NCLEX-PN Test #8 3 — Questions and Answers
Question 1: The PN walks into a client's room and finds the client unresponsive. After calling for help, what is the next action?
- Begin chest compressions at 30:2
- Check for a pulse for no more than 10 seconds while simultaneously checking for breathing (Correct answer)
- Attach the AED immediately
- Administer two rescue breaths
Correct answer: Check for a pulse for no more than 10 seconds while simultaneously checking for breathing
Per current AHA BLS guidelines: Call for help → Check responsiveness → Check pulse AND breathing simultaneously for no more than 10 seconds. If no pulse or absent/abnormal breathing, begin CPR with 30 compressions to 2 breaths at a rate of 100–120/min. For lone rescuers, compress first before rescue breaths.
Question 2: The nurse is monitoring a client's ECG and notes P waves that are absent with irregularly irregular QRS complexes. Which rhythm does this represent?
- Sinus tachycardia
- Ventricular fibrillation
- Atrial fibrillation (Correct answer)
- Third-degree heart block
Correct answer: Atrial fibrillation
Atrial fibrillation is characterized by: (1) absence of distinct P waves (replaced by chaotic fibrillatory waves), (2) irregularly irregular QRS complexes, and (3) variable ventricular rate. It is the most common sustained cardiac dysrhythmia and increases stroke risk due to atrial thrombus formation.
Question 3: A client in the ED presents with sudden onset chest pain, diaphoresis, and nausea. The 12-lead ECG shows ST elevation in leads II, III, and aVF. Which area of the heart is most likely affected?
- Anterior wall — left anterior descending artery
- Inferior wall — right coronary artery (Correct answer)
- Lateral wall — circumflex artery
- Posterior wall — right coronary artery
Correct answer: Inferior wall — right coronary artery
ST elevation in leads II, III, and aVF indicates inferior wall STEMI. The inferior wall is supplied by the right coronary artery (RCA) in ~80% of people. Inferior STEMI may also involve right ventricular infarction; administering nitroglycerin can cause profound hypotension in RV infarction.
Question 4: A client is in ventricular fibrillation. The defibrillator is available. What is the correct energy setting for biphasic defibrillation in an adult?
- 50 joules
- 100 joules
- 120–200 joules (per manufacturer) (Correct answer)
- 360 joules
Correct answer: 120–200 joules (per manufacturer)
Current AHA guidelines recommend 120–200 joules for biphasic defibrillation (device-specific) for ventricular fibrillation/pulseless ventricular tachycardia. Monophasic defibrillators use 360 joules. Biphasic waveforms require less energy and cause less myocardial damage than monophasic.
Question 5: The nurse is caring for a client with a permanent pacemaker. Which finding requires immediate action?
- Resting heart rate of 70 bpm
- Incision site ecchymosis on day 2 post-implant
- Hiccups and muscle twitching over the pacemaker site (Correct answer)
- Complaint of mild shoulder soreness
Correct answer: Hiccups and muscle twitching over the pacemaker site
Hiccups and muscle twitching near the pacemaker pocket suggest lead displacement or pacemaker malfunction with inadvertent stimulation of the diaphragm or pectoral muscles. This requires immediate notification of the provider and evaluation of pacemaker function. Lead displacement is a common early post-implant complication.
Question 6: A client arrives in the ED with suspected anaphylaxis after eating shellfish. Which medication is the priority first-line treatment?
- Diphenhydramine (Benadryl) 50 mg IV
- Methylprednisolone (Solu-Medrol) 125 mg IV
- Epinephrine 0.3–0.5 mg IM (1:1,000) into the lateral thigh (Correct answer)
- Ranitidine 50 mg IV
Correct answer: Epinephrine 0.3–0.5 mg IM (1:1,000) into the lateral thigh
Epinephrine IM is the only first-line treatment for anaphylaxis. It rapidly reverses bronchospasm, increases blood pressure, and reduces mucosal edema. Administration should not be delayed. Antihistamines and corticosteroids are adjunct therapies only — they are too slow to reverse life-threatening anaphylaxis.
NCLEX-PN Test #8 3
The PN walks into a client's room and finds the client unresponsive.
After calling for help, what is the next action?