Emergency Nursing NCLEX Practice Quiz 1 (20 Items)

1. Emergency Nursing NCLEX Practice Quiz 1 (20 Items)

2. 1. Nurse Ejay is assigned to a telephone triage. A patient called who was stung by a honeybee and is asking for help. The patient reports of pain and localized swelling but has no respiratory distress or other symptoms of anaphylactic shock. What is the appropriate initial action that the nurse should direct the patient to perform? A. Removing the stinger by scraping it.B. Applying a cold compress.C. Taking an oral antihistamine.D. Calling the 911. 1. Answer: A. Removing the stinger by scraping it. Since the stinger will continue to release venom into the skin, removing the stinger should be the first action . After removing the stinger, Antihistamine and cold compress follow. Option D: The caller should be further advised about symptoms that require 911 assistance.

3. 2. Nurse Anna is an experienced travel nurse who was recently employed and is assigned in the emergency unit. In her first week of the job, which of the following area is the most appropriate assignment for her? A. Triage.B. Ambulatory section.C. Trauma team.D. Psychiatric care 2. Answer: B. Ambulatory section. The ambulatory section deals with patients with relatively stable conditions. Options A, C, and D: These areas should be filled with nurses who are experienced with hospital routines and policies and has the ability to locate equipment immediately.

4. 3. A patient arrives at the emergency department who suffered multiple injuries from a head-on car collision. Which of the following assessment should take the highest priority to take? A. Irregular pulse.B. Ecchymosis in the flank area.C. A deviated trachea.D. Unequal pupils. 3. Answer: C. A deviated trachea. A deviated trachea is a symptom of tension pneumothorax, which will result in respiratory distress if left untreated.

5. 4. Nurse Kelly, a triage nurse encountered a patient who complains of mid-sternal chest pain, dizziness, and diaphoresis. Which of the following nursing action should take priority? A. Complete history taking.B. Put the patient on ECG monitoring.C. Notify the physician.D. Administer oxygen therapy via nasal cannula. 4. Answer: D. Administer oxygen therapy via nasal cannula. The priority goal is to increase myocardial oxygenation. Options A, B, and C: These actions are also appropriate and should be performed immediately.

6. 5. A group of people arrived at the emergency unit by a private car with complaints of periorbital swelling, cough, and tightness in the throat. There is a strong odor emanating from their clothes. They report exposure to a “gas bomb” that was set off in the house. What is the priority action? A. Direct the patients to the decontamination area.B. Direct the patients to the cold or clean zone for immediate treatment.C. Measure vital signs and auscultate lung sounds.D. Immediately remove other patients and visitors from the area.E. Instruct personnel to don personal protective equipment. 5. Answer: A. Direct the patients to the decontamination area. Decontamination in a specified area is the priority. Option B: The patients must undergo decontamination before entering cold or clean areas. Options C and D: Performing assessments and moving others delays contamination and does not protect the total environment. Option E: Personnel should don personal protective equipment before assisting with decontamination or assessing the patients.

7. 6. When an unexpected death occurs in the emergency department, which task is the most appropriate to delegate to a nursing assistant? A. Help the family to collect belongings.B. Assisting with postmortem care.C. Facilitate meeting between the family and the organ donor specialist.D. Escorting the family to a place of privacy. 6. Answer: B. Assisting with postmortem care. Postmortem care requires some turning, cleaning, lifting, and so on, and the nursing assistant is able to assist with these duties. Option A: In cases of questionable death, belongings may be retained for evidence, so the chain of custody would have to be maintained. Options C and D: A licensed nurse should take responsibility for the other tasks to help the family begin the grieving process.

8. 7. The physician has ordered cooling measures for a child with a fever who is likely to be discharged when the temperature comes down. Which task would be appropriate to delegate to a nursing assistant? A. Prepare and administer a tepid sponge bath.B. Explain the need for giving cool fluids.C. Assist the child in removing outer clothing.D. Advise the parent to use acetaminophen (Tylenol) instead of aspirin.8. You are preparing a child for IV conscious sedation before the rep 7. Answer: C. Assist the child in removing outer clothing. The nursing assistant can help with the removal of outer clothing, which allows the heat to dissipate from the child’s skin. Option A: Tepid baths are not usually given because of the possibility of shivering and rebound. Options B and D: Explaining and Advising are teaching functions that are a responsibility of the registered nurse.

9. 8. You are preparing a child for IV conscious sedation before the repair of a facial laceration. What information should you report immediately to the physician? A. The parent wants information about the IV conscious sedation.B. The parent is not sure regarding the child’s tetanus immunization status.C. The child suddenly pulls out the IV.D. The parent’s refusal of the administration of the IV sedation. 8. Answer: D. The parent’s refusal of the administration of the IV sedation. The refusal of the parents is an absolute contraindication; therefore the physician must be notified. Options A and C: The RN can reestablish the IV access and provide information about conscious sedation. Option B: Tetanus status can be addressed later.

10. 9. The emergency medical service has transported a patient with severe chest pain. As the patient is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and unpalpable pulse. Which of the following task is appropriate to delegate to the nursing assistant? A. Assisting with the intubation.B. Placing the defibrillator pads.C. Doing chest compressions.D. Initiating bag valve mask ventilation. 9. Answer: C. Doing chest compressions. Performing chest compressions are within the training of a nurse assistant. Option A: The use of the bag valve mask requires practice, and usually a respiratory therapist will perform the function. Option B: The defibrillator pads are clearly marked; however placement should be done by the RN or physician because of the potential for skin damage and electrical arcing.

11. 10. The nursing manager decides to form a committee to address the issue of violence against ED personnel. Which combination of employees would be best suited to fulfill this assignment? A. RNs, LPNs, and nursing assistants.B. At least one representative from each group of ED personnel.C. Experienced RNs and experienced paramedics.D. ED physicians and charge nurses. 10. Answer: B. At least one representative from each group of ED personnel. At least one representative from each group of ED personnel should be included because all employees are potential targets for violence in the ED.

12. 11. A patient suffered an amputation of the first and second digits in a chainsaw accident. Which task should be delegated to an LPN/LVN? A. Cleansing the amputated digits and placing them directly into an ice slurry.B. Cleansing the digits with sterile normal saline and placing in a sterile cup with sterile normal saline.C. Gently cleansing the amputated digits and the hand with povidone-iodine.D. Wrapping the cleansed digits in saline-moistened gauze, sealing in a plastic container, and placing it in an ice. 11. Answer: D. Wrapping the cleansed digits in saline-moistened gauze, sealing in a plastic container, and placing it in an ice.

13. 12. A patient arrives in the emergency unit and reports that a concentrated household cleaner was splashed in both eyes. Which of the following nursing actions is a priority? A. Use Restasis (Allergan) drops in the eye.B. Flush the eye repeatedly using sterile normal saline.C. Examine the patient’s visual acuity.D. Patch the eye. 12. Answer: B. Flush the eye repeatedly using sterile normal saline. Initial emergency action during a chemical splash to the eye includes immediate continuous irrigation of the affected eye with normal saline. Option A: Restasis (Allergan) drops are used to treat dry eyes. Option C: Patching the eye is not part of the first line treatment of a chemical splash. Option D: After irrigation, visual acuity then is assessed.

14. 13. A patient was brought to the emergency department after suffering a closed head injury and lacerations around the face due to a hit-run accident. The patient is unconscious and has minimal response to noxious stimuli. Which of the following assessment findings if observed after few hours, should be reported to the physician immediately? A. Bleeding around the lacerations.B. Withdrawal of the patient in response to painful stimuli.C. Bruises and minimal edema of the eyelids.D. Drainage of a clear fluid from the patient’s nose. 13. Answer: D. Drainage of a clear fluid from the patient’s nose. Clear drainage from the patient’s nose indicates that there is a leakage of CSF and should be reported to the physician immediately.

15. 14. A 5-year-old patient was admitted to the emergency unit due to ingestion of unknown amount of chewable vitamins for children at an unknown time. Upon assessment, the child is alert and with no symptoms. Which of the following information should be reported to the physician immediately? A. The child has been treated multiple times for injuries caused by accidents.B. The vitamin that was ingested contains iron.C. The child was nauseated and vomited once at home.D. The child has been treated several times for toxic substance ingestion. 14. Answer: B. The vitamin that was ingested contains iron. Iron is a toxic substance that can lead to massive hemorrhage, shock, coma, and kidney failure. Options A, C, and D: These information needs further investigation but will not change the immediate diagnostic testing or treatment plan.

16. 15. The following patients come at the emergency department complaining of acute abdominal pain. Prioritize them for care in order of the severity of the conditions.1. A 27-year-old woman complaining of lightheadedness and severe sharp left lower quadrant pain who reports she is possibly pregnant.2. A 43-year-old woman with moderate right upper quadrant pain who has vomited small amounts of yellow bile and whose symptoms have worsened over the week.3. A 15-year-old boy with a low-grade fever, right lower quadrant pain, vomiting, nausea, and loss of appetite for the past few days.4. A 57-year-old woman who complains of a sore throat and gnawing midepigastric pain that is worse between meals and during the night.5. A 59-year-old man with a pulsating abdominal mass and sudden onset of persistent abdominal or back pain, which can be described as a tearing sensation within the past hour. A. 2,5,3,4,1B. 3,1,4,5,2C. 5,1,3,2,4D. 2,5,1,4,3 15. Answer: C. 5,1,3,2,4 The patient with a pulsating mass has an abdominal aneurysm that may rupture and he may decompensate easily. The woman with lower left quadrant pain is at risk for a life-threatening ectopic pregnancy. The 15-year-old boy needs evaluation to rule out appendicitis. The woman with vomiting needs evaluation for gallbladder problems, which appear to be worsening. Lastly, the woman with mid epigastric pain is suffering from an ulcer, but follow-up diagnostic testing can be scheduled with a primary care provider.

17. 16. The following patients are presented with signs and symptoms of heat-related illness. Which of them needs to be attended first? A. A relatively healthy homemaker who reports that the air conditioner has been broken for days and who manifest fatigue, hypotension, tachypnea, and profuse sweating.B. An elderly person who complains of dizziness and syncope after standing in the sun for several hours to view a parade.C. A homeless person who is a poor historian; has altered mental status, poor muscle coordination, and hot, dry ashen skin; and whose duration of heat exposure is unknown.D. A marathon runner who complains of severe leg cramps and nausea, and manifests weakness, pallor, diaphoresis, and tachycardia. 16. Answer: C. A homeless person who is a poor historian; has altered mental status, poor muscle coordination, and hot, dry ashen skin; and whose duration of heat exposure is unknown. The signs and symptoms manifested by the homeless person indicate that a heat stroke is happening, a medical emergency, which can lead to brain damage. Option A: The homemaker is experiencing heat exhaustion, which can be managed by fluids and cooling measures. Option B: The elderly patient is at risk for heat syncope and should be advised to rest in a cool area and avoid similar situations. Option D: The runner is experiencing heat cramps, which can be managed with fluid and rest.

18. 17. An anxious female patient complains of chest tightness, tingling sensations, and palpitations. Deep, rapid breathing, and carpal spasms are noted. Which of the following priority action should the nurse do first? A. Provide oxygen therapy.B. Notify the physician immediately.C. Administer anxiolytic medication as ordered.D. Have the patient breathe into a brown paper bag. 17. Answer: D. Have the patient breathe into a brown paper bag. The patient is suffering from hyperventilation secondary from anxiety, the initial action is to let the patient breathe in a paper bag that will allow the rebreathing of carbon dioxide.

19. 18. An intoxicated patient comes into the emergency unit with an uncooperative behavior, mild confusion, and with slurred speech. The patient is unable to provide a good history but he verbalizes that he has been drinking a lot. Which of the following is a priority action of the nurse?A. Administer IV fluid incorporated with Vitamin B1 as ordered.B. Administer Naloxone (Narcan) 4 mg as ordered.C. Contact the family to get information of the patient.D. Obtain an order for the determination of blood alcohol level. 18. Answer: A. Administer IV fluid incorporated with Vitamin B1 as ordered. The patient has symptoms of alcohol abuse and there is a risk for Wernicke syndrome, which is caused by a deficiency in Vitamin B. Option B: Multiple drug abuse is not uncommon; however, there is currently nothing to suggest an opiate overdose that requires the administration of naloxone. Options C and D: Additional information or the results of the blood alcohol testing are part of the management but should not delay the immediate treatment.

20. 19. A nurse is providing discharge instruction to a woman who has been treated for contusions and bruises due to a domestic violence. What is the priority intervention for this patient?A. Making a referral to a counselor.B. Making an appointment to follow up on the injuries.C. Advising the patient about contacting the police.D. Arranging transportation to a safe house. 19. Answer: D. Arranging transportation to a safe house. Safety is a priority for this patient and she should not return to a place where violence could recur. Options A, B, and C: These are important for the long-term management of this case.

21. 20. In the work setting, what is the primary responsibility of the nurse in preparation for disaster management, that includes natural disasters and bioterrorism incidents?A. Being aware of the signs and symptoms of potential agents of bioterrorism.B. Making ethical decisions regarding exposing self to potentially lethal substances.C. Being aware of the agency’s emergency response plan.D. Being aware of what and how to report to the Centers for Disease Control and Prevention. 20. Answer: C. Being aware of the agency’s emergency response plan. In disasters preparedness, the nurse should know the emergency response plan. This gives guidance that includes the roles of the team members, responsibilities and mechanism of reporting.