ACLS POST TEST EXAM 1 NEWEST VERSION 2023-2024
ACTUAL 50 QUESTION AND CORRECT DETAILED
ANSWERS RATED A GRADE.
A nurse is assessing a client who is receiving continuous enteral nutrition via
a nasogastric (NG) tube. The client has developed clinical manifestations
consistent with hyperosmolar dehydration. Which of the following actions
should the nurse take in response to these assessment findings?
a. Empty the client's ostomy pouch when it is half full.
b. Switch the client's enteral formula to a lactose-free preparation.
c. Increase the rate of the continuous enteral feeding infusion.
d. Administer a hypotonic intravenous fluid replacement as prescribed.
CORRECT ANS: B
EXPERT RATIONALE
Hyperosmolar dehydration in a client receiving enteral feeding often results
from the high osmotic load of the formula, which can draw fluid into the
gastrointestinal tract, leading to osmotic diarrhea and subsequent fluid and
electrolyte imbalances. Switching to a lactose-free formula can help reduce
osmotic diarrhea, particularly if the client has undiagnosed lactose
intolerance, which exacerbates fluid loss. Option A is irrelevant to the
management of hyperosmolar dehydration as it addresses ostomy care, not
the underlying cause of the fluid imbalance. Option C would worsen the
condition by increasing the osmotic load. Option D is not a nursing action
but a provider-prescribed intervention; the nurse's immediate role is to
address the cause of the dehydration by modifying the formula.
,DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
A 62-year-old man received intravenous tissue plasminogen activator (tPA) 2
hours ago after a diagnosis of acute ischemic stroke. While assessing the
patient's vital signs, you observe swelling of the patient's lips and tongue.
Your best course of action will be to:
A. Administer aspirin and IV heparin.
B. Administer IV antihistamines and steroids.
C. Observe and reassess the patient every 15 minutes.
D. Request an emergent brain computed tomography scan.
CORRECT ANS: B
EXPERT RATIONALE
The swelling of the patient's lips and tongue is a sign of anaphylaxis, a known
complication of tPA administration. The immediate treatment for
anaphylaxis includes antihistamines and corticosteroids to reduce the
allergic response. Option A is incorrect because aspirin and heparin are not
indicated for anaphylaxis; they are used for thrombotic conditions. Option C
is inappropriate because anaphylaxis requires immediate treatment, not
observation. Option D is incorrect because the symptoms are systemic and
not related to intracranial bleeding.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral
Therapies
During a cardiac arrest, multiple attempts to establish a peripheral IV have
proved unsuccessful. Your best course of action at this time will be to:
,A. Insert a central line.
B. Attempt intraosseous access.
C. Discontinue resuscitation efforts.
D. Continue peripheral IV attempts until successful.
CORRECT ANS: B
EXPERT RATIONALE
When peripheral IV access is unsuccessful during a cardiac arrest,
intraosseous (IO) access is the recommended alternative. IO access is rapid,
reliable, and can deliver medications and fluids effectively. Option A,
inserting a central line, is time-consuming and may delay resuscitation.
Option C is inappropriate because resuscitation efforts should continue.
Option D is incorrect because continuing to attempt peripheral IV access can
cause unnecessary delays.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity: Emergency Care
Synchronized cardioversion:
A. Is used only for atrial dysrhythmias.
B. Delivers a shock during ventricular depolarization.
C. Delivers a shock between the peak and end of the T wave.
D. Is used only for rhythms with a ventricular rate of less than 60 beats/min.
CORRECT ANS: B
EXPERT RATIONALE
Synchronized cardioversion delivers a shock during ventricular depolarization
(the R wave) to avoid the vulnerable period of the cardiac cycle (the T wave).
Option A is incorrect because synchronized cardioversion can be used for
both atrial and ventricular dysrhythmias. Option C describes the timing to
avoid; the shock should not be delivered on the T wave. Option D is incorrect
, because synchronized cardioversion is used for tachyarrhythmias, not
bradycardias.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
An 84-year-old man presents with an acute onset of altered mental status.
The cardiac monitor shows the rhythm. The patient's BP is 58/30 mm Hg and
his ventilatory rate is 14 breaths/min. His skin is cool, moist, and pale. His
blood oxygen saturation level (SpO2) on room air is 95%. An IV has been
established. On the basis of the information provided, your best course of
action will be to:
A. Prepare for transcutaneous pacing.
B. Give amiodarone 300 mg IV push.
C. Give epinephrine 1 mg IV bolus and reassess.
D. Observe the patient and monitor for signs of deterioration.
CORRECT ANS: A
EXPERT RATIONALE
The patient is presenting with symptomatic bradycardia (altered mental
status, hypotension, cool/clammy skin) and requires immediate intervention.
Transcutaneous pacing is the treatment of choice for symptomatic
bradycardia that is unresponsive to atropine. Option B, amiodarone, is used
for tachyarrhythmias. Option C, epinephrine, may be used in cardiac arrest
but is not first-line for symptomatic bradycardia. Option D, observation, is
inappropriate because the patient is unstable.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity: Emergency Care
ACTUAL 50 QUESTION AND CORRECT DETAILED
ANSWERS RATED A GRADE.
A nurse is assessing a client who is receiving continuous enteral nutrition via
a nasogastric (NG) tube. The client has developed clinical manifestations
consistent with hyperosmolar dehydration. Which of the following actions
should the nurse take in response to these assessment findings?
a. Empty the client's ostomy pouch when it is half full.
b. Switch the client's enteral formula to a lactose-free preparation.
c. Increase the rate of the continuous enteral feeding infusion.
d. Administer a hypotonic intravenous fluid replacement as prescribed.
CORRECT ANS: B
EXPERT RATIONALE
Hyperosmolar dehydration in a client receiving enteral feeding often results
from the high osmotic load of the formula, which can draw fluid into the
gastrointestinal tract, leading to osmotic diarrhea and subsequent fluid and
electrolyte imbalances. Switching to a lactose-free formula can help reduce
osmotic diarrhea, particularly if the client has undiagnosed lactose
intolerance, which exacerbates fluid loss. Option A is irrelevant to the
management of hyperosmolar dehydration as it addresses ostomy care, not
the underlying cause of the fluid imbalance. Option C would worsen the
condition by increasing the osmotic load. Option D is not a nursing action
but a provider-prescribed intervention; the nurse's immediate role is to
address the cause of the dehydration by modifying the formula.
,DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
A 62-year-old man received intravenous tissue plasminogen activator (tPA) 2
hours ago after a diagnosis of acute ischemic stroke. While assessing the
patient's vital signs, you observe swelling of the patient's lips and tongue.
Your best course of action will be to:
A. Administer aspirin and IV heparin.
B. Administer IV antihistamines and steroids.
C. Observe and reassess the patient every 15 minutes.
D. Request an emergent brain computed tomography scan.
CORRECT ANS: B
EXPERT RATIONALE
The swelling of the patient's lips and tongue is a sign of anaphylaxis, a known
complication of tPA administration. The immediate treatment for
anaphylaxis includes antihistamines and corticosteroids to reduce the
allergic response. Option A is incorrect because aspirin and heparin are not
indicated for anaphylaxis; they are used for thrombotic conditions. Option C
is inappropriate because anaphylaxis requires immediate treatment, not
observation. Option D is incorrect because the symptoms are systemic and
not related to intracranial bleeding.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral
Therapies
During a cardiac arrest, multiple attempts to establish a peripheral IV have
proved unsuccessful. Your best course of action at this time will be to:
,A. Insert a central line.
B. Attempt intraosseous access.
C. Discontinue resuscitation efforts.
D. Continue peripheral IV attempts until successful.
CORRECT ANS: B
EXPERT RATIONALE
When peripheral IV access is unsuccessful during a cardiac arrest,
intraosseous (IO) access is the recommended alternative. IO access is rapid,
reliable, and can deliver medications and fluids effectively. Option A,
inserting a central line, is time-consuming and may delay resuscitation.
Option C is inappropriate because resuscitation efforts should continue.
Option D is incorrect because continuing to attempt peripheral IV access can
cause unnecessary delays.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity: Emergency Care
Synchronized cardioversion:
A. Is used only for atrial dysrhythmias.
B. Delivers a shock during ventricular depolarization.
C. Delivers a shock between the peak and end of the T wave.
D. Is used only for rhythms with a ventricular rate of less than 60 beats/min.
CORRECT ANS: B
EXPERT RATIONALE
Synchronized cardioversion delivers a shock during ventricular depolarization
(the R wave) to avoid the vulnerable period of the cardiac cycle (the T wave).
Option A is incorrect because synchronized cardioversion can be used for
both atrial and ventricular dysrhythmias. Option C describes the timing to
avoid; the shock should not be delivered on the T wave. Option D is incorrect
, because synchronized cardioversion is used for tachyarrhythmias, not
bradycardias.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
An 84-year-old man presents with an acute onset of altered mental status.
The cardiac monitor shows the rhythm. The patient's BP is 58/30 mm Hg and
his ventilatory rate is 14 breaths/min. His skin is cool, moist, and pale. His
blood oxygen saturation level (SpO2) on room air is 95%. An IV has been
established. On the basis of the information provided, your best course of
action will be to:
A. Prepare for transcutaneous pacing.
B. Give amiodarone 300 mg IV push.
C. Give epinephrine 1 mg IV bolus and reassess.
D. Observe the patient and monitor for signs of deterioration.
CORRECT ANS: A
EXPERT RATIONALE
The patient is presenting with symptomatic bradycardia (altered mental
status, hypotension, cool/clammy skin) and requires immediate intervention.
Transcutaneous pacing is the treatment of choice for symptomatic
bradycardia that is unresponsive to atropine. Option B, amiodarone, is used
for tachyarrhythmias. Option C, epinephrine, may be used in cardiac arrest
but is not first-line for symptomatic bradycardia. Option D, observation, is
inappropriate because the patient is unstable.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity: Emergency Care
