The College of Maasin

Nisi Dominus Frustra

College of Nursing and Allied Health Sciences
NCM 106-Emergency Nursing

Name: Date:

1. Michael works as a triage nurse, and four clients arrive at the emergency department at the same time. List the
order in which he will assess these clients from first to last.

1. A 50-year-old female with moderate abdominal pain and occasional vomiting.

2. A 35-year-old jogger with a twisted ankle, having a pedal pulse and no deformity.
3. An ambulatory dazed 25-year-old male with a bandaged head wound.
4. An irritable infant with a fever, petechiae, and nuchal rigidity.
A. 1, 2, 3, 4
B. 2, 1, 3, 4
C. 4, 3, 1, 2
D. 3, 4, 2, 1

2. In conducting a primary survey on a trauma patient, which of the following is considered one of the priority
elements of the primary survey?
A. Initiation of pulse oximetry.
B. Complete set of vital signs.
C. Clients allergy history.
D. Brief neurologic assessment.

3. A 65-year-old patient arrived at the triage area with complaints of diaphoresis, dizziness, and left-sided
chest pain. This patient should be prioritized into which category?
A. Non-urgent.
B. Urgent.
C. Emergent.
D. High urgent.

4. You respond to a call for help from the ED waiting room. There is an elderly patient lying on the floor. List the
order for the actions that you must perform.

1. Call for help and activate the code team.

2. Instruct a nursing assistant to get the emergency cart.
3. Initiate cardiopulmonary resuscitation (CPR).
4. Perform the chin lift or jaw thrust maneuver.
5. Establish unresponsiveness.

A. 5, 2, 4, 3, 1
B. 1, 5, 2, 4, 3
C. 1, 2, 5, 4, 3
D. 5, 1, 4, 3, 2

5. In caring for a victim of sexual assault, which task is most appropriate for an LPN/LVN?
A. Provide emotional support and supportive communication.
B. Assess immediate emotional state and physical injuries.
C. Ensure that the chain of custody is maintained.
D. Collect hair samples, saliva swabs, and scrapings beneath fingernails.

6. Following an emergency endotracheal intubation, nurses must verify tube placement and secure the tube. List
in order the steps that are required to perform this function?

1. Obtain an order for a chest x-ray to document tube placement.

2. Confirm that the breath sounds are equal and bilateral.
3. Auscultate the chest during assisted ventilation.
4. Secure the tube in place.

A. 1, 2, 3, 4
B. 4, 3, 2, 1
C. 3, 2, 4, 1
D. 4, 1, 2, 3
7. A 15-year-old male client arrives at the emergency department. He is conscious, coherent and ambulatory, but
his shirt and pants are covered with blood. He and his hysterical friends are yelling and trying to explain that they
were goofing around and he got poked in the abdomen with a stick. Which of the following comments should be
given first consideration?

A. Hes a diabetic, so he needs attention right away.

B. There was a lot of blood and we used three bandages.
C. The stick was really dirty and covered with mud.
D. He pulled the stick out, just now, because it was hurting him.

8. A prisoner, with a known history of alcohol abuse, has been in police custody for 48 hours. Initially, anxiety,
sweating, and tremors were noted. Now, disorientation, hallucination, and hyper-reactivity are observed. The
medical diagnosis is delirium tremens. What is the priority nursing diagnosis?

A. Risk for Situational Low Self-esteem related to police custody.

B. Risk for Nutritional Deficit related to chronic alcohol abuse.
C. Risk for Injury related to seizures.
D. Risk for Other-Directed Violence related to hallucinations.

9. In relation to submersion injuries, which task is most appropriate to delegate to an LPN/LVN?

A. Talk to a community group about water safety issues.

B. Stabilize the cervical spine for an unconscious drowning victim.
C. Remove wet clothing and cover the victim with a warm blanket.
D. Monitor an asymptomatic near-drowning victim.

10. You are assessing a patient who has sustained a cat bite to the left hand. The cat is up-to-date
immunizations. The date of the patients last tetanus shot is unknown. Which of the following is the priority
nursing diagnosis?

A. Risk for Impaired Mobility related to potential tendon damage.

B. Risk for Infection related to organisms specific to cat bites.
C. Ineffective Health Maintenance related to immunization status.
D. Impaired Skin Integrity related to puncture wounds.

11. A client in a one-car rollover presents with multiple injuries. Prioritize the interventions that must be initiated
for this patient.

1. Assess for spontaneous respirations.

2. Give supplemental oxygen per mask.
3. Insert a Foley catheter if not contraindicated.
4. Obtain a full set of vital signs.
5. Remove patients clothing.
6. Secure/start two large-bore IVs with normal saline.
7. Use the chin lift or jaw thrust method to open the airway.

A. 1, 7, 2, 6, 4, 5, 3
B. 7, 1, 4, 2, 3, 5, 6
C. 4, 1, 5, 7, 6, 3, 2
D. 5, 4, 1, 7, 2, 6, 3

12. A 36-year-old patient with a history of seizures and medication compliance of phenytoin (Dilantin)
and carbamazepine (Tegretol) is brought to the ED by the MS personnel for repetitive seizure activity that started
45 minutes prior to arrival. You anticipate that the physician will order which drug for status epilepticus?

A. Lorazepam (Ativan) IV.

B. Magnesium sulfate IV.
C. Carbamazepine (Tegretol) IV.
D. Phenytoin and Carbamazepine PO.
13. A client arrived at the emergency department after suffering multiple physical injuries including a fractured
pelvis from a vehicular accident. Upon assessment, the client is incoherent, pale, and diaphoretic. With vital
signs as follows: temperature of 97F (36.11 C), blood pressure of 60/40 mm Hg, heart rate of 143 beats/minute,
and a respiratory rate of 30 breaths/minute. The client is mostly suffering from which of the following shock?

A. Cardiogenic.
B. Distributive.
C. Hypovolemic.
D. Obstructive.

14. An ER nurse is handling a 50-year-old woman complaining of dizziness and palpitations that occur from time
to time. ECG confirms the diagnosis of paroxysmal supraventricular tachycardia. The client seems worried about
it. Which of the following is an appropriate response of the nurse?

A. You can be discharged now; this is a probable sign of anxiety.

B. You have to stay here for a few hours to undergo blood tests to rule out myocardial infarction.
C. Well need to keep you for further assessment; you may develop blood clots.
D. The physician will prescribe you blood-thinning medications to lessen the episodes of palpitations.

15. A client was brought to the ED due to an abdominal trauma caused by a motorcycle accident. During the
assessment, the client complains of epigastric pain and back pain. Which of the following is true regarding the
diagnosis of pancreatic injury?

A. Redness and bruising may indicate the site of the injury in blunt trauma.
B. The client is symptom-free during the early post-injury period.
C. Signs of peritoneal irritation may indicate pancreatic injury.
D. All of the above.

16. A 20-year-old male client was brought to the emergency department with a gunshot wound to the chest. In
obtaining a history of the incident to determine possible injuries, the nurse should ask which of the following?

A. What was the initial first aid done?

B. Where did the incident happen?
C. What direction did the bullet enter into the body?
D. How long ago did the incident occur?

17. When attending a client with a head and neck trauma following a vehicular accident, the nurses initial action
is to?

A. Do oral and nasal suctioning.

B. Provide oxygen therapy.
C. Initiate intravenous access.
D. Immobilize the cervical area.