180-Question Practice Examination with Answers & Rationales
Question 1 of 180
A nurse is providing an in-service about client evacuation during a fire. Which of the following
clients should the nurse evacuate first?
A. A client who is ambulatory and receiving oxygen.
B. A client who uses a wheelchair and is confused.
C. A client who is bedridden and wears a hearing aid.
✓ D. A client who has a fracture and is in balance suspension traction.
Correct Answer & Rationale:
,Answer: D. Using RACE principles, the client in balance suspension traction cannot self-evacuate and requires
special equipment. They are the most dependent and highest priority for evacuation planning. Ambulatory clients and
those with hearing aids can self-evacuate with direction.
A nurse in an emergency department is assessing a toddler who accidentally ingested lead.
Which of the following findings should the nurse expect?
✓ A. Cognitive impairment
B. Coughing
C. Hemoptysis
D. Excessive drooling
Correct Answer & Rationale:
Answer: A. Lead poisoning primarily affects the central nervous system, causing cognitive impairment,
developmental delays, learning difficulties, and behavioral changes. These are the hallmark neurological
manifestations of pediatric lead toxicity.
,A nurse in the emergency department is assessing a client who has status asthmaticus. The
nurse should expect which of the following findings?
A. Increase in peak expiratory rate flow
B. Epigastric pain
✓ C. Distended neck veins
D. Bradycardia
Correct Answer & Rationale:
Answer: C. Status asthmaticus causes severe air trapping and increased intrathoracic pressure, which impedes
venous return and results in distended neck veins. Peak expiratory flow is decreased (not increased). Tachycardia,
not bradycardia, is expected.
, A charge nurse is assigning client care tasks for the upcoming shift. Which of the following
tasks should the charge nurse assign to an assistive personnel (AP)?
A. Performing a thoracentesis
B. Inserting an endotracheal tube
✓ C. Obtaining blood cultures from a central catheter
D. Inserting an epidural catheter
Correct Answer & Rationale:
Answer: C. Obtaining blood cultures from a central catheter is within the scope of a trained AP under nurse
supervision. Thoracentesis, ET tube insertion, and epidural catheter insertion are invasive procedures requiring
advanced clinical skills that cannot be delegated to an AP.