16 original SNLE questions on critical care nursing, each with an explanation for all four options. Part of Adult Nursing, worth 40% of the Saudi Nursing Licensure Examination.
Q01 / 10medium0 correct
Adult Nursingmediumq015
A nurse finds an unresponsive adult in a hospital corridor with no normal breathing and no pulse after a 10-second check. A colleague has activated the emergency response and is bringing the defibrillator. What should the nurse do next?
All 16 questions
Every question below, with the reasoning for all four options. Try to answer before you open one.
Critical care nursing · medium
A nurse finds an unresponsive adult in a hospital corridor with no normal breathing and no pulse after a 10-second check. A colleague has activated the emergency response and is bringing the defibrillator. What should the nurse do next?
AOpen the airway and give two rescue breaths before compressions
BBegin chest compressions at 100 to 120 per minute with full recoil
CWait for the defibrillator to arrive before starting compressions
DInsert an oropharyngeal airway and ventilate before compressions
Show the answer and why the others fail
Answer: B. Begin chest compressions at 100 to 120 per minute with full recoil
A
Current resuscitation guidance begins with compressions rather than breaths, to minimize any delay in generating circulation.
B — correct
High-quality chest compressions are started immediately once pulselessness is confirmed. Rate 100 to 120/min, depth 5 to 6 cm in adults, full chest recoil, and minimal interruptions are the parameters most strongly linked to survival.
C
Any pause without compressions reduces coronary and cerebral perfusion; compressions continue until the pads are placed and the rhythm analyzed.
D
Advanced airway placement must not delay compressions; airway management is layered in without interrupting chest compressions.
TakeawayConfirmed cardiac arrest means immediate high-quality compressions — rate 100 to 120/min, depth 5 to 6 cm, full recoil, minimal interruptions.
Critical care nursing · hard
A mechanically ventilated patient suddenly becomes agitated with SpO2 falling to 82%, absent breath sounds on the right, tracheal deviation to the left, distended neck veins, and blood pressure 78/40 mmHg. What should the nurse anticipate?
AObtaining a portable chest radiograph before any intervention
BIncreasing the positive end-expiratory pressure to improve oxygenation
CAdministering a fluid bolus and a sedative for ventilator dyssynchrony
DImmediate needle decompression of the right chest followed by chest tube insertion
Show the answer and why the others fail
Answer: D. Immediate needle decompression of the right chest followed by chest tube insertion
A
Waiting for imaging in tension pneumothorax risks cardiac arrest; decompression must not be delayed.
B
Raising PEEP forces more air into the pleural space and worsens the tension physiology.
C
Sedation masks a life-threatening mechanical problem, and fluids cannot overcome obstruction of venous return.
D — correct
Absent unilateral breath sounds with contralateral tracheal deviation, distended neck veins, and hypotension is tension pneumothorax — an obstructive shock state. It is a clinical diagnosis requiring immediate decompression, before imaging.
TakeawayTension pneumothorax is a clinical diagnosis — decompress immediately rather than waiting for a chest radiograph.
Critical care nursing · medium
A nurse in the intensive care unit responds to a cardiac monitor alarm. The patient is unresponsive, apneic, and pulseless. The monitor displays a chaotic, irregular waveform with no discernible QRS complexes. A defibrillator is immediately available at the bedside. What is the priority action?
AInitiate high-quality cardiopulmonary resuscitation (CPR) for 2 minutes.
BPerform synchronized cardioversion at 100 joules.
CAdminister amiodarone 300 mg intravenously.
DDeliver an unsynchronized shock using the defibrillator.
Show the answer and why the others fail
Answer: D. Deliver an unsynchronized shock using the defibrillator.
A
CPR is essential in cardiac arrest, but when a defibrillator is immediately available and the rhythm is shockable (ventricular fibrillation), defibrillation takes priority over CPR.
B
Synchronized cardioversion is used for unstable tachyarrhythmias with a pulse; pulseless ventricular fibrillation requires unsynchronized defibrillation.
C
Amiodarone is an antiarrhythmic used for refractory ventricular fibrillation after defibrillation attempts, not as the initial intervention.
D — correct
The chaotic waveform is ventricular fibrillation, a shockable rhythm. Immediate defibrillation is the priority to terminate the arrhythmia and allow the heart's natural pacemaker to potentially resume an organized rhythm.
TakeawayIn cardiac arrest with a shockable rhythm (ventricular fibrillation or pulseless ventricular tachycardia) and a defibrillator immediately available, the priority is immediate defibrillation.
Critical care nursing · medium
A 58-year-old male presents to the emergency department with crushing substernal chest pain radiating to his left arm, diaphoresis, and nausea. An ECG reveals ST-segment elevation in leads II, III, and aVF. Vital signs are: blood pressure 88/56 mmHg, heart rate 112 bpm, respiratory rate 22 breaths/min, and SpO2 94% on room air. Which intervention should the nurse prioritize?
AAdminister sublingual nitroglycerin 0.4 mg as prescribed.
BPrepare the patient for immediate percutaneous coronary intervention.
CInitiate IV access and administer a fluid bolus as prescribed.
DStart a norepinephrine infusion to support blood pressure.
Show the answer and why the others fail
Answer: C. Initiate IV access and administer a fluid bolus as prescribed.
A
Nitroglycerin is contraindicated in inferior STEMI with hypotension (systolic BP <90 mm Hg) or suspected right ventricular infarction, as it can further reduce preload and worsen hemodynamic instability.
B
While emergent PCI is the definitive treatment, the immediate nursing priority is hemodynamic stabilization with IV fluids to ensure safe transport to the catheterization lab.
C — correct
In inferior STEMI with hypotension, right ventricular involvement is likely; the immediate nursing priority is to optimize preload with IV fluids to improve cardiac output, while simultaneously preparing for PCI.
D
Vasopressors like norepinephrine are reserved for persistent hypotension after adequate fluid resuscitation; they are not the first-line intervention in this scenario.
TakeawayIn inferior STEMI with hypotension, suspect right ventricular infarction. Avoid nitrates and prioritize IV fluid resuscitation to increase preload, while simultaneously preparing for emergent PCI. Vasopressors are second-line if fluids fail.
Critical care nursing · medium
A 35-year-old male is brought to the emergency department after a motor vehicle collision. He is alert but anxious. Vital signs: heart rate 110 bpm, blood pressure 90/60 mmHg, respiratory rate 24 breaths/min, temperature 36.5°C (97.7°F). The nurse suspects hypovolemic shock. Which assessment finding would best indicate inadequate tissue perfusion?
AWarm, flushed skin
BBounding peripheral pulses
CCool, pale skin
DIncreased urine output
Show the answer and why the others fail
Answer: C. Cool, pale skin
A
Warm, flushed skin is characteristic of vasodilation seen in neurogenic or septic shock. Hypovolemic shock triggers vasoconstriction, resulting in cool, pale skin.
B
Bounding pulses are associated with hyperdynamic states (e.g., sepsis, fever). In hypovolemic shock, pulses are typically weak and thready due to reduced stroke volume.
C — correct
Cool, pale skin is a direct sign of peripheral vasoconstriction, a compensatory mechanism that shunts blood to vital organs and indicates inadequate tissue perfusion in hypovolemic shock.
D
In hypovolemic shock, renal perfusion decreases, leading to oliguria (urine output <0.5 mL/kg/hr). Increased urine output would suggest adequate renal perfusion, not inadequate tissue perfusion.
TakeawayIn hypovolemic shock, cool, pale skin is a key sign of peripheral vasoconstriction and inadequate tissue perfusion, reflecting the body's compensatory mechanism to preserve blood flow to vital organs.
Critical care nursing · medium
A 55-year-old patient with severe community-acquired pneumonia is intubated for hypoxemic respiratory failure. Chest X-ray reveals diffuse bilateral infiltrates, and the PaO2/FiO2 ratio is 180. The patient is sedated and paralyzed. Which ventilator setting is most appropriate to minimize ventilator-induced lung injury?
ATidal volume 6 mL/kg predicted body weight
BTidal volume 12 mL/kg ideal body weight
CPositive end-expiratory pressure (PEEP) of 5 cm H2O
DFiO2 of 1.0 without positive end-expiratory pressure
Show the answer and why the others fail
Answer: A. Tidal volume 6 mL/kg predicted body weight
A — correct
Low tidal volume ventilation (6 mL/kg predicted body weight) is the standard of care for ARDS, as demonstrated by the ARDSNet trial, which showed reduced mortality and ventilator-induced lung injury.
B
High tidal volumes (10–15 mL/kg) were historically used but are now known to cause volutrauma and barotrauma, increasing mortality in ARDS. This setting is not lung-protective.
C
While PEEP is essential in ARDS to prevent alveolar collapse, a fixed low PEEP of 5 cm H2O is often insufficient. PEEP should be titrated based on oxygenation and lung mechanics, typically starting higher in moderate-to-severe ARDS.
D
Using 100% FiO2 without PEEP can lead to absorption atelectasis and oxygen toxicity. PEEP is necessary to maintain alveolar recruitment, and FiO2 should be titrated to the lowest level achieving adequate oxygenation.
TakeawayIn ARDS, lung-protective ventilation with low tidal volumes (6 mL/kg predicted body weight) reduces mortality and ventilator-induced lung injury.
Critical care nursing · medium
A patient in the intensive care unit is receiving a continuous infusion of norepinephrine via a peripheral intravenous line for septic shock. The nurse notes swelling, coolness, and blanching at the insertion site. What is the priority nursing action?
AApply a warm compress and elevate the extremity.
BReduce the infusion rate and notify the healthcare provider.
CDiscontinue the peripheral IV and prepare for central line insertion.
DStop the infusion and notify the healthcare provider immediately.
Show the answer and why the others fail
Answer: D. Stop the infusion and notify the healthcare provider immediately.
A
Warm compresses and elevation promote vasodilation and drug dispersion, which are part of the management of vasopressor extravasation, but they are not the first priority. The infusion must be stopped immediately to prevent further tissue damage.
B
Reducing the rate does not stop the extravasation and delays definitive management. The infusion must be stopped immediately to prevent ongoing tissue damage.
C
While central line access is preferred for vasopressor administration, the immediate priority is to stop the extravasation and initiate treatment to prevent tissue necrosis. Discontinuing the IV alone does not address the extravasated drug.
D — correct
Stopping the infusion prevents further extravasation of the vesicant, and prompt notification of the provider allows for timely administration of phentolamine, the antidote, to reverse vasoconstriction and prevent tissue necrosis.
TakeawayFor extravasation of vasopressors like norepinephrine, the priority nursing action is to stop the infusion immediately and notify the healthcare provider. Phentolamine, an alpha-adrenergic antagonist, is the antidote and should be infiltrated around the extravasation site as soon as possible to prevent ischemic tissue necrosis.
Critical care nursing · medium
A 28-year-old patient is admitted to the ICU after a severe traumatic brain injury from a motor vehicle collision. Cervical spine injury has been ruled out. The patient is intubated, sedated, and has an intracranial pressure (ICP) monitor in place. The current ICP reading is 26 mmHg. Which action should the nurse take first?
AHyperventilate the patient to achieve a PaCO2 of 25–30 mmHg.
BElevate the head of the bed to 30 degrees and keep the head midline.
CAdminister mannitol 0.5 g/kg IV as prescribed.
DNotify the healthcare provider immediately.
Show the answer and why the others fail
Answer: B. Elevate the head of the bed to 30 degrees and keep the head midline.
A
Prophylactic hyperventilation is not recommended because it can cause cerebral vasoconstriction and ischemia. A PaCO2 target of 25–30 mmHg is excessively aggressive; current guidelines suggest a temporary target of 30–35 mmHg only for acute neurological deterioration with signs of herniation, not as a first-line response to elevated ICP.
B — correct
Elevating the head of the bed to 30 degrees and maintaining head alignment promotes cerebral venous outflow and is a rapid, non-invasive intervention to lower ICP. Because cervical spine injury has been ruled out, this is safe and should be performed first.
C
Mannitol is an osmotic diuretic used to reduce ICP, but it is not the first action. Immediate nursing interventions to lower ICP, such as head-of-bed elevation, should be implemented first while preparing to administer mannitol if needed.
D
While the provider should be informed, the nurse's first action is to implement immediate bedside interventions to reduce ICP, such as head-of-bed elevation, before or while contacting the provider.
TakeawayFor elevated ICP in a patient with a cleared cervical spine, immediate nursing interventions include elevating the head of the bed to 30 degrees and keeping the head midline to promote cerebral venous drainage. Hyperventilation to a PaCO2 of 25–30 mmHg is no longer recommended due to the risk of ischemia; if used temporarily for herniation, target PaCO2 is 30–35 mmHg.
Critical care nursing · medium
A nurse is caring for a patient who is 2 days post–coronary artery bypass graft surgery. The patient suddenly develops hypotension, tachycardia, and distended neck veins. The nurse suspects cardiac tamponade. Which additional assessment finding would support this suspicion?
APulsus paradoxus greater than 10 mm Hg
BKussmaul respirations
CWidened pulse pressure
DTracheal deviation to the unaffected side
Show the answer and why the others fail
Answer: A. Pulsus paradoxus greater than 10 mm Hg
A — correct
Pulsus paradoxus, an exaggerated fall in systolic blood pressure during inspiration, is a classic sign of cardiac tamponade due to impaired ventricular filling.
B
Kussmaul respirations are deep, labored breaths characteristic of metabolic acidosis (e.g., diabetic ketoacidosis), not cardiac tamponade.
C
Widened pulse pressure is associated with aortic regurgitation, not cardiac tamponade, which typically causes a narrowed pulse pressure.
D
Tracheal deviation is a late sign of tension pneumothorax, not cardiac tamponade.
TakeawayCardiac tamponade presents with Beck's triad (hypotension, muffled heart sounds, distended neck veins) and pulsus paradoxus; prompt recognition and preparation for pericardiocentesis are critical.
Critical care nursing · medium
A nurse in the intensive care unit is caring for a patient who has been receiving unfractionated heparin for 5 days following a pulmonary embolism. The patient's platelet count has dropped from 250,000/mm³ to 80,000/mm³. The patient has no signs of active bleeding. Which action should the nurse take first?
AAdminister a platelet transfusion as prescribed.
BSwitch the infusion to low-molecular-weight heparin.
CObtain a stat D-dimer level to confirm the diagnosis.
DDiscontinue the heparin infusion and notify the healthcare provider.
Show the answer and why the others fail
Answer: D. Discontinue the heparin infusion and notify the healthcare provider.
A
Platelet transfusion is generally avoided in heparin-induced thrombocytopenia because it can increase the risk of thrombosis; the priority is to stop the offending agent.
B
Low-molecular-weight heparin has a high cross-reactivity rate with the antibodies causing heparin-induced thrombocytopenia and is contraindicated.
C
D-dimer is not diagnostic for heparin-induced thrombocytopenia; the diagnosis is based on platelet drop, clinical assessment, and specific antibody testing.
D — correct
Heparin-induced thrombocytopenia is a prothrombotic condition. The immediate nursing action is to stop all heparin and inform the provider to initiate an alternative anticoagulant.
TakeawayIn suspected heparin-induced thrombocytopenia, all heparin must be stopped immediately and a non-heparin anticoagulant initiated to prevent life-threatening thrombosis.
Critical care nursing · medium
A 68-year-old patient in the intensive care unit is being treated for a urinary tract infection with linezolid. The patient has a history of depression and takes fluoxetine daily. Within 24 hours of starting linezolid, the nurse notes agitation, diaphoresis, inducible clonus, and hyperreflexia. Vital signs: temperature 39.2°C, heart rate 112/min, blood pressure 160/90 mmHg. Which condition does the nurse suspect?
ANeuroleptic malignant syndrome
BAnticholinergic toxicity
CMalignant hyperthermia
DSerotonin syndrome
Show the answer and why the others fail
Answer: D. Serotonin syndrome
A
Neuroleptic malignant syndrome typically presents with lead-pipe rigidity, hyporeflexia, and a history of antipsychotic use, not clonus and hyperreflexia.
B
Anticholinergic toxicity presents with dry skin, mydriasis, and absent bowel sounds, not diaphoresis and clonus.
C
Malignant hyperthermia is triggered by volatile anesthetics or succinylcholine and presents with muscle rigidity, hyperthermia, and acidosis, not clonus or hyperreflexia.
D — correct
Linezolid has monoamine oxidase inhibiting activity, and when combined with fluoxetine (an SSRI), can precipitate serotonin syndrome, characterized by clonus, hyperreflexia, agitation, and hyperthermia.
TakeawaySerotonin syndrome is a potentially life-threatening condition caused by excess serotonergic activity, often due to drug interactions; key features include clonus, hyperreflexia, and hyperthermia.
Critical care nursing · medium
A 68-year-old patient in the ICU with suspected septic shock has received 30 mL/kg of intravenous crystalloid fluid. Blood cultures have been drawn and broad-spectrum antibiotics administered. The patient's blood pressure is 84/50 mm Hg, MAP 58 mm Hg, and heart rate is 114/min. Which order should the nurse anticipate next?
AInitiate a norepinephrine infusion.
BAdminister a 500 mL bolus of 0.9% sodium chloride.
CAdminister hydrocortisone 50 mg IV.
DObtain a serum lactate level.
Show the answer and why the others fail
Answer: A. Initiate a norepinephrine infusion.
A — correct
Norepinephrine is the first-line vasopressor for septic shock when hypotension persists despite initial fluid resuscitation, targeting a MAP of 65 mm Hg or higher.
B
While additional fluid boluses may be considered, the immediate priority for persistent hypotension after initial fluid resuscitation is to start vasopressor therapy to maintain a MAP of at least 65 mm Hg.
C
Hydrocortisone is reserved for patients with refractory septic shock who remain hypotensive despite adequate fluid resuscitation and vasopressor therapy.
D
Serum lactate is an important marker of tissue hypoperfusion in sepsis, but the immediate priority is to address ongoing hypotension with vasopressor therapy.
TakeawayIn septic shock, after initial fluid resuscitation, persistent hypotension requires prompt initiation of vasopressors, with norepinephrine as the first-line agent to achieve a MAP of at least 65 mm Hg.
Critical care nursing · medium
A 45-year-old patient in the ICU is experiencing continuous generalized tonic-clonic seizure activity for the past 8 minutes. Oxygen is being administered via non-rebreather mask, and vital signs are: BP 150/90 mm Hg, HR 120/min, SpO2 94%. Which medication should the nurse prepare to administer first?
AIntravenous propofol
BIntravenous levetiracetam
CIntravenous fosphenytoin
DIntravenous lorazepam
Show the answer and why the others fail
Answer: D. Intravenous lorazepam
A
Propofol is reserved for refractory status epilepticus when first- and second-line agents have failed, and it requires advanced airway management.
B
Levetiracetam is a second-line agent; it is not the initial drug of choice for aborting ongoing seizures.
C
Fosphenytoin is a second-line agent for status epilepticus; it is used if seizures persist after benzodiazepine administration.
D — correct
Benzodiazepines such as lorazepam are the recommended first-line treatment to rapidly terminate seizure activity in status epilepticus.
TakeawayIn status epilepticus, administer a benzodiazepine (e.g., lorazepam IV) as the first-line agent to rapidly terminate seizure activity.
Critical care nursing · medium
A nurse is caring for a patient in the surgical intensive care unit who underwent emergency laparotomy for blunt abdominal trauma 12 hours ago. The patient's abdomen is distended, urine output has decreased, and peak airway pressures have risen from 22 to 38 cm H2O over the past 2 hours. Blood pressure is 88/54 mm Hg, heart rate 118/min. Which action should the nurse take first?
ANotify the surgeon to prepare for immediate re-exploration.
BIncrease the set tidal volume on the ventilator to improve ventilation.
CAdminister a 500 mL bolus of 0.9% sodium chloride.
DMeasure intra-abdominal pressure via the indwelling urinary catheter.
Show the answer and why the others fail
Answer: D. Measure intra-abdominal pressure via the indwelling urinary catheter.
A
Surgical decompression may be necessary if intra-abdominal pressure is elevated and organ dysfunction is present, but the diagnosis must be confirmed first. Immediate notification without measurement is premature.
B
Increasing tidal volume would further elevate intrathoracic pressure, worsen venous return, and increase the risk of barotrauma. Lung-protective ventilation with low tidal volumes is indicated, not higher volumes.
C
Fluid resuscitation may be needed to support preload, but it does not address the underlying cause of the hypotension and organ dysfunction. The priority is to diagnose the suspected abdominal compartment syndrome before initiating treatment.
D — correct
The patient's distended abdomen, rising peak airway pressures, oliguria, and hypotension are classic signs of abdominal compartment syndrome. The first step is to confirm the diagnosis by measuring intra-abdominal pressure using the bladder catheter technique.
TakeawayIn critically ill patients with abdominal distension, hypotension, oliguria, and elevated peak airway pressures, suspect abdominal compartment syndrome and measure intra-abdominal pressure via the bladder catheter to confirm the diagnosis.
Critical care nursing · medium
A 22-year-old male is admitted to the ICU following a motor vehicle collision. He sustained a closed mid-shaft femur fracture that was stabilized with intramedullary nailing 24 hours ago. The nurse notes new-onset confusion, petechiae on the anterior chest and axillae, and an SpO2 of 88% on room air. What is the priority nursing intervention?
ABegin a continuous intravenous heparin infusion
BAdminister high-concentration oxygen via non-rebreather mask
CPrepare the patient for immediate fasciotomy
DPlace the patient in Trendelenburg position
Show the answer and why the others fail
Answer: B. Administer high-concentration oxygen via non-rebreather mask
A
Heparin is not recommended for fat embolism syndrome; it has not been shown to improve outcomes and may increase the risk of bleeding. Management is supportive, focusing on oxygenation and ventilation.
B — correct
The patient exhibits signs of fat embolism syndrome (FES): respiratory distress, petechiae, and neurological changes after a long bone fracture. Immediate priority is to correct hypoxemia with high-concentration oxygen to prevent further deterioration; supportive respiratory care is the cornerstone of FES management.
C
Fasciotomy is indicated for compartment syndrome, which presents with severe pain, pallor, pulselessness, and paresthesia in the affected limb, not with petechiae and confusion. This patient's presentation is consistent with fat embolism syndrome, not compartment syndrome.
D
Trendelenburg position (head down) would worsen respiratory distress and increase intracranial pressure, which is contraindicated in a patient with hypoxemia and neurological symptoms. The head of the bed should be elevated to promote ventilation.
TakeawayFat embolism syndrome classically presents with the triad of respiratory distress, petechiae, and neurological symptoms after a long bone fracture; priority management is supportive care with high-concentration oxygen therapy.
Critical care nursing · medium
A 55-year-old patient with acute respiratory distress syndrome (ARDS) is on mechanical ventilation with low tidal volume (6 mL/kg predicted body weight), FiO2 0.8, and PEEP 14 cm H2O. The patient's PaO2 is 55 mm Hg and SpO2 is 88%. Hemodynamics are stable. Which intervention should the nurse anticipate to improve oxygenation?
AIncrease FiO2 to 1.0 and reassess in 30 minutes.
BPrepare the patient for prone positioning.
CIncrease tidal volume to 10 mL/kg predicted body weight.
DAdminister a 500 mL bolus of normal saline.
Show the answer and why the others fail
Answer: B. Prepare the patient for prone positioning.
A
Increasing FiO2 alone is insufficient to correct hypoxemia caused by intrapulmonary shunting in ARDS; it does not address the underlying ventilation-perfusion mismatch and may delay definitive therapy.
B — correct
Prone positioning is recommended for patients with moderate to severe ARDS (PaO2/FiO2 < 150 mm Hg) to improve oxygenation and reduce mortality by redistributing perfusion and recruiting dorsal lung regions.
C
Higher tidal volumes increase the risk of ventilator-induced lung injury and mortality in ARDS; lung-protective ventilation with low tidal volumes (6 mL/kg) is the standard of care.
D
Fluid bolus is not indicated for isolated hypoxemia in ARDS; excessive fluids may worsen pulmonary edema and oxygenation, and the patient is hemodynamically stable.
TakeawayIn ARDS with PaO2/FiO2 < 150 mm Hg and refractory hypoxemia despite lung-protective ventilation, prone positioning improves oxygenation and reduces mortality.