answers 2025\2026 rated grade A+
A nurse on a medical-surgical unit is caring for a group of clients. The nurse should
notify the rapid response team 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 correct
answer B: 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. correct answer BCE
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 a rapid rewarming water of 40º to 42º C (104º to 108º F).
E. Infuse warmed IV fluids. correct answer ACDE
A nurse in the emergency department is assessing a client who is unresponsive.
The client's partner states, "He was pulling weeds in the yard and slumped to the
ground." Which of the following techniques should the nurse use to open the
client's airway?
A. Head-tilt, chin-lift
B. Modified jaw thrust
C. Hyperextension of the head
D. Flexion of the head correct answer A: The nurse should open the client's
airway by the head-tilt, chin-lift because the client is unresponsive without
suspicion of trauma.
A nurse is reviewing the common emergency management protocol for clients
who have 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.
D. Elevate the client's lower extremities. correct answer C: Administering
epinephrine during asystole is an appropriate action by the nurse because it
increases heart rate, improves