Question 1

The charge nurse on the night shift at an urgent care center is managing a sudden influx of high-acuity clients due to a large fire. Which leadership and decision-making style is most appropriate in this situation?

Accepted Answer

Answer reason: In emergency or disaster situations, rapid and decisive action is required to ensure patient safety and effective coordination of care. An autocratic or directive leadership style allows for quick decision-making and clear instructions, which is essential when time is limited and client acuity is high.

Question 2

A nurse is performing cardiopulmonary resuscitation (CPR) on an adult client. When performing chest compressions, the nurse should depress the sternum?

Accepted Answer

Answer reason: Standard adult compression depth is approximately 5 cm (about 2 inches), so the option that best matches guideline-based depth is the one in the 1.5–2 inch range. Shallower depths (e.g., under 1 inch) are insufficient and are associated with poor perfusion and worse outcomes. Depths approaching 3 inches increase the risk of injury and exceed typical recommended targets for adult compressions. Using the correct depth supports perfusion while minimizing avoidable trauma.

Question 3

When attending a client with a head and neck trauma following a vehicular accident, the nurse’s initial action is to?

Accepted Answer

Answer reason: With head and neck trauma after a vehicular accident, an unstable cervical spine must be presumed until proven otherwise, so immediate manual stabilization and collar/immobilization are the first nursing priority to avoid spinal cord compromise during any subsequent interventions. Oxygen, IV access, and suctioning may be needed, but they should be performed only after (or while maintaining) cervical stabilization to prevent worsening neurologic injury. A common pitfall is proceeding to airway maneuvers or suctioning without protecting the neck, which can convert a stable injury into a catastrophic one.

Question 4

A client is taken to the emergency department for an overdose of lorazepam. The nurse performs which action first?

Accepted Answer

Answer reason: Benzodiazepine overdose primarily threatens airway and breathing due to CNS depression and hypoventilation, so immediate stabilization follows ABC priorities. Providing supplemental oxygen supports oxygenation while the nurse rapidly evaluates ventilation status and prepares for advanced airway support if needed. Cardiac monitoring and IV access are important but are secondary to correcting the most time-sensitive physiologic threat. A focused assessment is part of care, but initial actions in overdose prioritize immediate respiratory support over further data collection.

Question 5

An emergency room nurse is caring for a patient. The patient goes into ventricular fibrillation. What intervention is appropriate?

Accepted Answer

Answer reason: Early defibrillation is the definitive intervention that offers the best chance to restore an organized rhythm and perfusing circulation. CPR is critical as a bridge while preparing the defibrillator and between shocks, but it does not correct the underlying shockable rhythm by itself. Synchronized cardioversion is used for unstable tachyarrhythmias with a pulse, and digoxin has no role in treating an acute VF arrest.

Question 6

A patient has fallen trying to get out of bed, and the nurse finds him on the floor with a scalp laceration that is actively bleeding. The priority is to?

Accepted Answer

Answer reason: Direct pressure is the fastest, safest initial intervention for an actively bleeding scalp laceration while additional assessment and help are obtained. Imaging and wound closure are secondary and should occur after bleeding is controlled and the patient is stabilized. Questioning the patient is non-urgent and does not address the current physiologic threat. After hemostasis, the nurse can assess neurologic status and coordinate provider evaluation for possible head injury.

Question 7

The nurse is assessing a client with a neurologic health problem and discovers a change in level of consciousness from alert to lethargic. What is the nurse's best action?

Accepted Answer

Answer reason: An acute decline in level of consciousness is a potential neurologic emergency that can rapidly progress to loss of airway protection, hypoventilation, and hemodynamic instability. The priority is immediate escalation to ensure rapid bedside evaluation and timely interventions (e.g., airway/oxygenation support, glucose check, urgent neuro workup). Completing a full neuro assessment or focusing on cranial nerves may delay critical stabilization and definitive management when deterioration is already evident. Waiting 30 minutes is unsafe because sudden lethargy can indicate rising intracranial pressure, stroke, or medication/sedation complications requiring urgent response.

Question 8

The nurse is caring for four clients in the infectious disease unit. Which client requires immediate intervention?

Accepted Answer

Answer reason: Hematemesis in suspected viral hemorrhagic fever signals active, potentially catastrophic bleeding with rapid risk of hypovolemic shock and death, requiring immediate stabilization and escalation of care. This presentation also represents an extreme transmission-risk event, demanding urgent activation of high-level isolation procedures and appropriate PPE to protect staff and other clients. By comparison, meningitis symptoms described are concerning but not an abrupt life-threatening change, and a low-grade fever with dry cough in HIV needs prompt evaluation but is not the most emergent change shown. Varicella already being managed in a negative-pressure room indicates appropriate containment without a new deterioration.

Question 9

Nurse Danj is caring for a client with multiple injuries sustained during a head on car collision. Which assessment finding takes priority?

Accepted Answer

Answer reason: A deviated trachea suggests tension pneumothorax or massive hemothorax, which can rapidly cause severe hypoxia and obstructive shock and requires immediate emergency intervention. Unequal pupils indicate possible increased intracranial pressure, but this typically does not kill as quickly as a progressing tension pneumothorax when ventilation is compromised. Flank ecchymosis suggests retroperitoneal bleeding and an irregular apical pulse indicates dysrhythmia risk, but both are prioritized after immediate airway/ventilation threats are addressed.

Question 10

A patient with delusions, auditory hallucinations, and aggressive behavior starts to act erratic, and the nurse is concerned about his safety. What is the nurse’s priority?

Accepted Answer

Answer reason: Calling for assistance ensures adequate staff support for de-escalation, maintaining a safe environment, and preparing for emergency interventions if needed. Notifying the provider allows timely orders for appropriate medications or higher-level interventions based on the patient’s current risk. By contrast, attempting to manage the situation alone with verbal redirection may be unsafe if the behavior is escalating, and restraints or IM antipsychotics are not first-line without first ensuring sufficient help and a controlled setting.

Question 11

Nurse Janus enters a room and finds a client lying on the floor. Which of the following actions should the nurse perform first?

Accepted Answer

Answer reason: Checking responsiveness rapidly guides next actions such as calling a rapid response/code and initiating airway/breathing support if needed. Moving the client back to bed before assessing can worsen occult injuries (e.g., head, neck, hip fracture) and delays critical interventions. Asking what happened is appropriate only after stabilizing and ensuring the client is responsive and safe.

Question 12

In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey?

Accepted Answer

Answer reason: Disability is a core primary-survey component and requires a rapid neurologic check (e.g., level of consciousness, pupils, gross motor/sensory) to identify impending airway compromise, intracranial injury, or spinal cord involvement. Allergy history and a complete set of vital signs are typically obtained during the secondary survey after stabilization. Pulse oximetry is useful adjunct monitoring, but the structured neurologic disability check is a defined priority element within the primary survey sequence.

Question 13

The nurse observes a fire near the nursing station. When planning evacuations, the nurse should initially evacuate?

Accepted Answer

Answer reason: Clients who can ambulate can be rapidly directed to exit routes with minimal assistance, which immediately decreases census in the danger area and frees staff to help higher-acuity patients. After ambulatory clients are out, the nurse can prioritize those needing equipment or multiple staff for safe transport. Prioritizing the most immobile clients first can delay overall evacuation and increase risk to more patients and staff if conditions deteriorate.

Question 14

A nurse on the day shift walks into a client's room and finds the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. The next nursing action is which of the following?

Accepted Answer

Answer reason: In an adult found unresponsive with absent breathing and no pulse, the priority is immediate high-quality CPR to restore minimal circulating blood flow to the brain and heart. After activating the emergency response system (calling for help), compressions should begin without delay because delays markedly reduce survival. Airway maneuvers, oxygen, and rescue breaths are important but are secondary to establishing circulation in pulseless arrest. Ventilation is added once compressions are in progress and a barrier device/AED is being retrieved and applied.

Question 15

A nurse attempts to relieve an airway obstruction on a 3-year-old conscious child. The nurse performs this maneuver correctly by standing behind the child, placing her arms under the child’s axillae and around the child, and positioning her hands to deliver the thrusts between the?

Accepted Answer

Answer reason: Correct hand placement is midline just above the navel and well below the xiphoid to avoid injury to the ribs, sternum, and upper abdominal organs. Positioning too high risks trauma (e.g., xiphoid/rib injury), and too low (toward the groin) is ineffective at generating adequate airway-expelling pressure. This option best describes the safe and effective landmark for thrust delivery in a 3-year-old.

Question 16

Nurse Kim is monitoring Mr. Torres, a 58-year-old client recovering from a bronchoscopy and biopsy. While assessing his condition, she watches for critical changes. Which observation, if noted in Mr. Torres, should Nurse Kim report to the physician immediately?

Accepted Answer

Answer reason: Post-bronchoscopy patients must be monitored for airway compromise because edema, laryngospasm, or bleeding can rapidly obstruct the upper airway. Stridor is an ominous sign of upper-airway narrowing and, when paired with worsening dyspnea, indicates impending respiratory failure requiring immediate escalation. In contrast, mild hoarseness/sore throat and thirst/dry mouth are common effects of scope irritation and NPO status/oxygen therapy. Small amounts of blood-tinged sputum can occur after biopsy and is expected unless it becomes frank bleeding or increases in volume.

Question 17

Nurse Ellen is preparing to administer Naloxone hydrochloride (Narcan) to a patient admitted with an opioid overdose. Before proceeding, she ensures that critical equipment is readily accessible at the bedside. What equipment should Nurse Ellen prioritize having on hand?

Accepted Answer

Answer reason: Opioid overdose primarily threatens airway and breathing due to respiratory depression, so immediate readiness for ventilation and advanced life support is the highest priority. Naloxone can rapidly reverse opioid effects but may not immediately restore adequate spontaneous respirations and the patient can deteriorate or require bag-mask ventilation and escalation. Having resuscitation equipment at the bedside supports prompt airway management, oxygenation, and CPR/ACLS if needed. While suction can be helpful for secretions or vomiting, it does not replace the capability to ventilate and resuscitate in a life-threatening hypoventilation scenario.

Question 18

As part of a health education program, the nurse teaches a group of parents about CPR (cardiopulmonary resuscitation). The nurse determines that the teaching has been effective when a parent states. Which of the following?

Accepted Answer

Answer reason: " High-quality CPR requires compressions at an appropriate rate to maintain coronary and cerebral perfusion during cardiac arrest. The recommended adult and pediatric compression rate is 100–120/min, making this statement an accurate indicator of effective learning. Calling for help before starting CPR is not universally correct because the sequence depends on age and whether the arrest is witnessed (e.g., immediate CPR first in an unwitnessed pediatric collapse). Abdominal thrusts are for conscious choking and are not indicated during CPR when ventilations fail to produce chest rise; instead, the rescuer should reposition the airway and continue CPR per guidelines.

Question 19

A client calls the telephone triage nurse to report fever, nausea, chills, and malaise. The nurse should instruct the client to come immediately to the emergency department after the client shares which additional data?

Accepted Answer

Answer reason: Neck stiffness suggests meningeal irritation and requires immediate evaluation for possible meningitis, including urgent assessment, appropriate isolation precautions, and prompt IV antibiotics after workup. By contrast, a mild tachycardia such as 106 can occur with fever/dehydration and is not, by itself, a trigger for immediate ED referral. A roommate with similar symptoms increases suspicion of an infectious illness but does not identify a time-critical complication as strongly as neck stiffness.

Question 20

A 20-year-old client who fell approximately 30' is unresponsive and breathless. A cervical spine injury is suspected. How should the first-responder open the client's airway for rescue breathing?

Accepted Answer

Answer reason: The jaw-thrust maneuver displaces the mandible forward to lift the tongue off the posterior pharynx while keeping the head and neck in neutral alignment. The head-tilt/chin-lift produces cervical extension and is avoided in trauma until C-spine injury is ruled out. Oropharyngeal and nasopharyngeal airways are adjuncts that may help maintain patency but do not replace the initial safest manual airway-opening technique in suspected C-spine trauma.

Question 21

The nurse walks into the patient’s room who is without a pulse, with no respirations, and is unresponsive. Which action by the nurse should be taken next?

Accepted Answer

Answer reason: In an unresponsive adult with absent breathing and no pulse, the priority is to immediately mobilize resuscitation resources (code team/AED/defibrillator) while CPR is initiated. Activating the emergency response system ensures rapid access to a defibrillator and additional trained personnel, which is time-critical in cardiac arrest. “Call for help” is less specific and may not reliably trigger the hospital’s formal code response compared with the emergency response system. After activation, the nurse should promptly start high-quality chest compressions while help and the AED arrive.

Question 22

A nurse has begun to resuscitate a 10-month old infant. In what location would the nurse check the infant's pulse?

Accepted Answer

Answer reason: The brachial pulse in the upper arm is recommended because it is accessible and provides a dependable assessment of circulation during resuscitation. Peripheral pulses like the radial can be difficult to palpate in shock or low-flow states, leading to false assumptions of pulselessness. Carotid assessment is more typical for children older than 1 year and adults, and temporal is not a standard pulse point for CPR decisions.

Question 23

A school nurse observes a 3-year-old begin to choke and turn blue while eating lunch. What should be the nurse's initial action?

Accepted Answer

Answer reason: This intervention generates high intrathoracic pressure to expel the foreign body and is the fastest life-saving step at the bedside. Back blows and chest thrusts are the recommended maneuver for infants, not a 3-year-old. Blind finger sweeps can push the object deeper and injure the airway, and calling 911 is important but should not delay immediate choking first aid when the rescuer is present.

Question 24

You are caring for a child with epiglottitis. What equipment is most important to have at the bedside?

Accepted Answer

Answer reason: Having emergency surgical-airway equipment at the bedside supports rapid intervention if intubation is unsuccessful or the airway suddenly closes. Monitoring devices (pulse oximetry, blood pressure) provide important data but do not prevent impending airway loss. A chest tube setup is unrelated to the primary, imminent risk in epiglottitis, which is airway compromise rather than pleural pathology.

Question 25

A nurse is working in an occupational health clinic when an employee walks in and states that he was struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first?

Accepted Answer

Answer reason: Even though the client is currently alert, feeling faint can rapidly progress to airway compromise or apnea due to dysrhythmias or neurologic effects. Airway assessment (patency, ability to speak, respiratory effort) guides urgent support before moving to circulation details or secondary survey findings. Pulse characteristics and inspection for entrance/exit wounds are important but occur after confirming airway and breathing are stable. Cervical spine concerns are addressed in trauma care, but in this scenario the most time-critical, life-saving first assessment remains airway.

Question 26

After a spontaneous vaginal delivery, a neonate is placed in the warmer in the "sniffing" position, has the airway cleared, and is dried. During the second survey, the nurse notes that the neonate's heart rate is 58/min and respirations are 30/min. What action should the nurse take?

Accepted Answer

Answer reason: A heart rate of 58/min after initial steps signifies inadequate perfusion and impending cardiovascular collapse, so compressions should be initiated immediately while ensuring effective positive-pressure ventilation. Epinephrine is reserved when the heart rate remains

Question 27

The nurse witnesses a neighbor's husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to open the airway. The nurse opens the airway in this victim by using which method?

Accepted Answer

Answer reason: The jaw-thrust technique opens the airway by displacing the mandible anteriorly without extending the neck, reducing the risk of worsening an unstable cervical spine. In contrast, the head tilt–chin lift requires neck extension and is avoided when spinal injury is possible. This approach aligns with first-responder trauma principles (ABC with C-spine precautions).

Question 28

A client in the mental health unit picks up a fire extinguisher and throws it at a nurse standing by the nurses' station. What is the most important intervention by the nurse?

Accepted Answer

Answer reason: Clearing the area rapidly decreases the number of potential victims and limits escalation while help is summoned per facility protocol. Verbal limit-setting or reflection of feelings may be appropriate only after the environment is controlled and the client is no longer an imminent physical threat. Pulling the fire alarm is not the safest or most appropriate response because it may trigger unit-wide disruption and is not the designated method for behavioral emergencies.

Question 29

The parent of a 3-year-old calls and tells the nurse of finding the child in the bathroom with an empty bottle of mouthwash. The parent thinks that the bottle was about one quarter full. What is the nurse's priority response?

Accepted Answer

Answer reason: " In a potential poisoning ingestion, the priority is immediate assessment of the child’s current condition to identify any airway, breathing, circulation, or neurologic compromise that would require activating emergency services. Asking what the child is doing right now quickly screens for red flags such as decreased level of consciousness, vomiting/aspiration risk, respiratory distress, or seizures, which cannot wait for detailed history-taking. After determining stability, the nurse can direct the parent to poison control and gather specifics (product, amount, time, symptoms) for targeted guidance. Advising dilution or other home interventions before assessing symptoms can be unsafe because it may worsen vomiting or aspiration risk depending on the substance and the child’s status.

Question 30

The emergency department nurse receives a client with extensive injuries to the head and upper back. The nurse will perform what action to allow the best visualization of the airway?

Accepted Answer

Answer reason: The jaw-thrust maneuver opens the airway by displacing the mandible forward without extending the neck, reducing risk of worsening a potential spinal injury. Keeping the client supine on a backboard supports spinal alignment and facilitates coordinated airway management in the emergency setting. Head-tilt chin-lift requires neck extension and is avoided when spinal injury is suspected; Trendelenburg is not an airway-visualization maneuver and may increase aspiration risk.

Question 31

The client has a dislocated shoulder and the nurse is assisting the health care provider with bedside procedural moderate sedation (conscious sedation). During the procedure, the client becomes restless and cries out "Help me!" What action should the nurse take first?

Accepted Answer

Answer reason: The quickest first action is to assess oxygenation by verifying pulse oximetry and ensuring the probe is reading accurately, while simultaneously scanning for adequate chest rise and respirations. Giving additional sedatives or opioids can worsen respiratory depression and delay identification of the true cause. Airway maneuvers are indicated if assessment shows obstruction or ineffective breathing, but an immediate oxygenation check is the safest first step in response to this change.

Question 32

A visiting home care nurse finds a client unconscious in the bedroom. The client has a history of abusing the selective serotonin reuptake inhibitor, sertraline. The nurse should immediately conduct which assessment?

Accepted Answer

Answer reason: In suspected medication misuse/overdose, immediate assessment of respiratory rate, depth, and effort determines whether to open the airway, provide ventilation, or activate emergency response. Circulatory checks like pulse and blood pressure are important but follow confirmation that breathing is adequate. Urinary output is not an immediate life-saving assessment in this scenario and is assessed later once stabilization occurs.

Question 33

The nurse is giving an end-of-shift report when a client with a chest tube is noted in the hallway with the tube disconnected. What is the most appropriate action?

Accepted Answer

Answer reason: Submerging the distal end in sterile normal saline temporarily recreates a water seal, preventing air from being sucked back into the chest while allowing air to escape. Clamping is generally avoided because it can trap air and precipitate a tension pneumothorax if an air leak is present. Reconnecting may be done after quickly restoring a water seal, but immediate priority is preventing further air entry with a safe temporary measure.

Question 34

The clinic nurse encounters a client who does not respond to verbal stimuli and initiates cardiopulmonary resuscitation (CPR). What should the nurse do? Prioritize the nurse’s actions from first (1) to last (5)?

Accepted Answer

Answer reason: Basic Life Support begins by confirming unresponsiveness to quickly identify cardiac arrest and avoid unnecessary CPR in a responsive person. Once unresponsiveness is established, the next immediate assessment is for a pulse (and breathing) to determine whether compressions are indicated. If there is no pulse, high-quality chest compressions are started before airway maneuvers and rescue breaths, because circulation is the most time-sensitive determinant of survival. Airway opening and delivering breaths follow compressions in the 30:2 sequence for a single rescuer when no advanced airway is present.

Question 35

The nurse suspects a foreign-body airway obstruction (FBAO) in a responsive infant. The nurse plans to relieve the obstruction by performing which action?

Accepted Answer

Answer reason: This approach is age-specific and avoids abdominal thrusts, which are not recommended for infants. Blind finger sweeps are contraindicated because they can push the object deeper and worsen obstruction or injure tissues. Attempting ventilation and simple head-tilt/chin-lift address poor airway tone, not a solid obstruction, and can delay definitive relief.

Question 36

When the nurse is monitoring a 53-year-old client who is undergoing a treadmill stress test, which finding will require the most immediate action?

Accepted Answer

Answer reason: Even mild pain can represent myocardial oxygen supply-demand mismatch during exertion and can rapidly progress to serious dysrhythmias or infarction. A heart rate of 134 beats/min is an expected physiologic response for many 53-year-olds depending on fitness and protocol targets, and a BP of 152/88 may be acceptable during exercise without other symptoms. An SpO2 of 91% is concerning and warrants prompt evaluation, but active chest pain represents the more immediate threat of acute coronary syndrome during the test.

Question 37

Under what circumstances should a patient's dentures be removed in order to provide proper assisted ventilations?

Accepted Answer

Answer reason: Dentures are generally left in place because they help maintain facial structure and improve mask seal, but they must be removed if they are loose, blocking the airway, or preventing effective ventilation. Keeping obstructive dentures in place increases the risk of inadequate ventilation and aspiration if they dislodge. Placing an oropharyngeal airway or the presence of head trauma alone does not automatically require denture removal unless the dentures are creating obstruction or impairing ventilation.

Question 38

You are working on 3 South. You hear an announcement over the public address system which says to prepare to evacuate the clients in a horizontal manner. Which of the following should you be prepared to do?

Accepted Answer

Answer reason: Horizontal evacuation means moving patients on the same floor to a safe area beyond fire/smoke doors, rather than using elevators or stairs to change floors. From 3 South, the appropriate action is to relocate laterally to another smoke compartment/unit on the same level. This approach reduces risk during a fire by limiting exposure to smoke and maintaining access to critical equipment and staffing on that floor. Options that move to 2 South or 4 South/4 North imply a change in floor level, which is characteristic of vertical evacuation and is not the first step when horizontal evacuation is announced.

Question 39

The nurse on a medical surgical unit enters a room, finds a client unresponsive with no pulse, and starts 2 minutes of CPR. The nurse receives and attaches an automated external defibrillator, but no shock is advised. Which action should the nurse perform next?

Accepted Answer

Answer reason: Continuous chest compressions are the intervention most strongly associated with improved coronary and cerebral blood flow until the next rhythm check. A prolonged pulse check delays compressions and should be limited to brief rhythm/pulse assessments per algorithm. Ventilations and airway maneuvers are important, but they should not interrupt or delay resumption of compressions after a no-shock decision.

Question 40

The nurse responds to a call for help from another staff member. Upon entering the client's room, the nurse observes an unlicensed assistive personnel (UAP) performing chest compressions on an unconscious adult client while another nurse is calling for the emergency response team. What action by the arriving nurse is the priority?

Accepted Answer

Answer reason: Since compressions are already in progress and help is being activated, the arriving nurse should focus on the next highest-impact action that can change survival outcome fastest. Stopping compressions to check a pulse delays CPR and is not appropriate unless there are clear signs of return of spontaneous circulation or rhythm analysis/pulse checks at appropriate intervals. Establishing IV access and preparing ventilation are important, but they generally follow prompt defibrillator application and ongoing high-quality CPR in the initial response.

Question 41

A 19-year-old suicidal client fell backward over a stair rail to the floor. The client is not breathing and does not have a pulse. After calling for assistance, which action does the nurse take?

Accepted Answer

Answer reason: High-quality chest compressions are started as soon as pulselessness is recognized to restore minimal perfusion to the brain and heart while help and an AED are obtained. Airway opening and rescue breaths are not the initial priority when there is confirmed cardiac arrest without a pulse. “Assess the client” is already completed to the extent needed because absent breathing and pulse establish the need to start CPR.

Question 42

A nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects. The initial nursing action is to?

Accepted Answer

Answer reason: An accidental disconnection of a chest tube from the drainage system creates an open pathway for air to enter the pleural space, risking rapid loss of negative intrapleural pressure and a pneumothorax. The immediate priority is to re-establish a temporary water seal by placing the distal end of the tube into sterile water, which allows air to vent out but limits air entry back into the chest. Calling the provider or replacing the entire system are important follow-up actions but do not address the immediate risk of air entrainment. Applying a dressing is indicated when the chest tube is pulled out of the chest insertion site, not when the tube disconnects from the drainage apparatus.

Question 43

On a home visit, the nurse finds four young children alone. The youngest child is crying and has bruises on the face and back and circular burns on the inner aspect of the right forearm. The nurse should?

Accepted Answer

Answer reason: The bruising pattern and circular burns suggest inflicted trauma that needs prompt assessment, documentation, pain control, and treatment of potential complications. Getting the child to the emergency department also initiates mandatory reporting pathways and multidisciplinary protection in a controlled setting. Calling child welfare services is necessary but does not address the immediate medical and safety needs as quickly as emergency evaluation does.

Question 44

The nurse witnesses a construction worker fall from a ladder. The nurse rushes to the victim, who is unresponsive, and uses which method to open the victim’s airway?

Accepted Answer

Answer reason: The jaw-thrust technique opens the airway by displacing the mandible forward without head extension, reducing the risk of worsening an occult C-spine injury. The head tilt–chin lift requires cervical extension and is avoided when trauma is suspected. “Neutral/sniffing” is a positioning goal but is not the primary manual airway-opening method in this trauma context.

Question 45

If you are posted to emergency department. During your shift a patient comes in with a severe retrosternal chest pain. On examination patient is in pain, b.p-110/70mm hg, respiration 24 and heart rate of 160 beats per minute. What will you do next?

Accepted Answer

Answer reason: This patient has severe retrosternal pain with marked tachycardia, so delaying for extended history or non-urgent vitals can miss a life-threatening, treatable event. Nurses should initiate urgent diagnostics within protocol rather than waiting for a provider order when time-sensitive emergencies are suspected. Checking temperature is not priority because it does not change the immediate management of potential myocardial ischemia or unstable rhythm.

Question 46

A nurse has identified what appears to be ventricular tachycardia on the cardiac monitor of a client being evaluated for possible myocardial infarction. What should be the nurse's first action?

Accepted Answer

Answer reason: Ventricular tachycardia may be with a pulse and the next steps depend on whether the client is responsive, breathing adequately, and has a palpable pulse and blood pressure. If the rhythm is artifact or the client is stable, emergent shocks or CPR would be inappropriate and harmful. CPR is indicated only for pulselessness, and defibrillation is reserved for pulseless VT/VF, so confirming clinical status first is safest.

Question 47

A patient with a history of hypertension in pregnancy calls the hospital complaining of a severe headache and blurred vision. How should the nurse respond?

Accepted Answer

Answer reason: Severe headache and blurred vision in a pregnant patient with a history of gestational hypertension are red-flag symptoms for severe preeclampsia/eclampsia risk and possible acute neurologic complication, requiring urgent emergency evaluation. Telephone triage prioritizes immediate safety; activating emergency medical services provides rapid assessment, blood pressure management, and transport while minimizing risk of seizure, stroke, or deterioration en route. Advising her to drive herself delays care and introduces safety hazards if symptoms worsen suddenly. Asking for symptom frequency or recommending ibuprofen in this context inappropriately defers emergent care and can increase maternal-fetal risk.

Question 48

A tornado has touched down 1 mile from the hospital and a tornado warning has been issued with sirens. The nursing staff caring for the 36 patients on the second floor medical-surgical unit should move the patients to?

Accepted Answer

Answer reason: During a tornado warning, the priority is immediate shelter-in-place in an interior, windowless area to reduce injury from flying glass and structural collapse. Hallways on lower-risk interior portions of the unit are quickly accessible for many patients and keep them away from exterior windows. Closing doors and windows helps limit debris and reduces wind pressure changes within rooms. Moving 36 patients to the basement via elevators is unsafe because elevators may fail or become a hazard during severe weather, and evacuating across the street delays protection and increases exposure to debris.

Question 49

A nurse must deliver a shock to a client in ventricular fibrillation by using a biphasic defibrillator. Which describes the amount of energy delivered with the first shock on an adult client?

Accepted Answer

Answer reason: This energy level is evidence-based to maximize successful termination of fibrillation while limiting myocardial injury compared with unnecessarily higher doses. 360 J is the traditional initial dose for monophasic defibrillators, not biphasic. Values like 120 J or 150 J can be correct for some specific biphasic waveforms, but without device-specific guidance, the standard exam answer is the initial 200 J.

Question 50

What is the tool used to help breathing in first aid?

Accepted Answer

Answer reason: A resuscitation mask (barrier device) enables effective rescue breaths while reducing exposure to bodily fluids and improving seal compared with mouth-to-mouth alone. A stethoscope is an assessment tool and does not provide ventilation, and a thermometer only measures temperature. Using a barrier device aligns with emergency response best practices for both patient support and rescuer safety.

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