Question 1

The nurse is caring for an unstable cardiac client and must be prepared for a possible cardiopulmonary emergency. What is the most important preparation the nurse should include?

Accepted Answer

Answer reason: In a potential cardiopulmonary emergency, the priority is immediate access to resuscitation equipment and medications to minimize time to defibrillation/airway management and improve survival. Knowing and ensuring rapid availability of the emergency cart supports a coordinated code response and enables prompt CPR, defibrillation, and advanced airway/IV interventions. Having oxygen or an oral airway available can be helpful, but these are narrower preparations and do not replace readiness for full resuscitation needs. Notifying family is important communication but does not address time-critical lifesaving actions.

Question 2

A 3-year-old child is brought to the emergency department not breathing, cyanotic, and lethargic. The mother states that she thinks he swallowed a penny. Which intervention should the nurse take first?

Accepted Answer

Answer reason: This presentation is consistent with severe foreign-body airway obstruction, where the priority is immediate relief of the obstruction to restore ventilation. For a child older than 1 year with ineffective cough or inability to breathe, thrusts are the first-line maneuver to expel the object. Oxygen is not effective until airflow is re-established, and delaying for oxygen can worsen hypoxia. Blind finger sweeps are contraindicated because they can push the object deeper and cause additional airway trauma, and back blows are primarily used for infants rather than a 3-year-old.

Question 3

The nurse is teaching rescue breathing to the daughter of an adult client. Which statement indicates that the client understands how to perform rescue breathing?

Accepted Answer

Answer reason:  Adult rescue breathing is performed at about 10–12 breaths per minute when the person has a pulse but is not breathing normally. Delivering one breath every 5–6 seconds matches this recommended ventilation rate and helps avoid hyperventilation and excessive intrathoracic pressure that can reduce venous return. Providing a breath every 3 seconds or 20 breaths per minute ventilates too rapidly and increases risk of gastric insufflation and poor perfusion. Waiting “every few minutes” is far too infrequent to maintain oxygenation and carbon dioxide clearance.

Question 4

A client at 36 weeks’ gestation chokes on her food while eating at a restaurant. Which statement is correct about performing the Heimlich maneuver on a pregnant client?

Accepted Answer

Answer reason: In late pregnancy, abdominal thrusts can injure the gravid uterus and reduce venous return, worsening maternal and fetal compromise. Chest thrusts are the recommended modification for a conscious choking pregnant client because they create airway pressure without compressing the abdomen. This provides effective relief of foreign-body airway obstruction while minimizing risk to the fetus. Options suggesting only back thrusts, no modification, or that the maneuver cannot be done are unsafe or incorrect because they delay effective airway clearance.

Question 5

A nurse is standing next to a person eating fried shrimp at a parade. Suddenly, the man clutches at his throat and is unable to speak, cough, or breathe. The nurse asks the man if he's choking, and he nods yes. What action should the nurse take next?

Accepted Answer

Answer reason: A conscious adult who cannot speak, cough, or breathe has a severe foreign-body airway obstruction requiring immediate abdominal thrusts. This intervention generates a rapid increase in intrathoracic pressure to expel the obstruction and restore airflow. Rescue breathing and head tilt–chin lift are for ventilation/airway opening when obstruction is not the primary issue or after loss of consciousness with airway management steps. Chest compressions are indicated if the victim becomes unresponsive (or if abdominal thrusts are not possible), not while the patient is conscious with classic severe choking signs.

Question 6

The community nurse is teaching disaster preparedness to community members. Which statement is most appropriate?

Accepted Answer

Answer reason:  Disaster preparedness teaching prioritizes essential resources needed to prevent dehydration and support basic hygiene when utilities are disrupted. This recommendation matches widely accepted emergency guidance for minimum household water storage (per person per day over several days). A 1-day food supply is inadequate for most disasters, and pets should be included in planning rather than assumed to self-sustain. Replacing stored water should follow the product’s expiration/rotation guidance rather than a blanket annual rule, making it less precise as the best teaching point.

Question 7

The nurse is supervising a basic life support class. Which action by the class participants would indicate the need for further instruction?

Accepted Answer

Answer reason: Performing chest compressions at a depth of 1.5 inches on the adult client High-quality adult CPR requires compressions that are deep enough to generate adequate coronary and cerebral perfusion, generally at least 2 inches (about 5–6 cm) while allowing full chest recoil. A depth of 1.5 inches is too shallow for an adult and is associated with ineffective circulation and poorer outcomes, so it reflects incorrect technique needing remediation. The other actions align with standard BLS sequence and equipment use: opening the airway with head-tilt chin-lift when no trauma is suspected, promptly placing AED pads on a bare chest, and using a bag-valve-mask for ventilations when trained and equipped. In BLS teaching, correcting compression depth is a priority because it is a major determinant of CPR effectiveness.

Question 8

A student nurse working with a registered nurse is assessing a child with epiglottitis. The student tells the client she needs to look at his throat. Which intervention by the registered nurse is most appropriate?

Accepted Answer

Answer reason: Epiglottitis is a potential airway emergency, and manipulating the oropharynx can precipitate sudden complete obstruction due to inflammation and laryngospasm. The safest plan is to avoid throat inspection outside a controlled setting where definitive airway equipment and expertise are immediately available. An anesthesiologist is appropriate to perform visualization with readiness for intubation in the operating room or equivalent controlled environment. Allowing a student (or even the RN) to attempt visualization at bedside increases the risk of rapid decompensation without guaranteed airway control.

Question 9

A postoperative client signals the nurse and states, “I felt something pop.” The nurse enters the room and notes a wound evisceration. What is the most important action by the nurse?

Accepted Answer

Answer reason: Evisceration is a surgical emergency where exposed viscera must be protected immediately to prevent drying, contamination, and further tissue injury. Applying sterile saline–moistened gauze maintains moisture and reduces infection risk while preparations are made for urgent surgical management. Other actions such as making the client NPO and notifying the surgeon are important but do not address the immediate threat to exposed organs. Prophylactic antibiotics and emotional support are secondary to rapid protection of the viscera and stabilization.

Question 10

The nurse is performing CPR on the 5-year-old in asystolic cardiac arrest. A second rescuer arrives. The client remains pulseless and apneic. What intervention should the team provide next?

Accepted Answer

Answer reason: Pediatric BLS uses different compression-to-ventilation ratios depending on the number of rescuers. When a second rescuer arrives for a pulseless, apneic child, the team should switch to the 2-rescuer CPR ratio of 15 compressions to 2 breaths to improve ventilation while maintaining adequate perfusion. Rescue breathing alone is inappropriate because the child has no pulse and needs full CPR. Defibrillation is not indicated for asystole, and the depth listed in another option is not appropriate for a 5-year-old, making the ratio change the best next action.

Question 11

The parent of a toddler telephones the ED nurse and, sobbing hysterically, states, “My baby just put an electrical cord in her mouth! What should I do?” Which statement by the nurse is priority?

Accepted Answer

Answer reason:  The priority in a suspected electrical injury is to stop the exposure immediately to prevent ongoing current flow and worsening burns or dysrhythmias. Ensuring the source is no longer in the child’s mouth addresses the immediate life-threatening hazard before further assessment questions. After the exposure is terminated, the nurse can assess for oral burns/bleeding and advise urgent evaluation/EMS based on symptoms. Asking about bleeding or appearance gathers data but does not first eliminate the danger.

Question 12

The clinic nurse is advising the parent of the 8-year- old who has ringworm and now has an extensive, itchy rash. Which instruction should the nurse provide?

Accepted Answer

Answer reason: A new extensive pruritic rash in a child being treated for a fungal infection could represent an allergic reaction to a topical agent, a worsening/incorrect diagnosis, or secondary bacterial involvement, all of which require in-person assessment. Prompt evaluation allows the clinician to assess severity, distribution, vital signs, mucous membrane involvement, and need for prescription therapy or discontinuation/substitution of the offending product. Advising OTC steroid use can mask infection or delay appropriate antifungal management, and “watchful waiting” risks progression if this is a drug reaction or evolving complication. Automatically stopping all medications without assessment is unsafe because ringworm requires antifungal treatment and the rash may not be medication-related.

Question 13

A 2-year-old child is brought to the emergency department in respiratory distress. The child is drooling, sitting upright, and leaning forward with chin thrust out, mouth open, and tongue protruding. Which nursing intervention is most appropriate?

Accepted Answer

Answer reason: This presentation (drooling, tripod position, mouth open) is classic for acute upper-airway obstruction risk such as epiglottitis, where agitation and airway manipulation can precipitate complete obstruction. The priority nursing action is to maintain a position of comfort and minimize distress while preparing for definitive airway management. Keeping the child upright on the parent’s lap supports airway patency and reduces anxiety. Airway inspection or gag stimulation is unsafe because it can trigger laryngospasm and sudden loss of the airway.

Question 14

Members of a resuscitation team arrive at the client’s bedside with a defibrillator. The nurse and an NA are performing CPR. What should be the nurse’s next action?

Accepted Answer

Answer reason: While another team member places defibrillator pads, compressions should continue until the moment rhythm analysis/shock requires everyone to be clear. Pausing CPR during pad placement or unnecessarily waiting to analyze rhythm increases “no-flow” time and worsens outcomes. Rescue breathing without compressions is inappropriate in an adult cardiac arrest unless compressions must briefly stop for a specific safety reason (e.g., shock delivery).

Question 15

The nurse is providing post resuscitation care to the client. The client’s HR is 80 bpm, and the RR is 14 breaths per minute and regular. Which action should the nurse perform next?

Accepted Answer

Answer reason: After return of spontaneous circulation, the immediate priority is post-resuscitation monitoring and support of airway, breathing, and circulation while preparing for escalation of care. A heart rate of 80 bpm and a regular respiratory rate of 14/min indicate adequate spontaneous perfusion and ventilation, so continued CPR or assisted ventilation is not indicated. AED rhythm analysis/defibrillation is reserved for pulseless shockable rhythms during arrest, not for a patient with stable vital signs. Ongoing close observation helps detect early deterioration (e.g., recurrent arrest, hypoxia, hypotension) and allows rapid intervention when ALS arrives.

Question 16

A 72-year-old man with cirrhosis is admitted to the hospital in a hepatic coma. What is the most important nursing intervention?

Accepted Answer

Answer reason: In any patient presenting in coma, immediate stabilization follows the ABC priority to prevent hypoxia and cardiopulmonary arrest. Hepatic coma markedly decreases protective airway reflexes, increasing the risk for airway obstruction and aspiration, so airway assessment and support must occur before other assessments or administrative tasks. Once oxygenation and circulation are ensured, secondary assessments such as neurologic checks can help trend encephalopathy severity but do not supersede resuscitation priorities. Admission completion and reorientation are delayed until the patient is physiologically stabilized and able to participate safely.

Question 17

While jogging, the nurse finds an adult lying on the ground. The nurse uses both tactile and verbal stimulation to determine that the client is unresponsive. What action should the nurse perform next?

Accepted Answer

Answer reason: For an adult found unresponsive outside the hospital, the BLS sequence prioritizes activating the emergency response system and getting an AED/advanced help to the scene as fast as possible. After confirming unresponsiveness, the next step is to call for help/EMS (or direct a bystander) because survival depends on early defibrillation and rapid escalation of care. Pulse checks are not the first action for a lone rescuer in this setting and should not delay EMS activation. Airway opening and compressions follow immediately after activation and assessment for normal breathing/pulse within the BLS algorithm.

Question 18

CPR is in progress when the client's wife and teenage son arrive. The nurse intercepts them and tries to move them away from the room, but the wife states, “He needs us there to pray for him!” The son keeps walking and attempts to enter. Which action is most appropriate?

Accepted Answer

Answer reason: Family presence during resuscitation is an evidence-supported practice when it can be done safely with a staff member assigned to support, explain events, and manage behavior. This approach respects client/family rights and spiritual needs while preventing interference with the code team and maintaining a controlled environment. Having a designated support person reduces distress and helps ensure the family remains at an appropriate location and can be escorted out if needed. Options focused on keeping them out or calling security are less therapeutic and should be reserved for situations where safety or care delivery is actually compromised.

Question 19

Hospital personnel are eating outdoors when a nearby train carrying anhydrous ammonia derails- Which direction by the emergency nurse experienced with biochemical contamination is most appropriate to reduce exposure?

Accepted Answer

Answer reason: " The core principle in hazardous materials incidents is immediate evacuation away from the plume to minimize dose and duration of exposure. Anhydrous ammonia is a highly irritating, toxic inhalation hazard; rapid movement out of the contaminated area is the most effective immediate self-protection step while awaiting further instructions (e.g., upwind/uphill guidance). Staying low or lying down can increase exposure if the gas hugs the ground or pools in low areas, and breath-holding is unreliable and unsafe in panic. Minimizing breaths while remaining in place falsely assumes low toxicity and delays definitive exposure reduction.

Question 20

The nurse is providing basic life support teaching to the parent of the 2-year-old. Which statement made by the parent would indicate the need for further instruction?

Accepted Answer

Answer reason:  Pediatric rescue breathing rates depend on age and are generally faster for children than for adults. For a child, the recommended rate is about 1 breath every 2–3 seconds (20–30/min) when providing rescue breathing without compressions. A rate of 1 breath every 5–6 seconds corresponds to adult rescue breathing (about 10–12/min) and is too slow for a child. The other statements align with basic life support concepts such as injury prevention reducing pediatric arrests, compressions around 100–120/min, and complete airway obstruction preventing effective speech/cough.

Question 21

An explosion occurred at a nearby factory. The ED charge nurse receives a call from EMS personnel that 35 clients will arrive by ambulance within 10 minutes. These clients were triaged at the scene as red and yellow according to the NATO mass casualty categories; others will be arriving, and the unit is short-staffed. Which action should the nurse initiate first?

Accepted Answer

Answer reason: The core principle is that mass-casualty incidents require immediate activation of the facility’s incident command structure so staffing, space, supplies, triage flow, and communication pathways are mobilized in an organized way. With 35 red/yellow patients arriving imminently and more expected, initiating the emergency response plan triggers predefined roles and rapid resource allocation that individual phone calls cannot match. This first step also enables coordinated decisions about surge capacity, interfacility diversion, and who to notify, preventing unsafe, fragmented actions. Contacting a director, calling in extra nurses, or rerouting patients may be appropriate next steps, but they should occur under the activated plan to ensure alignment with hospital-wide disaster procedures.

Question 22

The nurse is caring for a client who fell off the ladder. The client reports numbness in his lower extremities. The nurse should initially?

Accepted Answer

Answer reason: High-risk trauma with new neurologic symptoms requires immediate spinal motion restriction to prevent secondary spinal cord injury. A fall with lower-extremity numbness suggests possible spinal cord involvement, and any neck movement could worsen cord compression or instability. Stabilizing the cervical spine is the safest first nursing action while further assessment and emergency response are initiated. Testing neck range of motion is contraindicated, and focusing on lacerations or limb range of motion delays the critical safety intervention.

Question 23

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

Accepted Answer

Answer reason: For a single rescuer performing CPR without an advanced airway, current standard teaching is 30 compressions followed by 2 rescue breaths. This ratio balances ventilation needs while limiting pauses that reduce perfusion pressure. Ratios like 15:2 are typically associated with two-rescuer pediatric CPR rather than adult CPR. Therefore the best adult compression-to-ventilation ratio is 30:2.

Question 24

Which pulse should the nurse palpate during rapid assessment of an unconscious male adult?

Accepted Answer

Answer reason: In an unconscious adult, rapid pulse assessment should focus on a central pulse that remains palpable even with hypotension and poor peripheral perfusion. The carotid artery is a reliable central pulse site and is the recommended location for quickly checking circulation during adult basic life support assessment. Peripheral pulses like the radial may be absent in shock despite ongoing central circulation, leading to a dangerous delay in recognizing a pulse. The brachial pulse is primarily used for infants, and femoral can be used but is typically less immediate and less standard than carotid in adult rapid assessment.

Question 25

The nurse prepares to treat a pediatric client with a chemical burn to the eye. Which action does the nurse implement?

Accepted Answer

Answer reason: Immediate, continuous irrigation is the priority for chemical eye burns to dilute and remove the caustic agent and limit ongoing tissue damage. Using readily available water without delay is appropriate when a specific irrigant is not immediately at hand, because time to irrigation is more important than solution type early on. Patching can trap residual chemical against the cornea and worsen injury, and ice does not remove the chemical or stop alkali/acid penetration. Positioning/bed rest is supportive but does not address the emergent need to decontaminate the eye.

Question 26

A patient is admitted with severe shortness of breath and a history of congestive heart failure. What should the nurse do first?

Accepted Answer

Answer reason: In acute severe dyspnea, the priority is ABCs, and the nurse must first determine the adequacy of ventilation and oxygenation. Focused respiratory assessment (work of breathing, lung sounds, SpO2, ability to speak, mental status) identifies immediate instability and guides urgent escalation such as oxygen, rapid response activation, or provider notification. Giving a diuretic or tracking intake/output are important for heart failure, but they are not safe to initiate before establishing current airway/breathing status. Positioning can relieve dyspnea, but assessment comes first to identify life-threatening deterioration and to select the most appropriate immediate interventions.

Question 27

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

Accepted Answer

Answer reason: The brachial pulse is recommended for infants because it is typically easier to palpate than the carotid and provides a dependable indicator of circulation. Peripheral pulses such as radial or pedal can disappear early with poor perfusion and are not appropriate for arrest checks. Using the correct pulse site supports rapid, accurate recognition of pulselessness and timely initiation of high-quality CPR.

Question 28

The nurse is preparing to administer a dose of naloxone hydrochloride intravenously to a client with an intravenous opioid overdose. Which supportive medical equipment should the nurse plan to have at the client's bedside if needed?

Accepted Answer

Answer reason: In addition, abrupt reversal may precipitate acute withdrawal with agitation, vomiting, or aspiration risk, increasing the need for suction and airway management readiness. Resuscitation equipment (e.g., bag-valve-mask, oxygen delivery, suction, airway adjuncts) directly addresses ABC priorities during overdose care. A nasogastric tube does not treat the primary life threat in IV overdose, and paracentesis or central line kits are unrelated to the anticipated emergency.

Question 29

A Code Blue has been called on a patient and the team is attempting to resuscitate. While one nurse performs chest compressions, the other applies defibrillator pads. For which rhythm should the nurse apply a defibrillation shock?

Accepted Answer

Answer reason: Pulseless VT fits this principle as it is a malignant ventricular rhythm without effective cardiac output and requires immediate defibrillation in addition to high-quality CPR. Asystole and pulseless electrical activity are non-shockable rhythms managed with CPR, epinephrine, and treatment of reversible causes rather than defibrillation. Atrial fibrillation typically has organized ventricular activity and is treated with rate control or synchronized cardioversion when unstable, not unsynchronized shocks during a code.

Question 30

A client presents to the Emergency Department with massive burns over the bulk of the body mass. When planning care for the client, which should be carried out first?

Accepted Answer

Answer reason: Large surface-area burns also cause capillary leak with massive fluid shifts, placing the patient at immediate risk for hypovolemic (burn) shock, so early fluid resuscitation is time-critical. Pain control supports physiologic stability and facilitates necessary airway and circulatory interventions. Measures like infection prevention and tetanus prophylaxis are important but are secondary once immediate airway and perfusion threats have been addressed.

Question 31

The pediatric nurse reviews the Laboratory Results for a 6-year-old child who is undergoing chemotherapy with vincristine for acute lymphoblastic leukemia (ALL). Which finding is most concerning?

Accepted Answer

Answer reason: Temperature 100.8 F (38.2 C) Fever in a child receiving chemotherapy should be treated as a potential oncologic emergency because it may indicate infection during neutropenia and can rapidly progress to sepsis. A single oral temperature at or above 38.0 C warrants immediate evaluation, blood cultures, and prompt broad-spectrum antibiotics per febrile neutropenia protocols. The low WBC indicates immunosuppression but does not by itself signal an acute decompensation as strongly as fever does. Mouth pain and distal numbness are expected adverse effects (mucositis and vincristine neuropathy) that typically require symptom management rather than emergent sepsis workup.

Question 32

A client is receiving an IV infusion of piperacillin–tazobactam. The nurse notes the development of hives, and the client states, “I am having trouble breathing and am itchy all over.” After discontinuing the infusion, what priority action does the nurse take?

Accepted Answer

Answer reason: Trouble breathing with hives and generalized pruritus during an IV antibiotic infusion indicates an acute systemic hypersensitivity reaction with concern for anaphylaxis and impending airway compromise. The priority is immediate reversal of bronchospasm and support of airway/ventilation and perfusion; epinephrine is the first-line medication because it rapidly causes bronchodilation and reduces mucosal edema while supporting blood pressure. Diphenhydramine can help cutaneous symptoms but has slower onset and does not reliably treat life-threatening airway obstruction or shock. Focused assessment measures (pulse oximetry, lung sounds) are important but must not delay the definitive, time-critical intervention.

Question 33

A nurse is caring for a group of clients. Which of the following client should the nurse prioritize for immediate intervention?

Accepted Answer

Answer reason: Acute onset wheezing and dyspnea after IV medication administration is a potential anaphylactic or severe hypersensitivity reaction, which is immediately life-threatening due to rapid airway compromise. This presentation requires stopping the infusion, activating emergency response, and preparing to administer oxygen, epinephrine, and other supportive measures per protocol. The diabetes client’s glucose of 180 mg/dL is mildly elevated and not an immediate ABC threat, and postoperative pain at 6/10 can be treated promptly but is not typically life-threatening. Orthostatic lightheadedness on an ACE inhibitor warrants assessment and safety measures, but it is less urgent than suspected medication-induced bronchospasm/anaphylaxis.

Question 34

A cardiac monitor is displaying normal sinus rhythm, but the patient is unresponsive and the nurse is unable to palpate a central pulse. What action should the nurse implement?

Accepted Answer

Answer reason: The immediate priority is high-quality CPR to provide perfusion while the team assesses and treats reversible causes. Medications like epinephrine are given during the arrest, but they do not replace the need to start compressions right away. Defibrillation is reserved for shockable rhythms (ventricular fibrillation/pulseless VT), not for PEA with absent pulse.

Question 35

The nurse is caring for a patient experiencing anaphylaxis after eating shellfish. Which intervention should the nurse perform first?

Accepted Answer

Answer reason: Intramuscular epinephrine is first-line because it quickly provides alpha-1 vasoconstriction (improving blood pressure and reducing mucosal edema) and beta-2 bronchodilation (improving ventilation). Starting IV fluids can support hypotension but is secondary because it does not promptly relieve airway compromise or halt mediator effects. Elevating the head of the bed and emotional support may help comfort but do not treat the underlying fatal pathophysiology and must not delay epinephrine.

Question 36

A client with superior vena cava syndrome (SVCS) reports difficulty breathing and swelling of the face. What intervention should the nurse anticipate?

Accepted Answer

Answer reason: SVCS can rapidly compromise the airway due to edema of the face, neck, and upper airway, so airway protection is the priority when the client reports dyspnea and facial swelling. Preparing for intubation ensures immediate readiness for escalating respiratory distress and potential obstruction. Positioning supine would worsen venous congestion and respiratory effort, making it unsafe. Compression stockings and increased fluids do not address the life-threatening problem of impaired ventilation/airway patency in SVCS.

Question 37

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: A sudden, severe “worst headache” with suspected hemorrhagic stroke is a neurologic emergency where time-sensitive stabilization and rapid escalation of care takes priority over routine measures. Activating the rapid response team immediately mobilizes airway/breathing/circulation support, urgent neurologic evaluation, and expedited imaging/critical care resources to prevent deterioration from rising intracranial pressure or rebleeding. While a focused neuro assessment is important, it should not delay emergency escalation when a high-risk, rapidly evolving condition is suspected. Notifying the provider is also necessary, but the rapid response process is designed to initiate immediate bedside intervention and coordination faster than standard notification pathways. Analgesics can mask symptom evolution and do not address the life-threatening cause, so they are not the first action.

Question 38

The nurse finds a patient unresponsive and pulseless. After calling for help, which of the following actions should the nurse take next?

Accepted Answer

Answer reason: High-quality CPR prioritizes immediate circulation when a patient is confirmed pulseless, because delaying compressions rapidly worsens coronary and cerebral perfusion. After activating the emergency response system, the next action is to begin chest compressions at the recommended rate to provide critical blood flow while other resuscitation steps are organized. Ventilations are important but should not precede initial compressions once pulselessness is established, especially when a lone rescuer is starting BLS. Epinephrine is part of ACLS and is given after CPR is underway with rhythm assessment and access, not before compressions begin.

Question 39

A client is post-op day 1 from a tracheostomy placement. During the client’s bed bath, the external (outer) cannula dislodged from the tracheostomy stoma and fell on the floor. Which action by the nurse should be performed immediately?

Accepted Answer

Answer reason: Immediate ventilation/oxygen delivery via BVM to the stoma supports oxygenation while help and equipment are obtained. Re-inserting a contaminated tube from the floor is unsafe, and attempting reinsertion can create a false passage and worsen obstruction if the tract is not established. Holding the stoma open and calling the surgeon does not address the immediate ABC threat of hypoxia.

Question 40

The nurse assesses a client admitted to the hospital after sustaining a burn from a large outdoor fire. The client reports almost no pain at the injured site. Which intervention does the nurse recommend to the healthcare provider?

Accepted Answer

Answer reason: Large outdoor fires create high risk for inhalation injury and carbon monoxide exposure, and clients may have minimal burn pain when nerve endings are destroyed (deeper burn), so apparent comfort does not rule out life-threatening hypoxia. The priority recommendation is to support oxygenation early because carbon monoxide binds hemoglobin and reduces oxygen delivery even when the client initially looks stable. Moist dressings may be used after stabilization but do not address an immediate airway/gas-exchange threat. Blister aspiration increases infection risk, and opioid analgesia is not the priority when the client reports little pain and potential inhalation injury must be managed first.

Question 41

A client with hypothyroidism is three days postoperative and becomes confused, with marked hypothermia. Myxedema coma is suspected. Which action does the nurse perform first?

Accepted Answer

Answer reason: The first priority is ABCs—ensuring a patent airway (and supporting breathing/oxygenation) to prevent respiratory failure and arrest. Passive rewarming, IV fluids, and thyroid hormone are important treatments, but they do not take precedence over immediate stabilization of ventilation and airway protection. A common pitfall is focusing on hypothermia management first, which can delay recognition and treatment of impending respiratory collapse.

Question 42

A mother calls the children’s clinic and tells the nurse she found her toddler with an open and empty bottle of acetaminophen (Tylenol) and wants to know what to do. What is the priority nursing intervention?

Accepted Answer

Answer reason: A possible acetaminophen overdose is a medical emergency due to risk of severe liver toxicity. Immediate evaluation and treatment (e.g., activated charcoal, N-acetylcysteine) are time-sensitive, so the child must be brought to the ED without delay. Option A is outdated and unsafe. Option B is ineffective. Option D is irrelevant unless the child is unresponsive.

Question 43

The nurse is at the cafeteria getting lunch when she noticed an adult choking on their food and turns slightly blue. What initial action should the nurse take?

Accepted Answer

Answer reason: Abdominal thrusts generate high intrathoracic pressure to expel the foreign body and restore ventilation, preventing rapid progression to hypoxia and cardiac arrest. Looking into the mouth is only appropriate if the object is clearly visible and easily removable; blind finger sweeps risk pushing it deeper. Calling for transport delays definitive life-saving intervention, and “assess airway” is too nonspecific when the situation already signals a critical, time-sensitive airway compromise.

Question 44

A mother calls a neighbor who is a nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. The nurse would direct the mother immediately to?

Accepted Answer

Answer reason: In suspected ingestion of a potentially toxic household product, the safest first action is to obtain immediate, evidence-based instructions tailored to the substance, amount, and symptoms. Poison Control provides rapid triage, advises against unsafe first aid (especially inducing emesis with hydrocarbon/solvent products due to aspiration pneumonitis risk), and directs whether home observation or urgent evaluation is needed. Calling an ambulance or going straight to the ED may be necessary if the child is symptomatic (respiratory distress, altered mental status), but that decision is best guided by Poison Control after a brief assessment. This approach minimizes harm while expediting the correct level of emergency response.

Question 45

A nurse is performing cardiopulmonary resuscitation (CPR) on an infant. When performing chest compressions, the nurse compresses at least?

Accepted Answer

Answer reason: Standard BLS guidance targets at least about 100 compressions/min (commonly taught as 100–120/min), so this is the minimum rate that meets evidence-based resuscitation performance. Rates like 60 or 80/min are too slow and reduce cardiac output during CPR, worsening chances of return of spontaneous circulation. A rate like 160/min is unnecessarily high and can impair recoil and effective ventilation, leading to poorer perfusion.

Question 46

The nurse observes a client connected to a chest drainage system ambulate to the bathroom. The client's chest tube becomes disconnected from the client. The nurse should take which action?

Accepted Answer

Answer reason: An open chest tube insertion site can allow air to be sucked into the pleural space, rapidly causing or worsening a pneumothorax. A sterile occlusive dressing taped on three sides functions as a flutter valve, permitting air to escape during exhalation while limiting air entry during inhalation. Reinsertion is not within nursing scope and risks contamination/trauma, and fully sealing the site with continuous pressure/airtight dressing can trap air and precipitate a tension pneumothorax. After covering the site, the nurse should promptly assess respiratory status and notify the provider while preparing for further intervention.

Question 47

A nurse is reviewing fire safety information for their unit. What does the A stand for when using the acronym PASS?

Accepted Answer

Answer reason: The key safety principle is to direct the extinguishing agent where combustion is sustained, which is at the base of the flames, to interrupt the fuel/heat/oxygen interaction. This makes the “A” step the targeting action immediately after pulling the pin. Options suggesting sounding alarms or moving away reflect other fire response frameworks (e.g., RACE) rather than the PASS steps.

Question 48

A nurse finds a client with a dislodged chest tube from the incision site. What should the nurse do first?

Accepted Answer

Answer reason: An open chest-tube insertion site can rapidly pull air into the pleural space and precipitate an acute pneumothorax, so the immediate priority is to prevent further air entry. Covering the site promptly with a sterile dressing (commonly an occlusive petrolatum gauze) is the fastest nursing action to reduce air entrainment and protect the wound while further help is obtained. Taping on three sides is an intervention for an open “sucking” chest wound, not the priority instruction typically emphasized for a dislodged chest tube from the insertion site. Notifying the provider is necessary, but it comes after the nurse takes the immediate safety action to stabilize the client and prevent deterioration; reinserting the tube is outside nursing scope.

Question 49

The emergency hotline nurse receives a call from a client who believes he has developed frostbite on the fourth and fifth fingers of the right hand. Which action should the nurse instruct the client to take before going to the nearest emergency department?

Accepted Answer

Answer reason: Warm water (comfortably warm, not hot) provides uniform heat transfer and reduces the risk of thermal burns to numb, insensate tissue. Massage is contraindicated because it can cause mechanical damage to fragile, partially frozen tissue and worsen necrosis. Direct high heat (e.g., blow dryer on hot) and compression bandaging can both increase injury risk by causing burns or impairing already compromised circulation.

Question 50

The nurse has just been alerted to a tornado warning affecting the hospital. How should the nurse respond?

Accepted Answer

Answer reason: In most inpatient units, interior hallways (often designated severe-weather shelter areas) provide more structural protection than patient rooms with exterior windows. Closing doors may help limit debris spread but does not move patients away from the highest-risk zone. Sheltering under beds is not a standard hospital tornado action plan and is less protective than moving to a designated interior corridor under staff supervision.

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