Question 1

What is the first priority intervention for a patient found unconscious lying on the ward floor?

Accepted Answer

Answer reason: Airway takes priority in an unresponsive patient. Open the airway with head tilt–chin lift before further actions. Calling 9-1-1 is not the immediate ward response, tapping for responsiveness is redundant given the stated unconsciousness, and CPR follows after airway/breathing assessment.

Question 2

The blood alcohol concentration of a client admitted following a motor vehicle accident is 460mg/dL. The nurse should give priority to monitoring the client for?

Accepted Answer

Answer reason: A BAC of 460 mg/dL indicates severe alcohol intoxication with central nervous system depression; the immediate life‑threatening risk is impaired ventilation. Airway and breathing take priority—monitor for respiratory depression.

Question 3

The nurse is assessing a trauma client in the emergency room when she notes a penetrating abdominal wound with exposed viscera. The nurse should?

Accepted Answer

Answer reason: For abdominal evisceration, the priority is to protect exposed organs by covering them with sterile saline-moistened gauze to keep tissues moist and reduce infection risk. Do not attempt to reinsert contents or use dry/occlusive petroleum dressings.

Question 4

A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to?

Accepted Answer

Answer reason: Severe rigidity with hyperthermia after starting an antipsychotic indicates neuroleptic malignant syndrome, a life-threatening emergency requiring immediate transfer for intensive medical management. Withholding meds alone is insufficient; antiparkinsonian drugs treat EPS, not NMS; ordering labs is not the priority and beyond typical nursing scope.

Question 5

The nurse is caring for a client with full thickness burns to the lower half of the torso and lower extremities. During the emergent phase of injury, the primary nursing diagnosis would focus on?

Accepted Answer

Answer reason: In the emergent phase of major burns, the greatest risk is hypovolemic shock from capillary leak and third spacing; priority is fluid resuscitation, making fluid volume deficit the primary diagnosis.

Question 6

Which are the TABC of resuscitation?

Accepted Answer

Answer reason: In trauma/resuscitation, TABC prioritizes control of Temperature (prevent hypothermia) followed by Airway, Breathing, and Circulation. Option D lists this sequence correctly.

Question 7

The nurse identifies ventricular tachycardia on the heart monitor. The nurse should immediately?

Accepted Answer

Answer reason: For ventricular tachycardia with a pulse, immediate management is antiarrhythmic therapy (historically lidocaine; now often amiodarone). Atropine treats bradycardia, checking potassium is not immediate, and defibrillation is for pulseless VT/VF.

Question 8

The client presents to the emergency room with a hyphema. Which action by the nurse would be best?

Accepted Answer

Answer reason: Hyphema is blood in the anterior chamber after eye trauma. To reduce intraocular pressure and prevent rebleeding, keep the head elevated and apply cold to the eye; other options are unrelated.

Question 9

A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. Which nursing action is most appropriate?

Accepted Answer

Answer reason: With evisceration, the priority is to cover exposed viscera with sterile saline-moistened dressings to keep tissues moist and reduce infection/necrosis risk. Do not reinsert organs or apply pressure/binder; dry dressings are inadequate.

Question 10

The nurse is caring for the client following a thyroidectomy when suddenly the client becomes nonresponsive and pale, with a BP of 60 systolic. The nurse’s initial action should be to?

Accepted Answer

Answer reason: Unresponsiveness with systolic BP 60 indicates shock; the priority is to rapidly restore perfusion with an isotonic fluid bolus by increasing the normal saline infusion. Atropine is for bradycardia, lowering the head alone is insufficient, and a crash cart is premature while the patient still has a pulse.

Question 11

The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?

Accepted Answer

Answer reason: Post-op vitals (hypotension with tachycardia and tachypnea) suggest possible hemorrhage/shock. Immediate notification of the surgeon is priority for rapid intervention. Documentation or pain meds delay care; elevating the head worsens hypotension.

Question 12

The nurse is caring for a 9-year-old child admitted with asthma. Upon the morning rounds, the nurse finds an O2 sat of 78%. Which of the following actions should the nurse take first?

Accepted Answer

Answer reason: An SpO2 of 78% indicates severe hypoxemia. Following ABCs, the priority is to improve oxygenation immediately—apply supplemental oxygen—before notifying the provider or assessing unrelated parameters like pulse.

Question 13

A pre-term baby develops nasal flaring, cyanosis and diminished breath sounds on one side. The physician's diagnosis is spontaneous pneumothorax. Which of the following should the nurse prepare for FIRST?

Accepted Answer

Answer reason: Signs of pneumothorax in a newborn require immediate preparation for chest tube insertion to restore negative intrapleural pressure and re-expand the lung. Oxygen alone will not resolve the collapse, assisted ventilation can worsen the pneumothorax, and CPR is not indicated unless arrest occurs.

Question 14

The nurse is performing a physical assessment on a client with insulin dependent diabetes mellitus. Which of the following client complaints calls for IMMEDIATE nursing action?

Accepted Answer

Answer reason: Diaphoresis and tremors indicate acute hypoglycemia, which can rapidly progress to seizures or coma and requires immediate intervention. The other complaints reflect chronic issues (neuropathy), hyperglycemia symptoms, or a localized injection-site problem and are less urgent.

Question 15

The nurse is caring for a client in the coronary care unit. The display on the cardiac monitor indicates ventricular fibrillation. What should the nurse do FIRST?

Accepted Answer

Answer reason: Monitor artifact can mimic ventricular fibrillation. The priority is to verify the rhythm by assessing for a pulse; if pulseless, proceed with defibrillation and CPR.

Question 16

Which of the following is an obstetric emergency?

Accepted Answer

Answer reason: Uterine inversion causes sudden, severe postpartum hemorrhage and shock and requires immediate intervention, making it an obstetric emergency. Cord presentation is a risk for prolapse, occipito-posterior is a malposition, and involution is normal.

Question 17

What is the priority for a client in Addisonian crisis?

Accepted Answer

Answer reason: Addisonian crisis causes acute adrenal insufficiency with severe hypotension and risk of shock; immediate priority is preventing/treating shock with fluids and corticosteroids. Hypertension, infection, and anxiety are secondary concerns.

Question 18

In which medium should avulsed teeth be placed?

Accepted Answer

Answer reason: Milk best preserves periodontal ligament cell viability due to appropriate pH and osmolality and availability. Water is hypotonic and damages cells; saline lacks nutrients and offers shorter survival.

Question 19

The nurse detects blood-tinged fluid leaking from the nose and ears of a head trauma client. The appropriate nursing action would be to?

Accepted Answer

Answer reason: Blood-tinged drainage from nose/ears after head injury suggests a CSF leak from a skull fracture. Do not pack or apply pressure; instead, cover with a bulky, loose sterile dressing to allow drainage and permit observation.

Question 20

A 67 year-old client is admitted with substernal chest pain with radiation to the jaw. His admitting diagnosis is Acute Myocardial Infarction (MI). The PRIORITY nursing diagnosis for this client during the immediate 24 hours is?

Accepted Answer

Answer reason: Immediate post-MI priority follows ABCs; oxygenation is critical due to mismatch of oxygen supply and demand, making impaired gas exchange the highest priority.

Question 21

A client is admitted with complaints of chest pain three hours ago. The troponin level is reported as 10 mg/mL. Which of the following actions by the nurse is a priority?

Accepted Answer

Answer reason: Elevated troponin within hours of chest pain suggests myocardial injury. Immediate priority is to reduce myocardial oxygen demand and prevent further ischemia; placing the client on absolute bed rest achieves this. Notifying the provider and other measures can follow.

Question 22

A three year-old child comes to the pediatric clinic after the sudden onset of symptoms 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: Symptoms indicate acute epiglottitis with impending airway obstruction (drooling, muffled voice, tripod positioning). The priority is to get immediate medical help and prepare for airway management; do not examine the throat or obtain specimens, which can precipitate complete obstruction.

Question 23

A nurse enters a client's room to discover that the client has no pulse or respirations. After calling for help, the FIRST action the nurse should take is?

Accepted Answer

Answer reason: For an unresponsive client with no pulse or respirations, after activating emergency response, begin CPR with chest compressions (CAB sequence). Airway and IV access follow.

Question 24

When caring for a child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago, which of the following actions should the nurse take FIRST?

Accepted Answer

Answer reason: Within 1 hour of a large acetaminophen ingestion, the priority is decontamination to remove unabsorbed drug; induce emesis with syrup of ipecac (unless contraindicated). Antidote (N-acetylcysteine), IV fluids, or dialysis are not the first immediate step at 45 minutes post ingestion.

Question 25

A client with coronary artery disease has a sudden episode of cyanosis and a change in respirations. The nurse starts oxygen administration immediately. In this situation?

Accepted Answer

Answer reason: Acute cyanosis and respiratory change indicate hypoxia; initiating oxygen is an immediate emergency intervention that does not require waiting for a prescription.

Question 26

A client is brought to the emergency room following a motor vehicle accident. When assessing the client one-half hour after admission, the nurse notes several physical changes. Which of the following changes would require the nurse's IMMEDIATE attention?

Accepted Answer

Answer reason: Tracheal deviation indicates mediastinal shift, most commonly from a tension pneumothorax, which is an immediate life-threatening emergency requiring prompt decompression. The other findings are concerning but less immediately critical.

Question 27

The nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should FIRST?

Accepted Answer

Answer reason: BLS sequence begins by checking responsiveness. Verify unresponsiveness first, then call for help and proceed with airway/breathing steps.

Question 28

A client is unconscious following a tonic-clonic seizure. What should the nurse do FIRST?

Accepted Answer

Answer reason: Airway takes priority post-seizure; side-lying maintains airway patency, allows drainage of secretions, and reduces aspiration risk. Checking pulse or giving medication is secondary, and inserting a tongue blade is contraindicated.

Question 29

The nurse is caring for a client with COPD who suddenly complains of sharp pains in the right side of his chest, is cyanotic and has a tracheal deviation toward the right side. The nurse recognizes that these symptoms are probably due to?

Accepted Answer

Answer reason: Acute pleuritic chest pain with cyanosis and tracheal deviation indicates a tension pneumothorax, an emergency that shifts the mediastinum away from the affected side and causes severe hypoxia.

Question 30

The nurse is caring for a client who develops pulmonary edema and is exhibiting anxiety, diaphoresis, and crackles. Which of the following nursing interventions should be performed FIRST?

Accepted Answer

Answer reason: In acute pulmonary edema, the immediate priority is to reduce preload and improve ventilation. Sitting upright with legs dangling decreases venous return to the heart and helps oxygenation. Vital signs, contacting the provider, and administering medications follow after this initial action.

Question 31

A nurse is eating in the hospital cafeteria when a toddler at a nearby table chokes on a piece of food and appears slightly blue. The appropriate INITIAL action should be to?

Accepted Answer

Answer reason: A toddler with an obstructed airway requires immediate abdominal thrusts (Heimlich) to expel the object. Mouth-to-mouth will not ventilate through an obstruction, water is unsafe, and calling for help should follow the initial life-saving maneuver.

Question 32

While caring for a toddler with croup, which of the following signs requires the nurse's IMMEDIATE attention?

Accepted Answer

Answer reason: A toddler’s normal apical pulse is roughly 90–140 bpm; a pulse of 54 indicates severe bradycardia, often due to hypoxia and impending respiratory failure in croup, requiring immediate intervention. RR 30 can be within normal for a toddler; coughing secretions is protective; lethargy is concerning but bradycardia is most emergent.

Question 33

The nurse is caring for a client who is experiencing a seizure. Which of the following is a PRIORITY nursing action?

Accepted Answer

Answer reason: The immediate priority during a seizure is maintaining safety by preventing physical injury—removing hazards, padding side rails, and positioning safely. Interfering with the mouth or restraining the patient can worsen injury. Airway suctioning is done only after the seizure ends.

Question 34

While performing high-quality CPR on an adult, what action should you ensure is being accomplished?

Accepted Answer

Answer reason: Adult high-quality CPR requires a compression depth of at least 2 inches (5–6 cm). Other options are incorrect: rate should be 100–120/min (not 90–120), hand placement is the lower half of the sternum (not upper third), and chest should fully recoil rather than a measured 1 inch.

Question 35

How can rescuers ensure that they are providing effective breaths when using a bag-mask device?

Accepted Answer

Answer reason: Visible chest rise confirms adequate tidal volume and mask seal. The other options either risk barotrauma, are not required to verify effectiveness, or indicate an air leak.

Question 36

What ratio for compressions to breaths should be used for 1-rescuer infant CPR?

Accepted Answer

Answer reason: For single-rescuer infant CPR, the recommended compression-to-ventilation ratio is 30:2. The 15:2 ratio applies to two-rescuer infant CPR.

Question 37

A nurse is caring for a client in the ER following a myocardial infarction. Which of the following actions should the nurse anticipate if the client develops asystole?

Accepted Answer

Answer reason: Asystole is a non-shockable rhythm; defibrillation is not indicated. Lidocaine is for ventricular tachyarrhythmias, not asystole. The anticipated intervention is pharmacologic support such as atropine (with CPR/epi per ACLS).

Question 38

Which feature is most typical of neurogenic shock after spinal cord injury?

Accepted Answer

Answer reason: Neurogenic shock from high spinal cord injury causes loss of sympathetic tone leading to peripheral vasodilation (warm, dry skin) and unopposed vagal activity causing bradycardia with hypotension.

Question 39

An 18 year-old client is admitted to intensive care from the emergency room following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebrae. The nurse's PRIORITY assessment should be?

Accepted Answer

Answer reason: High cervical (C2) spinal cord injury can paralyze the diaphragm (innervated C3–C5) and compromise ventilation. Airway and breathing are the priority, so assess respiratory function first.

Question 40

A client with a documented pulmonary embolism has the following arterial blood gases: PO2 - 70 mm Hg, PCO2 - 32 mm Hg, pH - 7.45, SaO2 - 87%, HCO3 - 22. Based on this data, what is the FIRST nursing action?

Accepted Answer

Answer reason: ABGs show hypoxemia (PaO2 70, SaO2 87%) consistent with PE. The priority is to correct oxygenation; therefore administer oxygen before other actions.

Question 41

A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured at 480 liters/minute. Post-operatively the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do FIRST?

Accepted Answer

Answer reason: Peak flow fell from 480 to 200 L/min (

Question 42

What is the best position for a client in hypovolemic shock?

Accepted Answer

Answer reason: In hypovolemic shock, positioning that increases venous return and perfusion to vital organs is preferred. Trendelenburg (or legs-elevated) improves central blood flow; the other positions do not support perfusion in shock.

Question 43

A client with partial-thickness burns on the anterior chest and both arms is admitted to the emergency department. Which intervention should the nurse include as a PRIORITY in the plan of care?

Accepted Answer

Answer reason: Significant burns cause massive fluid shifts due to capillary leakage, placing the patient at high risk for hypovolemic shock. Early recognition of hypotension, tachycardia, and reduced urine output is critical to prevent life-threatening complications. Ice application and fibrous dressings can worsen tissue damage.

Question 44

Which intervention is MOST important immediately after a patient experiences a tonic-clonic seizure?

Accepted Answer

Answer reason: Side-lying positioning maintains airway patency, prevents aspiration, and allows secretions to drain safely after a seizure.

Question 45

The most important part of treatment immediately after snake bite ?

Accepted Answer

Answer reason: After a snakebite, keeping the victim calm and reassured helps reduce sympathetic stimulation, slowing lymphatic spread of venom while arranging rapid transport and limb immobilization. Incision and suction and tourniquets are not recommended due to tissue damage and ischemia risks. Antivenom is definitive therapy but is administered in a clinical setting after assessment and monitoring, not as the immediate first step in the field.

Question 46

Skin finding in hypovolemic shock?

Accepted Answer

Answer reason: In hypovolemic shock, reduced circulating volume triggers a sympathetic response with intense peripheral vasoconstriction to preserve blood flow to vital organs. Cutaneous perfusion falls and diaphoresis occurs, producing cool, pale, clammy skin. Warm or flushed skin is more typical of early distributive (e.g., septic) shock, and normal skin findings would not be expected in hypovolemia.

Question 47

Carotid pulse should be checked for?

Accepted Answer

Answer reason: BLS/ACLS guidelines state that a carotid (or femoral) pulse check should take at least 5 but no more than 10 seconds. Checking for less than 5 seconds risks missing a weak or slow pulse, while more than 10 seconds unnecessarily delays chest compressions. Rapid determination within this 5–10 second window optimizes timely CPR initiation.

Question 48

An 18 year old female presents to the Emergency Department with a generalized tonic-clonic seizure. Her seizure had lasted 20 minutes according to eyewitness accounts. Her SpO2 is currently 97% and she has already been given 2 doses of rectal diazepam but the seizures have not stopped. What is the SINGLE most appropriate management?

Accepted Answer

Answer reason: This is status epilepticus (>5 minutes) persisting despite two doses of a benzodiazepine (rectal diazepam). After adequate benzodiazepine therapy, the next step is a long-acting antiepileptic such as IV phenytoin or fosphenytoin to prevent seizure recurrence. IV lorazepam would duplicate first-line therapy already given, and phenobarbital is typically used after failure of phenytoin/fosphenytoin. Airway is currently adequate (SpO2 97%) and ICU referral/intubation are not the immediate next steps.

Question 49

First step in management of shock is?

Accepted Answer

Answer reason: Initial shock management follows the ABCs: securing airway and ensuring adequate oxygenation to prevent tissue hypoxia. Supplemental oxygen is the first immediate intervention while other resuscitation steps are initiated. IV fluids follow to restore perfusion depending on shock type. Antibiotics apply to septic shock after stabilization, and sedatives can worsen hypotension and are not first-line.

Question 50

The pulse in shock is usually?

Accepted Answer

Answer reason: In shock, decreased circulating volume and cardiac output trigger sympathetic compensation with tachycardia. Peripheral vasoconstriction and low stroke volume produce a thready, weak pulse. Thus the pulse is typically rapid and weak. An absent pulse suggests cardiac arrest, not the usual presentation of shock.

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