NCLEX-PN Test #18 3

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?

Accepted Answer

Immobilize the cervical spine and maintain spinal precautions during all movement and transfers

Answer

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?

Accepted Answer

Excessive secretions (SLUDGE: Salivation, Lacrimation, Urination, Defecation, GI cramps, Emesis), bradycardia, and miosis

Answer

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?

Accepted Answer

Hypovolemic (hemorrhagic) shock

Answer

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?

Accepted Answer

A client with a respiratory rate of 32/min, radial pulse absent but carotid pulse present, and follows commands

Answer

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:

Accepted Answer

Angioedema of the upper airway — a life-threatening anaphylactic emergency

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #18 3