing pressure of the presenting part on the cord.
Category reason: This is an obstetric emergency requiring immediate nursing intervention and positioning to prevent fetal compromise, aligning with NCLEX safety/emergency response decision-making.

Question 32

A nurse finds one of her clients unresponsive in his room. He is not breathing and does not have a pulse. After calling for help, what is the next action of the nurse?

Accepted Answer

Answer reason: High-quality CPR prioritizes circulation when an adult is unresponsive, apneic, and pulseless, because immediate perfusion of the brain and myocardium is time-critical. After activating the emergency response system, the nurse should start compressions right away at the recommended depth and rate with minimal interruptions. Opening the airway and giving breaths are performed after compressions are initiated, and ventilations should not delay compressions. Airway maneuvers such as head-tilt–chin-lift or jaw thrust are adjuncts and are secondary to initiating compressions in pulseless arrest.

Question 33

A nurse is working on a busy medical surgical unit when a fire breaks out in the trash can in a patient's room. What is her priority nursing action?

Accepted Answer

Answer reason: In a fire situation, the nurse follows RACE, prioritizing immediate life safety before equipment retrieval. The first priority is rescue—moving the patient to a safe location to prevent smoke inhalation, burns, and panic-related injury. After the patient is safe, the nurse should activate the alarm and then contain/extinguish the fire as appropriate. Retrieving an extinguisher or focusing on containment before rescuing the patient delays the most time-critical action: protecting human life.

Question 34

Depth of chest compression in adult CPR is ?

Accepted Answer

Answer reason: Current CPR guidance targets a depth of about 5–6 cm (at least 2 inches) in adults, balancing effective perfusion with avoidance of excessive injury. Among the options, 5 cm best matches this evidence-based target depth. Shallower depths such as 2.5–4 cm are generally inadequate for effective perfusion in adults and are associated with worse outcomes.

Question 35

The ratio of cardiac compression and artificial breathing is?

Accepted Answer

Answer reason: Current basic life support guidance for a single rescuer (and also for two-rescuer adult CPR) uses 30 compressions followed by 2 breaths to balance perfusion and oxygenation. This ratio helps maintain coronary and cerebral blood flow while still providing adequate ventilation. Ratios like 15:2 are used in pediatric two-rescuer CPR rather than routine adult CPR, making them common distractors in mixed-age questions.

Question 36

Scheduled fire drills should be performed?

Accepted Answer

Answer reason: Quarterly drills are a widely used minimum standard in many healthcare and residential care settings to ensure all shifts and new staff participate and to identify system gaps (alarms, evacuation routes, roles). Weekly drills are impractical and not typically required, while annual or twice-yearly drills risk skill decay and poorer readiness. More frequent drills may be mandated by local regulations, but among these choices quarterly best matches expected facility safety standards.

Question 37

A nurse has just performed an amniotomy on a client in labor. Which of the following is the priority action?

Accepted Answer

Answer reason: Amniotomy can suddenly release fluid and reduce the buffering effect around the umbilical cord, increasing the risk that the cord slips past the presenting part, especially if the fetal head is not well engaged. Cord prolapse is an obstetric emergency because cord compression can rapidly cause fetal hypoxia and bradycardia. The nurse’s first priority is to promptly identify this complication by assessing for cord prolapse immediately after membrane rupture (often via evaluation when there is concern and rapid recognition of risk). Continuous fetal heart monitoring is important, but it detects compromise after it occurs rather than directly addressing the highest-risk immediate complication.

Question 38

What is to be addressed first in a case of Polytrauma?

Accepted Answer

Answer reason: Ensuring a patent airway enables effective ventilation and oxygenation before other interventions can be meaningful. Circulation and blood pressure assessment/treatment are prioritized immediately after airway and breathing, but hemorrhage control is secondary if the patient cannot oxygenate. Neurologic assessment (disability) is performed after stabilizing airway/breathing/circulation because it is less immediately reversible than airway compromise.

Question 39

The fire alarm is ringing at a 50-bed nursing facility. Arrange the following actions by the nurse in the appropriate order from MOST important to LEAST important. You must use all options.?

Accepted Answer

Answer reason: A ringing alarm indicates activation, but the nurse must ensure the alarm/notification system is engaged so the facility response (fire department and internal team) mobilizes immediately. After alerting, the priority is to rescue residents in immediate danger by moving them away from the fire, then contain smoke and flames by closing fire doors, and finally account for all residents once immediate life threats are addressed. Listing/resident location is essential for accountability but is not the first action when clients may be in immediate danger and the response system must be activated.

Question 40

A second-year nursing student has just suffered a needlestick while working with a patient that is positive for AIDS. Which of the following is the most significant action that nursing student should take?

Accepted Answer

Answer reason: The core principle is that occupational exposure to potentially HIV-infected blood requires immediate post-exposure prophylaxis to reduce the risk of seroconversion, with greatest benefit when started as soon as possible. This option directly addresses the time-critical intervention after a needlestick from a known HIV-positive source, aligning with standard exposure management priorities. Pentamidine is used for Pneumocystis jirovecii pneumonia prophylaxis/treatment in immunocompromised patients and does not prevent HIV acquisition after exposure. Counseling and seeing a social worker may be appropriate supportive steps, but they are not as urgent or risk-reducing as initiating antiretroviral PEP promptly.

Question 41

A girl is unconscious, she is heavily dressed and her skin is reddish, dry and hot, what should you do?

Accepted Answer

Answer reason: This presentation suggests heat stroke (hot, dry, flushed skin with altered level of consciousness), which is a life-threatening emergency requiring immediate activation of EMS and rapid cooling. Initial response follows basic life support: assess breathing and pulse to determine if CPR is needed, while simultaneously calling 911. Removing the person from the heat source and loosening/remove excess clothing reduces ongoing heat exposure, and aggressive cooling is the key time-sensitive intervention to prevent organ damage. Option A is incomplete because it assumes CPR without first confirming absence of breathing/pulse and omits cooling measures.

Question 42

A nurse is caring for a group of clients in the psychiatric unit. Which of the following clients should the nurse implement seizure precautions?

Accepted Answer

Answer reason: Alcohol withdrawal can cause CNS hyperexcitability that progresses from tremors and autonomic instability to seizures and delirium tremens, making seizure risk a key immediate safety concern. Seizure precautions (e.g., padded side rails, airway/oxygen and suction readiness, close monitoring) directly mitigate injury and support rapid response if a seizure occurs. In contrast, opioid withdrawal is typically intensely uncomfortable but is not classically associated with life-threatening seizures. Stimulant and cannabis withdrawal more commonly cause mood, sleep, and appetite changes rather than a high acute seizure risk.

Question 43

The order to perform CPR as per American Heart Association is?

Accepted Answer

Answer reason: Airway opening and rescue breaths are performed after compressions are started, minimizing delays in circulation support. This sequencing improves likelihood of return of spontaneous circulation compared with older ABC sequencing. A common distractor is starting with airway/breathing, which can waste precious seconds before circulation is supported.

Question 44

Which would be the first step when a patient passes out at the front desk?

Accepted Answer

Answer reason: The core principle is to assess responsiveness first in an unresponsive or collapsed person to determine the need for emergency activation and resuscitation. A quick verbal and gentle physical stimulus establishes whether the person is truly unresponsive, which then guides the next actions (activate emergency response and assess breathing/pulse per protocol). Starting CPR without confirming unresponsiveness and cardiopulmonary arrest risks inappropriate compressions on a patient who may simply be syncopal. Calling 911 is crucial, but it follows immediate assessment so the urgency and resources needed are correctly determined.

Question 45

While working in the emergency department, a fire breaks out in the waiting room. The charge nurse tells you to get the fire extinguisher. Place the following steps in order for correctly using the fire extinguisher.

Accepted Answer

Answer reason: Removing the safety pin unlocks the handle mechanism so the extinguisher can discharge. After that, the nozzle should be aimed at the base of the flames, the handle squeezed to release the agent, and the stream swept side-to-side to cover the burning area. Starting with aiming or squeezing before releasing the pin would delay discharge and increase risk in an emergent fire situation.

Question 46

What immediate nursing intervention will you take in case of blood reaction?

Accepted Answer

Answer reason: Stopping the transfusion prevents further exposure while vital-sign monitoring detects early hemodynamic instability (fever, hypotension, tachycardia, respiratory distress) that may require emergent escalation. Notification of the provider and blood bank are essential next steps, but they occur after the immediate safety actions to prevent clinical deterioration. Monitoring alone without stopping the infusion can worsen a hemolytic or anaphylactic reaction by continuing antigen exposure.

Question 47

The nurse notices smoke coming from under the door of the clean linen room. Which of the following is the primary action of the nurse?

Accepted Answer

Answer reason: Getting help triggers the facility’s fire response (alarm/pull station, rapid notification, and additional staff) so evacuation and containment can be coordinated safely. Attempting to extinguish a potentially growing fire without backup delays alarm activation and increases risk to patients and staff. Closing all doors on the entire unit is not the first step; containment actions are done after initiating the emergency response and removing those in immediate danger.

Question 48

A nurse enters a client's room and finds the trash can on fire. The nurse immediately assists the client out of the room. What should the next nursing action be?

Accepted Answer

Answer reason: Activating the alarm promptly initiates the facility’s emergency response, summons the fire response team, and ensures rapid building-wide notification and escalation if needed. Closing the door is important but comes after the alarm step to avoid delaying mobilization of help and safety systems. Attempting to extinguish a fire before alarming others risks delay, exposure to smoke, and being trapped if the fire spreads.

Question 49

A male patient has a sucking stab wound to the chest. Which action should the nurse take first?

Accepted Answer

Answer reason: The immediate priority is to seal the chest wall defect with an occlusive dressing taped on three sides to create a flutter-valve effect that limits air entry while allowing trapped air to escape. This is an urgent airway/breathing intervention that can stabilize the patient before definitive management. Starting an IV, drawing labs, or preparing equipment are important but do not correct the immediate cause of respiratory compromise.

Question 50

A client diagnoses with stable angina secondary to ischemic heart disease has a prescription for sublingual (SL) nitroglycerin (NTG). The nurse should tell a client to follow which instructions if chest pain is not relieved after taking 3 NTG tablets 5 min apart?

Accepted Answer

Answer reason: Chewing aspirin provides early antiplatelet effect by inhibiting platelet aggregation, reducing thrombus propagation during suspected myocardial infarction. Driving to the ED is unsafe because symptoms can worsen suddenly and EMS can initiate monitoring and treatment en route. Calling the primary provider or taking additional nitroglycerin delays definitive care and increases risk of myocardial damage.

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