Question 1

The intensive care nurse is caring for a client diagnosed with a closed head injury. Which data would warrant immediate intervention?

Accepted Answer

Answer reason: A rapid drop in level of consciousness after head injury signals acute neurologic deterioration and possible rising intracranial pressure or expanding intracranial bleed. A change from a mild impairment (13) to a severe impairment (7) represents a major decline that threatens airway protection and cerebral perfusion and requires immediate escalation (airway support, urgent neuro evaluation/imaging). Headache can occur with closed head injury and is concerning but is not as immediately life-threatening as a marked GCS decline. Refusing to cough and deep-breathe increases pulmonary complication risk but does not supersede emergent neuro decline in priority.

Question 2

The UAP is holding the arms of a client who is having a tonic-clonic seizure. Which action should the nurse implement?

Accepted Answer

Answer reason: During a tonic-clonic seizure, restraining a client’s limbs increases the risk of fractures, joint dislocation, and soft-tissue injury because the involuntary muscle contractions are forceful and uncontrolled. The priority nursing action is to protect the client from injury by clearing hazards, supporting the head, and positioning to maintain airway/safety rather than restricting movement. The assistant should be directed to stop holding the arms and instead help with safe measures such as lowering the client to the floor/bed, padding side rails if available, and turning the client to the side after the seizure. Options that involve restraining or delaying action fail to address immediate safety and can worsen harm; notifying the charge nurse can occur after immediate protective actions are initiated.

Question 3

The client is admitted to the intensive care unit (ICU) experiencing status epilepticus. Which intervention should the nurse anticipate implementing first?

Accepted Answer

Answer reason: Status epilepticus is a neurologic emergency where ongoing seizure activity must be stopped rapidly to prevent hypoxia, acidosis, hyperthermia, and neuronal injury. First-line immediate pharmacologic treatment is an IV benzodiazepine because it has the fastest onset to abort active seizures. Ongoing monitoring (neuro checks, telemetry) is important but does not terminate the seizure and therefore is not the initial priority intervention. Longer-acting antiepileptics may follow for seizure prevention, but they are typically second-line after a rapid benzodiazepine to achieve immediate seizure control.

Question 4

A 31-year-old client is admitted to the hospital with respiratory failure. He is intubated in the emergency department, placed on 100% FIO2, and is coughing up copious secretions. What is the most appropriate action by the nurse?

Accepted Answer

Answer reason: Airway patency and oxygenation take priority in an intubated patient with respiratory failure, and copious secretions can obstruct the endotracheal tube and worsen ventilation. Immediate suctioning removes secretions, improves gas exchange, and decreases the risk of acute hypoxemia and ventilator-associated complications from retained secretions. An ABG and chest X-ray are important assessments after intubation, but they do not correct the immediate, reversible cause of compromised ventilation. Restraints are only indicated if the patient is pulling at the tube or lines and should never delay an urgent airway intervention.

Question 5

The client diagnosed with mitral valve stenosis complains of shortness of breath and chest pain while ambulating in the hall with a UAP. Which action should the nurse implement first?

Accepted Answer

Answer reason: Shortness of breath with chest pain during ambulation suggests acute cardiac decompensation or ischemia, so the immediate priority is to reduce myocardial oxygen demand and prevent collapse. Stopping activity and placing the client in a seated position quickly decreases exertional workload and improves safety while assessment begins. Delegating vital signs or obtaining an ECG are important but should follow immediate stabilization because they do not address the immediate risk of worsening symptoms and potential syncope. Asking about prior episodes delays urgent intervention when current symptoms indicate a possible emergent change in status.

Question 6

The nurse is educating a client who is diagnosed with hypothyroidism. The nurse explains the importance of medication adherence and the potential effects of trauma, emergency surgery, or severe infection, which would place the client at risk for which condition?

Accepted Answer

Answer reason: These stressors increase physiologic demands while thyroid hormone is insufficient, leading to impaired thermoregulation and ventilation with progressive hypoventilation, hypotension/bradycardia, and altered mental status. Medication nonadherence increases the likelihood that baseline thyroid hormone levels are too low to tolerate acute stress, making this emergency more likely. In contrast, thyroid storm is a hyperthyroid crisis, and malignant hyperthermia is an anesthesia-related genetic disorder rather than a hypothyroid complication.

Question 7

The nurse is assessing a client in the emergency room who was bitten by a brown recluse spider. Documentation of the assessment is correct when which of the following assessments has been recorded in the client’s record?

Accepted Answer

Answer reason: Accurate documentation should reflect localized pain and evolving necrosis at the bite site as key assessment findings. A bull’s-eye rash is characteristic of erythema migrans from Lyme disease, not spider bite. A herald patch suggests pityriasis rosea, and a linear papulovesicular eruption is more consistent with allergic contact dermatitis (e.g., poison ivy) rather than a recluse bite.

Question 8

The client with a left anterior descending (LAD) 90% blockage has crushing chest pain that is unrelieved by taking sublingual nitroglycerin. Which ECG finding is most concerning and should alert the nurse to immediately notify the HCP?

Accepted Answer

Answer reason: ST-segment elevation is the classic ECG hallmark of an acute transmural myocardial infarction (STEMI) and indicates time-critical myocardial injury, especially concerning with LAD disease because it can involve a large anterior territory. This finding warrants immediate provider notification for rapid activation of STEMI protocols (e.g., cath lab, thrombolysis when appropriate). By comparison, flipped T waves suggest ischemia but are less definitive for acute full-thickness injury, while Q waves typically reflect established infarction rather than an immediate evolving emergency; peaked T waves more commonly point to hyperkalemia.

Question 9

The triage nurse in the ED determines that the child is experiencing severe respiratory distress. Which assessment findings support the nurse’s conclusion?

Accepted Answer

Answer reason: Retractions and grunting indicate significant effort to maintain ventilation and functional residual capacity, while cyanosis reflects inadequate oxygenation. Bradycardia in a child is a late, ominous sign often caused by worsening hypoxia and decompensation, making this constellation highest acuity. Options with tachypnea/restlessness or wheeze without cyanosis/bradycardia are more consistent with earlier or less severe distress.

Question 10

The nurse is formulating a plan of care for the 22-month—old child with an LTB. Which symptoms should indicate to the nurse that the child is experiencing impending respiratory failure?

Accepted Answer

Answer reason: In LTB (croup), a child who is tiring may have decreasing breath sounds as airflow drops, which is a late and dangerous sign requiring urgent escalation. Earlier findings such as a barking cough or hoarseness can occur without impending failure and do not necessarily reflect inadequate ventilation. Behavioral changes like restlessness can be early hypoxia, but reduced inspiratory breath sounds more directly indicates critically reduced air entry.

Question 11

The heart rhythm of a client who has experienced cardiac arrest and is receiving cardiopulmonary resuscitation (CPR) deteriorates to ventricular fibrillation. What is the most important action of the nurse?

Accepted Answer

Answer reason: Ventricular fibrillation is a shockable cardiac arrest rhythm, and the priority is rapid defibrillation to terminate the chaotic electrical activity so an organized rhythm with perfusion can return. While high-quality CPR is essential, it is a bridging action that maintains some circulation until the definitive therapy (shock) can be delivered. Epinephrine is given after defibrillation attempts in the arrest algorithm and does not replace immediate defibrillation for VF. Vasopressin is not a first-line immediate step and is no longer prioritized over epinephrine in modern arrest management, making it inferior to prompt defibrillation here.

Question 12

A pregnant client arrives at the emergency department with abruptio placentae at 34 weeks’ gestation. The nurse is aware that the client is at risk for developing?

Accepted Answer

Answer reason: Abruptio placentae can trigger massive release of tissue thromboplastin from the damaged placenta into maternal circulation, activating widespread coagulation. This leads to consumption of platelets and clotting factors with secondary fibrinolysis, creating simultaneous microthrombi formation and bleeding risk. Clinically, this is a high-acuity obstetric emergency because uncontrolled hemorrhage can rapidly develop and labs may show falling fibrinogen, elevated D-dimer, and prolonged PT/aPTT. Isolated thrombocytopenia may occur as part of the consumptive process, but DIC best captures the systemic, life-threatening complication tied to placental abruption.

Question 13

A 19-year-old client comes to the emergency department with acute asthma. His respiratory rate is 44 breaths/minute, and he appears in acute respiratory distress. What is the most important action for the nurse to take?

Accepted Answer

Answer reason: The priority in acute asthma with severe tachypnea and visible respiratory distress is rapid reversal of bronchospasm to improve ventilation and oxygenation. A short-acting bronchodilator via nebulizer provides fast onset airway smooth-muscle relaxation and is a first-line emergency intervention. A full history and emotional support are important but must not delay immediate life-saving treatment. Applying a cardiac monitor can be done after initiating airway/breathing stabilization, as it does not directly relieve the obstruction driving the emergency.

Question 14

During observation of a child who has undergone cardiac catheterization, the nurse notes significant bleeding from the percutaneous femoral catheterization site. Which action should be taken first?

Accepted Answer

Answer reason: Uncontrolled hemorrhage is an immediate threat to circulation and requires prompt bleeding control before further assessment steps. Direct, continuous pressure at the femoral access site is the fastest intervention to reduce blood loss and prevent progression to hypovolemia and shock. Assessing vital signs and distal pulses is important, but delaying hemostasis risks rapid deterioration, especially in children with smaller circulating blood volume. Calling for assistance can occur simultaneously, but the nurse’s first priority action is to stop the bleeding at the source.

Question 15

A 14-year-old girl is admitted for sickle cell crisis. Which nursing intervention would be the most important?

Accepted Answer

Answer reason: Oxygen (as indicated), aggressive hydration, and timely analgesia address the core pathophysiology by improving perfusion/oxygenation and decreasing blood viscosity while controlling the stress response that can worsen sickling. Temperature monitoring can help detect infection, but it does not treat the acute crisis and is secondary to stabilizing oxygenation, circulation, and pain. Psychosocial assessment and family involvement are important but are not the most urgent interventions during an acute crisis.

Question 16

The nurse is teaching parents how to care for a child with bronchiolitis at home. What is the most important information for the nurse to provide?

Accepted Answer

Answer reason: Bronchiolitis can deteriorate quickly due to worsening lower-airway obstruction and fatigue, so caregiver education must prioritize early identification of danger signs to prevent hypoxemia and respiratory failure. Teaching parents to watch for increased work of breathing (retractions, nasal flaring, grunting), tachypnea, poor feeding, lethargy, or cyanosis supports timely escalation to urgent/emergency care. Prone positioning is unsafe for infants at home because it increases SIDS risk, so it is not appropriate as key home-care teaching. Warm mist is not a primary or reliably effective home intervention and can pose burn risk; the critical safety focus is recognizing worsening respiratory status.

Question 17

The adult client is newly admitted to the PACU from surgery. Which assessment finding should be the nurse’s priority?

Accepted Answer

Answer reason: Airway and breathing take priority in immediate post-op care because residual anesthesia/opioids can rapidly cause hypoventilation and hypoxemia. A respiratory rate of 6–8/min indicates clinically significant respiratory depression requiring urgent intervention (stimulation, airway support, oxygen, and possible naloxone per protocol). The other findings are expected/less urgent in PACU: scant drainage can be normal, easy arousability suggests adequate emergence, and the listed blood pressure is stable and not time-critical compared with ventilation failure. Addressing inadequate respirations prevents impending respiratory arrest and secondary hemodynamic collapse.

Question 18

The male client with a C-6 SCI tells the home health nurse he has had a severe pounding headache for the last 2 hours. Which intervention should the clinic nurse implement?

Accepted Answer

Answer reason: A severe, pounding headache in a patient with a high spinal cord injury strongly suggests autonomic dysreflexia, a time-sensitive emergency triggered by noxious stimuli below the lesion. The most common trigger is bladder distention from urinary retention or a blocked catheter, so immediately assessing recent urination/output helps identify and remove the precipitating cause quickly. Prompt recognition and relief of the trigger reduces the risk of dangerous hypertension and complications such as seizure or stroke. While constipation can also precipitate this syndrome, bladder issues are more frequent and should be assessed first when rapid intervention is needed.

Question 19

The nurse is admitting a client diagnosed with meningococcal meningitis and notes lesions over the face and extremities. Which priority intervention should the nurse implement?

Accepted Answer

Answer reason: Meningococcal meningitis with skin lesions suggests meningococcemia, a rapidly progressive, life-threatening infection that can deteriorate into septic shock and DIC within hours. The priority is immediate time-sensitive therapy to reduce bacterial load and improve survival, so empiric IV antibiotics must be started without delay. Diagnostic steps or additional assessments should not postpone definitive treatment when the diagnosis is already established and the presentation signals systemic involvement. Comfort measures for photophobia and a full neuro exam are appropriate but are secondary to urgent antimicrobial management.

Question 20

A client complains of crushing chest pain 3 hours prior to arrival in the emergency department. Initial vital signs show hypotension; a weak, thready pulse; cool, clammy skin; and confusion. Which intervention should the nurse perform first?

Accepted Answer

Answer reason: This presentation (hypotension, weak thready pulse, cool clammy skin, confusion) indicates shock with impaired perfusion and a high risk of rapid deterioration in oxygenation. The first priority is ABCs—ensure a patent airway and support breathing/oxygen delivery to prevent hypoxemia and cardiac arrest. Establishing IV access and obtaining a 12-lead EKG are important but are secondary to stabilizing airway/ventilation when signs of shock and altered mentation are present. Preparing for an intra-aortic balloon pump is an advanced therapy that is not the immediate first nursing action before initial stabilization.

Question 21

A client complains of progressively worsening shortness of breath since cutting the grass 3 days ago. The client has a history of asthma. The nurse knows this client is having a severe exacerbation and should immediately receive?

Accepted Answer

Answer reason: Airway and breathing support take priority in an acute severe asthma exacerbation because ventilation–perfusion mismatch can rapidly lead to hypoxemia. Immediate supplemental oxygen is the fastest intervention to improve oxygenation while other therapies are being prepared and administered. Inhaled short-acting beta2-agonists and systemic corticosteroids are essential, but they act on bronchospasm and airway inflammation and do not correct low oxygen saturation as immediately. IV fluids do not treat the underlying respiratory compromise and can worsen work of breathing if fluid overload develops.

Question 22

The nurse is assessing a 43-year-old client who sustained blunt chest trauma from a motor vehicle collision. The assessment data include sinus tachycardia, hypotension, and muffled heart sounds. There are no obvious signs of bleeding. The nurse interprets this information as indicating which condition?

Accepted Answer

Answer reason: Hypotension and sinus tachycardia reflect obstructive shock physiology from impaired preload. Muffled heart sounds are a classic finding because fluid/blood dampens transmission of cardiac sounds (part of Beck’s triad). The absence of external bleeding supports an internal obstructive cause rather than hemorrhagic shock, and pneumothorax would more typically be associated with unilateral absent breath sounds and hyperresonance rather than muffled heart tones.

Question 23

While the nurse is ambulating the client diagnosed with angina to the bathroom, the client begins to complain of chest pain radiating to the left arm. Which intervention should the nurse implement first?

Accepted Answer

Answer reason: Angina pain during ambulation signals myocardial ischemia from an oxygen supply–demand mismatch, so the first priority is to immediately decrease cardiac workload. Stopping activity and placing the client at rest (bed) reduces heart rate, blood pressure, and oxygen consumption, which can quickly lessen ischemia. After rest is initiated, the nurse can then administer prescribed sublingual nitroglycerin and apply oxygen as indicated by oxygen saturation/respiratory status. A stat ECG is important to evaluate for acute coronary syndrome, but it does not treat the immediate ischemic demand and should follow rapid stabilization measures.

Question 24

The nurse is caring for a client who is 1 day postoperative from a total thyroidectomy. The nurse determines it is necessary to call the rapid response team (RRT) when the client displays which of the following?

Accepted Answer

Answer reason: A harsh, high-pitched sound suggests upper-airway obstruction with impending respiratory failure, requiring immediate escalation and airway preparedness. Mild postoperative hoarseness can occur from endotracheal irritation or transient nerve irritation and is typically monitored rather than treated as an emergency unless worsening with respiratory distress. A blood pressure of 150/92 is not as immediately life-threatening as signs of airway obstruction, and decreased deep tendon reflexes is more consistent with hypercalcemia rather than the urgent hypocalcemia complications expected after thyroid/parathyroid disruption.

Question 25

A client with diabetes presents with polyphagia, polydipsia, and oliguria; he also complains of headache, malaise, and some visual changes. Assessment shows signs of dehydration. The nurse determines the client may be experiencing which condition?

Accepted Answer

Answer reason: The cluster of polydipsia, polyphagia, headache/malaise, and visual changes is most consistent with significant hyperglycemia, and dehydration can progress to reduced renal perfusion with decreased urine output (oliguria). Diabetes insipidus would cause marked polyuria rather than oliguria, and SIADH typically presents with fluid retention and hyponatremia rather than dehydration. Hypoglycemia more often causes adrenergic/neuroglycopenic symptoms (diaphoresis, tremor, confusion) instead of dehydration from hyperglycemia.

Question 26

The nurse observes sinus tachycardia with new-onset ST segment elevation on the ECG monitor of the client reporting chest pain. Which should be the nurse’s priority intervention?

Accepted Answer

Answer reason: Supplemental oxygen is a rapid, low-risk intervention the nurse can initiate at the bedside while activating the rest of the MI pathway. Drawing enzymes helps confirm diagnosis but does not treat the immediate threat and should not delay stabilizing measures. Nitroglycerin may be appropriate after assessing blood pressure and contraindications (e.g., RV infarct/PDE-5 inhibitor use), and contacting the cath lab is crucial but is not the first bedside intervention compared with ensuring oxygenation and initial stabilization.

Question 27

The nurse assesses the client brought to the ED via ambulance after a motorcycle crash. The client has paradoxical chest movement with respirations, multiple bruises across the chest and torso, crepitus, and tachypnea. What should the nurse do next?

Accepted Answer

Answer reason: Paradoxical chest movement after blunt trauma strongly suggests flail chest with underlying pulmonary contusion, which can rapidly progress to respiratory failure. The priority is ABCs—support ventilation and oxygenation—so anticipating advanced airway management is the most time-critical next step when tachypnea and chest wall instability are present. Securing additional IV access may be helpful but does not address the immediate threat of inadequate ventilation. Circumferential chest taping is contraindicated because it restricts chest expansion and can worsen hypoventilation; cervical collar adjustment is not the priority without an airway/breathing intervention need.

Question 28

The child is hospitalized after experiencing a sore throat and difficulty swallowing for a week. Laboratory tests reveal elevated WBCs, bands, and neutrophils. A throat culture completed a week ago showed Hemophizilus influenza type B. Based on the information, the nurse should be implementing interventions to treat which problem?

Accepted Answer

Answer reason: The history of severe sore throat and dysphagia with neutrophilic leukocytosis supports an invasive bacterial process rather than a viral lower-airway illness. Nursing care priorities for this condition center on airway protection, minimizing agitation, and readiness for advanced airway management and IV antibiotics. Bronchiolitis is typically viral (RSV) with wheezing and lower-respiratory signs, and tuberculosis is a chronic, systemic process rather than an acute throat-based presentation.

Question 29

A client has developed a fat embolus. The nurse is aware that the treatment of choice would be which of the following?

Accepted Answer

Answer reason: Antibiotics, I.V. fluids, steroids, and oxygen Fat embolism syndrome is managed primarily with rapid supportive care to treat hypoxemia and limit inflammatory lung injury while maintaining hemodynamic stability. High-flow oxygen and IV fluids are key to improve oxygen delivery and perfusion, and corticosteroids are commonly taught in NCLEX-style materials as part of therapy to reduce the inflammatory response and pulmonary edema. Antibiotics may be included when differentiating from or preventing secondary infection in this acute post-trauma setting, whereas bronchodilators or theophylline are not core treatments for fat embolism. Opioids can help pain/anxiety but are not the treatment of choice compared with immediate oxygenation and supportive measures.

Question 30

A client’s intracranial pressure (ICP) is fluctuating between 20 and 25 mm Hg. Which of the following nursing interventions is the most appropriate?

Accepted Answer

Answer reason: ICP of 20–25 mm Hg is elevated and can rapidly compromise cerebral perfusion and oxygenation, so the first nursing action is a rapid, systematic assessment of life-sustaining functions. Evaluating airway patency, ventilation/oxygenation, and circulation identifies immediately reversible causes of rising ICP (e.g., hypoventilation with hypercapnia, hypoxia, hypotension) and guides urgent escalation of care. The other options are either unsafe or non-priority: lowering the head of bed can worsen venous drainage and increase ICP, and encouraging visitation may increase stimulation. Targeting a MAP “less than 90” is not the goal; maintaining adequate MAP is critical to preserve cerebral perfusion pressure when ICP is high.

Question 31

A client in status epilepticus arrives at the emergency department accompanied by a family member. The nurse asks the client’s family member if anything may have predisposed the client to this condition. The nurse is most concerned when the family member states that the client?

Accepted Answer

Answer reason: Abrupt withdrawal of antiepileptic medication can rapidly lower the seizure threshold and precipitate seizure clustering, including progression to status epilepticus. This is a high-risk, directly causal history element that signals medication nonadherence/withdrawal as an immediate trigger requiring urgent stabilization and prevention of recurrence. The other choices are not typical direct precipitants of status epilepticus in the way sudden antiepileptic cessation is. Identifying this trigger also guides immediate management considerations (e.g., medication reconciliation and re-establishing therapeutic anticonvulsant levels once stabilized).

Question 32

A client is admitted with intervertebral disk prolapse and now shows new symptoms of loss of bladder control and paralysis of both legs. Which of the following nursing interventions should be the priority?

Accepted Answer

Answer reason: The nurse’s top priority is rapid escalation to the provider/rapid response pathway to prevent permanent neurologic deficits. Obtaining urinary drainage and giving anti-inflammatory medication may be supportive but must not delay definitive management. Increasing vital-sign frequency does not address the time-sensitive neurologic emergency and is a lower-priority action.

Question 33

A 2-year-old child comes to the emergency department with inspiratory stridor and a barking cough. A preliminary diagnosis of croup has been made. What is the most important intervention for the nurse to provide?

Accepted Answer

Answer reason: Airway patency is the top priority in any child with stridor because it signals upper-airway narrowing that can rapidly progress to obstruction. Croup causes subglottic edema, so immediate nursing focus is positioning, minimizing agitation, and being prepared for escalation (humidified oxygen, nebulized epinephrine, corticosteroids, and advanced airway support if worsening). Oxygen by mask may help hypoxemia, but it is secondary to ensuring a stable airway and may increase distress if forced. I.V. antibiotics are not routine for viral croup, and separating the parent can increase anxiety and worsen airway compromise.

Question 34

A client complains of wheezing, cough, and chest tightness. The client has a history of asthma, but has been out of medications for this condition for the past 3 weeks. Which is a priority nursing intervention?

Accepted Answer

Answer reason: Acute asthma symptoms reflect bronchospasm and airflow obstruction, so the immediate priority is to rapidly reverse bronchoconstriction and improve ventilation. A short-acting beta-agonist provides the fastest relief of wheeze, cough, and chest tightness and is first-line for an acute exacerbation. Corticosteroids (inhaled or systemic) reduce airway inflammation but have a delayed onset and are not the quickest intervention to relieve acute bronchospasm. Systemic steroids may be added if symptoms are moderate/severe or not responding, but initial priority is prompt rescue bronchodilation to prevent progression to respiratory failure.

Question 35

Aspiration is defined as the passage of regurgitated gastric contents or other foreign materials into the trachea and down to the smaller air units. The most common and severest form of aspiration is the aspiration of gastric contents. If aspiration is suspected, the nurse should?

Accepted Answer

Answer reason: Aspiration can rapidly cause hypoxemia from airway obstruction, chemical pneumonitis, and ventilation-perfusion mismatch, so airway and breathing take priority over notification steps. High-concentration supplemental oxygen is an immediate nursing intervention to support oxygenation while further assessment and interventions occur (e.g., positioning, suctioning, preparing for possible intubation). Calling the provider is important but should not delay stabilizing respiratory status. Lowering the head of the bed or elevating the foot of the bed can worsen aspiration risk and does not address the acute oxygenation problem.

Question 36

The mother of a 2-year-old child with epiglottitis says she needs to pick up her older child from school. The 2-year-old child begins to cry and appears more stridorous. What is the priority action by the nurse?

Accepted Answer

Answer reason: Epiglottitis is an airway emergency in which agitation and crying can rapidly worsen upper-airway obstruction, evidenced by increasing stridor. The priority is to minimize distress and keep the child calm while ensuring constant readiness for airway intervention, which is best supported by keeping the parent present. Arranging an alternative plan for the older child directly addresses the trigger for separation and helps reduce the child’s agitation. Reassurance statements without solving the separation issue are less effective and do not address the immediate airway-risk driver.

Question 37

A client with difficulty breathing has a respiratory rate of 34 breaths/minute and demonstrates anxious behaviors. He’s refusing all his medications, claiming they’re making him worse. Which nursing action is best?

Accepted Answer

Answer reason: Tachypnea with dyspnea and escalating anxiety can signal worsening respiratory compromise that requires urgent reassessment and possible escalation of therapy. A respiratory rate of 34/min indicates significant distress; refusal of all medications may further increase risk if critical treatments (e.g., bronchodilators, antibiotics, steroids) are being withheld. The priority is to communicate the acute change in condition so orders can be reviewed, causes evaluated, and immediate interventions initiated. Simply delaying meds or trying to negotiate partial adherence does not address the potential emergency, and covert administration violates informed consent and client rights.

Question 38

Emergency medical system personnel have used the Cincinnati Prehospital Stroke Scale to assess a client and have alerted the hospital that they’re transporting a client with a possible stroke. The nurse plans to administer fibrinolytics within which time period?

Accepted Answer

Answer reason: The widely tested target is administration within 60 minutes of ED arrival once eligibility is confirmed (e.g., noncontrast CT excludes hemorrhage and contraindications are ruled out). “4 hours of the onset of symptoms” is imprecise and does not reflect the core operational metric used in emergency stroke protocols. The shorter ED-time options reflect other stroke-system goals (such as rapid triage/CT) rather than the medication administration window.

Question 39

A client presents with diaphoresis, palpitations, jitters, and tachycardia approximately 1.5 hours after taking his regular morning insulin. What is the most appropriate intervention by the nurse?

Accepted Answer

Answer reason: These are classic adrenergic manifestations of hypoglycemia occurring at peak insulin action, which is an immediate safety threat. The nurse should rapidly confirm with a bedside glucose check while treating promptly with fast-acting carbohydrate to prevent neuroglycopenia and deterioration. Chest-pain protocols (nitroglycerin/ECG) do not match the insulin-timing pattern and symptom cluster. Giving more insulin would worsen the underlying problem, and the paracentesis/diuretic option is unrelated.

Question 40

The nurse checks on a diabetic client and finds the client lethargic, difficult to arouse, and profusely diaphoretic. The nurse immediately checks the client's blood glucose and finds it to be 40 mg/dl. Which of the following interventions is the priority?

Accepted Answer

Answer reason: Severe hypoglycemia with altered level of consciousness is a medical emergency requiring immediate rapid-acting glucose support while protecting the airway. Because the client is lethargic and difficult to arouse, oral carbohydrate is unsafe due to aspiration risk. Glucagon provides a prompt rise in serum glucose by stimulating hepatic glycogenolysis and can be given quickly without IV access. Assessing ketones and obtaining more insulin address hyperglycemia/ketosis and would worsen this presentation, delaying lifesaving treatment.

Question 41

The nurse is developing the plan of care for the child hospitalized in sickle cell crisis. Which nursing problem is priority?

Accepted Answer

Answer reason: In sickle cell crisis, vaso-occlusion can cause acute chest syndrome, where pulmonary infiltrates and hypoxemia reflect compromised perfusion and gas exchange that requires immediate intervention (oxygen, aggressive management, escalation). Pain and dehydration are important contributors to sickling, but they are addressed after stabilizing cardiopulmonary status. Infection risk is significant in sickle cell disease, yet it is not as immediately time-critical as acute pulmonary perfusion compromise during a crisis.

Question 42

A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 mm Hg and heart rate of 50 beats/minute. Which nursing intervention should be done first?

Accepted Answer

Answer reason: This presentation is classic for autonomic dysreflexia in a client with high spinal cord injury, causing sudden, life-threatening hypertension with reflex bradycardia. The priority initial action is to rapidly lower blood pressure by placing the client upright to promote venous pooling and reduce cerebral perfusion pressure. After positioning, the nurse should promptly search for and remove the noxious trigger (most commonly bladder distention, such as a kinked/blocked catheter). Medications like nitrates are considered if hypertension persists after nonpharmacologic measures and trigger removal; lying flat would worsen hypertension and stroke risk.

Question 43

A 9-year-old child is being discharged from the hospital after severe urticaria caused by an allergy to nuts. What is the most important instruction for the nurse to give the parents?

Accepted Answer

Answer reason: Food allergies can rapidly progress from cutaneous symptoms to life-threatening anaphylaxis with airway edema, bronchospasm, and cardiovascular collapse. Discharge teaching must prioritize emergency preparedness by ensuring caregivers and the child can recognize early systemic symptoms and administer intramuscular epinephrine promptly, since delays increase morbidity and mortality. Antihistamines and topical therapies may reduce itching and hives but do not prevent or treat airway compromise or shock. Education should also include carrying the device at all times and seeking emergency care after use due to possible biphasic reactions.

Question 44

While caring for the postoperative client following a total laryngectomy with radical neck dissection, the nurse observes that the client is restless and has a respiratory rate of 28 breaths per minute. Which action is the nurse’s priority?

Accepted Answer

Answer reason: Airway patency is the immediate priority when a post-laryngectomy client shows signs of respiratory distress such as restlessness and tachypnea. After total laryngectomy, the client breathes exclusively through the stoma, and mucus plugs or retained secretions can quickly obstruct the laryngectomy tube and cause hypoxia. Clearing the obstruction by suctioning directly treats the most rapidly life-threatening cause and can promptly improve ventilation. Applying oxygen by mask is ineffective because the upper airway is no longer connected to the lungs, and assessment (e.g., pulse oximetry) should not delay an urgent airway intervention when obstruction is strongly suspected.

Question 45

The intensive care nurse is caring for a client diagnosed with a TBI who is exhibiting decorticate posturing. Three hours later the client has flaccid posturing. Which action should the nurse implement first?

Accepted Answer

Answer reason: Progression from decorticate posturing to flaccid posturing signals rapid neurologic deterioration and possible brainstem failure from rising intracranial pressure, which is an emergency requiring immediate escalation of care. The nurse’s first priority is prompt notification for urgent evaluation and potential interventions (e.g., airway/ventilation changes, hyperosmolar therapy, imaging, or surgical decompression). Administering mannitol is typically a provider-directed therapy and should not delay escalation when there are signs of impending herniation. Waiting an hour or focusing on a lengthy assessment risks delaying time-critical treatment; focused reassessment can occur while activating the provider/rapid response pathway.

Question 46

A nurse is assessing a client with a history of substance abuse who has pinpoint pupils, a heart rate of 56 beats/minute, a respiratory rate of 6 breaths/minute, and a temperature of 96.4° F. The nurse determines that which is the most likely cause of the client's symptoms?

Accepted Answer

Answer reason: The profound bradypnea (RR 6) is the most dangerous and most characteristic finding pointing to opioid overdose rather than other substances. Bradycardia and hypothermia can accompany opioid-induced depression and reduced metabolic/respiratory drive. Amphetamines typically cause mydriasis, tachycardia, hypertension, and hyperthermia, while alcohol can depress respirations but does not usually cause pinpoint pupils as a key hallmark.

Question 47

The nurse is caring for a client diagnosed with a myocardial infarction. Which assessment data would warrant immediate attention by the nurse?

Accepted Answer

Answer reason: After an MI, new or worsening ventricular dysrhythmias indicate myocardial irritability and can quickly deteriorate into ventricular tachycardia or ventricular fibrillation, making them an immediate life-threatening finding. Multifocal PVCs (varying shapes) suggest multiple ectopic foci and a higher risk of malignant arrhythmias compared with isolated unifocal PVCs. The nurse should promptly assess the patient, check electrolytes/oxygenation, and notify the provider or activate emergency response per protocol. By contrast, urine output of 120 mL over 2 hours is acceptable (60 mL/hr), and elevated cardiac enzymes/WBCs are expected trends after MI rather than an immediate emergency.

Question 48

When assessing a 5-hour-old neonate born via vaginal delivery, which finding would prompt a nurse to call a physician?

Accepted Answer

Answer reason: Color is dusky, axillary temperature is 96.8° F (37° C), and the baby is spitting up mucus. In the immediate newborn period, central color changes suggesting hypoxemia are abnormal and require prompt evaluation because they may indicate respiratory compromise. Persistent duskiness is more concerning than common transitional findings like acrocyanosis or mucus swallowing. A low temperature for a neonate (even with the unit typo in parentheses) raises concern for cold stress, which can worsen oxygen consumption and respiratory status. While mild mucus spitting can be normal after vaginal delivery, the combination with abnormal color and possible hypothermia warrants calling the physician to assess for respiratory distress or other acute pathology.

Question 49

The client diagnosed with pericarditis complains of pressure in the chest and shortness of breath. The intensive care nurse assesses a decreasing systolic blood pressure and jugular vein distention. Which collaborative intervention should the nurse anticipate for this client?

Accepted Answer

Answer reason: Decreasing systolic blood pressure with jugular venous distention in a patient with pericarditis strongly suggests acute cardiac tamponade causing obstructive shock from impaired ventricular filling. The urgent collaborative priority is to remove pericardial fluid to restore preload and cardiac output, which is accomplished by pericardiocentesis. Cardiac catheterization does not treat tamponade and would delay definitive management, while ABGs may quantify hypoxemia but do not address the rapidly worsening hemodynamics. Spiritual support can be appropriate later, but it is not the immediate life-saving intervention when tamponade is suspected.

Question 50

A 17-year-old client with diabetes has a decreased level of consciousness, with a fingerstick glucose level of 45. Her family reports that she has been skipping meals in an effort to lose weight. Which nursing intervention is most appropriate?

Accepted Answer

Answer reason: With impaired swallowing/LOC, oral carbohydrates and enteral feedings are unsafe due to aspiration risk and will not provide fast enough glucose. Glucagon can be given promptly without IV access and mobilizes hepatic glycogen to raise serum glucose quickly, making it an appropriate first response while preparing for definitive glucose replacement. A normal saline bolus treats hypovolemia/shock rather than hypoglycemia, and waiting to call for orders delays urgent treatment when a standing protocol/emergent intervention is indicated.

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

Medical Emergencies NCLEX Practice Test

Continue Learning