Red- Priority 1-emergent

Injuries are life-threatening but survivable with immediate intervention.

Individuals in this group can progress rapidly to expectant category if treatment is delayed.
Examples of Catagory 1-emergent
- Mechanical airway obstruction
- Pneumothorax
- Open long bone fractures
- Partial amputations
- Chest wounds
- Abdominal wounds
- Burns 15%-40% of body surface area (BSA)

Yellow- Priority 2 Urgent

Injuries are life-threatening but survivable with intervention within the hour. Individuals in this
group can progress rapidly to expectant category if treatment is delayed. Expected wait for
treatment 45-60 min
- Complex, lower extremity fractures
- Vascular injuries without compromise
- Stable abdominal wounds
- CNS injuries
- GU injuries
- Facial injuries with no airway obstructions

Examples of Green - priority 3 non-urgent:

- Upper extremity fractures
- Sprains
- Burns (small surface area, not facial)
- Behavioral
- Psych
- Lacerations with minimal bleeding

Black- Expectant 4 - death

Injuries are extensive and chances of survival are unlikely even with definitive care.
Persons in this group should be separated from other casualties, but not abandoned.
Comfort measures should be provided when possible.
Examples of Black - expectant
- Burns over 60% of BSA
- Wounds involving multiple organs
- High spinal cord injuries
- Agonal respirations
- Pulseless
- Profound shock
Unresponsive patient with penetrating head wounds -Black
Small lacerations without significant bleeding- green
Tension pneumothorax-red
maxillofacial wounds without airway compromise-yellow
Incomplete amputations-red
Vascular injuries with adequate collateral circulation -yellow
2 & 3 degree burns over 60% of body -black
Behavioral disorders or psychological disturbances -green
Fractures requiring open reduction -yellow
Open fractures of the long bone-red

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. You are caring for a client with a frostbite on the feet. Place the
following interventions in the correct order.

1. Immerse the feet in warm water 100 F to 105 F (40.6 C to 46.1

C).
2. Remove the victim from the cold environment.
3. Monitor for signs of compartment syndrome.
4. Apply a loose, sterile, bulky dressing.
5. Administer a pain medication.

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

7. 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
8. 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.

9. 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.

10. 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.

11. 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.

12. 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

13. 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.

14. 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.

15. Which of these is not classified as a Category A biologic agent?

A. Staphylococcus enterotoxin B (SEB).

B. Clostridium botulinum toxin (botulism).
C. Bacillus anthracis (anthrax).
D. Francisella tularensis (tularemia).

16. A 15-year-old male client was sent to the emergency unit following
a small laceration on the forehead. The client says that he cant move
his legs. Upon assessment, respiratory rate of 20, strong pulses, and
capillary refill time of less than 2 seconds. Which triage category would
this client be assigned to?

A. Black.
B. Green.
C. Red.
D. Yellow.
17. 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.

18. 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.

19. 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?
20. 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.

Answers and Rationale

Below are the answers and rationale for the questions above. If you think the
answers are wrong, please comment below.

1. Answer: C. 4, 3, 1, 2

An irritable infant with fever and petechiae should be further assessed for other
meningeal signs. The patient with the head wound needs additional history and
assessment for intracranial pressure. The patient with moderate
abdominal pain is uncomfortable, but not unstable at this point. For the ankle
injury, a medical evaluation can be delayed 24 48 hours if necessary.

2. Answer: D. Brief neurologic assessment.

A brief neurologic assessment to determine the level of consciousness and pupil

reaction is part of the primary survey. Vital signs, clients allergy, and initiation
of pulse oximetry are considered part of the secondary survey.

3. Answer: C. Emergent.

Chest pain is considered an emergent priority, which is defined as potentially

life-threatening.
 Option B: Clients with urgent priority need treatment within 2 hours of
triage (e.g. kidney stones).
Option A: Non-urgent conditions can wait for hours or even days.
Option D: High urgent is not commonly used; however, in 5-tier triage
systems, High urgent patients fall between emergent and urgent in
terms of the time elapsing prior to treatment.

4. Answer: D. 5, 1, 4, 3, 2

Establish unresponsiveness first. (The patient may have fallen and sustained a
minor injury.) If the patient is unresponsive, get help and have someone initiate
the code. Performing the chin lift or jaw thrust maneuver opens the airway. The
nurse is then responsible for starting CPR. CPR should not be interrupted until
the patient recovers or it is determined that heroic efforts have been exhausted.
A crash cart should be at the site when the code team arrives; however, basic
CPR can be effectively performed until the team arrives.

5. Answer: A. Provide emotional support and supportive

communication.

The LPN/LVN is able to listen and provide emotional support for her patients.

Options B, C, and D: The other tasks are the responsibility of an RN or,

if available, a SANE (sexual assault nurse examiner) who has received
training to assess, collect and safeguard evidence, and care for these
victims.

6. Answer: B. 2, 5, 1, 4, 3

The victim should be removed from the cold environment first, and then the
rewarming process can be initiated. It will be painful, so give pain medication
prior to immersing the feet in a warmed water.
7. Answer: C. 3, 2, 4, 1

Auscultating and confirming equal bilateral breath sounds should be performed

in rapid succession. If the sounds are not equal or if the sounds are heard over
the mid-epigastric area, tube placement must be corrected immediately.
Securing the tube is appropriate while waiting for the x-ray study.

8. Answer: D. He pulled the stick out, just now, because it was hurting
him.

An impaled object may be providing a tamponade effect, and removal can

precipitate sudden hemodynamic decompensation. Additional history including a
more definitive description of the blood loss, depth of penetration, and medical
history should be obtained. Other information, such as the dirt on the stick or
history of diabetes, is important in the overall treatment

Options A and C: Other information, such as the dirt on the stick or

history of diabetes, is important in the overall treatment plan, but can
be addressed later.

9. Answer: C. Risk for Injury related to seizures.

The client shows neurologic hyperactivity and is on the verge of a seizure.

Patient safety is the priority. The patient needs chlordiazepoxide (Librium) to
decrease neurologic irritability and phenytoin (Dilantin) for seizures. Thiamine
and haloperidol(Haldol) will also be ordered to address the other problems.

Options A, B, and D: The other diagnoses are pertinent but not as

immediate.

10. Answer: D. Monitor an asymptomatic near-drowning victim.

The asymptomatic patient is currently stable but should be observed for delayed
pulmonary edema, cerebral edema, or pneumonia.

Options A and B: Teaching and care of critical patients are an RN

responsibility.
Option C: Removing clothing can be delegated to a nursing assistant.

11. Answer: B. Risk for Infection related to organisms specific to cat

bites.

Cats mouths contain a virulent organism, Pasteurella multocida, that can lead
to septic arthritis or bacteremia.

Options A and D: There is also a risk for tendon damage due to deep
puncture wounds. These wounds are usually not sutured.
Option C: A tetanus shot can be given before discharge.

12. Answer: A. 1, 7, 2, 6, 4, 5, 3

For multiple trauma victims, a lot of interventions will occur simultaneously as

team members assist in the resuscitation. Methods to open the airway such as
the chin lift or jaw thrust can be used simultaneously while assessing for
spontaneous respirations. However, airway and oxygenation are a priority.
Starting IVs for fluid resuscitation is part of supporting circulation. (EMS will
usually establish at least one IV in the field.) Nursing assistants can be directed
to take vitals and remove clothing. Foley catheter is necessary to closely
monitor output.

13. Answer: A. Lorazepam (Ativan) IV.

IV Lorazepam (Ativan) is the drug of choice for status epilepticus.

 Option B: Magnesium sulfate is given to control seizures in toxemia of
pregnancy.
Option C: Tegretol is used in the management of generalized tonic-
clonic, absence or mixed type seizures, but it does not come in an IV
form.
Option D: PO (per os) medications are inappropriate for this
emergency situation.

14. Answer: C. Hypovolemic.

Hypovolemic shock occurs when the volume of the circulatory system is too
depleted to allow adequate circulation to the tissues of the body. A fractured
pelvis will lose about one liter of blood hence symptoms such as hypotension,
tachycardia, and tachypnea will occur.

Option A: Causes of cardiogenic include massive myocardial

infarction or other cause of primary cardiac (pump) failure.
Option B: Distributive shock results from a relative inadequate
intravascular volume caused by arterial or venous vasodilation.
Option D: Obstructive shock is a form of shock associated with physical
obstruction of the major vessels or the heart itself.

15. Answer: A. Staphylococcus enterotoxin B (SEB).

Staphylococcus enterotoxin B (SEB) belongs to the category B priority

pathogen.

16. Answer: D. Yellow.

The client is possibly suffering from a spinal injury but otherwise, has a stable
status and can communicate so the appropriate tag is YELLOW.
17. Answer: C. You have to stay to undergo an electrophysiology study
as per doctors advice.

Paroxysmal supraventricular tachycardia (PSVT) is characterized by episodes of

rapid heart rate that occurs periodically and stops on its own. PSVT decreases
the cardiac output and can result to a thrombus. These clots could turn into
an embolus, which could eventually lead to a stroke.

18. Answer: D. All of the above

Blunt injury resulting from vehicular accidents could cause pancreatic injury.
Redness, bruising in the flank and severe peritoneal irritation are signs of a
pancreatic injury. The client is usually pain-free during the early post-injury
period, hence a comprehensive assessment and monitoring should be done.

19. Answer: C. What direction did the bullet enter into the body?

The entry point and direction of the bullet will predict the involve injuries of the
client.

Options A, B, and D: The other information is not as useful in

determining which diagnostic studies and care are needed immediately.

20. Answer: D. Immobilize the cervical area.

Clients with suspected or possible cervical spine injury must have their neck
immobilized until formal assessment occurs.

Options A, B, and C: Suctioning, oxygen therapy, and intravenous

access are also done after the cervical spine is immobilize.

1. Nurse Ejay is assigned to a telephone triage. A client called who was

stung by a honeybee and is asking for help. The client 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 client to perform?

A. Removing the stinger by scraping it.

B. Applying a cold compress.
C. Taking an oral antihistamine.
D. Calling the 911.

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

3. A client 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.

4. Nurse Kelly, a triage nurse encountered a client who complaints of

mid-sternal chest pain, dizziness, and diaphoresis. Which of the
following nursing action should take priority?
A. Complete history taking.
B. Put the client on ECG monitoring.
C. Notify the physician.
D. Administer oxygen therapy via nasal cannula.

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 clients to the decontamination area.

B. Direct the clients to the cold or clean zone for immediate treatment.
C. Measure vital signs and auscultate lung sounds.
D. Immediately remove other clients and visitors from the area.
E. Instruct personnel to don personal protective equipment.

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.

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 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 childs tetanus immunization status.
C. The child suddenly pulls out the IV.
D. The parents refusal of the administration of the IV sedation.

9. The emergency medical service has transported a client with severe

chest pain. As the client 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.

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.
11. A client 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.

12. A client 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 clients visual acuity.
D. Patch the eye.

13. A client was brought to the emergency department after suffering a

closed head injury and lacerations around the face due to a hit-run
accident. The client 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 client in response to painful stimuli.
C. Bruises and minimal edema of the eyelids.
D. Drainage of a clear fluid from the clients nose.

14. A 5-year-old client 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.

15. The following clients 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. 2,5,3,4,1
B. 3,1,4,5,2
C. 5,1,3,2,4
D. 2,5,1,4,3

16. The following clients 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.

17. An anxious female client 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 client breathe into a brown paper bag.

18. An intoxicated client comes into the emergency unit with an

uncooperative behavior, mild confusion, and with slurred speech. The
client 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 client.
D. Obtain an order for the determination of blood alcohol level.
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 client?

A. Making a referral to a counselor.

B. Making an appointment to follow up on the injuries.
C. Advising the client about contacting the police.
D. Arranging transportation to a safe house.

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 agencys emergency response plan.
D. Being aware of what and how to report to the Centers for Disease Control
and Prevention.

Answers and Rationale

Here are the answers and rationale for the NCLEX quiz.

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 that the nurse should direct to the client.

Options B and C: After removing the stinger, Antihistamine and cold

compress follow.
 Option D: The caller should be further advised about symptoms that
require 911 assistance.

2. Answer: B. Ambulatory section.

The ambulatory section deals with clients 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.

3. Answer: C. A deviated trachea.

A deviated trachea is a symptom of tension pneumothorax, which will result in

respiratory distress if left untreated.

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.

5. Answer: A. Direct the clients to the decontamination area.

Decontamination in a specified area is the priority.

Option B: The clients 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 clients.
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.

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 childs 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.

8. Answer: D. The parents 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.

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.

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.

11. Answer: D. Wrapping the cleansed digits in saline-moistened gauze,

sealing in a plastic container, and placing it in an ice.

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.

13. Answer: D. Drainage of a clear fluid from the clients nose.

Clear drainage from the clients nose indicates that there is a leakage of CSF
and should be reported to the physician immediately.

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.

15. Answer: C. 5,1,3,2,4

The client 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.

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 client 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.

17. Answer: D. Have the client breathe into a brown paper bag.
The client is suffering from hyperventilation secondary from anxiety, the initial
action is to let the client breathe in a paper bag that will allow the rebreathing
of carbon dioxide.

18. Answer: A. Administer IV fluid incorporated with Vitamin B1 as

ordered.

The client 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.

19. Answer: D. Arranging transportation to a safe house.

Safety is a priority for this client 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.

20. Answer: C. Being aware of the agencys 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.

1. Nurse Ejay is assigned to a telephone triage. A client called who was

stung by a honeybee and is asking for help. The client 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 client to perform?

A. Removing the stinger by scraping it.

B. Applying a cold compress.
C. Taking an oral antihistamine.
D. Calling the 911.

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

3. A client 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.

4. Nurse Kelly, a triage nurse encountered a client who complaints of

mid-sternal chest pain, dizziness, and diaphoresis. Which of the
following nursing action should take priority?
A. Complete history taking.
B. Put the client on ECG monitoring.
C. Notify the physician.
D. Administer oxygen therapy via nasal cannula.

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 clients to the decontamination area.

B. Direct the clients to the cold or clean zone for immediate treatment.
C. Measure vital signs and auscultate lung sounds.
D. Immediately remove other clients and visitors from the area.
E. Instruct personnel to don personal protective equipment.

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.

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 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 childs tetanus immunization status.
C. The child suddenly pulls out the IV.
D. The parents refusal of the administration of the IV sedation.

9. The emergency medical service has transported a client with severe

chest pain. As the client 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.

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.
11. A client 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.

12. A client 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 clients visual acuity.
D. Patch the eye.

13. A client was brought to the emergency department after suffering a

closed head injury and lacerations around the face due to a hit-run
accident. The client 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 client in response to painful stimuli.
C. Bruises and minimal edema of the eyelids.
D. Drainage of a clear fluid from the clients nose.

14. A 5-year-old client 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.

15. The following clients 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. 2,5,3,4,1
B. 3,1,4,5,2
C. 5,1,3,2,4
D. 2,5,1,4,3

16. The following clients 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.

17. An anxious female client 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 client breathe into a brown paper bag.

18. An intoxicated client comes into the emergency unit with an

uncooperative behavior, mild confusion, and with slurred speech. The
client 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 client.
D. Obtain an order for the determination of blood alcohol level.
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 client?

A. Making a referral to a counselor.

B. Making an appointment to follow up on the injuries.
C. Advising the client about contacting the police.
D. Arranging transportation to a safe house.

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 agencys emergency response plan.
D. Being aware of what and how to report to the Centers for Disease Control
and Prevention.

Answers and Rationale

Here are the answers and rationale for the NCLEX quiz.

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 that the nurse should direct to the client.

Options B and C: After removing the stinger, Antihistamine and cold

compress follow.
 Option D: The caller should be further advised about symptoms that
require 911 assistance.

2. Answer: B. Ambulatory section.

The ambulatory section deals with clients 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.

3. Answer: C. A deviated trachea.

A deviated trachea is a symptom of tension pneumothorax, which will result in

respiratory distress if left untreated.

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.

5. Answer: A. Direct the clients to the decontamination area.

Decontamination in a specified area is the priority.

Option B: The clients 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 clients.
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.

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 childs 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.

8. Answer: D. The parents 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.

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.

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.

11. Answer: D. Wrapping the cleansed digits in saline-moistened gauze,

sealing in a plastic container, and placing it in an ice.

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.

13. Answer: D. Drainage of a clear fluid from the clients nose.

Clear drainage from the clients nose indicates that there is a leakage of CSF
and should be reported to the physician immediately.

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.

15. Answer: C. 5,1,3,2,4

The client 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.

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 client 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.

17. Answer: D. Have the client breathe into a brown paper bag.
The client is suffering from hyperventilation secondary from anxiety, the initial
action is to let the client breathe in a paper bag that will allow the rebreathing
of carbon dioxide.

18. Answer: A. Administer IV fluid incorporated with Vitamin B1 as

ordered.

The client 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.

19. Answer: D. Arranging transportation to a safe house.

Safety is a priority for this client 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.

20. Answer: C. Being aware of the agencys 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.