Question

A Nurse is caring for a client in the emergency department.

Answer 1

Correct Answers

Blank 1 Correct Option: Preparing for intubation by obtaining the crash cart
Blank 2 Correct Option: Preparing to administer a dose of epinephrine

Rationale :

🔴 Preparing for intubation by obtaining the crash cart

🔴 The first action the nurse should take is to anticipate airway compromise. This client is showing signs of anaphylaxis, a life-threatening allergic reaction.

🔴 The symptoms of rapid onset hives, itchy throat, wheezing, and difficulty speaking indicate upper airway edema, which can lead to total airway obstruction.

🔴 The drop in blood pressure (126/86 → 86/66 mm Hg) and increased heart rate and respiratory rate are signs of compensatory shock, further confirming the urgency.

🔴 The nurse must immediately prepare for advanced airway management by retrieving the crash cart, which contains intubation equipment and emergency medications, to ensure the airway is protected if it deteriorates further.

🔴 This is a priority life-saving measure, even before medications are given.

💉 Preparing to administer a dose of epinephrine

💉 Epinephrine is the first-line medication for treating anaphylaxis. It rapidly relieves airway constriction, reverses hypotension, and reduces inflammation by stimulating alpha and beta-adrenergic receptors.

💉 Intramuscular epinephrine should be administered without delay in the setting of respiratory distress and circulatory collapse. It can help improve oxygenation, perfusion, and reduce bronchospasm.

💉 Administering epinephrine is essential, but the airway must be secured or prepared to be secured first in severe anaphylaxis due to the risk of airway closure.

💉 The nurse must ensure rapid access to epinephrine, anticipate further medication administration (e.g., steroids and H2 blockers), and monitor response closely.

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Answer 2

Correct Answers:

A private room

Rationale :

🔷 Scabies is a contagious parasitic skin infection caused by mites and requires contact precautions.

🔷 Clients with scabies should be placed in a private room to prevent direct skin-to-skin transmission.

🔷 Cohorting should only occur with clients who have the same confirmed infection; pediculosis capitis is a different infestation.

🔷 Negative or positive pressure rooms are unnecessary unless airborne or protective isolation is needed, which doesn't apply here.

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Answer 3

Correct Answers:

Basal cell carcinoma

Rationale :

🌟 A raised, flesh-colored lesion with pearly white borders is a classic presentation of basal cell carcinoma (BCC).

🌟 BCC is the most common type of skin cancer, usually caused by prolonged sun exposure, and most frequently appears on sun-exposed areas like the face, neck, or chest.

🌟 These lesions grow slowly and rarely metastasize but can become locally invasive if untreated.

🌟 The pearly, translucent appearance and rolled borders with possible central ulceration are hallmark traits that distinguish BCC from other skin cancers.

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Answer 4

Correct Answers:

Heart rate 54/min
Temperature 36.3' C (97.4' F)

Rationale :

✅ Heart rate 54/min

💓 Bradycardia is a hallmark sign of neurogenic shock due to the sudden loss of sympathetic nervous system stimulation following a spinal cord injury, especially if it occurs above the level of T6.

💓 The parasympathetic nervous system remains unopposed, primarily through the vagus nerve, resulting in a decrease in heart rate.

💓 Unlike other forms of shock (which typically involve tachycardia), neurogenic shock is unique for presenting with bradycardia due to this autonomic imbalance.

💓 Persistent bradycardia can further reduce cardiac output and worsen tissue perfusion, requiring close monitoring and possibly intervention such as atropine or pacing.

✅ Temperature 36.3° C (97.4° F)

🌡️ Hypothermia or borderline low temperatures are expected in neurogenic shock due to the inability to regulate vasodilation and constriction.

🌡️ The injury disrupts the body's thermoregulatory control, leading to uncontrolled heat loss through dilated peripheral vessels, especially in cooler environments.

🌡️ The client may feel cool to the touch, and shivering is often absent due to the neurological impairment, making external warming measures necessary.

🌡️ Maintaining normothermia is critical, as further temperature drops can worsen bradycardia and decrease perfusion.

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Answer 5

Correct Answers:

Hypovolemic shock.

Rationale :

🩸 Hypovolemic shock occurs when there is a significant loss of blood or fluid volume, leading to inadequate tissue perfusion and decreased cardiac output.

🩸 A blood loss of 800 mL during surgery is substantial and can cause hemodynamic instability, especially if not fully replaced or if the client has underlying vulnerabilities.

🩸 The client’s steadily decreasing blood pressure over the past 2 hours is a classic sign of ongoing volume depletion and progressive circulatory collapse.

🩸 Prompt recognition and intervention—typically with fluid resuscitation and possibly blood products—are critical to restore perfusion and prevent organ damage.

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Answer 6

Correct Answers:

Hematemesis

Rationale :

🟠 Hematemesis (vomiting blood) indicates active gastrointestinal bleeding, a serious and potentially life-threatening complication of peptic ulcer disease.

🟠 This condition can lead to hypovolemic shock, hemodynamic instability, and anemia if not promptly treated.

🟠 While symptoms like constipation, dyspepsia, and epigastric discomfort are common in peptic ulcers, they are not urgent or immediately life-threatening.

🟠 The nurse must prioritize hemorrhagic signs to ensure rapid intervention, stabilize the client, and prevent further complications.

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Answer 7

Correct Answers:

Sputum smear

Rationale :

🔬 The sputum culture for acid-fast bacillus (AFB) is the most reliable and definitive test to confirm active pulmonary tuberculosis.

🔬 It allows for the actual identification and growth of Mycobacterium tuberculosis, confirming not only presence but also viability and infectiousness.

🔬 While the sputum smear and chest x-ray may suggest TB, they are not conclusive. The Mantoux test detects TB exposure, not active disease.

🔬 Cultures also allow for drug susceptibility testing, which guides effective treatment planning.

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Answer 8

Correct Answers:

urticaria
blood pressure at 1630
Report of dysphagia.

Rationale :

✅ Urticaria

🌺 Urticaria (hives) appearing shortly after antibiotic administration is a sign of an allergic reaction, often the first indication of hypersensitivity.

🌺 In the context of cefaclor (a cephalosporin), this can progress rapidly to anaphylaxis if not addressed.

🌺 Immediate follow-up is needed to assess the severity and initiate appropriate interventions such as antihistamines or epinephrine.

✅ Blood pressure at 1630

📉 Although not shown numerically, the prompt implies concern. In suspected anaphylaxis, hypotension is a critical sign, suggesting circulatory collapse.

📉 A sudden drop in BP after exposure to an allergen confirms the need for urgent intervention, including fluid resuscitation and epinephrine.

📉 Monitoring and managing blood pressure is essential in preventing shock-related organ failure.

✅ Report of dysphagia

😮‍💨 Difficulty swallowing and the sensation of a lump in the throat are red flag signs of airway edema, which is a serious complication of anaphylaxis.

😮‍💨 These symptoms suggest that the airway may soon be compromised, requiring airway protection and emergency management.

😮‍💨 Rapid intervention can prevent complete airway obstruction and respiratory arrest.

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Answer 9

Correct Answers:

Encourage intake Of at least 3 L Of fluids per day.

Rationale :

💧 Urolithiasis (kidney stones) requires high fluid intake to help flush the urinary tract, promote stone passage, and prevent new stone formation.

💧 Encouraging at least 3 liters of fluid per day increases urine output, reduces urine concentration, and minimizes crystal aggregation.

💧 Adequate hydration is a cornerstone of both treatment and prevention of most types of kidney stones.

💧 Other interventions like ambulation are encouraged (not discouraged) to help stone movement, and heat (not cold) is typically used for flank pain relief.

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Answer 10

Correct Answers:

Typical pneumonia.

Rationale :

🦠 Streptococcus pneumoniae is the most common cause of typical pneumonia, characterized by a sudden onset of symptoms such as high fever, productive cough with purulent sputum, and pleuritic chest pain.

🦠 "Typical" pneumonia refers to infections by bacteria that primarily affect the alveoli, causing lobar consolidation, which is commonly seen on chest x-ray.

🦠 This is different from atypical pneumonia, which presents with more diffuse symptoms and is caused by organisms like Mycoplasma pneumoniae or Chlamydophila pneumoniae.

🦠 It is not considered aspiration or chemical pneumonia, which have different etiologies and clinical courses.

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Custom-N202 Exam 2~2025

No.

1 :
A Nurse is caring for a client in the emergency department.

Correct Answers

2 :
A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client

3 :
During a routine physical examination. a nurse observes a I-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer?

4 :
A nurse is assessing a client who has a spinal cord injury. Which of the following assessment findings should the nurse expect with neurogenic shock? (Select
all that apply.)

5 :
A nurse is providing postoperative care to a client Who lost 800 mL of blood during surgery. The client’s blood pressure has been steadily decreasing over the past 2 hr. Which of the following categories of shock should the nurse recognize is occurring?

6 :
A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority?

7 :
A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB?

8 :
A nurse is caring for a client.

Answer Options

9 :
A nurse is planning care for a client who has urolithiasis. Which of the following actions should the nurse take?

10 :
A nurse is caring for a client admitted with pneumonia caused by Streptococcus pneumoniae. Which of the following types of pneumonia is Streptococcus pneumoniae?

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Custom-N202 Exam 2~2025

No.

1 : A Nurse is caring for a client in the emergency department.

Correct Answers

2 : A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client

3 : During a routine physical examination. a nurse observes a I-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer?

4 : A nurse is assessing a client who has a spinal cord injury. Which of the following assessment findings should the nurse expect with neurogenic shock? (Selectall that apply.)

5 : A nurse is providing postoperative care to a client Who lost 800 mL of blood during surgery. The client’s blood pressure has been steadily decreasing over the past 2 hr. Which of the following categories of shock should the nurse recognize is occurring?

6 : A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority?

7 : A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB?

8 : A nurse is caring for a client.

Answer Options

9 : A nurse is planning care for a client who has urolithiasis. Which of the following actions should the nurse take?

10 : A nurse is caring for a client admitted with pneumonia caused by Streptococcus pneumoniae. Which of the following types of pneumonia is Streptococcus pneumoniae?

1 :
A Nurse is caring for a client in the emergency department.

2 :
A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client

3 :
During a routine physical examination. a nurse observes a I-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer?

4 :
A nurse is assessing a client who has a spinal cord injury. Which of the following assessment findings should the nurse expect with neurogenic shock? (Select
all that apply.)

5 :
A nurse is providing postoperative care to a client Who lost 800 mL of blood during surgery. The client’s blood pressure has been steadily decreasing over the past 2 hr. Which of the following categories of shock should the nurse recognize is occurring?

6 :
A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority?

7 :
A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB?

8 :
A nurse is caring for a client.

9 :
A nurse is planning care for a client who has urolithiasis. Which of the following actions should the nurse take?

10 :
A nurse is caring for a client admitted with pneumonia caused by Streptococcus pneumoniae. Which of the following types of pneumonia is Streptococcus pneumoniae?