Emergency Response And CPR Participation - NCLEX Pn

1. A 74-year-old client admitted for pneumonia suddenly becomes unresponsive while sitting in a chair; the LPN notes absent chest rise, agonal gasps, and no palpable carotid pulse. Which intervention should the nurse implement IMMEDIATELY?
   Answer: Start chest compressions at the recommended rate and depth while calling for help This question tests knowledge of emergency response and CPR participation for sudden unresponsiveness in a client with pneumonia. The priority framework is the ABCs, focusing on immediate circulation support when pulse is absent. Starting chest compressions at the recommended rate and depth while calling for help is the highest priority to maintain perfusion in cardiac arrest. Placing in high Fowler position (B) is inappropriate for arrest, obtaining vital signs (C) delays intervention, and delegating suctioning (D) assumes the code team without starting CPR. The decision-making principle is to initiate CPR immediately upon confirming no pulse and abnormal breathing. Agonal gasps indicate arrest, not effective respiration. A transferable strategy is to prioritize compressions over other actions in pulseless clients to buy time for advanced care.
2. The nurse should anticipate that the primary health care provider will prescribe which emergency medication?
   Answer: Naloxone. Naloxone is a competitive opioid antagonist that rapidly reverses opioid-induced CNS and respiratory depression by binding to opioid receptors and displacing the opioid drug. A respiratory rate of 4 breaths per minute in an unresponsive patient with suspected opioid overdose is a respiratory emergency requiring immediate reversal. Epinephrine (A) is used for anaphylaxis, cardiac arrest, and severe bronchospasm — not opioid overdose. Atropine (C) is used for symptomatic bradycardia and organophosphate poisoning. Amiodarone (D) is an antiarrhythmic used for ventricular fibrillation and ventricular tachycardia during cardiac arrest.
3. A 36-year-old client receiving a new intravenous medication suddenly develops hives, audible wheezing, and difficulty swallowing; blood pressure is 76/38 mm Hg and heart rate is 150/min. Which intervention should the nurse implement IMMEDIATELY?
   Answer: Administer intramuscular epinephrine per protocol and maintain airway while calling for emergency assistance This question tests knowledge of emergency response and CPR participation in medication anaphylaxis. The priority framework is immediate safety, using epinephrine for symptoms. Administering IM epinephrine and maintaining airway is the highest priority while calling help. Pausing medication (B) insufficient, history (C) post-care, and requesting diphenhydramine (D) secondary. The decision-making principle is recognizing anaphylaxis needing urgent reversal. Monitor vitals. A transferable strategy is to observe closely during new medication administration for reactions.
4. A 19-year-old client with a severe latex allergy is in an outpatient clinic and develops sudden wheezing and throat swelling after contact with latex gloves; blood pressure is 82/44 mm Hg, heart rate 138/min, and oxygen saturation 87%. Which step is PRIORITY in this situation?
   Answer: Administer intramuscular epinephrine per emergency protocol and activate emergency response This question tests knowledge of emergency response and CPR participation in latex anaphylaxis. The priority framework is immediate safety, treating with epinephrine. Administering IM epinephrine and activating response is the highest priority for airway and shock. Removing gloves (B) is insufficient, peak flow (C) delays, and requesting steroid (D) is slower. The decision-making principle is epinephrine for severe allergy symptoms. Stay with client. A transferable strategy is to avoid triggers but treat exposures aggressively with protocols.
5. Which action should the nurse take first?
   Answer: Give five back blows followed by five chest thrusts. For a conscious infant under 1 year of age with severe FBAO, the correct sequence is five back blows followed by five chest thrusts, repeated until the object is expelled or the infant loses consciousness. Abdominal thrusts (A) are explicitly contraindicated in infants because the abdomen is poorly protected and abdominal thrusts risk lacerating the liver, spleen, or other organs. Chest thrusts (part of Choice A) are used instead. A blind finger sweep (C) is contraindicated at any age — reaching blindly into the airway risks pushing the object deeper. The infant should be supported in a face-down position for back blows and then turned face-up for chest thrusts; holding by the feet and shaking (D) is not a recognized technique and could cause injury.
6. Which route of administration should the nurse anticipate for the fastest therapeutic effect in this emergency?
   Answer: Intramuscular (IM) or Intravenous (IV). In anaphylactic shock, speed of medication delivery is critical. Intramuscular injection into the anterolateral thigh is the standard first-line route for epinephrine administration in anaphylaxis — it provides rapid absorption directly into muscle tissue with a rich blood supply, producing peak plasma levels within 8 minutes. IV administration is used when the client is already in profound shock with vascular collapse or when IM access is not possible; it provides the fastest delivery but carries higher risk of cardiac side effects and requires careful dosing. Oral epinephrine (A) undergoes extensive first-pass metabolism and is not effective for emergency use. Subcutaneous injection (B) has slower and less predictable absorption than IM, particularly during anaphylaxis when peripheral vasoconstriction limits subcutaneous blood flow. Transdermal (D) is far too slow for any emergency.
7. The nurse recognizes that because the client is pulseless and unresponsive, the most likely underlying problem is:
   Answer: A sudden cardiac arrest requiring immediate resuscitation. In a post-operative cardiac surgery client, the sudden and simultaneous loss of pulse and consciousness represents cardiac arrest until proven otherwise, and must be treated as such with immediate resuscitation. Time is irreversible brain ischemia: without intervention, neurological injury begins within 4 to 6 minutes. Post-operative pneumonia (A) would cause respiratory distress and declining oxygenation but would not produce the sudden, simultaneous loss of pulse and consciousness. An opioid reaction (C) typically produces respiratory depression and reduced consciousness but preserves a detectable pulse. A TIA (D) causes focal neurological deficits without loss of pulse and typically self-resolves — it does not cause pulselessness.
8. What is the priority nursing action during this internal disaster response?
   Answer: Manually check the vital signs of all clients who were on monitors. When electronic monitoring fails due to a power outage, the nurse's immediate priority is to perform manual vital sign assessments on all clients who were being electronically monitored. Electronic monitors serve as continuous safety surveillance — when they fail, the nurse must re-establish that surveillance using manual techniques (blood pressure cuff, pulse palpation, direct respiratory observation) until power is restored or battery backup activates. Critically ill or unstable clients require the most immediate assessment. Contacting the news media (A) is not a nursing responsibility and diverts attention from client care. Moving clients to the hallway (C) is not indicated for a power outage and disrupts care unnecessarily. Delegating monitoring to family members (D) asks untrained individuals to perform clinical assessments that require professional nursing judgment.
9. Which role is most appropriate for the LPN/VN during a disaster triage situation?
   Answer: Provide immediate care for minor injuries to keep the area clear. The LPN/VN functions within the limits of their educational preparation and scope of practice, including during disaster responses. In a mass casualty triage setting, primary triage decisions — assigning triage tags, determining priority categories, and making transport decisions — are typically performed by registered nurses or advanced providers who have the scope of practice for independent complex assessment. The LPN/VN's most appropriate role is to provide direct care for clients who have already been triaged, including treating minor injuries, providing supportive care, and assisting more advanced providers. Administering complex emergency medications (C) and making transport priority decisions (D) also exceed LPN/VN independent scope during disaster operations.
10. A 40-year-old client with a history of opioid use is found in the outpatient restroom with pinpoint pupils, respirations 4/min and shallow, oxygen saturation 70%, heart rate 58/min, and the client is difficult to arouse but has a palpable pulse. Which intervention should the nurse implement IMMEDIATELY?
    Answer: Call for emergency assistance and begin rescue breathing or bag-valve-mask ventilation with oxygen as available This question tests knowledge of emergency response and CPR participation in opioid overdose. The priority framework is the ABCs, supporting breathing in respiratory depression. Calling for assistance and beginning rescue breathing is the highest priority to correct hypoxia. Obtaining vitals (B) delays, waiting for antidote (C) risks arrest, and searching belongings (D) is unethical. The decision-making principle is providing ventilation if pulse present but breathing inadequate. Naloxone may follow but breathing first. A transferable strategy is to suspect overdose in pinpoint pupils and bradypnea, prioritizing airway support.
11. A 72-year-old client in a rehabilitation facility suddenly clutches the throat while eating, cannot speak, has a weak ineffective cough, and becomes cyanotic; oxygen saturation is 76% and the client is alert but panicked. What is the nurse's FIRST action in this emergency?
    Answer: Perform abdominal thrusts until the obstruction is relieved or the client becomes unresponsive This question tests knowledge of emergency response and CPR participation in choking with airway obstruction. The priority framework is immediate safety, using abdominal thrusts for conscious choking. Performing abdominal thrusts until relieved or unresponsive is the highest priority to dislodge the obstruction. Giving water (B) worsens obstruction, encouraging cough (C) is for mild cases, and calling for x-ray (D) delays. The decision-making principle is the universal choking sign indicating severe blockage needing thrusts. Continue until effective or CPR needed. A transferable strategy is to assess cough effectiveness before intervening in choking incidents.
12. Which action is a priority for the nurse to take before the shock is delivered?
    Answer: Ensure that no one is touching the client or the client's bed. When the AED announces 'Stand Clear,' the nurse must immediately verify that all personnel have stepped away from the client and the bed — no contact with any part of the client, bed frame, or attached equipment. Electrical current from the shock can travel through conductive paths to anyone in contact, causing serious injury to rescuers. This safety check must occur before pressing the shock button. Continuing compressions during charging (A) is not safe — compressions must stop before the shock is delivered. Checking the carotid pulse (C) wastes critical time and is unnecessary — the AED has already analyzed the rhythm and determined a shockable rhythm is present. Turning off the AED (D) would abort the entire sequence and is directly contraindicated.
13. A second nurse arrives with the automated external defibrillator (AED). Which action should the nurse perform next to support safe and effective treatment?
    Answer: Turn on the AED and follow the voice prompts for pad placement. When an AED arrives, it should be powered on and its voice prompts followed immediately. The AED guides the entire sequence: it directs pad placement, instructs the rescuer when to pause compressions for rhythm analysis, advises whether a shock is indicated, and provides timing cues. The AED is designed to be operated by following its audio and visual instructions step by step. Choice A is partially correct — minimizing interruptions to compressions is important — but the AED's prompts will direct when to stop and resume; the nurse does not need to guess the timing. Choice D (drying the chest) is clinically correct practice for effective pad adhesion and is part of the pad placement process the AED will guide — it is not a separate step to perform before turning the device on. Stopping CPR to wait for the PHCP (C) is dangerous and unnecessary.
14. A 50-year-old client in the emergency department suddenly becomes unresponsive; the LPN notes no chest rise and cannot detect a pulse within 10 seconds. What should the nurse do NEXT after recognizing cardiac arrest?
    Answer: Start CPR and direct someone to activate the code and bring the AED This question tests knowledge of emergency response and CPR participation in ED arrest. The priority framework is the ABCs, starting CPR promptly. Starting CPR and directing for code and AED is the highest priority after confirmation. Inserting airway (B) is advanced, obtaining ECG (C) delays, and checking temperature (D) is irrelevant. The decision-making principle is immediate compressions in no pulse. Team response follows. A transferable strategy is to reassess pulse quickly but act on absence in unresponsiveness.
15. When performing chest compressions on a child of this age, the nurse should compress the chest to what depth?
    Answer: About 2 inches (5 cm). Per AHA BLS guidelines, compression depth varies by age group. For a child defined as age 1 year to puberty, the correct compression depth is about 2 inches (5 cm), representing approximately one-third of the anterior-posterior chest diameter. This is also described as the depth that produces a visible and palpable peripheral pulse during compressions. For context: infant compressions (under 1 year) should be 1.5 inches (4 cm); adult compressions should be at least 2 inches (5 cm) with a maximum of 2.4 inches (6 cm). Choice C (2.4 inches) is the adult maximum and would be too aggressive for a child's chest. Choice A (1 inch) is insufficient to generate adequate cardiac output in any age group.
16. A 70-year-old client with diabetes is in a skilled nursing facility and suddenly becomes unresponsive while ambulating; the LPN finds no pulse and no breathing. Which step is PRIORITY in this situation?
    Answer: Initiate CPR and send someone to activate the emergency response system and obtain the AED This question tests knowledge of emergency response and CPR participation in diabetic client arrest. The priority framework is the ABCs, initiating CPR for no pulse or breathing. Initiating CPR and activating response with AED is the highest priority despite diabetes history. Checking glucose (B) delays, recovery position (C) assumes breathing, and calling family (D) is non-urgent. The decision-making principle is treating as arrest unless proven otherwise. Etiology secondary to CPR. A transferable strategy is to start CPR in unresponsive pulseless clients regardless of comorbidities.
17. Which action should the nurse take?
    Answer: Provide comfort care and notify the primary health care provider of the death. A valid, signed DNR order is a legal advance directive that reflects the client's autonomous decision to forgo cardiopulmonary resuscitation. The nurse has a legal and ethical obligation to honor this order. When a client with a valid and immediately available DNR order becomes pulseless and apneic, the nurse provides comfort measures (positioning, pain management if applicable, presence), notifies the PHCP, and supports the family. Initiating CPR (B and D) directly violates the client's legally documented wishes. Asking family to change the DNR (C) is inappropriate — advance directives cannot be revoked at the bedside by family members under emergency pressure; changes require the client's own informed decision while competent. Note: if the DNR status were unknown or unavailable at the time of the arrest, the correct action would be to begin CPR while a second person locates the documentation.
18. A 45-year-old client receiving intravenous antibiotics reports sudden itching and throat tightness; within minutes the LPN notes wheezing, stridor, facial swelling, hives, blood pressure 78/40 mm Hg, heart rate 132/min, and oxygen saturation 86%. What is the nurse's FIRST action in this emergency?
    Answer: Stop the infusion and administer intramuscular epinephrine per emergency protocol while calling for help This question tests knowledge of emergency response and CPR participation in anaphylaxis during IV antibiotics. The priority framework is immediate safety, focusing on stopping the allergen and treating shock. Stopping the infusion and administering IM epinephrine per protocol while calling for help is the highest priority to reverse bronchospasm and hypotension. Notifying for antihistamine (B) delays, obtaining history (C) is post-stabilization, and applying blanket (D) ignores airway. The decision-making principle is recognizing anaphylaxis signs requiring epinephrine as first-line. Prompt action prevents progression to arrest. A transferable strategy is to always have epinephrine ready for suspected allergic reactions and activate help immediately.
19. Which assessment finding is the most critical indicator that the client is experiencing a life-threatening emergency?
    Answer: The absence of a palpable carotid pulse and breathing. The simultaneous absence of a palpable carotid pulse and spontaneous breathing are the definitive clinical findings that confirm cardiac arrest and require immediate resuscitative intervention. These two findings together indicate that the heart has stopped circulating blood and the client is not oxygenating — the classic definition of cardiac arrest. Slumped posture (A) can have many causes including sleep or syncope and is not definitive on its own. Cool and mottled skin (B) indicates poor peripheral perfusion and is a supporting finding consistent with arrest, but it is not as immediately diagnostic as the absence of pulse and breathing. Age and surgical history (D) are predisposing risk factors, not current assessment findings.
20. A 33-year-old client with a known peanut allergy is eating in a long-term care dining room and suddenly develops hoarseness, swelling of the lips, widespread hives, and difficulty breathing; vital signs are blood pressure 84/50 mm Hg, heart rate 140/min, respiratory rate 30/min, oxygen saturation 88%. Which intervention should the nurse implement IMMEDIATELY?
    Answer: Administer intramuscular epinephrine to the outer thigh per facility protocol and stay with the client This question tests knowledge of emergency response and CPR participation in anaphylaxis from peanut allergy. The priority framework is the ABCs, prioritizing airway and circulation in shock. Administering IM epinephrine per protocol and staying with the client is the highest priority to counteract histamine effects and monitor. Offering water (B) risks aspiration, delegating vitals (C) abandons the client, and giving antihistamine (D) is slower-acting. The decision-making principle involves immediate epinephrine for systemic symptoms. Monitoring prevents biphasic reaction. A transferable strategy is to treat any swelling with breathing difficulty as anaphylaxis needing urgent epinephrine.

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