Question 1

The client has experienced an electrical injury of the lower extremities. Which are the priority assessment data to obtain from this client?

Accepted Answer

Answer reason: Assessing pulse and rhythm rapidly identifies ventricular arrhythmias or conduction blocks that require emergent intervention. Respiratory status is important, but the stem specifies a lower-extremity electrical injury, and the most characteristic early lethal complication remains cardiac dysrhythmia. Range of motion and orientation are secondary assessments that do not address the most time-sensitive risk.

Question 2

Nurse Martin is monitoring a client in alcohol detoxification who is showing symptoms of increased tremors, irritability, hypertension, and fever. She should be alert for the potential development of?

Accepted Answer

Answer reason: The cluster of worsening tremors, irritability/agitation, hypertension, and fever strongly suggests escalating withdrawal and impending severe withdrawal. This pattern is most consistent with delirium tremens, which can include delirium, tachycardia, diaphoresis, and seizures and requires urgent recognition and treatment. Esophageal varices reflect portal hypertension/chronic liver disease rather than acute detox symptoms, and Wernicke-Korsakoff syndromes classically relate to thiamine deficiency with confusion/ataxia/ophthalmoplegia or amnestic confabulation rather than prominent autonomic hyperactivity.

Question 3

A client with hyperthyroidism is brought into the clinic by his son with significant tachycardia, nausea, altered mental status, and a high temperature. The son reports the patient has been on an oral antibiotic since yesterday for pneumonia and his cough is improving. What should be the nurse’s priority?

Accepted Answer

Answer reason: Priority care is to rapidly reduce circulating thyroid hormone effects and production; propylthiouracil inhibits thyroid hormone synthesis and also decreases peripheral conversion of T4 to T3, making it an appropriate immediate therapy. Synchronized cardioversion does not address the underlying endocrine driver of the tachyarrhythmia and is reserved for unstable rhythms after targeted medical management. Escalating antibiotics or repeating imaging may be appropriate for pneumonia evaluation, but they do not treat the immediate endocrine emergency driving the current instability.

Question 4

SITUATION: A client was brought to the emergency department with a barbiturate overdose. As a nurse in the department, which of the following is not an appropriate treatment option for barbiturate overdosage?

Accepted Answer

Answer reason: In toxic ingestions with CNS depression, the priority is airway protection because reduced consciousness increases aspiration risk. Activated charcoal can be used for some overdoses to reduce absorption, but it is not given to “induce vomiting,” and emesis is generally avoided in sedated patients due to aspiration risk. Supportive care with airway/ventilatory support and IV fluids is appropriate to treat respiratory depression and hypotension. Naloxone is reasonable when opioid co-ingestion is suspected because it reverses opioid-induced respiratory depression, even though it does not reverse barbiturate effects.

Question 5

A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client?

Accepted Answer

Answer reason: Stridor is a late, high-risk sign of upper-airway narrowing and demands urgent evaluation and intervention (e.g., rapid response, airway equipment, possible re-exploration). Hoarseness can occur from recurrent laryngeal nerve irritation and is important but is less immediately life-threatening than compromised airflow. Hypocalcemia is a common complication from parathyroid injury, but it typically develops over hours to days and is monitored by neuromuscular signs and calcium levels rather than presenting as an immediate airway emergency.

Question 6

The client with diverticular disease is scheduled for a sig moidoscopy and suddenly reports severe abdominal pain. On examination, the nurse notes a rigid abdomen with guarding. What action should the nurse take next?

Accepted Answer

Answer reason: Severe abdominal pain with a rigid, guarded abdomen indicates peritoneal irritation and possible perforation or acute abdomen, which is a time-sensitive emergency. The planned sigmoidoscopy should be halted and the provider must be alerted immediately for urgent evaluation and management to prevent worsening peritonitis/sepsis. Comfort measures or distraction do not address the potentially life-threatening cause and can delay definitive care. Reassurance about the test is inappropriate because proceeding with endoscopy could exacerbate a perforation and harm the client.

Question 7

The client has just had emergency intubation for respiratory distress. Immediately following insertion of the endotracheal tube, what action by the nurse is most appropriate?

Accepted Answer

Answer reason: Airway and ventilation must be verified immediately after intubation to ensure effective oxygenation and to rapidly detect esophageal or mainstem bronchus intubation. Auscultating both lung fields (and typically the epigastrium) provides the fastest bedside confirmation of ventilation distribution and can prompt immediate corrective action if breath sounds are absent or unilateral. Chest x-ray is an important confirmation step but is not the first, immediate nursing action because it takes time and the patient may be inadequately ventilated in the interim. Securing the tube and addressing communication needs are appropriate later, after initial placement/ventilation assessment.

Question 8

Nurse Davis is monitoring Anna, a patient who recently initiated a new antihypertensive medication. Shortly after administration, Anna exhibits acute onset of chest tightness, shortness of breath, tachypnea, and a decline in her level of consciousness. These findings are indicative of which of the following conditions?

Accepted Answer

Answer reason: Chest tightness, dyspnea, and tachypnea are consistent with bronchospasm and upper/lower airway edema, while decreased level of consciousness can reflect hypoxemia and hypotension from distributive shock. In contrast, orthostatic hypotension is typically triggered by position change and presents with dizziness/syncope rather than abrupt bronchospasm, and hypertensive crisis would more often feature severe hypertension with neurologic symptoms/headache rather than acute wheeze-like respiratory compromise. Although pulmonary embolism can cause sudden dyspnea and chest symptoms, the immediate temporal link to first doses of a new drug most strongly supports anaphylaxis as the single best explanation.

Question 9

An incoherent female client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and pretibial area. Knowing that these findings suggest severe hypothyroidism, nurse Libby prepares to take emergency action to prevent the potential complication of?

Accepted Answer

Answer reason: The core principle is that profound thyroid hormone deficiency can precipitate a life-threatening decompensation characterized by hypothermia, hypoventilation with CO2 retention, bradycardia, hypotension, and altered mental status. The client’s constellation of findings (incoherence plus respiratory acidosis and cardiovascular depression) indicates impending systemic failure consistent with this emergency. This condition requires immediate supportive care (airway/ventilation, cautious rewarming, hemodynamic support) and thyroid hormone replacement to prevent progression and death. A common distractor is thyroid storm, which is a hyperthyroid crisis with hyperthermia and tachycardia—opposite of what is presented here.

Question 10

In assessing the client’s potential for an inhalation injury as a result of a flame burn, what is the most important question to ask the client on admission?

Accepted Answer

Answer reason: Inhalation injury risk is driven primarily by the exposure circumstances, especially an enclosed-space fire, which concentrates smoke, superheated gases, and toxic combustion products. Establishing whether the burn occurred in a confined area directly predicts airway edema and carbon monoxide/cyanide exposure, which can rapidly become life-threatening and require immediate airway and oxygenation interventions. Past lung history or smoking status may affect reserve but does not determine whether significant inhalation exposure occurred in this event. A prior chest x-ray is not time-critical and does not help determine the presence of acute airway thermal/chemical injury at admission.

Question 11

A prisoner, with a known history of alcohol abuse, has been in police custody for 48 hours. Initially, anxiety, sweating, and tremors were noted. Now, disorientation, hallucination, and hyper-reactivity are observed. The medical diagnosis is delirium tremens. What is the priority nursing diagnosis?

Accepted Answer

Answer reason: The patient’s progression from tremors/diaphoresis to disorientation and hallucinations indicates escalating withdrawal severity and imminent complication risk. Prioritizing injury risk drives urgent actions such as seizure precautions, close monitoring, and rapid treatment to prevent trauma, aspiration, and cardiorespiratory collapse. Violence risk can occur with hallucinations, but it is typically secondary to stabilizing the physiologic crisis that can rapidly become fatal. Nutritional deficit and self-esteem concerns are important but do not supersede imminent safety threats.

Question 12

A 67-year-old client with a history of COPD, long-term steroid use, and poor nutrition is admitted for a rapidly progressing skin lesion on the left thigh. The nurse notes a large area of erythema, extreme tenderness, warmth, and edema. The client reports severe pain out of proportion to the appearance. The center of the lesion now appears dusky and violaceous, and the client has a temperature of 39.2°C (102.5°F) with a heart rate of 122 bpm. Which nursing action should the nurse prioritize?

Accepted Answer

Answer reason: This is a time-critical emergency requiring immediate escalation for rapid surgical evaluation, broad-spectrum IV antibiotics, and possible debridement to prevent shock and death. Comfort measures and local interventions are secondary and must not delay definitive management. Marking borders can help track spread but is not the priority when red-flag findings indicate a potentially life-threatening process.

Question 13

A 3-year-old child was brought to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling, and suprasternal retractions. What should the nurse do first?

Accepted Answer

Answer reason: Immediate notification activates emergency interventions (keep child calm, prepare for intubation/tracheostomy, administer humidified oxygen and IV antibiotics once stabilized) and mobilizes the team that can secure the airway. Direct throat examination can precipitate laryngospasm and complete obstruction, making it unsafe as an initial action. Diagnostic tests like airway x-ray or sputum collection are secondary and should not delay airway-focused emergency response.

Question 14

Emergency medical technicians transport a 27-year-old ironworker to the emergency department. They tell the nurse, “He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and he’s comatose. We intubated him and he’s maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual resuscitation bag.” Which intervention by the nurse has the highest priority?

Accepted Answer

Answer reason: In an acute multi-trauma patient who is comatose with a head injury, rapid neurologic assessment is a time-critical priority because it can reveal impending brain herniation and guide immediate interventions. Pupil size, symmetry, and reactivity are highly sensitive to rising intracranial pressure and cranial nerve III compression, and can change quickly even while airway is being supported. Trendelenburg positioning can worsen intracranial pressure and is not a routine shock maneuver, making it unsafe as a first priority action. Limb assessment is important for hemorrhage/neurovascular compromise, but immediate detection of catastrophic neurologic deterioration takes precedence here given coma and parietal hematoma.

Question 15

Your patient recently had abdominal surgery and tells you that he feels a popping sensation in his incision during a coughing spell, followed by severe pain. You anticipate an evisceration. Which supplies should you take to his room?

Accepted Answer

Answer reason: Evisceration is a postoperative emergency in which protruding abdominal contents must be protected from drying and contamination while preparing for rapid surgical management. Applying sterile dressings moistened with sterile normal saline maintains tissue viability and reduces the risk of infection and ischemic injury. A suture kit is not appropriate because bedside re-approximation is outside nursing scope and delays definitive care. Sterile water is hypotonic and can worsen tissue edema and cellular injury compared with isotonic saline.

Question 16

A client with a history of gastroenteritis presents with bilateral lower limb weakness that progresses gradually. Which of the following is the priority nursing action?

Accepted Answer

Answer reason: Using ABC priorities, airway and breathing threats outweigh mobility assistance or positioning for comfort. Close monitoring for signs of respiratory decline (e.g., decreasing vital capacity, weak cough, difficulty swallowing) enables timely escalation to ventilatory support. Assisting ambulation increases fall risk in a weakening patient, and muscle relaxants do not treat the underlying demyelinating process and could worsen respiratory depression.

Question 17

A 40-year-old male client who was burned was admitted under your care. Assessment reveals he has crackles, respiratory rate of 40/min, and is coughing up blood-tinged sputum. What action will the nurse take first?

Accepted Answer

Answer reason: g., pulmonary edema/ARDS or inhalation injury complications). Upright positioning immediately improves diaphragmatic excursion, reduces work of breathing, and can improve oxygenation while further emergency interventions (oxygen, airway support) are initiated. Chest physiotherapy is not a first action in acute respiratory distress and could worsen hypoxemia or provoke more bleeding. Digoxin is not indicated for this presentation, and urine output monitoring is important in burns but is secondary to stabilizing ventilation and oxygenation.

Question 18

After starting an IV dose of sulfamethoxazole (Bactrim®), the nurse notes that the patient is having difficulty breathing, his face is flushed, and he complains of back pain. Which type of hypersensitivity reaction is this patient most likely experiencing?

Accepted Answer

Answer reason: This presentation reflects an acute, life-threatening immediate (type I, IgE-mediated) hypersensitivity reaction with airway involvement. Difficulty breathing shortly after initiating an IV antibiotic is a red-flag for bronchospasm/laryngeal edema, and flushing supports systemic mast-cell mediator release. Back or flank pain can occur during anaphylaxis due to smooth-muscle spasm and systemic vasodilation-related effects. Cytotoxic and serum sickness reactions are typically delayed and would not present with sudden respiratory compromise during infusion, and “infectious” is not a hypersensitivity category.

Question 19

A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment?

Accepted Answer

Answer reason: Thrombolytic therapy is strictly time-dependent because the benefit rapidly decreases and the risk of intracranial hemorrhage increases as time from symptom onset lengthens. Determining the last-known-well time establishes eligibility for t-PA and guides urgent decision-making in the ED. This assessment directly impacts whether treatment is appropriate and safe, making it higher priority than collecting a full history. Medication and surgical history matter mainly as contraindication screening, but without an accurate onset time, safe administration cannot be determined.

Question 20

A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?

Accepted Answer

Answer reason: The first nursing priority is to rapidly lower blood pressure and reduce risk of stroke by placing the client upright to promote orthostatic pooling of blood and decrease cerebral perfusion pressure. After positioning, the nurse should promptly search for and remove triggers (most commonly bladder distention), but that comes after immediate BP-reducing positioning. Laying the client flat would worsen hypertension, and giving antihypertensives is considered after immediate nonpharmacologic measures and trigger removal when possible.

Question 21

The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and regained it. The client now has lost consciousness again. The nurse takes quick action, knowing this is compatible with?

Accepted Answer

Answer reason: This pattern signals rising intracranial pressure and impending herniation risk, requiring immediate emergency response and neurosurgical evaluation. The client’s second loss of consciousness after initially regaining it fits this time course. Subdural bleeding more often causes a slower, more progressive decline (especially in older adults or anticoagulated clients), and a concussion typically causes transient symptoms without a lucid interval followed by sudden collapse. Prompt recognition is critical because outcomes depend on rapid intervention.

Question 22

When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best described a lucid interval?

Accepted Answer

Answer reason: This pattern is a red-flag change in level of consciousness that can occur with conditions such as an epidural hematoma, where initial compensation is followed by rapid decline. The correct choice captures the key teaching point for caregivers: a period of seeming normality that later progresses to decreased responsiveness. Garbled speech is a focal neurologic deficit rather than the defining “lucid then decline” sequence, and inability to recall events is more consistent with concussion-related amnesia. “Warning” odors or visual disturbances describe aura phenomena seen with seizures or migraines, not lucid intervals after trauma.

Question 23

Which of the following positions would best aid breathing for a patient with acute pulmonary edema?

Accepted Answer

Answer reason: Acute pulmonary edema causes severe dyspnea from fluid in the alveoli, so the immediate goal is to maximize ventilation and reduce venous return to the heart (preload). Sitting upright in a high Fowler’s position lowers diaphragmatic pressure, improves lung expansion, and helps reduce pulmonary congestion by pooling blood in the lower extremities. Semi-Fowler’s may help but is less effective when respiratory distress is significant because it provides less thoracic expansion. Lying flat worsens orthopnea and increases venous return, which can intensify pulmonary edema.

Question 24

A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

Accepted Answer

Answer reason: Cluster breathing after a recent intracranial bleed suggests neurologic deterioration and possible rising intracranial pressure requiring rapid, concurrent assessment and escalation. This action prioritizes immediate evaluation of airway/breathing stability and neurologic status (vital signs plus GCS) while simultaneously notifying the provider, which best supports timely intervention. Simply counting respirations delays recognition of instability and does not address the underlying neurologic emergency. Calling to adjust ventilator settings alone may miss a primary CNS cause and fails to capture key deterioration indicators needed for urgent management decisions.

Question 25

What is the nursing priority if the client is suffering from 1st, 2nd, 3rd or 4th degree burns?

Accepted Answer

Answer reason: Burn patients—especially with facial/neck burns, soot, hoarseness, or singed nasal hairs—may deteriorate quickly and may require early intubation before swelling worsens. Circulation issues such as massive fluid shifts and electrolyte disturbances are critical but are addressed after ensuring adequate oxygenation and ventilation. Infection risk is a later priority (hours to days) once initial stabilization is complete. Pain control is important but must not delay life-saving airway management.

Question 26

Which of the following would indicate a serious complication from excessive suctioning of an endotracheal tube that requires immediate nursing intervention?

Accepted Answer

Answer reason: A sudden drop in heart rate is an urgent sign of clinical deterioration because it can quickly progress to hypotension, dysrhythmias, and cardiac arrest if suctioning continues. This finding indicates the nurse should immediately stop suctioning, provide 100% oxygen/ventilate, and reassess. Tachycardia is more consistent with stress or mild hypoxia and is generally less immediately ominous than a vagal-mediated bradycardic event during suctioning.

Question 27

A client with a ventriculoperitoneal shunt has a dazed appearance and grunting and has not responded to the caregiver for 10 minutes. Status epilepticus is suspected. Which nursing intervention should be performed first?

Accepted Answer

Answer reason: A benzodiazepine is first-line for acute termination of status epilepticus when IV access may not be immediately available, making rectal administration an appropriate rapid intervention. Further assessment for meningitis signs, lab work, or CT for shunt malfunction are secondary steps that can occur once airway/breathing are supported and the seizure is controlled. Delaying anticonvulsant therapy to pursue diagnostics increases the risk of complications and worsened outcomes.

Question 28

The nurse is caring for a child with suspected epiglottitis. Which finding is not associated with epiglottitis?

Accepted Answer

Answer reason: Typical findings include drooling, muffled “hot potato” voice/phonation, and inspiratory stridor from narrowed airflow. A barking/brassy cough is classically associated with croup (laryngotracheobronchitis), not epiglottitis. Recognizing this distinction guides urgent airway-focused management and avoids interventions that may worsen obstruction.

Question 29

The nurse is giving report to a licensed practical nurse (LPN) who will be helping to monitor a client who just had a total thyroidectomy. What will the nurse emphasize as most important to report immediately?

Accepted Answer

Answer reason: New-onset audible respirations signal stridor and impending airway occlusion, requiring immediate assessment and rapid intervention (e.g., activate rapid response, prepare for airway management). Changes in oxygen saturation can be a later sign after obstruction has progressed, so waiting for desaturation is unsafe. Blood pressure or rhythm changes may occur but are less immediately life-threatening than an evolving airway emergency in this setting.

Question 30

A patient has developed the cardiac arrhythmia Torsades de Pointes. The nurse should prepare to administer?

Accepted Answer

Answer reason: Magnesium stabilizes myocardial repolarization and suppresses early afterdepolarizations that trigger this rhythm. Amiodarone can further prolong the QT interval and may worsen the dysrhythmia, making it an unsafe choice in this context. Diltiazem targets supraventricular rhythms and does not treat this ventricular emergency. Lidocaine may be considered for some ventricular arrhythmias but is not the standard first-line treatment for torsades compared with magnesium.

Question 31

An LPN/LVN, under the RN's supervision, is assigned to provide nursing care for a client with Guillain-Barré syndrome (GBS). What observation should the LPN/LVN be instructed to report immediately?

Accepted Answer

Answer reason: Shallow breathing and diminished breath sounds suggest reduced ventilation from neuromuscular impairment and require immediate RN/rapid-response evaluation, including assessment of vital capacity and need for airway/ventilatory support. Numbness/tingling and bulbar findings can occur in GBS but are typically less immediately fatal than deteriorating ventilation unless clearly causing airway compromise. A heart rate of 102 can be mild sympathetic response or early dysautonomia, but it does not outweigh signs of inadequate breathing as the priority emergency finding.

Question 32

A client with a spinal cord injury at level C3 to C4 is being cared for by the nurse in the emergency department (ED). What is the priority nursing assessment?

Accepted Answer

Answer reason: High cervical spinal cord injuries can impair diaphragmatic function and accessory muscle use, placing the client at immediate risk for hypoventilation and respiratory arrest. In emergency care, ABC priorities dictate assessing and stabilizing airway and breathing before detailed neurologic mapping or hemodynamic evaluation. Continuous assessment of work of breathing and oxygenation identifies early ventilatory failure and guides urgent interventions such as assisted ventilation or intubation. Although spinal shock and neuro assessments are important, they are secondary to ensuring adequate ventilation and oxygen delivery.

Question 33

A client with a spinal cord injury (SCI) reports sudden severe throbbing headache that started a short time ago. Assessment of the client reveals increased blood pressure (168/94 mm Hg) and decreased heart rate (48 beats/min), diaphoresis, and flushing of the face and neck. What action should the nurse take first?

Accepted Answer

Answer reason: The presentation is classic for autonomic dysreflexia in a patient with SCI: sudden severe headache, hypertension, bradycardia, diaphoresis, and facial flushing. The priority intervention is to remove the triggering noxious stimulus, most commonly bladder distention from a blocked urinary catheter. Assessing the Foley for kinks/obstruction and restoring drainage treats the cause and can rapidly reduce blood pressure. Giving acetaminophen addresses pain but not the life-threatening hypertensive crisis, and notifying the provider comes after immediate measures to relieve the stimulus.

Question 34

A client is admitted to the cardiac unit for myocardial infarction (MI). How does the nurse prioritize actions?

Accepted Answer

Answer reason: In an acute myocardial infarction, the immediate priority is continuous cardiac monitoring to detect life-threatening dysrhythmias such as ventricular tachycardia or fibrillation, which can occur suddenly and require rapid intervention. Establishing IV access and preparing for thrombolytic therapy are critical next steps, but monitoring must be initiated first to ensure real-time assessment of cardiac status. Providing oral fluids is not a priority and may be contraindicated.

Question 35

The nurse is caring for a 2-year-old who is receiving a saline enema for treatment of intussusception. Reporting which client finding to the health care provider (HCP) is most important?

Accepted Answer

Answer reason: Blood in the stool (classically progressing toward “currant jelly” stool) suggests worsening obstruction with vascular compromise and may indicate failed reduction or impending necrosis/perforation, requiring urgent provider evaluation. In contrast, a normal brown stool and reduced crying can reflect improvement after reduction and comfort measures. Recurrent vomiting is concerning for persistent obstruction and dehydration, but overt blood per rectum is a more direct red flag for bowel injury and escalating emergency risk.

Question 36

The priority nursing intervention for a patient during the immediate post-operative period is?

Accepted Answer

Answer reason: Ensuring patency (positioning, suctioning, airway adjuncts, oxygen as ordered) prevents hypoxia, which can deteriorate into arrest faster than circulatory issues are typically recognized. Vital signs and hemorrhage surveillance are essential but come after ABC stabilization and are meaningful only if oxygenation is secured. Intake and output monitoring is important for ongoing assessment but is not the first, life-preserving action immediately after surgery.

Question 37

A 59-year-old male suddenly develops crushing chest pain while mowing the lawn. He is pale, sweaty, and nauseated. His vital signs are BP 150/90, HR 96, RR 18, and SpO₂ 95% on room air. What should you do first?

Accepted Answer

Answer reason: This patient’s classic ischemic symptoms (crushing chest pain with diaphoresis and nausea after exertion) make MI a priority emergency where immediate aspirin is indicated unless contraindicated (e.g., allergy or active GI bleeding). Supplemental oxygen is not first-line when SpO₂ is already adequate, as routine oxygen without hypoxemia has no proven benefit and may cause harm. Nitroglycerin can be helpful but requires additional contraindication screening (e.g., recent PDE-5 inhibitor use, right ventricular infarct concern) and does not replace immediate aspirin. Rapid transport is essential, but giving aspirin promptly can be done without delaying definitive care and directly improves outcomes.

Question 38

An LPN/LVN’s assessment of two diabetic patients reveals all of these findings. Which would you instruct the LPN/LVN to report immediately? 1. Fingerstick glucose reading of 185 mg/dL 2. Numbness and tingling in both feet 3. Profuse perspiration 4. Bunion on the left great toe?

Accepted Answer

Answer reason: This finding requires immediate evaluation of blood glucose and prompt intervention (rapid-acting carbohydrate if able to swallow or IV dextrose/glucagon per protocol). A glucose of 185 mg/dL is mild hyperglycemia and typically not an immediate emergency in the absence of symptoms of DKA/HHS. Numbness/tingling and a bunion suggest chronic neuropathy/foot issues that need follow-up and foot care but are not as time-critical as suspected hypoglycemia.

Question 39

The emergency department nurse assesses a new client and finds constricted pupils, drowsiness, impaired memory, and slurred speech. Which vital sign would be most concerning to the nurse?

Accepted Answer

Answer reason: A respiratory rate of 10/min is bradypnea and may indicate impending respiratory failure, requiring prompt airway and breathing support and possible antidote consideration. The listed blood pressure and pulse are within acceptable ranges and do not represent an acute instability compared with depressed respirations. A temperature of 99°F is essentially normal and is not as urgent as compromised ventilation.

Question 40

The telemetry technician tells the primary nurse the client in room 420 has a straight line. Which intervention should the primary nurse implement first?

Accepted Answer

Answer reason: A “straight line” on telemetry may indicate true asystole or a monitoring artifact. The nurse must immediately assess the client to determine if cardiac arrest is present. Checking for a pulse and blood pressure confirms whether the client is experiencing a life-threatening condition requiring immediate resuscitation. Equipment checks or team activation should follow after verifying the client’s status.

Question 41

The nurse provides care for a client diagnosed with a spinal cord injury at the level of T2. The nurse enters the room and notes that the client has facial flushing, is sweating profusely, and has a blood pressure of 260/160 mm Hg. Which medication does the nurse prepare to administer?

Accepted Answer

Answer reason: A high spinal cord injury with sudden severe hypertension, facial flushing, and diaphoresis is classic for autonomic dysreflexia, a true hypertensive emergency requiring rapid blood pressure control. An IV antihypertensive vasodilator is appropriate to reduce afterload and prevent complications such as intracranial hemorrhage or seizures while the trigger (often bladder/bowel distention) is addressed. This option provides fast onset and titratable BP reduction in the acute setting. A stool softener is not an immediate treatment for life-threatening hypertension, and antiemetics/benzodiazepines do not correct the underlying sympathetic surge driving the blood pressure.

Question 42

A woman who had cesarean delivery 5 hours ago now appears anxious and reports shortness of breath. The nurse should assess for which priority problem before contacting the health care provider (HCP)?

Accepted Answer

Answer reason: A common source is a deep vein thrombosis, and unilateral calf warmth and redness are key assessment findings that support this life-threatening diagnosis. Identifying DVT evidence helps prioritize rapid escalation (e.g., urgent evaluation and treatment) over less urgent postoperative issues. Fever and leukocytosis may indicate infection but are typically not the most immediate cause of sudden dyspnea at 5 hours post-op, and incisional discomfort is expected and not linked to acute respiratory compromise.

Question 43

A client comes to the emergency department in acute decompensated heart failure. The client is very anxious, with a respiratory rate of 30/min and pink, frothy sputum. After placing the client on oxygen via nasal cannula, which of these actions is the next priority?

Accepted Answer

Answer reason: An IV loop diuretic provides prompt venodilation and diuresis, decreasing preload and pulmonary capillary hydrostatic pressure to improve oxygenation. Arterial blood gases are diagnostic and should not delay immediate therapy when clinical signs of pulmonary edema are present. Digoxin is not a rapid rescue medication for acute pulmonary edema, and dopamine is reserved for hypotension/poor perfusion with low cardiac output rather than primary volume overload with respiratory distress.

Question 44

The nurse receives an obese client in the postanesthesia care unit who underwent a procedure under general anesthesia. The nurse notes an oxygen saturation of 88%. Which is the most appropriate initial intervention?

Accepted Answer

Answer reason: Obesity and residual anesthetic effects increase risk of soft-tissue airway collapse and hypoventilation, so opening the airway is the fastest nurse-initiated corrective action. This maneuver can rapidly improve air entry and oxygenation while additional supports (e.g., supplemental O2, airway adjuncts) are prepared if needed. Assessment steps like lung auscultation or pupillary checks do not address the immediate life threat, and notifying anesthesia is appropriate after initiating basic airway opening measures.

Question 45

A self-employed auto mechanic is diagnosed with carbon monoxide poisoning. Admission vital signs are blood pressure 90/42 mm Hg, pulse 84/min, respirations 24/min, and oxygen saturation 94% on room air. What is the nurse's priority action?

Accepted Answer

Answer reason: Delivering 100% oxygen via nonrebreather hastens dissociation of carbon monoxide from hemoglobin and reduces carboxyhemoglobin half-life. Titrating oxygen based on SpO2 can dangerously underestimate severity because standard oximetry cannot distinguish oxyhemoglobin from carboxyhemoglobin. Bronchodilators or steroids do not address the primary life-threatening problem of impaired oxygen delivery in carbon monoxide poisoning.

Question 46

A client with an SCI at level C3-C4 is being cared for in the emergency department (ED). What is the priority assessment?

Accepted Answer

Answer reason: A high cervical spinal cord injury (C3–C4) can impair diaphragmatic innervation and intercostal muscle function, creating an immediate threat to airway and ventilation. Using ABC priorities in the ED, breathing status must be assessed first because hypoventilation and rapid respiratory failure can occur early and be fatal. Respiratory effort and pulse oximetry provide rapid, continuous indicators of ventilatory adequacy and oxygenation to guide urgent support (e.g., assisted ventilation/intubation). Neuro checks (sensation/mobility) and hemodynamic monitoring are important but do not supersede the immediate risk of respiratory compromise at this level.

Question 47

You are evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns you immediately?

Accepted Answer

Answer reason: A rate of 8/min suggests hypoventilation with rising CO2 and risk of respiratory acidosis and altered mental status. The other findings are expected or compensatory in emphysema: tripod positioning improves accessory muscle use, barrel chest reflects chronic hyperinflation, and mild crackles can occur without being the most urgent threat. The immediate priority is to address inadequate ventilation rather than chronic adaptations.

Question 48

Treatment for Bradycardia remember! All trained dogs eat?

Accepted Answer

Answer reason: This medication is the first-line initial drug because it blocks muscarinic receptors, reducing parasympathetic tone and increasing SA node firing and AV conduction. If the patient does not respond or the rhythm is high-grade block, immediate pacing and/or catecholamine infusions are the next escalation steps. One common pitfall is delaying pacing in unstable patients while repeatedly trying medications.

Question 49

The nurse is caring for an intubated client whose oxygen saturation begins to drop. What action should the nurse take first?

Accepted Answer

Answer reason: Bag-valve ventilation provides rapid, definitive support when the ventilator circuit is disconnected, malfunctioning, or obstructed and buys time to troubleshoot the cause. After stabilizing oxygenation with manual ventilation, the nurse can then assess for causes such as displaced tube or unequal ventilation by auscultating and checking tube position. Suctioning may be needed if secretions are suspected, but initiating it first can worsen hypoxemia and delays the most time-critical intervention.

Question 50

The nurse receives report on the assigned team of clients on the oncology unit. All are receiving chemotherapy. Which client should the nurse check on first?

Accepted Answer

Answer reason: New-onset back pain with leg weakness in a client with cancer is most concerning for malignant spinal cord compression. Back pain plus new neurologic deficit is a red-flag pattern because cord compression can progress quickly to loss of function and permanent paralysis if not addressed immediately, so this client takes highest priority for urgent assessment. Alopecia and oral mucositis are common chemotherapy-related effects, hemoglobin of 8 g/dL is significant but not automatically the most immediate threat without instability, and potassium of 3.4 mEq/L represents only mild hypokalemia despite ongoing vomiting.

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