NCLEX-PN Test #18 3 Flashcards

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?

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.

A client is brought to the ED with suspected poisoning from organophosphate pesticide. Which clinical manifestations should the nurse anticipate?

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).

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?

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.

The nurse is triaging four clients in the ED. Using the START triage system, which client receives a "red" (immediate) tag?

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.

A client was stung by a bee and reports tightness in the throat, hoarseness, and difficulty swallowing within minutes. The nurse recognizes this as:

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.

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?

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.