NCLEX-PN Test #18 3 — Questions and Answers
Question 1: An alert adult client arrives in the ED after a motor vehicle accident with a suspected cervical spine injury. The client is breathing and has a radial pulse. What is the priority intervention?
- Establish IV access and draw blood for lab work
- Immobilize the cervical spine and maintain spinal precautions during all movement and transfers (Correct answer)
- Perform a head-to-toe trauma assessment
- Obtain a CT scan of the spine immediately
Correct answer: Immobilize the cervical spine and maintain spinal precautions during all movement and transfers
With a suspected cervical spine injury, the priority — after confirming airway, breathing, and circulation — is spinal immobilization (C-collar, backboard, log-roll technique for all movement) to prevent secondary spinal cord injury. All movement must maintain spinal alignment until injury is ruled out by imaging.
Question 2: A client is brought to the ED with suspected poisoning from organophosphate pesticide. Which clinical manifestations should the nurse anticipate?
- Dry skin, dilated pupils, tachycardia, and urinary retention (anticholinergic toxidrome)
- Excessive secretions (SLUDGE: Salivation, Lacrimation, Urination, Defecation, GI cramps, Emesis), bradycardia, and miosis (Correct answer)
- Agitation, hyperthermia, and clonus (serotonin syndrome)
- Sedation, respiratory depression, and pinpoint pupils (opioid toxidrome)
Correct answer: Excessive secretions (SLUDGE: Salivation, Lacrimation, Urination, Defecation, GI cramps, Emesis), bradycardia, and miosis
Organophosphates inhibit acetylcholinesterase, causing excess acetylcholine activity — a cholinergic toxidrome (SLUDGE/DUMBELS). Features include excessive secretions, miosis (pinpoint pupils), bradycardia, bronchospasm, and seizures. Treatment: atropine (blocks muscarinic effects) and pralidoxime (reactivates cholinesterase if given early).
Question 3: A client with multiple trauma has a systolic blood pressure of 74 mmHg and heart rate of 138 bpm. The skin is cool, pale, and clammy. Which type of shock is most likely?
- Neurogenic shock
- Septic shock (distributive)
- Hypovolemic (hemorrhagic) shock (Correct answer)
- Cardiogenic shock
Correct answer: Hypovolemic (hemorrhagic) shock
Hypovolemic/hemorrhagic shock following trauma presents with: hypotension, compensatory tachycardia, and signs of peripheral vasoconstriction (cool, pale, clammy skin). Neurogenic shock presents with bradycardia and warm skin (loss of sympathetic vasoconstriction); septic shock presents with warm skin and fever; cardiogenic shock with elevated JVP and pulmonary crackles.
Question 4: The nurse is triaging four clients in the ED. Using the START triage system, which client receives a "red" (immediate) tag?
- A client who is walking and asking for pain medication
- A client with no respirations even after repositioning the airway
- A client with a respiratory rate of 32/min, radial pulse absent but carotid pulse present, and follows commands (Correct answer)
- A client with a minor laceration and normal vitals
Correct answer: A client with a respiratory rate of 32/min, radial pulse absent but carotid pulse present, and follows commands
START triage: Red (immediate) = client who breathes only after airway repositioning, OR respiratory rate > 30/min, OR absent radial pulse, OR cannot follow simple commands — but IS alive. This client: RR 32 (>30), absent radial pulse, but follows commands = meets criteria for immediate (red) tag. Black = no respirations after repositioning. Green = walking wounded. Yellow = delayed.
Question 5: A client was stung by a bee and reports tightness in the throat, hoarseness, and difficulty swallowing within minutes. The nurse recognizes this as:
- A local allergic reaction that can be managed with oral antihistamines
- Angioedema of the upper airway — a life-threatening anaphylactic emergency (Correct answer)
- Vasovagal syncope from anxiety related to the bee sting
- A delayed hypersensitivity reaction (Type IV) that will peak at 48 hours
Correct answer: Angioedema of the upper airway — a life-threatening anaphylactic emergency
Throat tightness, hoarseness, and dysphagia within minutes of an insect sting indicate angioedema of the upper airway — a life-threatening component of anaphylaxis (Type I IgE-mediated immediate hypersensitivity). Airway obstruction can occur rapidly. IM epinephrine is the immediate treatment; airway management (intubation, cricothyrotomy) may be required.
Question 6: The nurse is assessing a client after head trauma. The Glasgow Coma Scale (GCS) score is calculated as: E2, V3, M4. What is the total GCS score, and what does it indicate?
- GCS 9 — moderate traumatic brain injury (Correct answer)
- GCS 11 — mild traumatic brain injury with close monitoring needed
- GCS 7 — severe traumatic brain injury
- GCS 13 — no significant neurological impairment
Correct answer: GCS 9 — moderate traumatic brain injury
GCS scoring: Eye response E2 (opens to pain) + Verbal response V3 (inappropriate words) + Motor response M4 (withdrawal from pain) = GCS 9. GCS 9–12 indicates moderate traumatic brain injury. GCS ≤8 indicates severe TBI requiring intubation. GCS 13–15 indicates mild TBI. Serial GCS assessment tracks neurological deterioration.
NCLEX-PN Test #18 3
An alert adult client arrives in the ED after a motor vehicle accident with a suspected cervical spine injury.
The client is breathing and has a radial pulse.
What is the priority intervention?