NURS 121L-B Medical-Surgical Nursing: Emergency Response & Code
Situations (2026 Update) WCU
1. A nurse enters a room and finds a patient unresponsive with no palpable
pulse. After calling for help and activating the emergency response system,
what is the next priority action?
A. Administer 100% oxygen via bag-valve mask.
B. Start high-quality chest compressions.
C. Establish intravenous access for medication.
D. Perform an immediate tracheal intubation.
Answer: B
Rationale: According to the 2026 ACLS and BLS guidelines, if a patient is pulseless and
unresponsive, high-quality chest compressions should be initiated immediately to maintain
perfusion until a defibrillator is available.
2. Which clinical manifestation would most likely trigger the activation of the
Rapid Response Team (RRT) rather than a Code Blue?
A. A patient becomes suddenly apneic.
B. Loss of a palpable carotid pulse.
C. Acute change in mental status and a drop in SpO2 to 88%.
D. Confirmation of Ventricular Fibrillation on the monitor.
Answer: C
Rationale: The RRT is designed for early intervention when a patient’s condition is
deteriorating (e.g., respiratory distress or neurological changes) to prevent full cardiac or
respiratory arrest (Code Blue).
,3. During a Code Blue, the rhythm monitor shows Ventricular Fibrillation (VF).
The team has already delivered one shock. What is the next step in the
sequence?
A. Check for a pulse immediately.
B. Administer 1 mg of Epinephrine IV.
C. Resume chest compressions for 2 minutes.
D. Administer 300 mg of Amiodarone IV.
Answer: C
Rationale: Following a shock, chest compressions should be resumed immediately for 2
minutes before the next rhythm or pulse check to minimize interruptions in perfusion.
4. A patient in the ICU develops Pulseless Electrical Activity (PEA). Which of the
following is a reversible cause (‘H’) that the nurse should anticipate assessing?
A. Hyperglycemia
B. Hypertension
C. Hypovolemia
D. Hypernatremia
Answer: C
Rationale: The ‘H’s’ of PEA include Hypovolemia, Hypoxia, Hydrogen ion (acidosis),
Hypo/Hyperkalemia, and Hypothermia. Hypovolemia is a leading cause of PEA.
5. What is the recommended compression depth for an adult patient during CPR
to ensure effective cardiac output?
A. At least 1 inch (2.5 cm)
B. At least 2 inches (5 cm) but no more than 2.4 inches (6 cm)
C. Exactly 3 inches (7.5 cm)
D. Between 1.5 and 2 inches
Answer: B
, Rationale: Current guidelines recommend a depth of at least 2 inches (5 cm) to effectively
compress the heart, but avoiding excessive depth (over 2.4 inches) to prevent injury.
6. In a shockable rhythm (VF/pVT), when is the administration of Epinephrine
usually initiated according to ACLS protocols?
A. After the second unsuccessful shock.
B. After the first unsuccessful shock.
C. Immediately upon arrival of the crash cart.
D. Only after Amiodarone has failed.
Answer: A
Rationale: In VF/pVT, Epinephrine is typically given after the second shock has failed to
restore a rhythm. For non-shockable rhythms (Asystole/PEA), it is given as soon as
possible.
7. A patient with a history of heart failure is found gasping for air with pink,
frothy sputum. Which emergency condition is most likely?
A. Acute Pulmonary Edema
B. Pulmonary Embolism
C. Tension Pneumothorax
D. Acute Respiratory Distress Syndrome (ARDS)
Answer: A
Rationale: Pink, frothy sputum is a classic sign of acute pulmonary edema, often associated
with left-sided heart failure and fluid backup into the lungs.
Situations (2026 Update) WCU
1. A nurse enters a room and finds a patient unresponsive with no palpable
pulse. After calling for help and activating the emergency response system,
what is the next priority action?
A. Administer 100% oxygen via bag-valve mask.
B. Start high-quality chest compressions.
C. Establish intravenous access for medication.
D. Perform an immediate tracheal intubation.
Answer: B
Rationale: According to the 2026 ACLS and BLS guidelines, if a patient is pulseless and
unresponsive, high-quality chest compressions should be initiated immediately to maintain
perfusion until a defibrillator is available.
2. Which clinical manifestation would most likely trigger the activation of the
Rapid Response Team (RRT) rather than a Code Blue?
A. A patient becomes suddenly apneic.
B. Loss of a palpable carotid pulse.
C. Acute change in mental status and a drop in SpO2 to 88%.
D. Confirmation of Ventricular Fibrillation on the monitor.
Answer: C
Rationale: The RRT is designed for early intervention when a patient’s condition is
deteriorating (e.g., respiratory distress or neurological changes) to prevent full cardiac or
respiratory arrest (Code Blue).
,3. During a Code Blue, the rhythm monitor shows Ventricular Fibrillation (VF).
The team has already delivered one shock. What is the next step in the
sequence?
A. Check for a pulse immediately.
B. Administer 1 mg of Epinephrine IV.
C. Resume chest compressions for 2 minutes.
D. Administer 300 mg of Amiodarone IV.
Answer: C
Rationale: Following a shock, chest compressions should be resumed immediately for 2
minutes before the next rhythm or pulse check to minimize interruptions in perfusion.
4. A patient in the ICU develops Pulseless Electrical Activity (PEA). Which of the
following is a reversible cause (‘H’) that the nurse should anticipate assessing?
A. Hyperglycemia
B. Hypertension
C. Hypovolemia
D. Hypernatremia
Answer: C
Rationale: The ‘H’s’ of PEA include Hypovolemia, Hypoxia, Hydrogen ion (acidosis),
Hypo/Hyperkalemia, and Hypothermia. Hypovolemia is a leading cause of PEA.
5. What is the recommended compression depth for an adult patient during CPR
to ensure effective cardiac output?
A. At least 1 inch (2.5 cm)
B. At least 2 inches (5 cm) but no more than 2.4 inches (6 cm)
C. Exactly 3 inches (7.5 cm)
D. Between 1.5 and 2 inches
Answer: B
, Rationale: Current guidelines recommend a depth of at least 2 inches (5 cm) to effectively
compress the heart, but avoiding excessive depth (over 2.4 inches) to prevent injury.
6. In a shockable rhythm (VF/pVT), when is the administration of Epinephrine
usually initiated according to ACLS protocols?
A. After the second unsuccessful shock.
B. After the first unsuccessful shock.
C. Immediately upon arrival of the crash cart.
D. Only after Amiodarone has failed.
Answer: A
Rationale: In VF/pVT, Epinephrine is typically given after the second shock has failed to
restore a rhythm. For non-shockable rhythms (Asystole/PEA), it is given as soon as
possible.
7. A patient with a history of heart failure is found gasping for air with pink,
frothy sputum. Which emergency condition is most likely?
A. Acute Pulmonary Edema
B. Pulmonary Embolism
C. Tension Pneumothorax
D. Acute Respiratory Distress Syndrome (ARDS)
Answer: A
Rationale: Pink, frothy sputum is a classic sign of acute pulmonary edema, often associated
with left-sided heart failure and fluid backup into the lungs.
