2026/2027 Exam All Answers
and Illustrations Given
A nurse on a medical-surgical unit is caring for a group of clients. The
nurse should notify the rapid response tea for which of the following
clients?
A.) Client who has a pressure injury of the right heel whose blood
glucose is 300 mg/dL
B.) Client who reports right calf pain and shortness of breath
C.) Client who has blood on a pressure dressing in the femoral area
following a cardiac catheterization
,D.) Client who has dark red coloration of left toes and absent pedal
pulse - ANSWER ✔✔B.) Client who reports right calf pain and
shortness of breath
The nurse should identify that the client is at risk for respiratory arrest
due to a possible embolism. The nurse should call the rapid response
team because the manifestations can indicate the beginning of a rapid
decline in the client's condition.
A nurse is caring for a client who has ingested a toxic agent. Which of
the following actions should the nurse plan to take? (Select all that
apply.)
A.) Induce vomiting
B.) Instill activated charcoal
C.) Perform a gastric lavage with aspiration
D.) Administer syrup of ipecac
E.) Infuse IV fluids - ANSWER ✔✔B.) Instill activated charcoal
C.) Perform a gastric lavage with aspiration
E.) Infuse IV fluids
A nurse in the emergency department is caring for a client who fell
through the ice on a pond and is unresponsive and breathing slowly.
, Which of the following actions should the nurse take? (Select all that
apply.)
A.) Remove wet clothing
B.) Maintain normal room temperature
C.) Apply warm blankets
D.) Use of rapid rewarming water 40-42 degrees celsius (104-108
degrees fahrenheit)
E.) Infuse warmed IV fluids - ANSWER ✔✔A.) Remove wet clothing
C.) Apply warm blankets
D.) Use of rapid rewarming water 40-42 degrees celsius (104-108
degrees fahrenheit)
E.) Infuse warmed IV fluids
A nurse is reviewing the common emergency management protocol for
clients who has asystole. Which of the following actions should the nurse
plan to take during this cardiac emergency?
A.) Perform defibrillation
B.) Prepare for transcutaneous pacing
C.) Administer IV epinephrine
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