with 100% Correct Answers | Verified | Updated 2025
/Grade A+ Assured
Question 1
A client presents to the Emergency Department (ED) with severe respiratory
distress, audible wheezing, and an SpO2 of 88% on room air. The
nurse's priority intervention is to:
A) Obtain a full medical history.
B) Administer a rapid-acting bronchodilator via nebulizer and apply high-flow
oxygen.
C) Obtain an arterial blood gas (ABG).
D) Prepare for chest tube insertion.
E) Administer a corticosteroid intravenously.
Correct Answer: B) Administer a rapid-acting bronchodilator via
nebulizer and apply high-flow oxygen.
Rationale: The client is in severe respiratory distress and hypoxic.
The immediate priority is to improve oxygenation and airflow.
Rapid-acting bronchodilators (e.g., albuterol) and high-flow oxygen
directly address these life threats.
Question 2
A client is admitted to the ED after a motor vehicle collision (MVC). The client
is unresponsive with a Glasgow Coma Scale (GCS) of 6. What is the
nurse's priority intervention regarding airway management?
A) Insert a nasopharyngeal airway (NPA).
B) Perform a head tilt-chin lift maneuver.
C) Prepare for immediate endotracheal intubation.
D) Administer supplemental oxygen via nasal cannula.
E) Place the client in a recovery position.
Correct Answer: C) Prepare for immediate endotracheal intubation.
Rationale: A GCS of 8 or less indicates severe neurological
impairment and a compromised airway, necessitating definitive
,airway management via endotracheal intubation to protect the
airway and ensure adequate ventilation.
Question 3
A client presents with crushing substernal chest pain radiating to the left
arm. Their ECG shows ST-segment elevation in leads II, III, and aVF. What is
the nurse's priority medication to administer (if not contraindicated)?
A) IV Metoprolol
B) Oral Aspirin (chewable)
C) IV Morphine Sulfate
D) IV Nitroglycerin
E) IV Heparin
Correct Answer: B) Oral Aspirin (chewable)
Rationale: For suspected acute myocardial infarction (AMI), chewable
aspirin is the immediate priority (if not contraindicated) due to its
antiplatelet effect, which helps to prevent further clot formation at
the site of coronary occlusion.
Question 4
A client is experiencing pulseless ventricular tachycardia (pVT). After
initiating chest compressions, what is the next priority intervention?
A) Administer 1 mg Epinephrine IV.
B) Defibrillation.
C) Administer 300 mg Amiodarone IV.
D) Check for a pulse.
E) Establish advanced airway.
Correct Answer: B) Defibrillation.
Rationale: Pulseless VT is a shockable rhythm. Early defibrillation is
the most critical intervention to terminate the dysrhythmia and
restore a perfusing rhythm.
Question 5
A client with diabetes presents with altered mental status, cool and clammy
,skin, and a blood glucose level of 45 mg/dL. The client is conscious but
unable to swallow. What is the nurse's priority intervention?
A) Administer oral glucose paste.
B) Administer IV Dextrose 50% (D50).
C) Administer subcutaneous insulin.
D) Administer IM Glucagon.
E) Provide a complex carbohydrate snack.
Correct Answer: B) Administer IV Dextrose 50% (D50).
Rationale: The client is severely hypoglycemic and unable to swallow,
making oral glucose unsafe due to aspiration risk. IV D50 is the
fastest and most effective way to raise blood glucose in this
situation. IM Glucagon is an alternative if IV access cannot be
obtained quickly.
Question 6
A client involved in a high-speed MVC presents with unilateral absent breath
sounds, tracheal deviation to the unaffected side, and hypotension. These
findings are indicative of:
A) Simple pneumothorax.
B) Hemothorax.
C) Flail chest.
D) Tension pneumothorax.
E) Pulmonary contusion.
Correct Answer: D) Tension pneumothorax.
Rationale: A tension pneumothorax is a life-threatening condition
where air accumulates in the pleural space under pressure,
compressing the lung, mediastinum, and great vessels. Tracheal
deviation occurs away from the injured side.
Question 7
What is the most appropriate initial intervention for a client with a suspected
tension pneumothorax?
, A) Chest tube insertion.
B) Supplemental oxygen.
C) Needle decompression.
D) Bag-valve mask ventilation.
E) Placing the client in a Fowler's position.
Correct Answer: C) Needle decompression.
Rationale: Needle decompression (thoracostomy) is the immediate,
life-saving intervention for a tension pneumothorax to relieve the
trapped air and pressure within the pleural space. This is typically
followed by a chest tube insertion.
Question 8
A client is experiencing an acute anaphylactic reaction with severe dyspnea,
stridor, and hypotension. What is the nurse's priority medication to
administer?
A) Diphenhydramine (Benadryl) IV.
B) Albuterol via nebulizer.
C) Epinephrine 1:1,000 intramuscularly.
D) IV corticosteroids.
E) IV fluids.
Correct Answer: C) Epinephrine 1:1,000 intramuscularly.
Rationale: Epinephrine is the first-line and most critical medication
for severe anaphylaxis. It rapidly reverses bronchospasm, causes
vasoconstriction to raise blood pressure, and reduces edema.
Question 9
When performing the primary survey (ABCDE) on a trauma client, what does
"D" stand for?
A) Distal pulses
B) Deep tendon reflexes
C) Disability (neurological status)
D) Deformity