NYU nursing A&E III exam 1
questions with complete solutions
Course
A&E
Question 1
A nurse is caring for a patient admitted with an acute ischemic stroke. Which nursing action has
the highest priority upon admission?
A. Assess the patient's airway, breathing, and circulation.
B. Obtain a complete health history.
C. Begin discharge planning.
D. Encourage oral fluid intake.
Correct Answer: A. Assess the patient's airway, breathing, and circulation.
Rationale
The priority in any emergency is to assess and stabilize the airway, breathing, and circulation
(ABCs). Stroke patients are at risk for airway compromise due to decreased level of
consciousness or impaired swallowing.
Question 2
A patient with acute decompensated heart failure presents with severe dyspnea, bilateral crackles,
and an oxygen saturation of 84% on room air. What is the nurse's priority intervention?
A. Apply supplemental oxygen and place the patient in High Fowler's position.
B. Encourage increased oral fluids.
C. Place the patient flat in bed.
D. Prepare the patient for discharge.
Correct Answer: A. Apply supplemental oxygen and place the patient in High Fowler's
position.
Rationale
Patients with pulmonary edema require immediate improvement of oxygenation. High Fowler's
position decreases venous return, improves lung expansion, and helps reduce respiratory distress.
,Question 3
A patient with septic shock has received the prescribed intravenous fluids but remains
hypotensive with a mean arterial pressure (MAP) of 58 mmHg. Which intervention should the
nurse anticipate next?
A. Initiation of a norepinephrine infusion.
B. Administration of a diuretic.
C. Restriction of intravenous fluids.
D. Administration of oral antihypertensive medication.
Correct Answer: A. Initiation of a norepinephrine infusion.
Rationale
Persistent hypotension despite adequate fluid resuscitation is characteristic of septic shock and
requires vasopressor therapy, with norepinephrine commonly used as the first-line agent.
Question 4
A patient receiving intravenous heparin suddenly develops bleeding from the gums and
hematuria. What is the nurse's priority action?
A. Stop the heparin infusion and notify the healthcare provider.
B. Continue the infusion as prescribed.
C. Encourage increased fluid intake.
D. Administer aspirin.
Correct Answer: A. Stop the heparin infusion and notify the healthcare provider.
Rationale
Active bleeding indicates a serious adverse effect of anticoagulation. The infusion should be
stopped immediately, the patient assessed, and the provider notified. Protamine sulfate may be
required if significant bleeding occurs.
Question 5
A patient with chronic obstructive pulmonary disease (COPD) becomes increasingly drowsy and
difficult to arouse. Which complication should the nurse suspect?
,A. Carbon dioxide retention
B. Hyperthyroidism
C. Hypoglycemia
D. Hypernatremia
Correct Answer: A. Carbon dioxide retention
Rationale
Hypercapnia causes headache, confusion, drowsiness, and decreased level of consciousness due
to respiratory failure.
Question 6
A patient with diabetes mellitus is found confused and diaphoretic. Point-of-care blood glucose is
42 mg/dL. What is the nurse's priority intervention?
A. Administer rapid-acting glucose according to protocol.
B. Administer regular insulin.
C. Encourage exercise.
D. Restrict carbohydrates.
Correct Answer: A. Administer rapid-acting glucose according to protocol.
Rationale
Symptomatic hypoglycemia is a medical emergency requiring immediate glucose replacement to
prevent neurological injury.
Question 7
A patient receiving a blood transfusion develops fever, chills, flank pain, and hypotension. What
should the nurse do first?
A. Stop the blood transfusion immediately.
B. Slow the transfusion rate.
C. Administer acetaminophen.
D. Continue the transfusion while monitoring.
, Correct Answer: A. Stop the blood transfusion immediately.
Rationale
These findings suggest an acute hemolytic transfusion reaction. The transfusion must be stopped
immediately while maintaining IV access with normal saline and following institutional
transfusion reaction protocols.
Question 8
A patient develops facial swelling, wheezing, generalized urticaria, and hypotension immediately
after receiving intravenous contrast media. Which medication should the nurse administer first?
A. Epinephrine
B. Diphenhydramine
C. Hydrocortisone
D. Acetaminophen
Correct Answer: A. Epinephrine
Rationale
Epinephrine is the first-line treatment for anaphylaxis because it rapidly reverses airway edema,
bronchospasm, and hypotension.
Question 9
A patient with chronic kidney disease has a serum potassium level of 7.0 mEq/L and ECG
changes showing peaked T waves. Which intervention should the nurse anticipate first?
A. Administer intravenous calcium gluconate.
B. Encourage potassium-rich foods.
C. Restrict fluid intake.
D. Administer oral iron supplements.
Correct Answer: A. Administer intravenous calcium gluconate.
Rationale
questions with complete solutions
Course
A&E
Question 1
A nurse is caring for a patient admitted with an acute ischemic stroke. Which nursing action has
the highest priority upon admission?
A. Assess the patient's airway, breathing, and circulation.
B. Obtain a complete health history.
C. Begin discharge planning.
D. Encourage oral fluid intake.
Correct Answer: A. Assess the patient's airway, breathing, and circulation.
Rationale
The priority in any emergency is to assess and stabilize the airway, breathing, and circulation
(ABCs). Stroke patients are at risk for airway compromise due to decreased level of
consciousness or impaired swallowing.
Question 2
A patient with acute decompensated heart failure presents with severe dyspnea, bilateral crackles,
and an oxygen saturation of 84% on room air. What is the nurse's priority intervention?
A. Apply supplemental oxygen and place the patient in High Fowler's position.
B. Encourage increased oral fluids.
C. Place the patient flat in bed.
D. Prepare the patient for discharge.
Correct Answer: A. Apply supplemental oxygen and place the patient in High Fowler's
position.
Rationale
Patients with pulmonary edema require immediate improvement of oxygenation. High Fowler's
position decreases venous return, improves lung expansion, and helps reduce respiratory distress.
,Question 3
A patient with septic shock has received the prescribed intravenous fluids but remains
hypotensive with a mean arterial pressure (MAP) of 58 mmHg. Which intervention should the
nurse anticipate next?
A. Initiation of a norepinephrine infusion.
B. Administration of a diuretic.
C. Restriction of intravenous fluids.
D. Administration of oral antihypertensive medication.
Correct Answer: A. Initiation of a norepinephrine infusion.
Rationale
Persistent hypotension despite adequate fluid resuscitation is characteristic of septic shock and
requires vasopressor therapy, with norepinephrine commonly used as the first-line agent.
Question 4
A patient receiving intravenous heparin suddenly develops bleeding from the gums and
hematuria. What is the nurse's priority action?
A. Stop the heparin infusion and notify the healthcare provider.
B. Continue the infusion as prescribed.
C. Encourage increased fluid intake.
D. Administer aspirin.
Correct Answer: A. Stop the heparin infusion and notify the healthcare provider.
Rationale
Active bleeding indicates a serious adverse effect of anticoagulation. The infusion should be
stopped immediately, the patient assessed, and the provider notified. Protamine sulfate may be
required if significant bleeding occurs.
Question 5
A patient with chronic obstructive pulmonary disease (COPD) becomes increasingly drowsy and
difficult to arouse. Which complication should the nurse suspect?
,A. Carbon dioxide retention
B. Hyperthyroidism
C. Hypoglycemia
D. Hypernatremia
Correct Answer: A. Carbon dioxide retention
Rationale
Hypercapnia causes headache, confusion, drowsiness, and decreased level of consciousness due
to respiratory failure.
Question 6
A patient with diabetes mellitus is found confused and diaphoretic. Point-of-care blood glucose is
42 mg/dL. What is the nurse's priority intervention?
A. Administer rapid-acting glucose according to protocol.
B. Administer regular insulin.
C. Encourage exercise.
D. Restrict carbohydrates.
Correct Answer: A. Administer rapid-acting glucose according to protocol.
Rationale
Symptomatic hypoglycemia is a medical emergency requiring immediate glucose replacement to
prevent neurological injury.
Question 7
A patient receiving a blood transfusion develops fever, chills, flank pain, and hypotension. What
should the nurse do first?
A. Stop the blood transfusion immediately.
B. Slow the transfusion rate.
C. Administer acetaminophen.
D. Continue the transfusion while monitoring.
, Correct Answer: A. Stop the blood transfusion immediately.
Rationale
These findings suggest an acute hemolytic transfusion reaction. The transfusion must be stopped
immediately while maintaining IV access with normal saline and following institutional
transfusion reaction protocols.
Question 8
A patient develops facial swelling, wheezing, generalized urticaria, and hypotension immediately
after receiving intravenous contrast media. Which medication should the nurse administer first?
A. Epinephrine
B. Diphenhydramine
C. Hydrocortisone
D. Acetaminophen
Correct Answer: A. Epinephrine
Rationale
Epinephrine is the first-line treatment for anaphylaxis because it rapidly reverses airway edema,
bronchospasm, and hypotension.
Question 9
A patient with chronic kidney disease has a serum potassium level of 7.0 mEq/L and ECG
changes showing peaked T waves. Which intervention should the nurse anticipate first?
A. Administer intravenous calcium gluconate.
B. Encourage potassium-rich foods.
C. Restrict fluid intake.
D. Administer oral iron supplements.
Correct Answer: A. Administer intravenous calcium gluconate.
Rationale
