Nclexrn Quiz: Abcs And Emergency Priorities

What this quiz covers

This quiz focuses on Abcs And Emergency Priorities, giving you a quick way to practice the rules, question types, and explanations that matter most for Nclexrn.

How to use this quiz

Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.

Question 1

1. Ensure airway protection by positioning and preparing for suction and possible intubation (correct answer)
2. Administer a proton pump inhibitor after verifying the order
3. Obtain consent for endoscopy and document teaching
4. Delegate insertion of a second intravenous line to the licensed practical nurse

Explanation: This question assesses emergency priorities using the ABCs (airway, breathing, circulation) framework in a client with massive upper GI bleeding. The relevant framework is the ABCs, emphasizing airway protection amid vomiting. Ensuring airway protection by positioning and preparing for suction/intubation is the highest priority due to risk of aspiration with hypotension (84/48 mm Hg). Administering PPI (B), obtaining consent (C), and delegating IV (D) are lower priority as medications and procedures follow airway security. The decision-making principle highlights ABCs by prioritizing prevention of aspiration to maintain breathing. In emergencies, nurses should position to protect airways during bleeding. A general strategy for prioritizing care in emergency situations focuses on ABC stabilization and hemorrhage control.

Question 2

1. Apply oxygen and elevate the head of the bed (correct answer)
2. Prepare to administer intravenous heparin after verifying the order
3. Obtain a 12-lead electrocardiogram
4. Delegate obtaining a STAT troponin level to phlebotomy

Explanation: This question assesses emergency priorities using the ABCs (airway, breathing, circulation) framework in a client with suspected pulmonary embolism. The relevant framework is the ABCs, emphasizing oxygenation and positioning for breathing support. Applying oxygen and elevating the head of the bed is the highest priority to address hypoxemia (85%) and hypotension (92/58 mm Hg) amid acute distress. Preparing heparin (B), obtaining ECG (C), and delegating troponin (D) are lower priority as anticoagulation and diagnostics follow stabilization. The decision-making principle highlights ABCs by prioritizing oxygen to improve perfusion before targeted therapies. In emergencies, nurses should quickly oxygenate and position to alleviate symptoms. A general strategy for prioritizing care in emergency situations involves ABC-focused interventions and rapid diagnostic preparation.

Question 3

1. Place the client supine with legs elevated and begin isotonic intravenous fluids (correct answer)
2. Obtain a stool sample for occult blood testing
3. Call the provider to request an order for endoscopy
4. Delegate rechecking hemoglobin to the laboratory technician

Explanation: This question assesses emergency priorities using the ABCs (airway, breathing, circulation) framework in a client with hemorrhagic shock from GI bleed. The relevant framework is the ABCs, prioritizing circulation with positioning and fluids. Placing supine with legs elevated and starting IV fluids is the highest priority for hypotension (86/52 mm Hg) and low hemoglobin (6.9 g/dL). Obtaining stool sample (B), calling for endoscopy (C), and delegating hemoglobin (D) are lower priority as diagnostics follow resuscitation. The decision-making principle highlights ABCs by using positioning to improve perfusion. In emergencies, nurses should initiate shock management immediately. A general strategy for prioritizing care in emergency situations involves ABC stabilization and source control preparation.

Question 4

1. Perform abdominal thrusts (Heimlich maneuver) (correct answer)
2. Offer sips of water to help clear the obstruction
3. Assess lung sounds and obtain a full set of vital signs
4. Delegate calling the family to the unit clerk

Explanation: This question assesses emergency priorities using the ABCs (airway, breathing, circulation) framework in a client with airway obstruction from choking. The relevant framework is the ABCs, prioritizing airway clearance. Performing abdominal thrusts is the highest priority for universal choking sign and cyanosis with low oxygen (76%). Offering water (B), assessing lungs (C), and delegating calls (D) are incorrect or lower priority as water can worsen obstruction, and assessments delay intervention. The decision-making principle highlights ABCs by focusing on mechanical clearance to restore airway patency. In emergencies, nurses should recognize choking and act immediately. A general strategy for prioritizing care in emergency situations involves quick airway assessment and basic life support maneuvers.

Question 5

1. Keep the child calm, provide humidified oxygen, and prepare for emergent airway management (correct answer)
2. Obtain a throat culture and inspect the oropharynx with a tongue blade
3. Start an intravenous line and administer antipyretics
4. Delegate measurement of urine output to the unlicensed assistive personnel

Explanation: This question assesses emergency priorities using the ABCs (airway, breathing, circulation) framework in a pediatric client with suspected epiglottitis. The relevant framework is the ABCs, prioritizing airway support without agitation. Keeping calm, providing humidified oxygen, and preparing for airway management is the highest priority for stridor and low oxygen (89%) to avoid complete obstruction. Obtaining throat culture (B), starting IV/antipyretics (C), and delegating urine (D) are incorrect or lower priority as inspection can worsen swelling, and others delay airway focus. The decision-making principle highlights ABCs by minimizing stimulation for airway preservation. In emergencies, nurses should prepare for intubation calmly. A general strategy for prioritizing care in emergency situations emphasizes gentle handling and rapid escalation.

Question 6

1. Apply 100% oxygen via nonrebreather mask (correct answer)
2. Obtain a chest radiograph to assess for inhalation injury
3. Assess pain level and administer prescribed analgesics
4. Delegate collection of a urine specimen to the unlicensed assistive personnel

Explanation: This question assesses emergency priorities using the ABCs (airway, breathing, circulation) framework in a client with carbon monoxide poisoning. The relevant framework is the ABCs, prioritizing high-concentration oxygen to displace CO. Applying 100% oxygen via nonrebreather is the highest priority for elevated carboxyhemoglobin (18%) and signs of inhalation injury. Obtaining x-ray (B), assessing pain (C), and delegating urine (D) are lower priority as imaging and pain management follow oxygenation. The decision-making principle highlights ABCs by focusing on oxygen therapy to improve tissue perfusion. In emergencies, nurses should administer high-flow oxygen immediately. A general strategy for prioritizing care in emergency situations involves quick toxin recognition and supportive interventions.

Question 7

1. Stop the transfusion and keep the intravenous line open with normal saline (correct answer)
2. Obtain a new set of vital signs and lung sounds for documentation
3. Delegate calling the blood bank to the unit secretary
4. Administer furosemide after obtaining a provider order

Explanation: This question assesses emergency priorities using the ABCs (airway, breathing, circulation) framework in a client with transfusion-related acute lung injury. The relevant framework is the ABCs, focusing on stopping the harm and supporting breathing. Stopping the transfusion and keeping the IV open with saline is the highest priority to halt the reaction causing dyspnea and crackles. Obtaining vital signs (B), delegating to call blood bank (C), and administering furosemide (D) are lower priority as they follow cessation, with furosemide needing verification but not first. The decision-making principle highlights ABCs by prioritizing removal of the offending agent to protect circulation and breathing. In emergencies, nurses should immediately discontinue harmful infusions and stabilize. A general strategy for prioritizing care in emergency situations involves quick identification of reactions and immediate cessation of triggers.

Question 8

1. Initiate intravenous access and prepare to administer atropine per protocol (correct answer)
2. Administer sublingual nitroglycerin for chest pain
3. Obtain a pain rating and reassess in 10 minutes
4. Delegate a repeat blood pressure measurement to the unlicensed assistive personnel

Explanation: This question assesses emergency priorities using the ABCs (airway, breathing, circulation) framework in a client with symptomatic bradycardia. The relevant framework is the ABCs, emphasizing circulation support in hypotension. Initiating IV access and preparing atropine is the highest priority for bradycardia (44/min) and low blood pressure (78/52 mm Hg) per ACLS protocols. Administering nitroglycerin (B), assessing pain (C), and delegating BP (D) are inappropriate or lower priority as nitro worsens hypotension, and pain is secondary. The decision-making principle highlights ABCs by prioritizing pharmacological intervention for unstable rhythms. In emergencies, nurses should prepare for pacing or medications. A general strategy for prioritizing care in emergency situations stresses rapid rhythm assessment and protocol-driven actions.

Question 9

1. Apply oxygen and prepare for airway support due to declining respiratory status (correct answer)
2. Request an order for vitamin K administration
3. Perform a full neurological assessment and document findings
4. Delegate obtaining a stat head computed tomography transport to the unlicensed assistive personnel

Explanation: This question assesses emergency priorities using the ABCs (airway, breathing, circulation) framework in a client with traumatic brain injury and coagulopathy. The relevant framework is the ABCs, emphasizing airway and breathing support in declining status. Applying oxygen and preparing for airway support is the highest priority for low respiratory rate (10/min) and hypoxemia (90%), preventing further brain injury. Requesting vitamin K (B), performing neuro assessment (C), and delegating CT (D) are lower priority or inappropriate as reversal and imaging follow respiratory stabilization, with delegation unsafe for transport. The decision-making principle highlights ABCs by prioritizing ventilation amid neurological decline. In emergencies, nurses should stabilize breathing first. A general strategy for prioritizing care in emergency situations stresses rapid ABC intervention before diagnostics.

Question 10

1. Markedly decreased breath sounds bilaterally (correct answer)
2. Heart rate 132/min after bronchodilator therapy
3. Reports of chest tightness with wheezing
4. Inability to speak in full sentences

Explanation: This question assesses emergency priorities using the ABCs (airway, breathing, circulation) framework in a client with severe asthma exacerbation. The relevant framework is the ABCs, identifying critical breathing compromise. Markedly decreased breath sounds bilaterally requires urgent intervention as 'silent chest' indicates severe airflow obstruction and impending respiratory failure. Tachycardia (B), chest tightness (C), and inability to speak (D) are concerning but lower priority than absent sounds, which signal escalation beyond initial therapy. The decision-making principle highlights ABCs by prioritizing recognition of silent chest for immediate advanced airway support. In emergencies, nurses should monitor for worsening signs like diminished sounds. A general strategy for prioritizing care in emergency situations emphasizes rapid reassessment of breathing and escalation to intubation if needed.

Question 11

1. Apply firm manual pressure to the femoral access site (correct answer)
2. Check the most recent hemoglobin and hematocrit results
3. Call the provider to request an order for pain medication
4. Delegate obtaining a full set of vital signs to the unlicensed assistive personnel

Explanation: This question assesses emergency priorities using the ABCs (airway, breathing, circulation) framework in a client with post-procedure hemorrhage. The relevant framework is the ABCs, prioritizing circulation by controlling bleeding. Applying firm manual pressure is the highest priority to stop hemorrhage from the femoral site, addressing tachycardia (122/min) and hypotension (78/46 mm Hg). Checking labs (B), requesting pain medication (C), and delegating vital signs (D) are lower priority as they do not immediately halt bleeding, with pain management secondary. The decision-making principle highlights ABCs by focusing on hemorrhage control to restore circulation before assessments or delegation. In emergencies, nurses should rapidly assess for bleeding and apply direct pressure. A general strategy for prioritizing care in emergency situations involves quick ABC evaluation, immediate hemorrhage control, and team activation for support.

Question 12

1. Prepare to administer naloxone per protocol and obtain a provider order if required by facility policy
2. Increase oxygen to 6 L/min via nasal cannula and reassess oxygen saturation in 5 minutes
3. Open the airway with a head-tilt chin-lift (or jaw-thrust if indicated) and begin bag-valve-mask ventilation with 100% oxygen (correct answer)
4. Ask the unlicensed assistive personnel to obtain a full set of vital signs and capillary blood glucose

Explanation: This question assesses emergency priorities using the ABCs framework in a client experiencing opioid-induced respiratory depression. The relevant clinical guideline here is the ABC priority system, where airway and breathing take precedence over all other interventions. Opening the airway and providing bag-valve-mask ventilation (Option C) is the highest priority because the client has severe respiratory depression (rate 6/min), hypoxemia (SpO2 82%), and gurgling respirations indicating airway compromise. While naloxone (Option A) is important for reversing opioid effects, establishing adequate ventilation must occur first to prevent respiratory arrest. Increasing oxygen via nasal cannula (Option B) is insufficient when the client has inadequate respiratory effort, and obtaining vital signs (Option D) delays critical airway management. The decision-making principle emphasizes that when breathing is compromised, immediate ventilatory support supersedes medication administration or assessment activities. In emergency situations involving respiratory depression, nurses must rapidly intervene to secure the airway and provide ventilation before addressing the underlying cause, as hypoxemia can lead to cardiac arrest within minutes.

Question 13

1. Place the client on continuous cardiac monitoring and prepare to administer intravenous calcium gluconate per protocol (correct answer)
2. Teach the client to avoid potassium-rich foods and provide written dietary instructions
3. Obtain a repeat potassium level in 1 hour to confirm the laboratory result
4. Delegate to the nursing assistant to obtain a urine specimen for urinalysis

Explanation: This question assesses emergency priorities using the ABCs framework in a client with severe hyperkalemia causing cardiac dysrhythmias. The relevant clinical guideline prioritizes immediate cardiac monitoring and calcium administration in hyperkalemia with ECG changes. Placing on cardiac monitoring and preparing calcium gluconate (Option A) is the highest priority because the client has dangerously high potassium (6.8 mEq/L) with bradycardia and peaked T waves, indicating imminent risk of cardiac arrest. Teaching dietary restrictions (Option B) is inappropriate during acute crisis, waiting to recheck labs (Option C) delays urgent treatment, and obtaining urine specimens (Option D) is not immediately relevant. The decision-making principle emphasizes that hyperkalemia with cardiac manifestations requires immediate membrane stabilization with calcium to prevent ventricular fibrillation or asystole. In emergency situations involving severe hyperkalemia, nurses must rapidly initiate continuous cardiac monitoring and administer IV calcium gluconate, as cardiac arrest can occur suddenly with potassium levels above 6.5 mEq/L.

Question 14

1. Administer prescribed intravenous opioid for reported incisional pain rated 8/10
2. Reposition the client, perform a jaw-thrust, and apply a bag-valve-mask with 100% oxygen as needed (correct answer)
3. Call the provider to request an order for continuous positive airway pressure therapy
4. Delegate to the nursing assistant to obtain a temperature and apply warm blankets

Explanation: This question assesses emergency priorities using the ABCs framework in a post-operative client with obstructive sleep apnea experiencing respiratory depression. The relevant clinical guideline prioritizes immediate airway management in clients with compromised breathing and altered consciousness. Repositioning the client, performing a jaw-thrust, and applying bag-valve-mask ventilation (Option B) is the highest priority because the client has severe hypoxemia (SpO2 79%), bradypnea (rate 8/min), and is difficult to arouse with snoring and apnea. Administering opioids (Option A) would worsen respiratory depression, calling for CPAP orders (Option C) delays urgent intervention, and obtaining temperature (Option D) is not immediately relevant to the respiratory crisis. The decision-making principle emphasizes that post-operative respiratory depression requires immediate mechanical support of ventilation, especially in clients with pre-existing sleep apnea. In emergency situations involving post-anesthesia respiratory compromise, nurses must rapidly open the airway and provide ventilatory support, as hypoxemia can quickly progress to cardiac arrest in sedated patients.

Question 15

1. Place the client in high-Fowler position and apply high-flow oxygen (correct answer)
2. Obtain a complete allergy history and document the reaction
3. Call the provider to request an order for antihistamines
4. Delegate vital signs recheck to the unlicensed assistive personnel

Explanation: This question assesses emergency priorities using the ABCs (airway, breathing, circulation) framework in a client with angioedema and potential airway compromise. The relevant framework is the ABCs, focusing on airway patency and oxygenation in anaphylactic reactions. Placing the client in high-Fowler position with high-flow oxygen is the highest priority to reduce swelling and improve breathing amid stridor and low oxygen saturation (90%). Obtaining allergy history (B), calling for antihistamines (C), and delegating vital signs (D) are lower priority or incorrect as they delay immediate airway support, with delegation not addressing the urgent need. The decision-making principle highlights ABCs by prioritizing positioning and oxygen to maintain airway before pharmacological or historical interventions. In emergencies, nurses should rapidly assess for airway threats and act to stabilize before gathering details. A general strategy for prioritizing care in emergency situations emphasizes immediate airway management, oxygenation, and preparation for advanced interventions like intubation.

Question 16

1. Administer a short-acting bronchodilator via nebulizer and apply supplemental oxygen (correct answer)
2. Obtain a detailed allergy history and review the home medication list
3. Teach pursed-lip breathing and provide written asthma action plan education
4. Request a provider order for a chest radiograph before initiating treatment

Explanation: This question assesses emergency priorities using the ABCs framework in a client experiencing severe asthma exacerbation. The relevant clinical guideline prioritizes immediate bronchodilation and oxygenation in acute bronchospasm with hypoxemia. Administering a short-acting bronchodilator via nebulizer and applying supplemental oxygen (Option A) is the highest priority because the client shows signs of severe asthma attack with hypoxemia (SpO2 88%), inability to speak in full sentences, and significantly reduced peak flow. Obtaining allergy history (Option B) delays critical treatment, teaching breathing techniques (Option C) is inappropriate during acute distress when the client cannot focus on learning, and requesting imaging (Option D) postpones urgent bronchodilator therapy. The decision-making principle emphasizes that in acute bronchospasm, immediate pharmacological intervention to open airways takes precedence over assessment or educational activities. In emergency situations involving severe asthma, nurses must rapidly administer bronchodilators and oxygen simultaneously, as delays in treatment can lead to respiratory failure requiring intubation.

Question 17

1. Increase oxygen and apply noninvasive positive pressure ventilation (continuous positive airway pressure) per protocol (correct answer)
2. Obtain a stat basic metabolic panel to evaluate potassium and creatinine levels
3. Administer the next scheduled dose of intravenous furosemide and reassess in 30 minutes
4. Delegate to the nursing assistant to obtain daily weight and measure intake and output

Explanation: This question assesses emergency priorities using the ABCs framework in a client experiencing acute pulmonary edema. The relevant clinical guideline prioritizes immediate respiratory support in clients with severe hypoxemia and pulmonary congestion. Increasing oxygen and applying noninvasive positive pressure ventilation (Option A) is the highest priority because the client has severe hypoxemia (SpO2 84%), tachypnea (rate 32/min), and pink frothy sputum indicating life-threatening pulmonary edema. Obtaining labs (Option B) delays critical intervention, administering furosemide (Option C) takes time to work and doesn't address immediate hypoxemia, and measuring weights (Option D) is not urgent. The decision-making principle emphasizes that in acute pulmonary edema, immediate respiratory support through CPAP/BiPAP reduces work of breathing and improves oxygenation faster than diuretics alone. In emergency situations involving flash pulmonary edema, nurses must rapidly apply positive pressure ventilation to push fluid out of alveoli and prevent respiratory failure requiring intubation.

Question 18

1. Administer sublingual nitroglycerin for chest pain relief
2. Start two large-bore intravenous lines, place the client supine, and begin a rapid isotonic fluid bolus per protocol (correct answer)
3. Obtain a complete medication reconciliation and allergy history
4. Delegate to the unit clerk to call the cardiac catheterization lab

Explanation: This question assesses emergency priorities using the ABCs framework in a client experiencing ST-elevation myocardial infarction with cardiogenic shock. The relevant clinical guideline prioritizes circulation support in hemodynamically unstable cardiac patients. Starting large-bore IVs and administering rapid isotonic fluid bolus (Option B) is the highest priority because the client has severe hypotension (78/44 mmHg) indicating cardiogenic shock, which threatens immediate survival. While nitroglycerin (Option A) treats chest pain, it would dangerously lower blood pressure further in a hypotensive patient. Obtaining medication history (Option C) and calling the cath lab (Option D) are important but secondary to stabilizing hemodynamics. The decision-making principle emphasizes that circulation takes precedence when blood pressure is critically low, as inadequate perfusion leads to organ failure and death. In emergency situations involving STEMI with shock, nurses must rapidly address hypotension through fluid resuscitation and prepare for advanced cardiac interventions, as every minute of hypoperfusion increases mortality risk.

Question 19

1. Encourage the client to take small sips of water to help clear the obstruction
2. Perform abdominal thrusts and activate emergency response according to facility policy (correct answer)
3. Assess lung sounds and obtain a full set of vital signs before intervening
4. Delegate to the nursing assistant to obtain suction equipment while the nurse documents the event

Explanation: This question assesses emergency priorities using the ABCs framework in a client with complete airway obstruction. The relevant clinical guideline mandates immediate intervention for foreign body airway obstruction using established choking protocols. Performing abdominal thrusts and activating emergency response (Option B) is the highest priority because the client shows classic signs of complete obstruction: inability to speak, stridor, cyanosis, and the universal choking sign (clutching throat). Encouraging water (Option A) is contraindicated and could worsen obstruction, assessing lung sounds (Option C) wastes critical time when the diagnosis is clear, and delegating for equipment (Option D) delays life-saving intervention. The decision-making principle emphasizes that complete airway obstruction requires immediate physical intervention to dislodge the foreign body before respiratory arrest occurs. In emergency situations involving choking, nurses must rapidly perform abdominal thrusts (Heimlich maneuver) without delay, as brain damage begins within 4-6 minutes of oxygen deprivation.

Question 20

1. Apply direct pressure and a tourniquet above the wound if bleeding is not controlled, and activate the massive hemorrhage protocol per facility policy (correct answer)
2. Obtain a full pain assessment and administer prescribed analgesia
3. Send the client to radiology for imaging to rule out femur fracture
4. Delegate to the nursing assistant to start a peripheral intravenous line and draw blood cultures

Explanation: This question assesses emergency priorities using the ABCs framework in a trauma client with hemorrhagic shock. The relevant clinical guideline prioritizes immediate hemorrhage control in clients with active bleeding and hemodynamic instability. Applying direct pressure and tourniquet if needed while activating massive hemorrhage protocol (Option A) is the highest priority because the client has uncontrolled bleeding with signs of shock (BP 84/50, HR 142, low hemoglobin). Pain assessment (Option B) is secondary to life-threatening bleeding, sending to radiology (Option C) is unsafe with unstable vitals, and delegating IV insertion (Option D) to unlicensed personnel is inappropriate. The decision-making principle emphasizes that controlling external hemorrhage takes immediate precedence over all other interventions in trauma. In emergency situations involving massive bleeding, nurses must rapidly apply direct pressure and tourniquets when indicated, as every minute of uncontrolled hemorrhage depletes blood volume and increases mortality risk.