Question 1

The nurse is obtaining assessment data from a client with a suspected diagnosis of lung cancer. The nurse is most concerned if the client exhibits which symptom?

Accepted Answer

Answer reason: In a client with suspected lung cancer, low blood pressure can indicate acute complications such as massive pleural effusion causing obstructive physiology, sepsis, hemorrhage/hemoptysis-related volume loss, or pericardial involvement leading to tamponade physiology. This finding is more urgent than nonspecific symptoms like dizziness or generalized weakness, which may occur with many less emergent conditions. Recurrent pleural effusions are concerning and suggest advanced disease, but they are typically a slower-developing problem unless they are causing acute respiratory compromise and do not inherently indicate immediate shock.

Question 2

A client with shortness of breath has decreased-to-absent breath sounds on the right side, from the apex to the base. The nurse interprets this assessment data as indicating which condition?

Accepted Answer

Answer reason: This pattern fits pneumothorax, where lung collapse on the affected side reduces air entry from apex to base and presents with acute dyspnea. Asthma and chronic bronchitis typically cause diffuse bilateral wheezing/rhonchi rather than absent sounds confined to one side. Pneumonia more often produces focal crackles/bronchial breath sounds and may increase tactile fremitus rather than cause complete absence of breath sounds over the whole side.

Question 3

Which assessment would the nurse consider as a late sign of shock in a 6- month-old infant?

Accepted Answer

Answer reason: Hypotension is a late and ominous finding in pediatric shock because it indicates failure of compensatory mechanisms and impending cardiovascular collapse. The stated pressure is abnormally low for a 6-month-old, consistent with decompensated shock. Delayed capillary refill and pale, cool, mottled skin are earlier signs of poor perfusion and vasoconstriction rather than a late sign.

Question 4

Administration of which medication would be the most important in treating unrepaired transposition of the great arteries?

Accepted Answer

Answer reason: Keeping the ductus arteriosus open is the most time-critical intervention to improve systemic oxygen delivery until definitive repair or atrial septostomy is performed. Prostaglandin E1 maintains ductal patency, directly addressing the life-threatening physiology. Diuretics, inotropes, or ACE inhibitors may help heart failure symptoms but do not correct the immediate need for circulatory mixing.

Question 5

A nurse notes dyspnea and calf pain in a 14-year-old client 48 hours after open reduction of a fractured femur. Which nursing diagnosis has the highest priority?

Accepted Answer

Answer reason: Airway and breathing problems take priority over comfort, mobility, or education because hypoxemia can rapidly become life-threatening. This diagnosis directly targets the urgent physiologic problem implied by the symptoms and prompts rapid assessment and escalation of care (e.g., oxygen, monitoring, notifying the provider). Acute pain and impaired mobility are expected post-op issues but are lower priority than suspected respiratory compromise.

Question 6

A client complains of being stung by a yellow jacket which caused “welps” on the skin and light-headedness. The nurse knows first-line treatment consists of?

Accepted Answer

Answer reason: Light-headedness after a hymenoptera sting suggests a systemic reaction with possible evolving anaphylaxis and hemodynamic instability. Immediate IV access is a priority so the team can rapidly administer emergency medications (e.g., epinephrine, antihistamines, corticosteroids) and give isotonic fluids for hypotension. Cool compresses address only local inflammation and do not treat systemic involvement. Oxygen may be needed, but without IV access the nurse delays the ability to deliver definitive resuscitative therapy and manage shock.

Question 7

A client suffers from a right radial fracture. The client now complains of severe pain in the right arm accompanied with edema in the fingers. The nurse suspects?

Accepted Answer

Answer reason: Severe, escalating pain after a fracture with distal swelling is a classic early warning of rising intracompartmental pressure that threatens perfusion. Edema in the fingers suggests impaired venous return and increasing pressure distal to the injury, which can quickly progress to ischemia and tissue necrosis if not treated emergently. A key distinguishing feature is pain out of proportion to the injury and worsening despite immobilization/analgesia, often preceding neurologic deficits. Carpal tunnel and ulnar nerve palsy primarily present with focal numbness/tingling and weakness in specific nerve distributions rather than marked swelling with severe, progressive pain after a long-bone fracture. This situation requires immediate action (neurovascular checks, loosening restrictive dressings, urgent provider notification) because fasciotomy may be needed.

Question 8

The nurse is providing education for a client who is insulin dependent and often skips the ordered dose of insulin at home. The nurse teaches the client that omitting the insulin can result in which of the following?

Accepted Answer

Answer reason: The resulting free fatty acid breakdown produces ketone bodies, leading to metabolic acidosis and dehydration—hallmarks of a life-threatening emergency. Skipping insulin therefore raises the risk of severe hyperglycemia with ketosis rather than low blood glucose. A common distractor is hypoglycemia, which is associated with excessive insulin or missed meals, not omitted insulin.

Question 9

A client is injected with radiographic contrast medium and immediately shows signs of dyspnea, flushing, and pruritus. Which intervention should take priority?

Accepted Answer

Answer reason: Immediate dyspnea with flushing and pruritus after contrast suggests an acute hypersensitivity reaction that can rapidly progress to airway edema and anaphylaxis. Airway and breathing are the highest priority because hypoxia can occur within minutes and is life-threatening. Checking vital signs and calling the provider are important but secondary to ensuring ventilation and preparing for emergency measures (e.g., oxygen, suction, emergency medications per protocol). A cold pack at the IV site addresses local discomfort and does not treat the systemic reaction.

Question 10

The child with type 1 DM presents in the school nurse’s office an hour before the lunch period reporting disorientation. Which information is most important for the nurse to obtain?

Accepted Answer

Answer reason: The immediate priority is to objectively confirm the current glucose level so the nurse can initiate fast-acting carbohydrate treatment per protocol without delay. Ketones are more relevant for suspected hyperglycemia/diabetic ketoacidosis and do not guide the immediate, time-sensitive management of acute neuroglycopenic symptoms. Morning insulin dose and temperature may provide context, but they do not supersede the need to assess for an immediately reversible glucose-related emergency.

Question 11

The child is presenting with burn injuries. What should be the nurse’s priority during the initial assessment?

Accepted Answer

Answer reason: Edema of the upper airway may progress quickly after a thermal or smoke exposure, making early recognition and intervention critical. Assessing for hoarseness, stridor, soot in the mouth/nose, singed nasal hairs, and work of breathing directly targets the highest-priority risk. Burn size/shape and history are important but come after stabilizing airway and breathing, and addressing parent concerns is not the immediate priority in an emergency assessment.

Question 12

The nurse is ambulating a client. After ambulating 50 feet, the client experiences chest pain. What should be the priority intervention by the nurse?

Accepted Answer

Answer reason: Chest pain during exertion suggests myocardial ischemia, and the immediate priority is to stop activity to reduce cardiac workload and oxygen demand. Having the client sit (or rest) is the fastest, safest action the nurse can perform immediately while assessing vital signs and symptom severity. Returning the client to bed may be appropriate but is slower and adds unnecessary exertion/transfer risk in the moment. After resting, the nurse can proceed with further interventions (e.g., notify provider, obtain ECG, and administer prescribed nitroglycerin as indicated and safe based on blood pressure and contraindications).

Question 13

A client admitted for a lower extremity deep vein thrombosis is experiencing dyspnea, chest pain, and diminished breath sounds. The nurse suspects this client may be developing which condition?

Accepted Answer

Answer reason: This commonly presents with acute dyspnea and pleuritic chest pain; breath sounds may be decreased in affected regions due to reduced perfusion and ventilation. The other options are less consistent with a DVT complication: pneumothorax/hemothorax are typically related to trauma or procedures and often have unilateral marked findings, while pulmonary hypertension is usually a chronic process rather than an acute deterioration. Given the known DVT plus new respiratory symptoms, an acute embolic event is the most urgent and likely diagnosis.

Question 14

What is the most important nursing intervention for a client having a tonicclonic seizure?

Accepted Answer

Answer reason: Nursing priority follows ABCs: position the client to promote ventilation (e.g., side-lying if possible), protect the head, and ensure oxygen/suction are available to support breathing. Timing and observing seizure characteristics are important for evaluation, but they do not supersede preventing respiratory compromise. Placing anything in the mouth is unsafe because it can cause dental trauma, aspiration, or obstruct the airway, especially during active convulsions.

Question 15

A 30-year-old client is admitted to the progressive care unit with a C5 fracture from a motorcycle collision. Which assessment would take priority?

Accepted Answer

Answer reason: A C5 fracture places the client at risk for acute respiratory compromise, so continuous oxygenation assessment provides the fastest indicator of a life-threatening deterioration. Neurologic assessment is important, but it is secondary to ensuring adequate oxygenation and ventilation. Bladder distention and emotional support are lower priority concerns once immediate cardiopulmonary stability is addressed.

Question 16

A client is experiencing an episode of autonomic dysreflexia and becomes hypertensive. The most important intervention by the nurse would be?

Accepted Answer

Answer reason: Autonomic dysreflexia is a hypertensive emergency typically triggered by noxious stimuli below the level of spinal cord injury, and immediate actions must rapidly reduce blood pressure to prevent stroke or seizure. Upright positioning promotes venous pooling in the lower extremities, decreasing venous return and lowering systemic blood pressure while the nurse identifies and removes the trigger (commonly bladder or bowel distention). Positions that increase venous return (Trendelenburg, lying flat, elevating legs) can worsen hypertension and increase the risk of intracranial hemorrhage. This intervention is the fastest, safest first step that can be initiated immediately at the bedside.

Question 17

A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which symptom(s) should also be anticipated?

Accepted Answer

Answer reason: The classic presentation includes sudden severe headache, flushing/diaphoresis above the level of injury, and marked hypertension from unopposed sympathetic discharge. The baroreceptor reflex then produces vagal stimulation leading to bradycardia. Shock would more often present with hypotension, and respiratory depression is not the hallmark pattern of this emergency.

Question 18

A client was given morphine for pain at 9:00 am. At 9:45 a.m., the nurse assesses the client and notes a respiratory rate of 4 breaths/minute. The nurse recognizes that the client is at highest risk for which of the following?

Accepted Answer

Answer reason: A respiratory rate of 4/min represents severe hypoventilation with imminent progression to apnea, hypoxemia, and hypercapnic respiratory failure if not rapidly reversed. This makes impending respiratory arrest the most immediate and life-threatening risk, requiring emergency interventions (stimulation, airway support, naloxone as ordered). An asthma attack is not the expected acute complication of morphine compared with profound respiratory depression, and seizures are not the primary anticipated consequence at this presentation.

Question 19

A client diagnosed with asthma is experiencing an anaphylactic reaction to a drug. After administering initial emergency care, the nurse would?

Accepted Answer

Answer reason: Anaphylaxis can cause acute bronchospasm and airway edema, so restoring ventilation and oxygenation remains an immediate priority even after initial emergency measures. In a client with asthma, beta-agonist bronchodilators rapidly relax bronchial smooth muscle and improve airflow when wheezing/bronchoconstriction persists. Beta-adrenergic blockers can worsen bronchospasm and blunt the physiologic response to epinephrine, making them unsafe in this setting. Serum electrolytes do not address the time-critical airway threat, and positioning flat can worsen respiratory effort and aspiration risk; the client is typically kept upright if breathing is compromised.

Question 20

A child arrives in the emergency department after ingesting poisonous amounts of salicylates. The nurse is aware that obvious signs of toxicity will be evident when?

Accepted Answer

Answer reason: In typical acute ingestions, these become evident within a few hours rather than instantly, because absorption and distribution take time. Waiting 6 hours or longer risks missing the early toxidrome and delaying key interventions (e.g., decontamination, serial levels, acid–base monitoring). “Immediately” is less accurate because obvious systemic findings generally are not present at the moment of ingestion.

Question 21

A 14-year-old male client is brought to the hospital with smoke inhalation because of a house fire. What is the priority intervention by the nurse?

Accepted Answer

Answer reason: Smoke inhalation is an airway and breathing emergency because thermal injury and inhaled irritants can cause rapidly progressive upper-airway edema and bronchospasm. The nurse must prioritize ABCs to prevent sudden airway obstruction and hypoxia, which can become fatal before other assessments are completed. Establishing and maintaining airway patency also enables effective oxygen delivery and ventilation while further evaluation is performed. Assessing burns or oral mucosa can help identify inhalation injury, but these are secondary to immediately securing the airway when inhalation is suspected. Gathering history is delayed until the patient is stabilized.

Question 22

The nurse is caring for an 8-year-old child who arrived at the emergency department with chemical burns to both legs. What is the priority intervention for this child?

Accepted Answer

Answer reason: Chemical burns are a time-sensitive emergency because ongoing contact allows the agent to continue tissue destruction. The first priority is immediate decontamination by irrigating with copious water to dilute and remove the chemical, stopping further injury before any wound coverings or medications. Covering with dressings or applying topical antibiotics can trap residual chemical against the skin and delays the key step of removal. Debridement and grafting are definitive treatments performed later after stabilization and full assessment of burn depth/extent.

Question 23

During the assessment of a client, the nurse distinguishes that a client has status asthmaticus, instead of asthma, when the client has which characteristic?

Accepted Answer

Answer reason: A constant, ongoing episode that remains unrelieved despite bronchodilators signals refractory airflow obstruction and impending respiratory failure risk. Frequency-based choices (several per month or less than six per year) describe asthma severity patterns but do not define an acute emergency state. While minimal response to bronchodilators is concerning, the defining clinical picture is a sustained, unremitting attack with failure to improve, which demands emergency escalation.

Question 24

The nurse is planning care for the client in the PACU. The client had lengthy abdominal surgery with the general anesthetic agent isoflurane. Which client problem should the nurse plan to attend to first?

Accepted Answer

Answer reason: A client who cannot stay awake after stimulation may be unable to maintain a patent airway, has higher risk of hypoventilation, and can rapidly deteriorate, making this the most urgent problem to address first. Priority actions would include assessing airway patency, respiratory rate/effort, oxygenation, and level of consciousness, and escalating care if ventilation is inadequate. Pain and anxiety are important but are addressed after physiologic stability is ensured, and skin integrity is not an immediate life-threatening concern.

Question 25

A client in labor suddenly sits upright, clutches her chest, and gasps for breath. Which laboratory finding indicates that the client’s condition is worsening?

Accepted Answer

Answer reason: As DIC develops, clotting factors are consumed, producing impaired coagulation and abnormal clotting studies, including an increased PT. A worsening trend is therefore reflected by prolonged clotting times rather than markers of hypercoagulability. Increased fibrinogen and increased platelets are not consistent with consumptive coagulopathy, and a shortened PTT would suggest faster clotting rather than deterioration from factor depletion.

Question 26

A client presents in the emergency department with acute onset of fever, headache, stiff neck, nausea/vomiting, and mental status changes. From which condition is the client most likely suffering?

Accepted Answer

Answer reason: The combination of fever, severe headache, nuchal rigidity, and altered mental status is classic for acute meningitis and represents a time-sensitive neurologic emergency. Nausea/vomiting commonly accompanies increased intracranial pressure and meningeal inflammation. Upper-airway infections like pharyngitis, rhinosinusitis, or a peritonsillar abscess primarily cause sore throat/facial pain, muffled voice, and local findings rather than neck stiffness with acute mental status changes. This presentation warrants immediate isolation precautions, prompt diagnostics (e.g., blood cultures/LP when safe), and rapid initiation of empiric IV antibiotics to reduce mortality.

Question 27

After undergoing a thyroidectomy, a client develops hypocalcemia and tetany caused by inadvertent damage to the parathyroid glands. Which medication should the nurse anticipate administering?

Accepted Answer

Answer reason: Symptomatic hypocalcemia is a time-sensitive situation because it can cause laryngospasm, seizures, and dysrhythmias, so rapid calcium replacement is indicated. IV calcium gluconate stabilizes excitable membranes and promptly relieves tetany while underlying calcium/PTH balance is addressed. Potassium chloride treats hypokalemia, sodium bicarbonate addresses metabolic acidosis, and phosphorus would worsen hypocalcemia by binding calcium.

Question 28

The client with asthma has pronounced wheezing and signs of a possible impending asthma attack. Which intervention should the nurse implement first?

Accepted Answer

Answer reason: Acute asthma exacerbations are treated first by rapidly reversing bronchospasm to improve ventilation and oxygenation. A short-acting inhaled beta-2 agonist is the fastest, first-line rescue therapy and directly addresses the immediate airway narrowing suggested by pronounced wheezing and impending attack. Coughing/deep breathing does not relieve bronchoconstriction and can delay definitive therapy. Preparing for intubation and notifying the provider may be necessary if the client fails to respond or deteriorates, but they do not precede immediate bronchodilation when the client is still moving air.

Question 29

The nurse is assessing the 18-year-old diagnosed with mumps. Which findings should be most concerning to the nurse?

Accepted Answer

Answer reason: Mumps commonly causes parotitis with jawline swelling and can also cause fever, headache, earache, anorexia, and pain with chewing, which are expected and less urgent. Neck stiffness with photophobia indicates potential CNS involvement and risk of rapid clinical deterioration. Priority nursing action is prompt provider notification and preparation for emergent assessment/diagnostics and supportive management.

Question 30

A client has a respiratory rate of 4 breaths/minute. The most important assessments for the nurse to obtain would be?

Accepted Answer

Answer reason: Mental status is an early and sensitive indicator of hypoxia/hypercapnia and helps determine airway protection and need for urgent support. Pulse oximetry provides rapid, noninvasive information about oxygen saturation to guide immediate interventions and escalation of care. ABG can further define acid-base and CO2 retention but is slower and secondary to rapid bedside indicators when the patient may be decompensating. Heart sounds or reflex checks do not address the most immediate life-threatening consequences of severe bradypnea.

Question 31

A client has started a new drug for hypertension. Thirty minutes after he takes the drug, he develops chest tightness, shortness of breath, tachypnea, and decreased level of consciousness. The nurse interprets this assessment data as indicating?

Accepted Answer

Answer reason: These findings indicate acute, life-threatening impairment in ventilation/oxygenation with altered mental status, which is a key sign of impending or actual respiratory failure. A rapid onset after a new antihypertensive can reflect an acute drug reaction causing bronchospasm and severe hypoxemia/hypercapnia, leading to tachypnea and decreased level of consciousness. An asthma attack can cause chest tightness and dyspnea, but the mental status change signals more advanced physiologic decompensation than uncomplicated bronchospasm. Pulmonary embolism is possible with sudden dyspnea, but the timing immediately after taking a medication points more strongly to an acute reaction progressing to ventilatory failure. Rheumatoid arthritis does not explain an abrupt respiratory compromise.

Question 32

Nursing management of a client with a pulmonary embolism will primarily focus on which action?

Accepted Answer

Answer reason: The nurse must rapidly assess SpO2, respiratory rate/effort, breath sounds, mental status, and signs of worsening hypoxia to guide immediate escalation (oxygen, rapid response, higher level of care). Checking the oxygen device is secondary to determining whether the patient is adequately oxygenating and deteriorating. Looking for clot sources and considering repeat V/Q scanning are important later but do not address the immediate life-threatening threat of impaired gas exchange.

Question 33

A 7-year-old child who ingested several leaves of a poinsettia plant has arrived in the emergency department. What is the priority nursing intervention?

Accepted Answer

Answer reason: The priority in any ingestion/toxic exposure is rapid assessment and readiness to manage airway, breathing, and circulation, because deterioration can be unpredictable and time-sensitive. Even though poinsettia ingestion is typically low toxicity and often causes only mild GI irritation, the nurse must be prepared to respond to vomiting, aspiration risk, or unexpected allergic/irritant reactions while monitoring and obtaining appropriate guidance (e.g., poison control/provider orders). Options focused on teaching or emotional support are appropriate after physiologic stability is ensured and immediate risks are addressed. Preparation for urgent intervention aligns with emergency nursing priorities and safety-focused care in a potential poisoning presentation.

Question 34

A 3-year-old child is given a preliminary diagnosis of acute epiglottitis. Which nursing intervention is appropriate?

Accepted Answer

Answer reason: Acute epiglottitis is an airway emergency because any agitation or pharyngeal stimulation can trigger laryngospasm and sudden complete obstruction. The priority nursing action is to avoid procedures that manipulate the throat until the airway is secured by an experienced provider in a controlled setting. Throat culture and tongue-blade inspection can precipitate acute airway collapse and should be avoided. Positioning may support comfort, but it does not address the key safety principle of preventing iatrogenic airway occlusion in this condition.

Question 35

A nurse is caring for a full-term neonate who’s receiving phototherapy for hyperbilirubinemia. The nurse determines immediate intervention is necessary when the neonate exhibits which of the following?

Accepted Answer

Answer reason: An absent Moro reflex is an abnormal neurologic finding suggesting CNS involvement and requires immediate action (stop lights to assess, notify provider, and escalate care). In contrast, greenish stools are expected because phototherapy increases bilirubin excretion in stool. A transient maculopapular rash and bronze discoloration can occur with phototherapy and are typically monitored rather than treated as an immediate emergency unless accompanied by other concerning findings.

Question 36

The nurse is caring for a diabetic, postpartum client who has developed an infection. The nurse is aware that infections in diabetic clients tend to be more severe and can quickly lead to complications. The nurse should assess this client for which condition?

Accepted Answer

Answer reason: Postpartum clients may have fluctuating insulin needs, and when combined with infection, impaired glucose utilization can drive lipolysis and ketone production leading to metabolic acidosis and dehydration. Early assessment for diabetic ketoacidosis is critical because it can progress quickly to shock and altered mental status if not treated promptly. Anemia does not represent the characteristic rapid, life-threatening complication pattern triggered by infection in diabetes, and respiratory acid–base disorders are not the primary expected emergency mechanism here.

Question 37

Which strategy is the best plan of care for a child with acute epiglottitis?

Accepted Answer

Answer reason: Acute epiglottitis is an airway emergency where any action that increases agitation or obstructs airflow can precipitate sudden complete airway blockage. Upright positioning optimizes airway patency, decreases work of breathing, and supports oxygenation while definitive airway management is arranged. Offering oral fluids can worsen distress and aspiration risk, and interventions that provoke crying or swallowing can rapidly deteriorate the airway. Antibiotics are important but are secondary to immediate airway support and stabilization, and routine respiratory isolation is not the priority for preventing imminent respiratory failure.

Question 38

A 40-year-old client is being treated for GI bleeding. On his fifth day of hospitalization, he begins to have tremors, is agitated, and is experiencing hallucinations. The nurse is aware that these symptoms may indicate which condition?

Accepted Answer

Answer reason: Tremors, marked agitation, and hallucinations on hospital day 5 are classic for alcohol withdrawal (potentially progressing to delirium tremens), especially when access to alcohol is interrupted by hospitalization. An allergic response more typically presents with urticaria, bronchospasm, or hypotension rather than prominent tremor and hallucinations. Hypoxia can cause restlessness and confusion, but hallucinations with tremor in this timeframe more strongly points to withdrawal and requires urgent safety monitoring and treatment.

Question 39

A client found unconscious at home is brought to the emergency department. Physical examination shows cherry-red mucous membranes, nail beds, and skin. The nurse interprets these findings as indicating which of the following?

Accepted Answer

Answer reason: Being found unconscious at home strongly supports an inhalational household exposure scenario (e.g., faulty heater, poor ventilation). This finding is not typical of aspirin toxicity, which more often causes tinnitus, hyperventilation, and mixed respiratory alkalosis/metabolic acidosis. Hydrocarbon ingestion primarily causes respiratory irritation/aspiration pneumonitis, and spider bites usually produce local necrosis or systemic neurotoxic effects rather than diffuse cherry-red coloration.

Question 40

The client has an entrance wound on the right hand and an exit wound on the left hand after contact with a high-power electrical line. Considering the nature and trajectory of the electrical current, which nursing action is priority?

Accepted Answer

Answer reason: The priority is immediate cardiac assessment because arrhythmias can be sudden and rapidly fatal even when external burns appear limited. A 12-lead provides a baseline and can reveal ischemia, conduction blocks, or ectopy that guide urgent monitoring and treatment. Neuro checks, lung auscultation, and extremity ROM are important secondary assessments but do not address the most time-sensitive life threat from this current path.

Question 41

The nurse is caring for the client involved in an MVA who sustained an unstable pelvic fracture. Which HCP order should be the nurse’s priority?

Accepted Answer

Answer reason: Administering blood directly supports oxygen-carrying capacity and circulating volume while definitive hemorrhage control is arranged. Diagnostic tests like CT are important but should not delay life-saving resuscitation when internal bleeding is likely. Screening tests (urinalysis, toxicology) are non-urgent compared with treating potential exsanguination.

Question 42

The nurse is admitting a hospitalized client who has a renal calculi. Which should be the nurse's priority?

Accepted Answer

Answer reason: Initial nursing priority on admission follows ABCs and immediate physiologic stability, beginning with a focused assessment to identify urgent complications and guide rapid interventions. Renal colic can be severe and may indicate obstruction; characterizing pain location, severity, and associated symptoms helps determine acuity and the need for prompt analgesia and further evaluation. While increasing fluids and straining urine are important, they are secondary actions that should follow assessment and stabilization, and aggressive fluids may be inappropriate if there is significant obstruction. Informed consent for a procedure is not a priority at admission and is typically obtained by the provider performing the procedure, with the nurse verifying understanding and documentation.

Question 43

The nurse is caring for the 12-kg child following cardiac surgery. The chest tube drainage totals 200 mL for the past hour. Which is the nurse’s best action?

Accepted Answer

Answer reason: Excessive chest tube output after cardiac surgery can indicate active hemorrhage with risk for rapid hypovolemia and shock, requiring urgent escalation of care. For a 12-kg child, 200 mL in one hour is a large volume loss and is not expected postoperative drainage. The priority nursing action is to immediately alert the provider/surgical team so evaluation and interventions (e.g., labs, volume/blood replacement, possible return to OR) can occur without delay. Routine actions like documenting/monitoring or troubleshooting connections do not address the immediate threat to perfusion and can dangerously postpone definitive management.

Question 44

The 6-year-old child is diagnosed with pheochromocytoma. Which assessment finding should lead the nurse to conclude that this child is in crisis?

Accepted Answer

Answer reason: Marked agitation and hyperexcitability are consistent with acute adrenergic toxicity and would prompt urgent evaluation for associated hypertensive emergency, tachyarrhythmias, and end-organ compromise. The other options are either nonspecific or do not fit the expected crisis picture; for example, a systolic BP of 120 mm Hg in a 6-year-old is not a clear hypertensive crisis indicator, and bradycardia is less consistent with catecholamine excess. Urine color/muscle pain suggests rhabdomyolysis or hemoglobin/myoglobin issues rather than a classic pheochromocytoma crisis presentation. Therefore, the neurologic/behavioral adrenergic signs are the most concerning for crisis.

Question 45

A 19-year-old client went to a party, took “some pills,” and drank beer. He is brought to the emergency department because he won’t wake up. When assessing the client, the nurse would anticipate which of the following?

Accepted Answer

Answer reason: The expected assessment finding is hypoventilation, which commonly presents as slow, shallow breathing and can rapidly progress to apnea. This finding is the most immediately dangerous because it threatens oxygenation/ventilation and signals need for airway support and possible antidote depending on suspected agent (e.g., opioids). Hyperreflexia and muscle spasms are more consistent with stimulant/toxin syndromes (e.g., serotonin syndrome) rather than depressant overdose, and tachypnea is less typical when the primary problem is respiratory depression.

Question 46

The nurse’s initial assessment of the client is indicative of probable opioid overdose complicated by alcohol ingestion. What is the most important intervention for the nurse to perform?

Accepted Answer

Answer reason: Administer I.V. naloxone (Narcan). Opioid overdose is a time-critical emergency because it can rapidly cause life-threatening respiratory depression and hypoventilation. A fast-acting opioid antagonist reverses opioid effects at the receptor level, directly addressing the most immediate threat to airway and breathing even when alcohol co-ingestion is present. Fluids and drug screening do not reverse the primary cause of ventilatory failure and can be delayed until stabilization. Monitoring alone is insufficient because deterioration can occur quickly without active reversal and supportive measures.

Question 47

A client ingested a large amount of acetaminophen at 1:00 a.m. Two hours later, the client comes to the emergency department and is diagnosed with acetaminophen poisoning. What is the priority intervention for this client?

Accepted Answer

Answer reason: Early management of an acute overdose prioritizes limiting further absorption of the toxin while simultaneously stabilizing the patient. Within a few hours of ingestion, activated charcoal can bind acetaminophen in the GI tract and reduce systemic uptake, making it the most time-sensitive initial intervention among the choices. Gastric lavage is rarely indicated and is generally reserved for life-threatening ingestions very soon after ingestion with protected airway. Blood work (including acetaminophen level and liver enzymes) is important to guide antidote therapy, but it does not mitigate absorption and therefore is not the first priority action in this timing window.

Question 48

A team of nurses is preparing a trauma room for the arrival of a child with partial-thickness burns to both lower extremities and portions of the trunk. Which fluid should be ready for immediate use?

Accepted Answer

Answer reason: This fluid most directly supports intravascular volume expansion early and aligns with standard initial burn resuscitation formulas. Hypotonic fluids containing dextrose can worsen hyponatremia and third-spacing and are not first-line for initial volume replacement. Colloids and potassium-containing solutions are avoided initially because vascular permeability is high early on and urine output/renal function must be established before adding potassium.

Question 49

A 10-month-old child is found choking and soon becomes unconscious. Which intervention should a nurse attempt first after opening the airway?

Accepted Answer

Answer reason: In an unconscious infant with suspected foreign-body airway obstruction, the priority after opening the airway is to attempt ventilation to determine if air will move and to provide oxygenation. If breaths do not go in, this confirms persistent obstruction and triggers cycles of CPR with chest compressions and visual inspection/removal of a visible object. Blind finger sweeps are avoided because they can push the object deeper and cause trauma. Back blows and chest thrusts are indicated for a conscious choking infant; once unconscious, management shifts to ventilation attempts and CPR-based relief of the obstruction.

Question 50

The client just returned to the nursing unit following a total laryngectomy. Which observation by the nurse requires the most immediate intervention?

Accepted Answer

Answer reason: Post-laryngectomy patients are at high risk for acute airway and oxygenation compromise, and hypoxemia is an immediate life threat requiring rapid intervention. An SpO2 of 82% indicates severe inadequate oxygenation and demands prompt assessment of the airway/stoma patency, oxygen delivery via the stoma, and possible suctioning or escalation of care. Inability to speak is expected after total laryngectomy due to loss of vocal cords and is not emergent. Blood-tinged secretions and a partially filled JP drain can occur postoperatively and are typically monitored unless bleeding becomes heavy or signs of shock develop.

Train with a large NCLEX question bank and jump into a full exam-style simulator

Medical Emergencies NCLEX Practice Test

Continue Learning