Question 1

Which action by the nurse is best when delivering external cardiac compressions during CPR?

Accepted Answer

Answer reason: Effective external cardiac compressions require firm, vertical downward pressure using the heel of the hand to generate adequate depth and forward blood flow. This action maximizes perfusion and is a core component of high-quality CPR.

Question 2

A client is 4 hours post-op following a left carotid endarterectomy. Which assessment finding would cause the nurse the most concern?

Accepted Answer

Answer reason: New neurologic deficits (lethargy with right-sided weakness) after carotid surgery suggest an acute stroke or cerebral hypoperfusion; this is an emergency and takes priority over mild vital sign changes or small wound drainage.

Question 3

A client is admitted to the emergency department with complaints of crushing chest pain that radiates to the left jaw. After obtaining a stat electrocardiogram, the nurse should?

Accepted Answer

Answer reason: Suspected acute coronary syndrome requires ABC priorities. After the ECG, the immediate nursing action is to improve oxygenation. Oxygen at 2 L/min via nasal cannula addresses hypoxia risk. IV access and history can follow, and pupil checks are not a priority.

Question 4

A client was transferred to the hospital unit as a direct admit from a small community hospital. While the nurse is obtaining part of the admission history, the client suddenly becomes semiconscious. Assessment reveals a systolic BP of 70, heart rate of 130, and respiratory rate of What is the nurse's initial action?

Accepted Answer

Answer reason: The client is hypotensive with altered consciousness, indicating shock. The immediate priority is to improve perfusion by positioning—lower the head of the bed or position supine to enhance cerebral and central circulation—then establish IV access and notify the provider.

Question 5

In a 39-year-old pregnant woman at 38 weeks with a BP of 174/112 mmHg and 2+ proteinuria, what is the primary complication you aim to prevent by lowering her blood pressure?

Accepted Answer

Answer reason: Severe preeclampsia with markedly elevated BP poses an immediate risk of intracranial hemorrhage; the primary objective of antihypertensive therapy is to prevent maternal stroke. Seizures are prevented by magnesium sulfate rather than by BP lowering alone.

Question 6

A woman at 32 weeks' gestation is bleeding vaginally and shows moderate fetal distress after an automobile crash. Which action should the nurse take first to reduce fetal stress?

Accepted Answer

Answer reason: Provide high-flow oxygen first to improve maternal and thus fetal oxygenation, the most immediate intervention to reduce fetal distress after trauma. Other options do not correct hypoxia as rapidly or are not first-line.

Question 7

What do you look for when checking for "absence of signs of life"?

Accepted Answer

Answer reason: Absence of signs of life is identified by unresponsiveness or unconsciousness and not breathing normally—therefore, all listed findings apply.

Question 8

A client taking anticoagulant medication has developed cardiac tamponade. Which finding is associated with cardiac tamponade?

Accepted Answer

Answer reason: Cardiac tamponade causes pulsus paradoxus—an exaggerated drop (>10 mmHg) in systolic BP during inspiration.

Question 9

In order to be effective in administering cardiopulmonary resuscitation to a 5-year-old, the nurse must remember to?

Accepted Answer

Answer reason: For a 5-year-old, effective CPR per the provided guidance uses a ventilation ratio of one breath for every five compressions. Brachial pulse checks are for infants; two-handed compressions are typical for adults; 80–90/min is not the recommended child compression rate.

Question 10

According to the American Heart Association (2005) guidelines, the compression-to-ventilation ratio for one-rescuer cardiopulmonary resuscitation is?

Accepted Answer

Answer reason: The AHA 2005 CPR guidelines set a 30:2 compressions-to-breaths ratio for a single rescuer, standard across adults (and single-rescuer child/infant).

Question 11

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

Accepted Answer

Answer reason: AEDs can be used on a drowning victim only after removing them from the water and drying the chest to allow the pads to adhere and to prevent the current from conducting through the water.

Question 12

What is the immediate treatment for a two-year-old who swallowed kerosene from a soda bottle stored in the garage?

Accepted Answer

Answer reason: Hydrocarbon ingestion poses a high aspiration risk; emetics and salt solutions are contraindicated. Mineral oil can help reduce gastric irritation and absorption without inducing vomiting, whereas a weak salt solution may trigger emesis, and milk of magnesia or tea offer no benefit.

Question 13

A client is admitted with hyperglycemic hyperosmolar syndrome (HHS). What is the priority nursing intervention?

Accepted Answer

Answer reason: HHS is a life‑threatening hyperglycemic crisis. If IV fluids are not an option among the choices, the next priority is to start insulin to reduce the extreme hyperglycemia. Oral fluids are inadequate in severe dehydration; glucose should be checked more frequently than every 4 hours, and potassium is replaced only after labs and adequate urine output.

Question 14

Which drug is first-line for ventricular fibrillation?

Accepted Answer

Answer reason: In cardiac arrest due to ventricular fibrillation, the first medication recommended by ACLS is epinephrine (1 mg IV/IO every 3–5 minutes), given after defibrillation/CPR cycles. Amiodarone is used for shock-refractory VF/VT after epinephrine.

Question 15

A client complaining of severe shortness of breath is diagnosed with congestive heart failure. The nurse observes a falling pulse oximeter reading. The client's color changes to gray, and she expectorates large amounts of pink, frothy sputum. The FIRST action of the nurse would be which of the following?

Accepted Answer

Answer reason: The client shows acute pulmonary edema with severe hypoxia (falling SpO2, gray color, pink frothy sputum). Follow the ABCs—secure the airway and breathing first by providing supplemental oxygen before other actions.

Question 16

The client returns to the unit from surgery with a blood pressure of 90/50, a pulse of 132, and respirations of 30. Which action by the nurse should receive priority?

Accepted Answer

Answer reason: Post-op hypotension with tachycardia and tachypnea suggests possible hemorrhage or shock. This is an emergent, unstable situation requiring immediate provider notification for urgent intervention. Monitoring or asking how he feels delays care, and unstable patients should not be delegated to an LPN.

Question 17

A client has just finished her lunch, which consisted of shrimp with rice, fruit salad, and a roll. The client calls for the nurse, stating, 'My throat feels thick and I'm having trouble breathing.' What action should the nurse implement first?

Accepted Answer

Answer reason: After eating shellfish, the client has throat swelling and dyspnea, suggesting anaphylaxis. The immediate priority is airway support; sitting upright in high Fowler's optimizes ventilation while help is called. PO diphenhydramine is slow and unsafe with airway compromise; Trendelenburg worsens breathing, and aminophylline drip is not first-line.

Question 18

A client arrives in the emergency room after a motor vehicle accident. Witnesses tell the nurse they observed the client's head hit the side of the car door. Nursing assessment findings include BP 70/34, heart rate 130, and respirations of 22. What is the client's most appropriate priority nursing diagnosis?

Accepted Answer

Answer reason: BP 70/34 with tachycardia after trauma indicates hypovolemic shock. By the ABCs, circulatory compromise takes priority; the immediate nursing diagnosis is fluid volume deficit due to probable blood loss. Airway is not compromised and RR is adequate; cerebral perfusion issues are secondary to restoring volume.

Question 19

The nurse is caring for a child four days after a tracheostomy tube insertion. The child's mother calls the desk and says, "He pulled out his trach tube and threw it on the floor; it's closing—come quickly, he can't breathe." What is the best action for the nurse to take?

Accepted Answer

Answer reason: Early postoperative tracheostomy decannulation is an airway emergency. The priority is to maintain airway patency by keeping the stoma open and summoning help. Do not cover the stoma, do not use a contaminated tube from the floor, and do not rely on nasal cannula oxygen when the patient breathes via the stoma.

Question 20

Apnea can be prevented by?

Accepted Answer

Answer reason: Neonatal apnea is managed and prevented by tactile stimulation, ensuring airway patency, and providing assisted ventilation when needed—therefore all of the above.

Question 21

What is the correct chest compression-to-ventilation ratio for a neonate?

Accepted Answer

Answer reason: Per NRP guidelines, neonatal CPR uses a 3:1 compression-to-ventilation ratio (90 compressions and 30 breaths per minute). Other ratios apply to older pediatric or adult CPR.

Question 22

Upon admission to an intensive care unit, a client diagnosed with an acute myocardial infarction is ordered oxygen. The nurse knows that the major reason that oxygen is administered in this situation is to?

Accepted Answer

Answer reason: In acute MI the myocardium is ischemic; supplemental oxygen is given primarily to increase oxygen delivery to the injured myocardial tissue. While it may relieve dyspnea and cyanosis, the key goal is improving myocardial oxygenation.

Question 23

The nurse arrives at the scene of a motorcycle accident and finds the client unresponsive, apneic, and pulseless. After calling for a spectator to help, what would be the nurse's next action?

Accepted Answer

Answer reason: Adult BLS sequence is C-A-B; for an unresponsive, apneic, pulseless client the immediate next step after calling for help is to start high-quality chest compressions. Airway/ventilation follows; precordial thump is not routinely recommended.

Question 24

The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, which priority intervention does the nurse plan?

Accepted Answer

Answer reason: In DKA the priority acute therapy is IV regular (short-acting) insulin to stop ketogenesis and correct hyperglycemia; acidosis resolves with insulin, dextrose is added later when glucose drops, and ECG monitoring is supportive but not the primary intervention.

Question 25

Which of the following nursing assessment findings indicates hypovolemic shock in a client who has had a 15% blood loss?

Accepted Answer

Answer reason: Hypovolemic shock is characterized by decreased perfusion and hypotension; a systolic BP

Question 26

What is the APGAR of a newborn, and when should we start neonatal resuscitation?

Accepted Answer

Answer reason: An Apgar score of 0–3 indicates severe depression/asphyxia and warrants immediate neonatal resuscitation.

Question 27

All of the following therapies may be required in a one-hour-old infant with severe birth asphyxia except?

Accepted Answer

Answer reason: Initial management of severe birth asphyxia focuses on resuscitation and support: glucose for hypoglycemia, normal saline for volume expansion, and calcium gluconate if hypocalcemia. Corticosteroids like dexamethasone are not indicated in neonatal asphyxia.

Question 28

In neonatal resuscitation, chest compression-to-ventilation ratio is?

Accepted Answer

Answer reason: NRP guidelines recommend a 3:1 compression-to-ventilation ratio for neonatal CPR, prioritizing ventilation (about 90 compressions and 30 breaths per minute).

Question 29

In newborn resuscitation, the ratio of cardiac compressions to breaths is?

Accepted Answer

Answer reason: Neonatal resuscitation guidelines recommend a 3:1 compression-to-ventilation ratio (about 90 compressions and 30 breaths per minute) because most newborn arrests are asphyxial.

Question 30

Define the contraindication for bag-and-mask ventilation.

Accepted Answer

Answer reason: In suspected congenital diaphragmatic hernia, bag-mask ventilation can inflate the stomach and intestines in the thorax, worsening respiratory compromise. Intubation with gastric decompression is preferred.

Question 31

The equipment used in newborn resuscitation is?

Accepted Answer

Answer reason: All listed items are standard neonatal resuscitation equipment: a DeLee trap for suctioning, a stethoscope to assess heart rate, and a bag and mask for positive-pressure ventilation.

Question 32

The sequence of steps for neonatal resuscitation?

Accepted Answer

Answer reason: In neonatal resuscitation, thermal management is addressed first to prevent cold stress, followed by airway, breathing, and circulation—sequence TABC.

Question 33

A client is admitted to the hospital after sustaining burns to the chest, abdomen, right arm, and right leg. The shaded areas in the illustration indicate the burned areas on the client's body. Using the rule of nines, the nurse would determine about what percentage of the client's body surface has been burned?

Accepted Answer

Answer reason: Rule of nines (adult): anterior trunk 18% + one entire arm 9% + one entire leg 18% = 45% TBSA.

Question 34

What is the treatment for a sudden worsening of TOF?

Accepted Answer

Answer reason: Acute hypercyanotic (tet) spells in Tetralogy of Fallot are treated with high-flow oxygen, morphine to reduce catecholamine surge and calm the child, and propranolol to relieve RV outflow tract spasm—thus all listed options are appropriate.

Question 35

Bag-and-mask ventilation in newborn resuscitation is contraindicated in?

Accepted Answer

Answer reason: In congenital diaphragmatic hernia, bag-mask ventilation forces air into the stomach and intestines that are herniated into the thorax, worsening lung compression and hypoventilation. Immediate endotracheal intubation with gastric decompression is preferred.

Question 36

Highest nursing priority for a client with status asthmatics is.........?

Accepted Answer

Answer reason: Status asthmaticus is a life‑threatening airway/ventilation emergency. The immediate nursing priority is continuous assessment of breathing and oxygenation to detect impending respiratory failure and prompt interventions.

Question 37

As part of initial first aid of epistaxis, it is advised to pinch nose. How long should ideally nose be pinched?

Accepted Answer

Answer reason: First aid for epistaxis involves continuous compression of the soft part of the nose for about 5–10 minutes. Among the choices, 5–8 minutes best matches recommended practice.

Question 38

The nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which is an early sign of this oncological emergency?

Accepted Answer

Answer reason: Early SVC syndrome causes venous congestion of the face and eyes, producing facial/periorbital edema. Cyanosis and mental status changes are late signs; arm edema can occur but facial/periorbital swelling is typically the earliest hallmark.

Question 39

When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the low-Fowler position with the knees slightly bent and encourages the client to lie still. What is the next nursing action?

Accepted Answer

Answer reason: Evisceration is a surgical emergency. After positioning, the priority is to protect exposed organs by covering them with sterile saline-moistened dressings to prevent drying and infection. Do not attempt to reinsert; then notify the provider and monitor vitals.

Question 40

A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition?

Accepted Answer

Answer reason: High-pressure ventilator alarm with unilateral absence of breath sounds after chest trauma suggests a pneumothorax on that side, an emergency requiring immediate assessment.

Question 41

The nurse should evaluate that defibrillation of a client was most successful if which observation was made?

Accepted Answer

Answer reason: Successful defibrillation is indicated by return of spontaneous circulation with a normal sinus rhythm, adequate blood pressure, and improved responsiveness. Option 1 shows arousability, sinus rhythm, and a normal BP.

Question 42

A client arrives in the emergency department with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action?

Accepted Answer

Answer reason: With a penetrating eye injury and an object protruding, do not irrigate, patch (adds pressure), or remove the object. Establish baseline vision while avoiding manipulation; assess visual acuity and then protect the eye with a shield and notify the provider.

Question 43

All of the following measures are used to decrease brain edema, except?

Accepted Answer

Answer reason: Dextrose solutions are hypotonic in vivo and can worsen cerebral edema and increase ICP. Hyperventilation reduces PaCO2 and cerebral blood volume; mannitol is an osmotic diuretic; corticosteroids help reduce vasogenic cerebral edema.

Question 44

A patient with diabetes mellitus type 2 is sweating, dizzy, and confused. What is the priority nursing action?

Accepted Answer

Answer reason: Sweating, dizziness, and confusion suggest hypoglycemia. Following the nursing process, assess first by checking blood glucose, then treat per protocol. IV insulin would worsen hypoglycemia; orange juice is given after confirming and if the patient can swallow; rechecking vitals is not the immediate priority.

Question 45

A nurse is caring for a client with deep vein thrombosis (DVT) who suddenly develops acute shortness of breath and chest pain. What is the nurse’s priority action?

Accepted Answer

Answer reason: DVT with sudden dyspnea and chest pain suggests pulmonary embolism. The priority is to optimize oxygenation and reduce work of breathing by positioning upright and administering oxygen. Other options are unsafe or delay life-saving care; massaging the leg may dislodge more clot.

Question 46

Immediate management of choice to restore blood pressure and peripheral circulation is?

Accepted Answer

Answer reason: For acute hypotension/shock, the first-line immediate step is rapid infusion of isotonic crystalloids such as Ringer lactate to restore intravascular volume and improve perfusion. Trendelenburg is not recommended, and inotropes/colloids are not first line before volume resuscitation.

Question 47

Child with suspected epiglottitis arrives with stridor. Nurse’s first action?

Accepted Answer

Answer reason: Suspected epiglottitis with stridor is an airway emergency. Avoid oral manipulation or fluids; prepare for securing the airway (intubation/tracheostomy).

Question 48

What is the priority action for a nurse when a client with electrical burns has a cool distal extremity with no palpable pulses and a large eschar on the left lower extremity?

Accepted Answer

Answer reason: Cool extremity with absent pulses under a circumferential eschar after electrical burns indicates acute compartment syndrome and limb ischemia. This is a medical emergency requiring immediate provider notification for escharotomy/fasciotomy.

Question 49

A nurse is observing a local softball game when one of the players is hit in the nose with a ball. The player's nose is visibly deformed and bleeding. The best way for the nurse to control the bleeding is to?

Accepted Answer

Answer reason: First-aid for epistaxis is to have the person lean forward and apply firm pressure by pinching the soft part of the nose for 10–15 minutes. This limits bleeding and prevents aspiration or swallowing blood. Tilting back risks aspiration; ice may reduce swelling but is not the best method to stop bleeding; packing with tissue can dislodge clots and worsen bleeding.

Question 50

The nurse is caring for a client after a laryngectomy. The client is anxious, with a respiratory rate of 32 and an oxygen saturation of 88. The nurse's first action should be to?

Accepted Answer

Answer reason: Post-laryngectomy clients are at high risk for airway obstruction from secretions. With hypoxia (SpO2 88%) and tachypnea, the priority is to clear the airway; oxygen alone will not help if the airway is blocked.

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