Question 1

A client with MG is preparing for discharge. What instructions that needs to be included in the education of the client's family members?

Accepted Answer

Answer reason:  Myasthenia gravis can cause fluctuating skeletal muscle weakness that may involve bulbar and respiratory muscles, creating risk for sudden respiratory failure (myasthenic crisis). Family members should be prepared to respond immediately to apnea or cardiac arrest while emergency services are activated, making basic life support training a key discharge teaching point. Preparing thin/pureed foods is unsafe because thin liquids increase aspiration risk when swallowing muscles are weak, so that option is a distractor. Massage of lower extremities does not address the primary life-threatening complication, and IV pump administration is not a typical family-managed discharge skill for MG.

Question 2

A hurricane is coming, and nurses have been activated to open a shelter. What items should the public be encouraged to bring to the shelter?

Accepted Answer

Answer reason: Bringing prescription meds and documentation (e.g., medication list, allergies, diagnoses, provider contacts) allows safe administration, reduces medication errors, and supports triage for chronic conditions. Shelters typically cannot reliably supply individualized prescriptions on arrival, so lacking these items increases risk for acute decompensation. In contrast, nonessential electronics are impractical in crowded shelters with limited power and can create safety/security issues.

Question 3

When parents call the emergency room to report that a toddler has swallowed drain cleaner, the nurse instructs them to call for emergency transport to the hospital. While waiting for an ambulance, the nurse would suggest for the parents to give sips of which substance?

Accepted Answer

Answer reason: Small sips of a neutral diluent can help reduce concentration of the caustic agent in the mouth/esophagus while awaiting EMS, without attempting to neutralize the chemical. Milk is sometimes suggested in some references, but it is not clearly superior to water and may increase vomiting risk in some children, which would re-expose mucosa. Tea and soda provide no benefit; soda’s carbonation can promote gastric distention and emesis, increasing aspiration and additional esophageal injury.

Question 4

The nurse is caring for an acutely ill 10 year-old client. Which of the following assessments would require the nurses immediate attention?

Accepted Answer

Answer reason:  Airway and breathing problems are the highest priority because they can rapidly lead to hypoxia, respiratory arrest, and cardiac arrest. Slow, irregular respirations suggest impending respiratory failure or central nervous system depression and require immediate assessment and intervention (positioning, oxygen/ventilation support, rapid response). In contrast, fever at 38.5°C and diaphoresis can reflect infection or stress but are not as immediately life-threatening as ineffective ventilation. A rapid bounding pulse may occur with fever or early shock, but without compromised respirations it is typically addressed after stabilizing breathing.

Question 5

The nurse has identified what appears to be ventricular tachycardia on the cardiac monitor of a client being evaluated for possible myocardial infarction. The first action the nurse would perform is to?

Accepted Answer

Answer reason: The immediate priority is an ABC assessment to determine responsiveness, presence of a pulse, adequacy of breathing, and hemodynamic stability, because management differs for pulseless versus perfusing VT. If the patient is pulseless, the next steps are high-quality CPR and defibrillation; if there is a pulse but instability, synchronized cardioversion is indicated. Activating a code team or preparing equipment may be necessary, but it should follow the rapid bedside assessment that determines the correct emergency pathway.

Question 6

An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to?

Accepted Answer

Answer reason: After confirming unresponsiveness and activating the emergency response system, the nurse should rapidly assess breathing and a central pulse (carotid) for no more than 10 seconds. Absence of a pulse indicates the need to begin chest compressions and proceed with CPR steps. Abdominal thrusts are for a conscious choking victim, and rescue breaths/airway opening are not prioritized over confirming pulselessness in an unresponsive adult once help is activated.

Question 7

An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next?

Accepted Answer

Answer reason: Remaining with the client allows rapid recognition of compromised breathing, excessive secretions/vomiting, or cyanosis so timely positioning and emergency support can be initiated. Padding side rails is a preventive measure but is secondary once the seizure has already started and the client is unconscious. Inserting an oral airway or suctioning during active convulsions risks oral trauma and aspiration; cardiac arrest should not be assumed without an assessment of breathing and pulse.

Question 8

A woman who delivered 5 days ago and had been diagnosed with preeclampsia calls the hospital triage nurse hotline to ask for advice. She states "I have had the worst headache for the past 2 days. It pounds and by the middle of the afternoon everything I look at looks wavy. Nothing I have taken helps." What should the nurse do next?

Accepted Answer

Answer reason: Severe postpartum headache with visual disturbances in a client with recent preeclampsia signals possible hypertensive emergency with imminent risk of eclampsia or stroke. The safest nursing action is immediate emergency activation while maintaining phone contact to assess for worsening symptoms (eg, seizure activity) and ensure she is not left alone. Sending EMS provides rapid assessment, blood pressure management, seizure precautions, and expedited transport, which is more appropriate than advising self-transport. Options suggesting reassurance, delayed follow-up, or further medication-history questioning fail to address the time-critical neurologic red flags and maternal safety risk.

Question 9

The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs 2 hours ago. The nurse should?

Accepted Answer

Answer reason: g., concussion, subdural/epidural bleed) requiring urgent assessment and imaging. In the home setting, the safest action is rapid escalation to emergency evaluation because neurologic deterioration can be rapid and time-sensitive. Calling the provider introduces delay when the priority is immediate emergency assessment and stabilization. Reassurance or “call if worse” is unsafe because the client is already demonstrating abnormal neurologic findings that meet criteria for emergent care.

Question 10

The nurse is caring for a client who had a total hip replacement 4 days ago. Which assessment requires the nurse's immediate attention?

Accepted Answer

Answer reason: Acute, new-onset dyspnea in a post–hip replacement client is a potential life-threatening emergency, most concerning for pulmonary embolism from postoperative venous thromboembolism. This requires immediate assessment of airway/breathing, vital signs and oxygenation, rapid provider notification/rapid response activation as indicated, and urgent interventions (e.g., oxygen) while preparing for diagnostic workup. The other findings are important but not as immediately life-threatening: urinary frequency may reflect irritation/retention issues, inadequate analgesia needs reassessment, and muscle spasms can occur postoperatively without indicating imminent cardiopulmonary collapse. Prioritization follows ABCs and recognition of high-risk postoperative complications.

Question 11

The nurse is caring for a patient with a coronary thrombosis who is receiving prescribed streptokinase (striptease). The patient reports the onset of a rash as well as feeling hot while experiencing chills. The nurse should IMMEDIATELY implemented the plan of care for?

Accepted Answer

Answer reason: New rash with chills and a feeling of being hot during infusion is most consistent with an infusion-related allergic reaction that requires immediate nursing response (stop infusion, assess airway/breathing/circulation, notify provider, and prepare to treat anaphylaxis). This presentation is not typical for pulmonary embolus, which would more likely cause acute dyspnea, pleuritic chest pain, tachycardia, and hypoxemia. It is also not consistent with peripheral arterial occlusion, which would present with pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia in an extremity.

Question 12

The clinic nurse is preparing to administer an allergy immunotherapy injection to a client recently initiated on the therapy. Which statement by the client indicates a need for further teaching?

Accepted Answer

Answer reason: " Allergen immunotherapy carries a risk of immediate systemic reactions, including anaphylaxis, most likely occurring shortly after injection. Therefore, clients must remain in the clinic for an observation period (commonly about 30 minutes) after every injection, regardless of prior tolerance. Leaving immediately eliminates access to rapid assessment and emergency treatment such as epinephrine and airway support if a reaction develops. In contrast, mild local redness can be expected, and reporting generalized hives later is appropriate because delayed systemic symptoms can occur.

Question 13

The normal rate of chest compressions in minute for adult in CPR .........

Accepted Answer

Answer reason: Rates slower than this tend to generate insufficient forward blood flow, reducing the likelihood of return of spontaneous circulation. Rates faster than this often lead to shallow compressions and incomplete recoil, which decreases venous return and lowers perfusion pressures. Current BLS guidelines therefore specify this target range as the standard for adult chest compressions.

Question 14

When caring for an infant during cardiac arrest, which pulse must be palpated to determine cardiac function?

Accepted Answer

Answer reason: The carotid pulse is harder to locate in infants due to short neck anatomy and can be less practical during rapid assessment. Radial and pedal pulses are more likely to be absent early in shock or low-flow states, increasing the risk of delayed CPR initiation. Rapid, accurate pulse assessment supports timely recognition of pulselessness and activation of resuscitation measures.

Question 15

The nurse plans to teach effective CPR. Which of the ff is the best indication of effective CPR on an adult client?

Accepted Answer

Answer reason: Effective CPR is best indicated by evidence that chest compressions are generating forward blood flow and perfusing vital organs. A palpable central pulse synchronous with compressions reflects adequate intrathoracic pressure changes and stroke volume from compressions. Chest rise only confirms ventilation effectiveness, not circulation, and skin color/temperature changes are delayed and unreliable during resuscitation. An organized rhythm on the monitor during compressions can represent electrical activity without adequate mechanical output, so it is not the best indicator of effective compressions.

Question 16

You come upon an unconscious victim with a palpable pulse he does not appear to be breathing. And you are unable to deliver the first breath .. what is the next step...????

Accepted Answer

Answer reason: When an unresponsive victim has a pulse but is not breathing, the priority is to open the airway and provide rescue breaths rather than chest compressions. Inability to deliver an initial breath most commonly indicates inadequate airway positioning or an obstructed airway, so the immediate corrective action is to re-open the airway with proper head-tilt/chin-lift and attempt ventilation again. If breaths still do not go in, the algorithm then shifts to treating as suspected foreign-body airway obstruction with cycles of compressions and airway checks, not blind abdominal thrusts. Starting CPR immediately is reserved for pulselessness or persistent inability to ventilate after appropriate airway maneuvers per BLS sequence.

Question 17

A client is being brought into the emergency department after suffering a head injury. The first action by the nurse is to determine the client's?

Accepted Answer

Answer reason: After a head injury, hypoventilation or irregular breathing can rapidly cause hypoxia and hypercapnia, which worsen secondary brain injury by increasing intracranial pressure. Assessing rate and depth quickly identifies impending respiratory failure and the need for airway interventions or assisted ventilation. Level of consciousness and motor function are critical neurologic checks, but they come after immediate stabilization of breathing. Pulse and blood pressure are important for perfusion assessment, yet they do not prevent the immediate threat of hypoxia.

Question 18

The nurse caring for a client who has just sustained a chemical splash to the eye. Which of the following actions should the nurse take first?

Accepted Answer

Answer reason: Immediate copious irrigation is the priority intervention after ocular chemical exposure because it rapidly dilutes and removes the caustic agent, limiting ongoing tissue destruction and preventing deeper corneal injury. This action is time-critical and should begin at once using readily available water if sterile solutions are not immediately accessible. Assessments such as visual acuity and consultations can follow once decontamination is underway, because delaying irrigation worsens outcomes. Occlusive patching is inappropriate initially because it can trap the chemical against ocular tissues and delay continued flushing.

Question 19

The nurse observes a fire in a client's room. The nurse should take which initial action?

Accepted Answer

Answer reason: Removing the client from immediate danger prevents rapid smoke inhalation and burn injury, which can be fatal within minutes. After the client is safe, the nurse activates the alarm to mobilize the facility response and initiate evacuation procedures. Attempting to extinguish the fire or smother it first is inappropriate because it delays getting the client out of harm’s way and may expose the nurse to avoidable risk.

Question 20

The nurse is caring for a 1-month-old infant suspected of having cardiac arrest. Which pulse should the nurse palpate for assessment?

Accepted Answer

Answer reason: In infants (

Question 21

While doing CPR the compression ventilation ratio in an adult should be?

Accepted Answer

Answer reason: Current CPR guidance for a single rescuer in adults uses 30 compressions followed by 2 rescue breaths to minimize interruptions in compressions. This ratio balances oxygen delivery with the need to keep perfusion pressures up by limiting pauses. Ratios like 15:2 are used in specific pediatric/two-rescuer contexts and would lead to more frequent compression interruptions in adult CPR.

Question 22

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take?

Accepted Answer

Answer reason: Providing supplemental oxygen is an appropriate immediate nursing action while also positioning the client to protect the airway and preparing for suctioning as needed. Restraining the client can cause musculoskeletal injury and does not prevent seizure-related harm. Placing any object in the mouth risks dental injury and aspiration, and IV pain medication does not address the acute physiologic risk during a seizure.

Question 23

A nurse is working in a residential facility when a fire breaks out in one hallway. The nurse and an elderly client are trapped in the client's room and cannot get out.The nurse should..?

Accepted Answer

Answer reason: In a fire, the priority is to minimize exposure to smoke/heat and create a barrier between the patient and the fire environment while awaiting rescue. Closing a door helps confine smoke and flames and reduces the amount of toxic smoke entering the immediate area; moving into a smaller enclosed space can further limit smoke infiltration if the main room is becoming compromised. Opening a window can draw smoke into the room by changing airflow and may worsen smoke exposure. Leaving the door open increases smoke and heat entry, rapidly making the room untenable. Hiding under a bed does not provide respiratory protection and may delay rescue while smoke continues to accumulate.

Question 24

Which best describes the length of time it should take to perform a pulse check during the BLS assessment?

Accepted Answer

Answer reason: A pulse check should be brief to avoid delaying chest compressions in a pulseless patient and to reduce the risk of prolonged, inaccurate assessment during high-stress emergencies. The recommended window is no more than 10 seconds, balancing speed with enough time to detect a pulse if present. Longer time ranges would unnecessarily delay life-saving compressions, while very short checks increase the chance of missing a weak pulse.

Question 25

A nurse is caring for a male client who is experiencing a potential cocaine overdose presented to the emergency department with increased heart rate, high blood pressure, and chest pain. Which of the following actions will the nurse take first?

Accepted Answer

Answer reason: Airway, breathing, and circulation guide first actions in any unstable patient, and chest pain with stimulant toxicity raises concern for myocardial ischemia and hypoxemia. Providing oxygen is a rapid, low-risk intervention that improves myocardial oxygen delivery while further assessment and definitive therapies are initiated. A 12-lead ECG is essential but is diagnostic rather than immediately supportive and should follow initial stabilization measures. IV access is important for medication delivery, but it does not immediately improve oxygenation, and indiscriminate antihypertensive use (especially beta-blockers) can worsen cocaine-associated vasospasm and hypertension.

Question 26

A nurse is in the emergency department seeing patients. Which of the following patients is most concerning?

Accepted Answer

Answer reason: ACE inhibitors can cause angioedema, which may rapidly progress to upper-airway obstruction and is a time-critical emergency. Tongue swelling is a red-flag sign requiring immediate airway assessment, stopping the offending medication, and urgent escalation for potential epinephrine/advanced airway support. By contrast, asymptomatic severe hypertension is concerning but is typically managed as hypertensive urgency without immediate airway threat unless end-organ damage is present. Limb injuries like a broken fibula or a forearm stab wound may require prompt evaluation, but they do not inherently signal imminent airway compromise the way angioedema does.

Question 27

The nurse is caring for the following assigned clients. The nurse should initially follow-up with the client who?

Accepted Answer

Answer reason: Safety is the immediate priority in a behavioral health setting, and escalating agitation with loud, hostile behavior can quickly progress to violence. This client’s behavior indicates loss of control and poses an imminent risk to other clients and staff, requiring prompt de-escalation, limit setting, and possible need for additional support/security. Repeated handwashing and interrupting in group are problematic but are typically non-urgent unless they impair basic functioning or safety. A voluntarily admitted client requesting discharge is an important legal/administrative issue, but it is not as time-critical as addressing potential imminent harm.

Question 28

A patient is in cardiac arrest with a shockable rhythm. What is the next step after delivering a shock?

Accepted Answer

Answer reason: Pulse or rhythm checks are deferred until after about 2 minutes of CPR to minimize interruptions in compressions. Epinephrine is part of the algorithm but is given during CPR cycles (typically after the second shock) rather than as the immediate next step post-shock. Repeating a shock immediately without a CPR interval increases hands-off time and worsens outcomes.

Question 29

A nurse in the psychiatric unit is caring for a client with schizophrenia who was involuntarily admitted for threatening others with a weapon. The client suddenly throws a chair at another client and then refuses to go to a quiet room or to take any prescribed medications. Which of the following actions should the nurse take next?

Accepted Answer

Answer reason: Immediate safety takes priority when a patient is actively violent and has already harmed/threatened others. Removing the client with adequate staff support reduces risk of injury to other clients and staff and allows initiation of a safer containment plan (e.g., seclusion/restraints per protocol and provider order if required). Verbal de-escalation is appropriate early, but after a chair is thrown and the client refuses redirection/medications, the situation has escalated beyond reliance on conversation alone. One-to-one observation is a longer-term control measure and does not immediately stop ongoing danger in the moment.

Question 30

A nurse is providing emergency care to a patient with a head injury. What is the priority action for the nurse?

Accepted Answer

Answer reason: Manual in-line stabilization and cervical immobilization should be initiated immediately before repositioning or performing other assessments that could move the neck. Vital signs and neurologic checks are important but are performed after spinal precautions are in place to avoid worsening a potential cord injury. Looking for ear canal fluid suggests basilar skull fracture, but it is not the first action in the initial emergency response.

Question 31

A nurse suspects an infant may have a tracheoesophageal fistula or esophageal atresia. What is the most important intervention by the nurse?

Accepted Answer

Answer reason: Airway and breathing take priority in any suspected congenital airway–GI connection because feeds and secretions can be aspirated into the trachea, rapidly causing hypoxia and respiratory distress. Immediate oxygen supports oxygenation while the infant is stabilized and further interventions are arranged. Notifying the provider is necessary, but it follows immediate stabilization measures when the infant is at risk for compromised gas exchange. Providing warmth and parent communication are supportive actions but do not address the most life-threatening risk first.

Question 32

When a child has been poisoned, it is important for the nurse to identify the ingested poison. What is the most appropriate intervention to identify the poison?

Accepted Answer

Answer reason: Accurate identification in pediatric poisoning is best achieved by preserving the actual substance/container so ingredients, concentration, and quantity can be verified rapidly and reliably. Children and parents may give incomplete or incorrect histories due to fear, stress, or limited recall, which can delay appropriate antidote or decontamination decisions. Retaining bottles, labels, blister packs, plant material, or vomitus enables definitive product identification and supports poison control/toxicology recommendations. Contacting poison control is essential for management guidance, but preserving the evidence is the most direct intervention to identify the specific agent involved.

Question 33

What is the most important information for a nurse to tell parents if their child ingests a poison?

Accepted Answer

Answer reason: Immediate poison management depends on the specific substance, dose, and time since ingestion, so parents need expert, real-time guidance tailored to the exposure. Poison control can rapidly determine the risk, provide first-aid instructions (including what not to do), and advise whether home observation is safe or urgent EMS/ED evaluation is needed. Inducing vomiting is no longer routinely recommended because it can worsen outcomes (e.g., aspiration, caustic re-exposure). Automatically going to the ED or simply watching at home may delay the correct, exposure-specific intervention.

Question 34

When giving rescue breathing to an infant under age 1 year, what is the ratio of breaths per second?

Accepted Answer

Answer reason: For an infant (

Question 35

The nurse realizes that a fire has started in the client’s room. Which action should be taken by the nurse first?

Accepted Answer

Answer reason: The core priority in a fire is immediate life safety using the RACE sequence (Rescue, Alarm, Contain, Extinguish/Evacuate). The first nursing action is to rescue anyone in immediate danger by moving the client out of the room to a safe area, reducing exposure to smoke inhalation and burns. Activating the alarm and notifying the operator are essential but occur after the person at risk has been removed from direct danger when the fire is in the client’s room. Attempting to smother the fire first can delay rescue and can be unsafe if the fire grows or produces toxic smoke.

Question 36

A 2-year-old child is found on the floor next to his toy chest. After first determining unresponsiveness and calling for help, which step should be taken next?

Accepted Answer

Answer reason: Pediatric basic life support follows an ABC-focused initial sequence once unresponsiveness is confirmed and help is activated. The next priority is to ensure a patent airway with head-tilt–chin-lift (or jaw-thrust if trauma is suspected), because ventilation is often the key problem in children. You cannot deliver effective rescue breaths until the airway is opened, and delaying airway positioning can worsen hypoxia. Pulse check and compressions are performed after airway and breathing assessment, with compressions indicated only if there is no pulse or a very low pulse with poor perfusion.

Question 37

The nurse applies AED pads to the client’s chest, and a shock is advised. What should be the nurse’s next action?

Accepted Answer

Answer reason: Defibrillation safety requires ensuring no one is in contact with the patient during shock delivery to prevent bystander injury and avoid motion artifact that can interfere with rhythm assessment. After the AED advises a shock, the immediate priority is to verbally and visually confirm “clear” before pressing the shock button. Pushing the button without clearing the patient creates an avoidable electrical hazard. The AED does not always auto-shock; many units require the rescuer to initiate shock after confirming the area is clear.

Question 38

A client admitted with angina complains of severe chest pain and suddenly becomes unresponsive. After establishing unresponsiveness, which action should the nurse take first?

Accepted Answer

Answer reason: After confirming unresponsiveness, the priority is immediate activation of the emergency response system so additional skilled help and a defibrillator arrive without delay. Early team activation improves survival in sudden cardiac arrest and allows simultaneous tasks (CPR, rhythm assessment, airway management) to occur. Airway and breathing checks are important, but they can be initiated immediately after calling for help, and delaying activation risks prolonged time to defibrillation. In an angina patient with sudden collapse, a lethal dysrhythmia is likely, making rapid emergency response critical.

Question 39

The ED charge nurse is informed that an unknown number of clients were exposed to a nerve agent during a terrorist attack. Which medication should the nurse prepare to have readily available in sufficient quantities to treat the clients?

Accepted Answer

Answer reason: The immediate antidotal priority is to block muscarinic effects to dry secretions and improve ventilation, which is achieved with atropine and often requires large, repeated dosing in mass exposure. The other options treat different toxidromes (e.g., beta-blocker for hypertension, vasopressor for shock, alpha-blocker for catecholamine excess) and do not reverse cholinergic crisis. Stocking adequate atropine supports rapid, protocol-driven disaster response for multiple symptomatic victims.

Question 40

The nurse is attempting to relieve a foreign body air- way obstruction from an infant. The infant suddenly becomes. unresponsive. Which action should the nurse perform next?

Accepted Answer

Answer reason: An unresponsive choking infant should be managed using the BLS algorithm for unresponsive choking, which starts with CPR. Chest compressions generate intrathoracic pressure and can help dislodge the foreign body while maintaining circulation, and they allow periodic airway checks for a visible object between compression cycles. Back blows are used for responsive infants with severe obstruction, not after the infant becomes unresponsive. Rescue breathing alone is not appropriate because ventilations may not go in when the airway is obstructed, and compressions are needed to attempt relief and provide perfusion while help is activated.

Question 41

A staff nurse at the nurses’ station answers the phone and is told there is a bomb in a client’s room. What action should the nurse take at this time?

Accepted Answer

Answer reason: In a bomb-threat call, the immediate priority is to keep the caller on the line and gather actionable information that can guide rapid risk reduction and law-enforcement response (location, time of detonation, description of device, motive). Asking focused questions can improve the specificity of the threat assessment and supports safer evacuation/search procedures. Placing the caller on hold or transferring the call risks losing the caller and forfeiting critical details needed for an effective emergency response. Notifying others (e.g., charge nurse/security) is important, but it should occur while maintaining the call whenever possible (e.g., via discreet signaling) rather than ending the opportunity to collect information.

Question 42

A child has ingested a poisonous substance. What is the priority intervention?

Accepted Answer

Answer reason: Immediate poisoning first aid prioritizes stopping further exposure while maintaining airway safety. Removing any residual substance from the mouth prevents continued absorption and reduces aspiration risk if the child vomits spontaneously. Inducing vomiting is no longer recommended because it can worsen esophageal injury and increase aspiration, especially with caustics or hydrocarbons. Giving large amounts of water can be harmful (vomiting/aspiration risk) and is not a universal antidote; emergency services/poison control should be contacted after the immediate hazard is removed and the child’s breathing is ensured.

Question 43

The nurse arrives at a local park to find a group of people surrounding a pediatric victim who collapsed just seconds ago. The child is not breathing and is without a pulse, so a witness calls for emergency assistance. Which compression-to-ventilation ratio should be used by the nurse when initiating single-rescuer CPR?

Accepted Answer

Answer reason: In a pulseless, apneic child, high-quality compressions with minimal interruptions are the priority until additional rescuers and an AED/EMS arrive. A 15:2 ratio is reserved for two-rescuer pediatric CPR because it increases ventilation frequency when one rescuer can maintain compressions while the other ventilates. Ratios like 30:1 or 15:1 are not recommended in current BLS guidelines for CPR with rescue breaths.

Question 44

Which advice should a nurse give over the telephone to the mother of a 7- year-old child with abdominal pain, a low-grade fever, and vomiting?

Accepted Answer

Answer reason: Abdominal pain with fever and vomiting in a child can indicate an acute surgical abdomen (e.g., appendicitis) and requires prompt in-person evaluation to prevent perforation and sepsis. Telephone advice should prioritize safety and rapid escalation when potentially life-threatening conditions cannot be ruled out remotely. Advising home measures like fluids may delay needed assessment, and suggesting caregiver-performed abdominal tests is inappropriate and unreliable. Immediate emergency evaluation allows timely physical exam, labs/imaging, and interventions if indicated.

Question 45

Resuscitation efforts have been provided for two minutes for the 4-month-old in cardiac arrest, and CPR is now paused. The cardiac monitor shows sinus tachycardia. What intervention should the nurse implement next?

Accepted Answer

Answer reason: After a 2-minute CPR cycle, rhythm is reassessed and, if an organized rhythm is present, the next priority is to determine whether there is a perfusing pulse to distinguish ROSC from ongoing pulseless arrest. In infants, the recommended pulse check site is the brachial artery, assessed quickly (within 10 seconds) to avoid prolonged interruptions in compressions. Sinus tachycardia is a non-shockable rhythm, so preparing to defibrillate is inappropriate unless a shockable rhythm (VF/pVT) is identified. If no pulse is found or it is

Question 46

The nurse sees the coworker assisting the obviously pregnant client who appears to be choking. The coworker’s fist and hand placement is appropriate. Which description best describes the coworker’s hand placement?

Accepted Answer

Answer reason: Proper chest-thrust hand placement is on the center of the chest over the lower half of the sternum, similar to the position used for compressions but delivered as sharp thrusts. Placing hands at or above the umbilicus or between the umbilicus and sternum describes abdominal thrust positioning, which is not recommended in late pregnancy. The sternal notch is too high and risks ineffective thrusts and potential airway/neck injury.

Question 47

The adult client reports to the nurse that he feels like he is choking. The client is coughing loudly, and his skin is acyanotic. What action should the nurse take next?

Accepted Answer

Answer reason: A loud, effective cough with normal skin color indicates a mild (partial) airway obstruction with adequate air exchange. In this situation, the priority is to encourage continued coughing and observe closely because the obstruction may clear spontaneously but can also rapidly worsen. Abdominal thrusts are reserved for severe obstruction (inability to cough/speak/breathe, silent cough, cyanosis), and initiating rescue breathing is inappropriate while the client is conscious and ventilating. Chest thrusts over the sternum describe CPR compressions and would be indicated only if the client becomes unresponsive and pulseless, not during an effective cough.

Question 48

A power outage occurs at a hospital, and a backup generator supplying power to a telemetry unit fails. After obtaining a flashlight, what is the nurse’s next best action?

Accepted Answer

Answer reason: Direct assessment determines who needs urgent interventions (e.g., airway, breathing, circulation support) and who requires immediate relocation to higher-acuity monitoring. Notifying the supervisor is important but should not delay identifying unstable patients when monitoring systems have failed. Delegation and obtaining oxygen supplies are subsequent actions guided by the findings of this urgent assessment.

Question 49

A male client is brought to the employee health clinic reporting some type of chemical was splashed in his eyes. Which action should the nurse implement first?

Accepted Answer

Answer reason: Immediate decontamination is the priority in ocular chemical exposure because ongoing contact rapidly causes corneal and conjunctival injury. Continuous irrigation dilutes and removes the chemical, limiting depth of penetration and preventing worsening burns while definitive evaluation is arranged. Assessing vision and completing documentation are important but must not delay irrigation. Transport to an ophthalmologist is appropriate after initial flushing and stabilization, since time-to-irrigation is the key outcome determinant.

Question 50

A client comes to the emergency department following a motor vehicle collision with questionable loss of consciousness. To quickly rule out a serious injury, the nurse should first?

Accepted Answer

Answer reason: Initial trauma care follows the ABCs to rapidly identify and treat immediately life-threatening problems. Airway obstruction or inadequate ventilation can cause rapid hypoxia and death, so these must be assessed and supported before secondary assessments. Circulation assessment addresses major hemorrhage and shock, which are also time-critical after a collision. Level of consciousness, vital signs, and focused cervical spine assessment are important but occur after stabilizing the most urgent threats to life.

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