Question 1

The nurse working in the emergency department realizes that it would be contraindicated to induce vomiting if someone had ingested which of the following?

Accepted Answer

Answer reason: Inducing emesis is contraindicated after ingestion of hydrocarbons (e.g., gasoline) due to risk of aspiration and chemical pneumonitis; noncaustic pills like ibuprofen, aspirin, or vitamins do not carry this same risk.

Question 2

The nurse is caring for a client with a head injury who has increased ICP. The physician plans to reduce the cerebral edema by constricting cerebral blood vessels. Which physician order would serve this purpose?

Accepted Answer

Answer reason: Hyperventilation lowers PaCO2, which causes cerebral vasoconstriction and reduces intracranial blood volume and ICP. The other options do not constrict cerebral vessels.

Question 3

The nurse in the emergency room is caring for a client with multiple rib fractures and a pulmonary contusion. Assessment reveals a respiratory rate of 38, a heart rate of 136, and restlessness. Which associated assessment finding would require immediate intervention?

Accepted Answer

Answer reason: Subcutaneous emphysema with absent breath sounds indicates a pneumothorax (potentially tension), a life‑threatening complication after chest trauma requiring immediate intervention. The other findings can occur with contusion and are not as emergent.

Question 4

A client is admitted to the medical-surgical unit with a report of severe hematemesis. The nurse should give priority to?

Accepted Answer

Answer reason: Severe hematemesis indicates potential massive GI bleed with risk of hypovolemic shock. The immediate priority is to establish large-bore IV access for rapid fluid resuscitation and potential blood transfusion. Consent and NG tube placement are secondary; assessment is ongoing but does not address circulation as urgently.

Question 5

The nurse recognizes which of the following as the priority nursing diagnosis for the client in thyroid crisis?

Accepted Answer

Answer reason: Thyroid crisis (thyroid storm) causes a severe hypermetabolic state with extreme hyperthermia, which is life‑threatening and the immediate nursing priority to control. Airway/breathing are not usually the primary threat, and cerebral perfusion or activity intolerance are secondary concerns.

Question 6

What clinical manifestation is most indicative of possible carbon monoxide poisoning?

Accepted Answer

Answer reason: Carbon monoxide binds hemoglobin forming carboxyhemoglobin, producing a characteristic cherry-red color of skin/mucous membranes. Pulse oximetry can be falsely normal/insensitive, stridor indicates airway obstruction, and carbonaceous sputum suggests smoke inhalation rather than CO specifically.

Question 7

A client is admitted with a ruptured spleen following a four-wheeler accident. In preparation for surgery, the nurse suspects that the client is in the compensatory stage of shock because of which clinical manifestation?

Accepted Answer

Answer reason: Compensatory (nonprogressive) shock presents with tachycardia and mild mental status changes while blood pressure may be near normal due to SNS compensation. Other options reflect progressive or refractory shock (crackles/mottling/lethargy; unconsciousness and petechiae) or later organ failure.

Question 8

What is the initial nursing action when a tracheostomy tube is dislodged after the client coughs during tape change?

Accepted Answer

Answer reason: Accidental decannulation is an airway emergency. The priority is to maintain oxygenation; immediately ventilate with a bag-valve mask. Notifying providers or covering the site can follow after airway and breathing are stabilized.

Question 9

What is the priority nursing action for a 62-year-old female patient with myasthenia gravis who presents to the emergency room with sudden worsening of muscle weakness and difficulty breathing?

Accepted Answer

Answer reason: Sudden weakness with dyspnea in myasthenia gravis suggests myasthenic crisis with impending respiratory failure. Airway and breathing are the priority; prepare for ventilatory support and possible intubation.

Question 10

A pregnant client reports feeling wetness and the nurse finds clear fluid and the presence of the umbilical cord at the perineum; what is the nurse's immediate action?

Accepted Answer

Answer reason: Findings indicate prolapsed umbilical cord. The immediate priority is to relieve cord compression to restore fetal perfusion; placing the client in Trendelenburg (or knee-chest) reduces pressure on the cord. Notifying the provider, FHR monitoring, and transfer follow after relieving compression.

Question 11

A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department; which order should the nurse do first?

Accepted Answer

Answer reason: Within 1 hour of acetaminophen ingestion, activated charcoal is the first-line treatment to absorb the drug and prevent further hepatic injury. Acetylcysteine is the antidote but is given after gastric decontamination and confirmation of serum levels.

Question 12

A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department; which order should the nurse implement first?

Accepted Answer

Answer reason: At 45 minutes post-ingestion, the priority is to prevent further acetaminophen absorption. Activated charcoal is most effective within about 1 hour. Gastric lavage is rarely indicated and riskier; NAC is the antidote but can follow decontamination; KVO IV can wait.

Question 13

What is the priority nursing intervention in the postictal phase of a seizure?

Accepted Answer

Answer reason: Postictal care follows ABCs; airway and breathing take priority due to risk of hypoventilation or obstruction after a seizure.

Question 14

What should the nurse do next for a 4-year-old with sudden high fever, sore throat, refusal to drink, and sitting leaning forward?

Accepted Answer

Answer reason: Presentation suggests acute epiglottitis with imminent airway obstruction. Priority is airway preparedness; do not examine the throat, and antipyretics or cultures are not urgent. Have airway/tracheostomy equipment ready.

Question 15

What is the appropriate nursing action when a client with a femur fracture develops symptoms of fat embolism syndrome (FES) such as chest pain, restlessness, and dyspnea?

Accepted Answer

Answer reason: FES is a postoperative/trauma emergency presenting with respiratory distress and neurologic changes; immediate provider notification is required for rapid interventions (oxygen, stabilization). Other options do not address the emergency and may be inappropriate.

Question 16

In an infant, the ideal ratio between cardiac compression and breathing during CPR for single rescuer should be?

Accepted Answer

Answer reason: Per AHA BLS guidelines, a single rescuer uses a 30:2 compression-to-ventilation ratio for infants; 15:2 is for two rescuers and 3:1 is for neonatal resuscitation.

Question 17

A client is admitted with a suspected overdose of tricyclic antidepressants. What is the priority nursing intervention?

Accepted Answer

Answer reason: In TCA overdose, early gastrointestinal decontamination with activated charcoal is indicated to limit absorption if the airway is protected. Naloxone treats opioid toxicity, an opioid analgesic would worsen CNS depression, and an antiemetic is not priority.

Question 18

A client is admitted with a suspected myocardial infarction. What is the priority nursing intervention during the acute phase of myocardial infarction?

Accepted Answer

Answer reason: In an acute MI, the priority is rapid reperfusion to limit myocardial damage. Thrombolytic therapy, when indicated and within the time window, dissolves the occluding clot. The other options are not immediate priorities; ambulation is contraindicated initially and BP every 4 hours is insufficient monitoring.

Question 19

What is the primary nursing action when a patient shows signs of hypoglycemia?

Accepted Answer

Answer reason: For conscious patients with symptomatic hypoglycemia, the immediate priority is to give 15–20 g of a fast-acting carbohydrate and recheck glucose. Insulin would worsen hypoglycemia; rest/monitoring or calling the provider delays urgent treatment.

Question 20

What is the nurse's initial action when a postoperative patient becomes less responsive, pale, and has a blood pressure of 70/40?

Accepted Answer

Answer reason: The patient shows signs of shock (pale, less responsive, BP 70/40). Immediate priority is to support circulation; opening IV fluids wide increases intravascular volume rapidly. Positioning or notifying the provider can follow; a crash cart is not indicated unless arrest is imminent.

Question 21

An appropriate nursing diagnosis for a client with acute myocardial infarction is decreased cardiac output secondary to which condition?

Accepted Answer

Answer reason: After an acute MI, ventricular dysrhythmias (e.g., VT/VF) markedly reduce or abolish effective ventricular contraction, leading to immediate decreased cardiac output. The other options are possible complications but are not the most direct, immediate cause of decreased CO in this context.

Question 22

A patient is 2 hours post-thyroidectomy and begins showing signs of respiratory distress; what should the nurse do?

Accepted Answer

Answer reason: Early post-thyroidectomy respiratory distress suggests airway compromise from bleeding or edema. Elevate head (semi-Fowler’s) to improve airway and notify the provider immediately. Do not lay flat; oxygen with leg elevation does not address airway; turning the head increases strain on the incision.

Question 23

Which guideline should the nurse incorporate when conducting a cardiopulmonary resuscitation (CPR) training session?

Accepted Answer

Answer reason: Current AHA BLS sequence is C-A-B: start chest compressions immediately, then manage airway and breathing. The 'look, listen, and feel' step is outdated, and arrest should not be determined by unresponsiveness alone.

Question 24

Which of the following is NOT included in the first aid for snake bite?

Accepted Answer

Answer reason: Evidence-based first aid for snakebite includes immobilizing the limb, reassuring the patient, and rapid transport to a medical facility; seeking a snake charmer is ineffective and unsafe.

Question 25

In the ER, which assessment finding would require immediate intervention by the nurse for a patient with asthma?

Accepted Answer

Answer reason: A sudden absence of breath sounds (silent chest) indicates severe airway obstruction and impending respiratory failure in asthma, requiring immediate intervention. The other findings are concerning but not as emergent.

Question 26

A client's telemetry monitor displays ventricular tachycardia; which action should the nurse take first?

Accepted Answer

Answer reason: When VT is seen on the monitor, the nurse must first assess the patient to determine stability and presence of a pulse. Checking level of consciousness (and pulse) guides whether to call a code and defibrillate or to prepare for synchronized cardioversion.

Question 27

A patient with chronic kidney disease missed 3 dialysis sessions and has a potassium level of 8.1, wide QRS complexes, heart rate of 58, and lethargy; which order should the nurse implement first?

Accepted Answer

Answer reason: Severe hyperkalemia with ECG changes (wide QRS, bradycardia) is life-threatening. The immediate priority is to stabilize the myocardium with IV calcium. Insulin/dextrose shifts potassium temporarily, dialysis removes potassium definitively, and sodium polystyrene is slow; all follow after membrane stabilization.

Question 28

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

Accepted Answer

Answer reason: Clear nasal drainage after head injury may be cerebrospinal fluid from a basilar skull fracture. Do not occlude or tilt the head back. Allow drainage to flow and collect it for testing; notify the provider.

Question 29

Which type of assessment is performed to identify life-threatening problems such as choking, stab wounds, or heart attack?

Accepted Answer

Answer reason: Emergency assessments are rapid checks aimed at detecting and addressing immediate life-threatening conditions (e.g., airway obstruction, major trauma, myocardial infarction). Focus and initial assessments are not designed for urgent life threats; 'critical assessment' is not a standard nursing assessment type.

Question 30

A client is admitted with acute respiratory distress syndrome (ARDS). What is the priority nursing intervention?

Accepted Answer

Answer reason: ARDS causes severe hypoxemia; immediate priority is airway and breathing. Mechanical ventilation with oxygen (often with PEEP) is required to maintain oxygenation. Other options do not address the life-threatening hypoxia.

Question 31

What is the priority nursing intervention during an eclamptic attack?

Accepted Answer

Answer reason: During an eclamptic seizure, immediate priority is airway maintenance to prevent hypoxia and aspiration. Oxygen and magnesium sulfate are given after airway is secured; restraints are contraindicated.

Question 32

What immediate action should the nurse take for a post-op patient who is unresponsive and begins vomiting?

Accepted Answer

Answer reason: Place the unresponsive vomiting client in the lateral recovery position to protect the airway and prevent aspiration; calling the surgeon or inserting an NG tube is not the immediate priority, and elevating the HOB alone is insufficient when unresponsive.

Question 33

CPR and defibrillation should be initiated in which kind of arrhythmia?

Accepted Answer

Answer reason: Ventricular fibrillation is a shockable cardiac arrest rhythm; initiate immediate CPR and defibrillation. The other rhythms are not indications for immediate defibrillation with CPR.

Question 34

During the assessment of a patient with third-degree AV block, which complication should the nurse monitor for?

Accepted Answer

Answer reason: Third-degree AV block can cause profound bradycardia and asystole, placing the patient at high risk for sudden cardiac arrest. Hyperkalemia is a cause rather than a complication; stroke and heart failure are less immediate risks compared with arrest.

Question 35

In Basic Life Support what does the acronym D R A B C D stand for?

Accepted Answer

Answer reason: DRABCD in BLS stands for Danger, Response, Airway, Breathing, Compressions (CPR), Defibrillation. Option A matches this sequence best; the other options are incorrect in wording or order.

Question 36

A client with an esophageal tamponade develops symptoms of respiratory distress, including inspiratory stridor. The nurse should give priority to?

Accepted Answer

Answer reason: Respiratory distress and stridor with an esophageal tamponade (e.g., Sengstaken–Blakemore tube) indicate airway obstruction from balloon displacement or overinflation. Priority is to immediately deflate the balloons and remove the tube to relieve the obstruction. Oxygen or head elevation will not resolve the blockage, and increasing balloon pressure worsens it.

Question 37

Which nursing intervention is most effective in managing a client brought to the emergency department due to drug poisoning?

Accepted Answer

Answer reason: Activated charcoal is the preferred initial decontamination for many oral poisonings because it binds drugs in the GI tract and reduces absorption. Gastric lavage and cathartics are not routinely recommended and carry more risks; milk dilution is ineffective.

Question 38

During a vaginal delivery, if the client’s umbilical cord prolapses, what is the emergency position?

Accepted Answer

Answer reason: Knee-chest or extreme Trendelenburg uses gravity to relieve pressure on a prolapsed umbilical cord and improve fetal perfusion until definitive management.

Question 39

What is the normal rate of chest compressions per minute for an adult during CPR?

Accepted Answer

Answer reason: AHA adult CPR guidelines recommend a chest compression rate of 100–120 per minute to optimize perfusion; slower or faster rates reduce effectiveness.

Question 40

What is the correct compression to ventilation ratio during CPR for an adult?

Accepted Answer

Answer reason: According to AHA BLS guidelines for adult CPR, provide 30 chest compressions followed by 2 ventilations.

Question 41

During a pelvic exam, the patient becomes lightheaded and diaphoretic; what should the nurse do first?

Accepted Answer

Answer reason: Lightheadedness and diaphoresis during a pelvic exam suggests a vasovagal episode with hypotension. The priority is to improve cerebral perfusion by placing the patient in Trendelenburg (legs elevated, head lowered). Orange juice treats hypoglycemia, a cold compress is supportive, and calling the physician is not the immediate first action.

Question 42

A client is admitted with sickle cell crises and sequestration. Upon assessing the client, the nurse would expect to find?

Accepted Answer

Answer reason: Splenic sequestration crisis pools blood in the spleen, causing acute hypovolemia and potential shock, which presents with hypotension. Moist mucous membranes and decreased respirations are not expected; increased BP is unlikely.

Question 43

A client with a C3 spinal cord injury experiences autonomic hyperreflexia. After placing the client in high Fowler’s position, the nurse’s next action should be to?

Accepted Answer

Answer reason: Autonomic dysreflexia is usually triggered by noxious stimuli, most commonly bladder distention from a kinked or obstructed catheter. After elevating the head of bed, the priority is to remove the trigger—first check catheter patency and relieve bladder distention. Antihypertensives or provider notification follow if blood pressure remains elevated; oxygen is not the priority.

Question 44

The nurse is the first person to arrive at the scene of a motor vehicle accident. When rendering aid to the victim, the nurse should give priority to?

Accepted Answer

Answer reason: In emergency care, the primary survey follows the ABCs. The airway must be secured first because airway obstruction leads to rapid hypoxia, cardiac arrest, and death. All other assessments follow only after ensuring a patent airway.

Question 45

How many times per minute should CPR be performed on heart attack patients?

Accepted Answer

Answer reason: Given the provided options in this quiz, the closest choice indicating frequent CPR is 10 times per minute; therefore D is selected.

Question 46

What is the primary use of the corner device?

Accepted Answer

Answer reason: The device is intended to support management of the ABCs—maintaining airway, supporting breathing, and aiding circulation—so all listed purposes apply.

Question 47

A client is admitted to the unit 2 hours after an explosion causes burns to the face. The nurse would be most concerned with the client developing which of the following?

Accepted Answer

Answer reason: Facial burns raise strong suspicion for inhalation injury; rapid airway swelling can occur within hours. Laryngeal edema threatens airway patency and is the most urgent complication compared with fluid or electrolyte changes.

Question 48

The first action that the nurse should take if she finds the client has an O2 saturation of 68% is?

Accepted Answer

Answer reason: An SpO2 of 68% indicates life-threatening hypoxemia. Following ABCs, the priority is to improve oxygenation immediately by applying supplemental oxygen. Elevating the head may help but is secondary; waiting to recheck or assessing pulse delays urgent treatment.

Question 49

When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should?

Accepted Answer

Answer reason: A prolapsed cord requires immediate actions to relieve pressure on the cord and improve fetal oxygenation. Elevating the hips (e.g., Trendelenburg or knee‑chest) reduces cord compression. Do not attempt to replace the cord, left lateral is insufficient, and the cord should be covered with saline-moistened gauze, not dry.

Question 50

The primary reason for rapid continuous rewarming of the area affected by frostbite is to?

Accepted Answer

Answer reason: Rapid continuous rewarming restores perfusion and halts ice-crystal formation, minimizing tissue ischemia and necrosis—thereby lessening cellular damage. Pain control and blister prevention are secondary.

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