Question 1

A 48-year-old was seen in the Emergency Department two days ago after a motor vehicle accident and was admitted with a femur fracture, tib/fib fracture, and a splenic laceration. Which cluster of symptoms is most concerning?

Accepted Answer

Answer reason: This cluster suggests fat embolism syndrome, a time-sensitive complication classically occurring 24–72 hours after long-bone fractures. Respiratory compromise (tachypnea/hypoxemia) with a petechial rash reflects fat globules and inflammatory injury in pulmonary capillaries, which can rapidly progress to acute respiratory failure. This finding requires urgent assessment (oxygenation, ABGs) and escalation of care rather than routine pain or mobility management. By contrast, a small hemoglobin change like 13.1 to 12.7 is minimal and less predictive of acute decompensation than evolving respiratory signs after femur fracture.

Question 2

The nurse working on a medical-surgical unit is caring for assigned clients. The nurse should plan to initially assess the client who?

Accepted Answer

Answer reason: Post-thyroidectomy dysphagia can indicate evolving airway compromise from neck hematoma, laryngeal edema, or recurrent laryngeal nerve injury, making it a potential ABC emergency. This finding can precede stridor and respiratory distress, so the nurse should assess airway patency, respiratory effort, neck swelling, and ability to handle secretions immediately. The other scenarios are important but are less immediately life-threatening: wound pain needs analgesia/reassessment, and missed incentive spirometry is a preventable risk but not an acute airway obstruction. Informed consent should be addressed preoperatively, but an 8-hour window does not supersede a possible postoperative airway emergency.

Question 3

A nurse is caring for a patient diagnosed with peptic ulcer disease (PUD). Which of the following findings should the nurse report to the healthcare provider immediately?

Accepted Answer

Answer reason: Vomiting blood indicates active hemorrhage, and the accompanying hypotension suggests significant volume loss requiring urgent evaluation and resuscitation. The other findings are common, non-emergent manifestations or etiologic information that do not signal immediate instability. Prompt reporting supports rapid interventions such as IV access/fluids, type and crossmatch, and endoscopic hemostasis.

Question 4

A nurse is caring for a child who is post-tonsillectomy. Which of the following findings should the nurse report to the healthcare provider immediately?

Accepted Answer

Answer reason: Visible bright red oral bleeding indicates active bleeding that can rapidly progress and may require urgent surgical or airway intervention. Early signs of bleeding can be subtle, but frank bleeding is never expected and warrants immediate provider notification and rapid response. In contrast, mild throat pain and a low-grade fever can occur postoperatively, and occasional swallowing is more concerning when frequent/persistent (suggesting occult blood), not when occasional.

Question 5

The nurse should complete a focused assessment of which body system for a patient who recently took cocaine?

Accepted Answer

Answer reason:  Cocaine is a potent sympathomimetic that increases catecholamines, leading to tachycardia, hypertension, coronary vasospasm, and increased myocardial oxygen demand. These effects place the patient at high risk for acute chest pain syndromes, dysrhythmias, and myocardial infarction even without prior cardiac disease. A focused cardiovascular assessment (vitals, heart rhythm, perfusion, and chest pain evaluation with prompt ECG if indicated) targets the most time-sensitive, life-threatening complications. Other systems can be affected, but they are generally less immediately critical than potential cardiac ischemia/arrhythmia in recent cocaine use.

Question 6

The nurse should anticipate intubation for a patient with a Glasgow coma scale score less than what?

Accepted Answer

Answer reason: A commonly tested clinical threshold is that a GCS less than 8 indicates severe impairment with high risk of aspiration and hypoventilation, so endotracheal intubation should be anticipated. This aligns with emergency neurologic management where airway, breathing, and oxygenation are stabilized before further diagnostics or interventions. Higher scores like 10 or 13 indicate less severe impairment and do not, by themselves, mandate intubation without other signs of airway compromise.

Question 7

A 58-year-old male with a history of hypertension and diabetes is now complaining of chest pain radiating to his left arm and shortness of breath. His blood pressure is 88/52 mmHg, and his pulse is 48 beats per minute. The ECG shows sinus bradycardia with ST-segment depression. What is the priority nursing intervention at this time?

Accepted Answer

Answer reason: Unstable bradycardia with hypotension and ischemic symptoms requires immediate stabilization to restore adequate cardiac output and perfusion. With a heart rate of 48 bpm plus BP 88/52 mmHg, chest pain, and dyspnea, the patient meets criteria for urgent bradycardia management where pacing is a rapid, definitive bedside intervention. Nitrates can worsen hypotension and should be avoided in a patient already shocky. Additional diagnostics and consults are secondary to correcting the life-threatening perfusion problem first.

Question 8

The nurse provides care for a patient who returns to the unit following abdominal surgery. The most recent vital signs are as follows: temperature is 100 F (37.8 C); blood pressure (BP) is 88/60 mm Hg; heart rate (HR) is 110 beats per minute; respiratory rate is 24 breaths per minute; oxygen saturation is 97%; and the central venous pressure (CVP) is 2 mm Hg. Which healthcare provider prescription should the nurse implement first based on the current data?

Accepted Answer

Answer reason: The patient shows signs of hypovolemia (low BP, tachycardia, low CVP). The priority is rapid fluid resuscitation to restore circulating volume. Vasopressors like dopamine are not first-line until fluid status is corrected.

Question 9

Which of the following vital sign alterations would be expected in a patient with septic shock?

Accepted Answer

Answer reason: Septic shock is characterized by systemic vasodilation and capillary leakage, leading to persistent hypotension despite fluid resuscitation. The other options are inconsistent with the typical presentation.

Question 10

What should the nurse do first when a client with a head injury begins to have clear drainage from his nose?

Accepted Answer

Answer reason: Clear nasal drainage after a head injury may indicate cerebrospinal fluid (CSF) leakage. The nurse should not obstruct the flow (no compression or tilting back) because this can increase intracranial pressure or risk infection. The priority is to collect the fluid for assessment (e.g., glucose testing or halo sign) while allowing it to drain freely.

Question 11

SITUATION: A 65-year-old patient with a history of hypertension and diabetes mellitus is admitted to the hospital for chest pain. The patient is anxious, diaphoretic, and reports a pain level of 8/10 in the chest radiating to the left arm. An ECG reveals ST-segment elevation in the anterior leads. Which intervention should the nurse prioritize first?

Accepted Answer

Answer reason: This patient is experiencing an acute ST-elevation myocardial infarction (STEMI). The immediate priority is to improve oxygen delivery to ischemic myocardial tissue. Oxygen is typically administered first (especially in classic NCLEX prioritization frameworks), followed by medications such as nitroglycerin and preparation for reperfusion therapy.

Question 12

A client had a cesarean delivery 12 hours ago. Pain management includes a patient-controlled pump for the administration of Morphine (morphine sulfate). Which nursing diagnosis, if formulated for the client, is the highest priority?

Accepted Answer

Answer reason: Morphine (an opioid) can cause respiratory depression, which is a life-threatening complication. Using ABC prioritization (Airway, Breathing, Circulation), breathing takes priority over pain or other concerns. Therefore, ineffective breathing pattern is the highest priority nursing diagnosis.

Question 13

The client is admitted to the telemetry unit due to chest pain. The client has polysubstance abuse, and the nurse assesses that the client is anxious and irritable and has moist skin. What should the nurse do in order of priority from first to last? All options must be used.

Accepted Answer

Answer reason: The priority is rapid assessment and stabilization. First, obtain vital signs to assess hemodynamic status. Next, apply cardiac monitoring (electrodes) for continuous ECG. Then gather relevant history (including substance use) to guide care. Pain management (morphine) is performed after initial assessment and monitoring are established.

Question 14

A child was found unconscious at home and brought to the emergency department by the fire and rescue unit. Physical examination showed cherry red mucous membranes, nail beds, and skin. The nurse suspects the child’s condition was the result of which of the following?

Accepted Answer

Answer reason: Cherry-red discoloration of the skin and mucous membranes is a classic but rare sign of carbon monoxide poisoning. Carbon monoxide binds hemoglobin with high affinity, forming carboxyhemoglobin, which impairs oxygen delivery to tissues and leads to hypoxia despite normal oxygen levels in the blood. This can rapidly cause loss of consciousness. The other options do not produce this characteristic finding.

Question 15

The nurse is planning care for a client who came to the emergency department after an aspirin overdose. Which of the following interventions should the nurse include in the client's plan of care?

Accepted Answer

Answer reason: In acute salicylate ingestion, early gastrointestinal decontamination can reduce further systemic absorption and help limit progression to toxicity. Activated charcoal binds many ingested drugs in the GI tract and is a standard initial intervention when the patient presents within an appropriate time window and has a protected airway. Inducing emesis is no longer recommended because it increases aspiration risk and has unreliable toxin removal. Laxatives are not a primary or reliable strategy for overdose management, and sodium bicarbonate is used for systemic alkalinization/urinary alkalinization (typically IV) rather than orally to treat “stomach acidity.”.

Question 16

The nurse on a psychiatric floor is evaluating the effectiveness of medications given. Which of the following findings requires additional assessment by the nurse?

Accepted Answer

Answer reason: Hyperthermia after receiving an antipsychotic is a red-flag for neuroleptic malignant syndrome, a life-threatening medication reaction requiring immediate focused assessment and escalation (vitals, rigidity, mental status, autonomic instability) and rapid treatment. Haloperidol is a high-potency typical antipsychotic with higher risk for severe EPS and NMS compared with many other agents. In contrast, nausea with an SSRI is a common early adverse effect, and drooling can be seen with antipsychotic-related EPS and should be assessed but is typically less immediately dangerous than hyperthermia. A respiratory rate of 10/min after benzodiazepine use warrants monitoring for sedation/respiratory depression, but isolated mild bradypnea without other instability is generally less suggestive of an emergent syndrome than antipsychotic-associated hyperthermia.

Question 17

What should be the initial bolus of crystalloid fluid replacement for a pediatric patient in shock?

Accepted Answer

Answer reason: Standard first-line management is an isotonic crystalloid bolus of 20 mL/kg (e.g., normal saline or lactated Ringer’s) given promptly, then reassessed for clinical response (mental status, capillary refill, pulses, urine output, blood pressure). Smaller volumes like 10–15 mL/kg may be used in select contexts (e.g., certain cardiac concerns), but they are not the typical initial dose for undifferentiated pediatric shock. A 30 mL/kg single initial bolus exceeds the commonly recommended starting bolus and increases risk of fluid overload without stepwise reassessment.

Question 18

A nurse is caring for a client with stable angina who reports chest pain while walking. The nurse should?

Accepted Answer

Answer reason: Stopping activity immediately reduces myocardial oxygen demand (heart rate, blood pressure, contractility) and can abort worsening ischemia. Continuing to walk increases oxygen demand and raises the risk of progression to unstable angina or infarction. A long-acting nitrate is not used for rapid relief of acute exertional chest pain, and the provider is notified if pain persists despite rest and prescribed PRN therapy or if symptoms suggest an acute coronary syndrome.

Question 19

Which finding in a client with influenza requires priority nursing intervention?

Accepted Answer

Answer reason: These are signs of increased work of breathing and impending respiratory compromise, making airway and breathing the immediate priority. In influenza, progression to lower respiratory involvement can rapidly lead to hypoxemia and respiratory failure, requiring prompt assessment and escalation (oxygen, respiratory support, provider notification). Compared with a mildly low SpO2 that can be monitored and reassessed, visible accessory muscle use indicates the client is struggling to ventilate right now. Fever and decreased intake are common in influenza and are important to manage, but they are not as immediately life-threatening as signs of respiratory distress.

Question 20

A nurse is caring for a patient experiencing ventricular tachycardia with a pulse. Which of the following is not an appropriate intervention for this patient?

Accepted Answer

Answer reason: Defibrillation is an unsynchronized shock reserved for pulseless VT or ventricular fibrillation, where there is no effective cardiac output. Delivering an unsynchronized shock to a patient with an organized rhythm and a pulse can precipitate R-on-T and deteriorate the rhythm into ventricular fibrillation. Correcting electrolyte abnormalities (e.g., hypokalemia, hypomagnesemia) addresses reversible causes and helps prevent recurrence.

Question 21

The nurse cares for a client with chronic kidney disease (CKD) who has missed scheduled hemodialysis treatments. For which clinical finding will the nurse immediately notify the health care provider?

Accepted Answer

Answer reason: ECG changes such as peaked T waves progressing to QRS widening indicate worsening conduction abnormalities and imminent malignant dysrhythmias or cardiac arrest, requiring urgent intervention. In contrast, edema, hypertension, and modest weekly weight gain reflect fluid overload that is important but typically less immediately fatal than severe potassium-related cardiotoxicity. This finding warrants immediate provider notification and rapid hyperkalemia management while preparing for emergent dialysis.

Question 22

The nurse is admitting a patient who is drooling, has a hoarse voice, dysphagia, and appears to be in respiratory distress. What is the priority action for this nurse?

Accepted Answer

Answer reason: g., epiglottitis or severe edema). The priority is to ensure patency and oxygenation using an airway-focused response (rapid escalation, prepare for advanced airway, minimize agitation). Diagnostic steps such as throat cultures can precipitate worsening obstruction and are not prioritized before stabilization. Antibiotics are important once the airway is protected, while placing the patient supine can worsen obstruction and respiratory effort.

Question 23

A 40-year-old woman is admitted with diabetic ketoacidosis. Which of the following is the most appropriate nursing intervention?

Accepted Answer

Answer reason: Continuous insulin infusion is the standard approach to stop ketone production and lower glucose in a controlled manner, while hourly glucose checks guide titration and reduce the risk of overly rapid drops. Dietary measures (oral fluids/jello or snacks) are inappropriate in the acute phase and do not correct the underlying ketoacidosis; patients may also be nauseated or altered and require IV therapy. Teaching is important but is not the immediate priority during an active emergency when stabilization and close monitoring are required.

Question 24

Which is the best position for a client with autonomic dysreflexia?

Accepted Answer

Answer reason: Autonomic dysreflexia is an acute, life-threatening hypertensive crisis triggered by noxious stimuli below the level of spinal cord injury, so immediate actions aim to rapidly lower blood pressure and reduce risk of stroke. Sitting the client upright maximizes orthostatic pooling of blood in the lower extremities, which helps decrease venous return and lower systemic blood pressure. This is the quickest, safest positioning intervention that can be done while the nurse searches for and removes the precipitating cause (e.g., bladder distention). Less-upright positions like semi-Fowler’s do not reduce blood pressure as effectively, and side-lying positions do not provide the same orthostatic benefit.

Question 25

A nurse in the pediatric unit is caring for a 10-year-old client with sickle cell disease complaining of severe chest pain and shortness of breath. Which intervention should the nurse perform first?

Accepted Answer

Answer reason: Severe chest pain with shortness of breath in sickle cell disease is concerning for acute chest syndrome and hypoxemia, so airway and breathing take priority. Supplemental oxygen increases oxygen delivery and helps limit further sickling triggered by low oxygen tension. IV fluids and opioid analgesia are important supportive measures, but they do not correct an immediate oxygenation threat and therefore come after stabilizing respiration. Hydroxyurea is a long-term disease-modifying therapy and is not an emergent first-step intervention for acute respiratory symptoms.

Question 26

A client with cervical cancer reports severe pelvic pain rated 9/10. The nurse notes that the client is pale, diaphoretic, and has a heart rate of 118. What is the nurse’s initial action?

Accepted Answer

Answer reason: Pallor, diaphoresis, and tachycardia in the setting of severe pain are red flags for possible hypovolemia or evolving circulatory compromise, which must be ruled out first using ABC-focused assessment. Shock requires immediate recognition because delayed intervention can rapidly progress to hypotension, altered mental status, and organ hypoperfusion. Giving an opioid before assessing stability can further mask deterioration and may worsen hemodynamics or respiratory status. While identifying the pain source and tachycardia triggers is important, the initial priority is to assess for and respond to a potential medical emergency.

Question 27

A 2-year-old child with asthma presents with severe respiratory distress. Which sign indicates impending respiratory failure?

Accepted Answer

Answer reason: In pediatric asthma, impending respiratory failure is suggested by decompensation from fatigue and worsening hypoxemia/hypercapnia, leading to altered mental status and cardiovascular collapse. Bradycardia is a late, pre-arrest sign in children and indicates severe hypoxia with inadequate ventilation. Decreased level of consciousness reflects rising CO2 and reduced cerebral oxygen delivery, signaling the child can no longer sustain the work of breathing. In contrast, wheezing, nasal flaring, accessory muscle use, tachypnea, and a prolonged expiratory phase are earlier signs of respiratory distress that can still be compensated.

Question 28

The nurse is reviewing morning lab results and assessment data for four clients. Which client should the nurse assess first?

Accepted Answer

Answer reason: Postoperative confusion, diaphoresis, and fever suggest possible sepsis, hypoxia, or acute deterioration, which are life-threatening conditions requiring immediate assessment. Although elevated INR is concerning, mild gum bleeding is less urgent compared to signs of systemic instability.

Question 29

A nurse is caring for four clients on a medical-surgical unit. Which client should the nurse assess first?

Accepted Answer

Answer reason: Hoarseness after thyroidectomy may indicate laryngeal nerve injury or developing airway obstruction due to edema or hematoma. Airway compromise is life-threatening and takes priority over infection, fluid overload, or pain.

Question 30

The nurse on the medical-surgical unit receives report on four clients. Which client should the nurse assess first?

Accepted Answer

Answer reason: Neck swelling, tachypnea, and frequent swallowing after thyroidectomy indicate a developing hematoma and impending airway obstruction, which is an immediate life-threatening emergency. Although hypoglycemia and severe hyponatremia are critical, airway compromise takes absolute priority.

Question 31

A child with a congenital heart defect is experiencing a cyanotic episode. How should the nurse position this patient?

Accepted Answer

Answer reason: Bringing the knees to the chest increases systemic vascular resistance, which reduces the right-to-left shunt and promotes more blood flow through the pulmonary circulation for oxygenation. This position also helps calm the child and decreases venous return from the legs, improving ventilation-perfusion matching during the spell. High Fowler’s may ease work of breathing but does not address the shunting mechanism as effectively, while supine can worsen respiratory mechanics and oxygenation.

Question 32

A 68-year-old client with hypertension is admitted with worsening shortness of breath. The nurse notes: • BP 162/96 mmHg • HR 118 bpm • RR 32 with accessory muscle use • Bibasilar crackles, frothy pink sputum • S3 heart sound present • Patient reports waking up at night “gasping for air” Which nursing intervention is the priority?

Accepted Answer

Answer reason: The priority is immediate support of oxygenation and ventilation using ABCs, because frothy pink sputum, crackles, tachypnea with accessory muscle use, and S3 suggest acute pulmonary edema from heart failure. Upright positioning reduces venous return and improves lung expansion, and supplemental oxygen addresses hypoxemia while further therapies are initiated. Diuretics are important to reduce preload and pulmonary congestion but do not correct the immediate life-threatening gas-exchange problem as quickly as positioning and oxygen. Foley placement and inotrope preparation may be appropriate later based on response and hemodynamics, but they are not first actions when respiratory distress is present.

Question 33

The nurse receives orders from a health care provider. Which order will be implemented first?

Accepted Answer

Answer reason: Airway and breathing take absolute priority (ABCs). Oxygen administration directly addresses oxygenation and prevents hypoxia, which is immediately life-threatening. Although albuterol is important for bronchodilation, oxygen should be initiated first to stabilize the patient’s oxygen status before other treatments. Oral medications and fluids are lower priority in an acute situation.

Question 34

A female child, age 2, is brought to the emergency department after ingesting an unknown number of aspirin tablets about 30 minutes earlier. On entering the examination room, the child is crying and clinging to the mother. Which data should the nurse obtain first?

Accepted Answer

Answer reason: In a potential poisoning, the priority is rapid assessment of vital signs to identify life-threatening instability (ABCs). Salicylate toxicity can quickly affect respiratory status and acid-base balance, making immediate physiologic assessment critical.

Question 35

A patient complaining of shortness of breath and “my heart is racing” shows supraventricular tachycardia on the monitor. The patient is diaphoretic, anxious, and pale. What should the nurse do?

Accepted Answer

Answer reason: The patient is unstable with symptomatic SVT. Immediate action includes calling for help and ensuring IV access for rapid administration of medications (e.g., adenosine). Defibrillation is not first-line for SVT unless deterioration occurs.

Question 36

On assessment, the nurse notes that the client has burns inside the mouth and is wheezing. Several hours later, the wheezing is no longer heard. What is the nurse’s next action?

Accepted Answer

Answer reason: With oral burns, the risk of rapid upper-airway swelling and impending obstruction is high, so early airway control is prioritized before intubation becomes difficult or impossible. Preparing for intubation is the safest immediate action because it addresses ABCs and prevents sudden respiratory failure. Raising the head of the bed may help comfort and ventilation but does not mitigate the imminent risk of airway closure, and documentation is not the priority in a potential airway emergency.

Question 37

Early this morning, a female client had a subtotal thyroidectomy. During evening rounds, nurse Tina assesses the client, who now has nausea, a temperature of 105° F (40.5° C), tachycardia, and extreme restlessness. What is the most likely cause of these signs?

Accepted Answer

Answer reason: It can be precipitated by thyroid manipulation or inadequate control of hyperthyroidism around the time of thyroidectomy. The timing (same day postop) plus hyperthermia to 105°F and prominent sympathetic overactivity strongly fit this emergency. Tetany after thyroidectomy would instead suggest hypocalcemia from parathyroid injury, typically causing perioral numbness, tingling, cramps, and laryngospasm rather than extreme hyperthermia.

Question 38

The nurse is caring for a client admitted with epiglottitis. Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available?

Accepted Answer

Answer reason: Having a surgical airway kit available prepares the team for an emergent airway when endotracheal intubation is not possible due to severe supraglottic swelling. Oxygen can support oxygenation but does not bypass a completely obstructed airway, making it insufficient as the key safety preparation. IV supplies and an infusion pump are supportive for medications/fluids but do not address the imminent risk of airway loss.

Question 39

The nurse is caring for an 80-year-old with chronic bronchitis. Upon the morning rounds, the nurse finds an O2 sat of 76%. Which of the following actions should the nurse take first?

Accepted Answer

Answer reason: An SpO2 of 76% indicates critical oxygenation failure requiring prompt supplemental oxygen to prevent respiratory and cardiac decompensation. Rechecking later delays treatment, and assessing the pulse does not address the primary problem of inadequate oxygenation. The provider should be notified after initiating urgent supportive care and reassessing response.

Question 40

Which of the following interventions should be the first priority when treating a client experiencing chest pain while walking?

Accepted Answer

Answer reason: Chest pain with exertion suggests myocardial ischemia, and the immediate priority is to reduce cardiac workload and oxygen demand while preventing injury from possible syncope. Stopping activity and placing the client in a resting position is the fastest, safest intervention a nurse can do at the moment symptoms occur. Diagnostic testing (ECG) and medication (nitroglycerin) are important next steps, but they come after terminating the provoking activity and stabilizing the client. Returning the client to bed may be appropriate after the client is safely seated and assessed, but it is not the most immediate action during active ambulation-related pain.

Question 41

A patient has an acute upper GI hemorrhage. Your interventions include?

Accepted Answer

Answer reason: Acute upper GI hemorrhage is a time-critical emergency where the immediate priority is to stabilize perfusion and prevent progression of hemorrhagic shock. Initial nursing management focuses on ABCs, rapid circulatory support (e.g., large-bore IV access, fluids/blood as ordered, monitoring vitals and urine output), while simultaneously expediting evaluation to locate the source (often via endoscopy) so definitive hemostasis can occur. This option appropriately combines stabilization with the diagnostic pathway that enables targeted control of bleeding. Choices focused on only volume replacement or only source control are incomplete for the initial emergency response because patients can rapidly decompensate before definitive hemostasis is achieved.

Question 42

The nurse in a neonatal intensive care unit (NICU) receives a telephone call to prepare for the admission of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse’s highest priority?

Accepted Answer

Answer reason: Apgar scores of 1 and 4 indicate severe neonatal depression with immediate risk of ineffective ventilation and bradycardia, so airway and breathing support must be ready on arrival. Positive-pressure ventilation is the single most important intervention in neonatal resuscitation, and ensuring the bag is connected to oxygen allows rapid delivery of effective ventilations. Monitoring and thermoregulation are important supportive measures but do not treat the immediate life-threatening problem of inadequate ventilation. Starting an IV with dextrose addresses glucose/fluid needs later and is not the first action when cardiopulmonary stabilization is at stake.

Question 43

A nursing student answers a call light and finds a patient to be short of breath. She pushes the emergency button on the wall and the primary nurse enters the room. The first thing the nurse should do is?

Accepted Answer

Answer reason: Checking pulse oximetry provides an objective, quick measure of hypoxemia while simultaneously initiating low-flow oxygen addresses a potentially life-threatening problem without delaying care. A full head-to-toe assessment and diagnostic testing like an ABG are appropriate after initial stabilization and focused respiratory assessment. Asking about anxiety is unsafe as an initial step because it can prematurely attribute dyspnea to a non-life-threatening cause and delay treatment of respiratory compromise.

Question 44

A 43-year-old with esophageal varices awoke from sleep and is having an acute episode of hematemesis. What is the nurse’s priority intervention?

Accepted Answer

Answer reason: Upright positioning reduces aspiration and improves respiratory mechanics while facilitating clearance of blood. Suctioning maintains airway patency when ongoing bleeding and vomiting are present. Blood products and labs are important for hemorrhage management, but they do not address the most time-critical threat compared with preventing airway compromise.

Question 45

A nurse is caring for a client in the third stage of labor. After the delivery of the newborn, the placenta has not been expelled after 20 minutes. The client begins to exhibit a steady vaginal trickle of blood and complains of dizziness. The fundus is boggy and slightly above the umbilicus. (Select the most appropriate nursing action): Which action should the nurse take first?

Accepted Answer

Answer reason: A boggy, enlarged uterus with ongoing bleeding shortly after delivery indicates uterine atony, the most common cause of postpartum hemorrhage and an immediate threat to maternal perfusion. The first-line, fastest nursing intervention is to perform firm fundal massage to stimulate uterine contraction and mechanically reduce bleeding. Medications like oxytocin are appropriate but typically follow or accompany massage and require an order, while massage can be initiated immediately. Notifying the provider is important, but stabilizing with an immediate corrective action for the likely cause takes priority over communication alone.

Question 46

A few minutes after the nurse has given an intradermal injection of an allergen to a patient who is undergoing skin testing for allergies, the patient reports feeling anxious, short of breath, and dizzy. Which action included in the emergency protocol should the nurse take first?

Accepted Answer

Answer reason: Give epinephrine 0.5 mg intramuscularly. The core principle is that suspected anaphylaxis requires immediate first-line treatment with intramuscular epinephrine to rapidly reverse airway edema/bronchospasm and support blood pressure. The patient’s acute dyspnea, anxiety, and dizziness minutes after allergen exposure is highly concerning for systemic allergic reaction with impending respiratory and circulatory compromise. Oxygen and IV access are important supportive measures but do not stop the anaphylactic cascade and should follow after epinephrine. Albuterol can help bronchospasm but is an adjunct and does not treat upper-airway edema or hypotension, so it is not the initial priority.

Question 47

A 68-year-old client with a history of COPD is admitted with worsening dyspnea and confusion. Vital signs: HR 112/min, RR 10/min (shallow), BP 146/88 mmHg, SpO2 82% on room air. Arterial blood gases: pH 7.28, PaCO2 60 mmHg, HCO3 26 mEq/L. Which nursing action is priority?

Accepted Answer

Answer reason: An SpO2 of 82% and acidemia with hypercapnia (acute ventilatory failure) make correcting oxygenation the time-critical first step to prevent tissue hypoxia and deterioration. A bronchodilator can help airflow obstruction, but it will not raise oxygen saturation as quickly as high-concentration oxygen in an unstable patient. Prone positioning is not a first-line nursing priority for COPD exacerbation, and increasing fluids is supportive care that does not address the immediate respiratory emergency.

Question 48

Nurse Vega is attending to Mr. Ellis, a 68-year-old male client who suddenly sits up in bed, struggling to breathe, with an arterial oxygen saturation of 88%. Which oxygen delivery method should Nurse Vega select to most effectively improve Mr. Ellis’s condition?

Accepted Answer

Answer reason: A non-rebreather provides the highest oxygen concentration among the listed low-to-moderate flow devices (when run at high flow with the reservoir bag inflated), making it the most effective immediate choice to improve oxygenation. A nasal cannula and simple mask deliver lower and more variable FiO2 and may be insufficient in this level of respiratory distress. A face tent is primarily for humidification and is unreliable for precise, high-concentration oxygen delivery in an emergency.

Question 49

A 72-year-old male with a known abdominal aortic aneurysm (AAA) measuring 6.5 cm is admitted with sudden, severe abdominal and back pain. He is diaphoretic and restless. Vital signs: BP 78/50 mmHg, HR 132 bpm, RR 28, SpO2 88% on room air. The nurse notes a distended abdomen and mottled lower extremities. Which action should the nurse take first?

Accepted Answer

Answer reason: This presentation strongly indicates a ruptured/leaking AAA with hemorrhagic shock, where definitive management is immediate operative repair to stop bleeding. Initial supportive steps (oxygen, IV access, cautious fluids) are important but do not correct the life-threatening source and should occur while mobilizing surgery, not instead of it. Aggressive large-volume crystalloid can worsen bleeding by increasing pressure and dilution, so resuscitation is typically controlled and paired with rapid surgical readiness. Simply notifying the provider is insufficient given the obvious emergency requiring rapid activation of the surgical/rapid response pathway and preparation for the OR.

Question 50

Nurse Carter is attending to a male patient diagnosed with a cerebral aneurysm who suddenly reports experiencing a severe headache. What should Nurse Carter do first?

Accepted Answer

Answer reason: A sudden, severe “worst headache” in a patient with a known cerebral aneurysm is a red flag for rupture and subarachnoid hemorrhage, which is a time-critical neurologic emergency. The nurse’s first priority is rapid escalation for emergent evaluation and interventions (e.g., neuroimaging, airway/blood pressure management, preparation for definitive neurosurgical care) to limit secondary brain injury. Giving analgesics first can mask worsening neurologic status and delays definitive treatment of a potentially fatal bleed. Sitting with the patient or notifying the nurse manager does not address the immediate life-threatening risk.

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