1.

After surgery, Gina returns from the Post-anesthesia Care Unit (Recovery Room) with
a nasogastric tube in place following a gall bladder surgery. She continues to complain of
nausea. Which action would the nurse take?
a. Call the physician immediately.
b. Administer the prescribed antiemetic.
c. Check the patency of the nasogastric tube for any obstruction.
d. Change the patient’s position.

2. A client with multiple injuries following a vehicular accident is transferred to the

critical care unit. He begins to complain of increased abdominal pain in the left upper
quadrant. A ruptured spleen is diagnosed and he is scheduled for emergency
splenectomy. In preparing the client for surgery, the nurse should emphasize in his
teaching plan the:
a. Complete safety of the procedure
b. Expectation of postoperative bleeding
c. Risk of the procedure with his other injuries
d. Presence of abdominal drains for several days after surgery

3. A 60 year old male client comes into the emergency department with complaints of
crushing substernal chest pain that radiates to his shoulder and left arm. The admitting
diagnosis is acute myocardial infarction (MI). Immediate admission orders include
oxygen by nasal cannula at 4L/minute, blood work, a chest radiograph, a 12-lead
electrocardiogram (ECG) and 2 mg of morphine sulfate given intravenously. The nurse
should first:
a. order the chest radiograph
b. obtain a 12 lead ECG
c. administer the morphine
d. obtain a blood work

4. The emergency room nurse admits a child who experienced a seizure at school. The
father comments that this is the first occurrence, and denies any family history of
epilepsy. What is the best response by the nurse?
a. Do not worry. Epilepsy can be treated with medications.
b. “The seizure may or may not mean your child has epilepsy.
c. Since this was the first convulsion, it may not happen again.
d. Long term treatment will prevent future seizures

5. A child in the Emergency Room is diagnosed with an acute episode of Croup (Acute
laryngotracheo – bronchitis). During the initial assessment, which of the following
finding would the nurse expect to find?
a. Diffuse expiratory wheezing
b. Inspiratory stridor with a brassy cough
c. Decreased aeration in lung fields
d. Shallow respirations
6. A homeless individual is brought to the Emergency Room after having been out in
subfreezing temperatures for three to four days. The toes of the patient’s right foot appear
hard and cold with mottling, and are unresponsive to touch. Which of the following
would NOT be included in the initial management of this patient by the Emergency
Room nurse?
a. Rewarm the extremity with controlled and rapid rewarming until the injured part
flushes
b. Wrap the affected extremity in a blanket and apply moist heat
c. Place sterile gauze between the affected digits
d. Elevate the affected extremity

7. A client arrives in the emergency department following a motor vehicle accident with
multiple injuries to the head, chest, and extremities with minimal bleeding. Which would
the nurse assess first?
a. Airway status
b. Blood pressure
c. Level of consciousness
d. Quality of peripheral pulses

8. What is the nursing priority if the client is suffering from 1st, 2nd, 3rd or 4th degree
burns?
a. fluid and electrolyte balance
b. infection
c. pain
d. airway

9. A client with a drug overdose is admitted to the emergency department. Which nursing
intervention would the nurse implement?
a. Administration of syrup of ipecac
b. Discussion of why the client took the drug overdose
c. Administration of respiratory and cardiovascular support
d. Referral for psychiatric care

10. A client with a C6 spinal cord injury arrives at the emergency department
complaining of a pounding headache. He has a blood pressure level of 180/100 mm Hg
and is sweating profusely. Which nursing intervention would be most appropriate?
a. Assessing the client for increased intracranial pressure (ICP)
b. Assessing the client for a distended bladder
c. Placing the client in a supine position
d. Preparing the client for an emergency tracheostomy.

1. Answer: C
Rationale: Nausea is one of the common complaints of a patient after receiving general
anesthesia. But this complaint could be aggravated by gastric distention especially in a
patient who has undergone abdominal surgery. Insertion of the NGT helps relieve the
problem. Checking on the patency of the NGT for any obstruction will help the nurse
determine the cause of the problem and institute the necessary intervention.

2. Answer: D
Drains are usually inserted into the splenic bed to facilitate removal of fluid in the area
that could lead to abscess formation.

3. Answer: C
Rationale: The nurse’s priority at this time is to alleviate the chest pain of the client.
Obtaining chest radiograph, ECG and blood work are all important and can be done after
administering morphine.

4. Answer: B
Rationale: There are many possible causes for a childhood seizure. These include fever,
central nervous system conditions, trauma, metabolic alterations and idiopathic

5. Answer: B
Rationale: Croup is an upper airway obstruction and the signs and symptoms are because
of difficulty getting air past the upper airway. Wheezing is found with Asthma,
decreased aeration in lung fields is found with Pneumonia. Shallow respirations are
unlikely; the child may exhibit retractions, but not shallow respirations.

6. Answer: B
Rationale: This patient is suffering from frostbite, due to prolonged exposure to sub-
freezing temperatures without proper protection. Frostbite is a condition in which there is
trauma to the tissues without actual freezing of tissue fluids. Exposed areas of the body
such as hands, feet, earlobes, etc. are all subject to this. The affected part becomes hard,
cold, and is not sensitive to touch, and mottled bluish-white in color. The aim of nursing
care is to restore normal temperature and circulation to the part.

7. Answer: A
Rationale: When dealing with an emergency, the ABCs — airway, breathing, and
circulation — are the priorities and must be maintained first. Blood pressure,
neurological, and neurovascular assessments are important, but in this case, airway is the
priority.

8. Answer: B
Rationale: Infection is a priority for all types of burns. Airway is a priority only for burns
to the face and neck. Pain is a second priority for 1st and 2nd degree burns. Fluid and
electrolyte balance is a second priority for 3rd and 4th degree burns [no pain because
nerve endings are damaged].

9. Answer: C
Rationale: Regardless of the cause, the priority in an emergency situation is the ABCs —
airway, breathing, and circulation; thus, the priority would be to provide support for
breathing and circulation. Eliminating the drug from the body is important, but only after
respiratory and cardiovascular support is provided.

10. Answer: B
Rationale: The client is probably experiencing autonomic hyperreflexia, a medical
emergency usually triggered by a distended bladder; a distended bowel or pain also may
lead to autonomic hyperreflexia.

1. A client with multiple injury following a vehicular accident is transferred to the critical
care unit. He begins to complain of increased abdominal pain in the left upper quadrant.
A ruptured spleen is diagnosed and he is scheduled for emergency splenectomy. In
preparing the client for surgery, the nurse should emphasize in his teaching plan the:
a. Complete safety of the procedure
b. Expectation of postoperative bleeding
c. Risk of the procedure with his other injuries
d. Presence of abdominal drains for several days after surgery

2. After you managed to stabilize the respiratory function of your burn patient, your next
goal is to prevent this you have to replace the lost fluid and electrolytes. In starting fluid
replacement therapy, the total volume and rate of IV fluid repalcement are gauged by the
patient’s response and by the patient’s response and by the resuscitation formula. In
determining the adequacy of fluid resuscitation, it is essential for you to monitor the:
a. urine output
b. blood pressure
c. intracranial pressure
d. cardiac output

3. You are a nurse in the emergency department and it is during the shift that Mr. CT is
admitted in the area due to a fractured skull from a motor accident. You scheduled him
for surgery under which classification?
a. Urgent
b. Emergent
c. Required
d. Elective

4. Lucky was in a vehicular acccident where he sustained injury to his left ankle. In the
Emergency room, you noticed anxious he looks. You establish rapport with him and to
reduce his anxiety, you initially:
a. Identify yourself and state your purpose in being with the client
b. Take him to the radiology section for x-ray of affected extremity
c. Talk to the physician for an order of valium
d. Do inspection and palpation to check extent of his injuries

5. The client diagnosed with a mild concussion is being discharged from the emergency
department. Which discharge instruction should the nurse teach the client’s significant
other?
a. Awaken the client every two hours.
b. Monitor for increased intracranial pressure.
c. Observe frequently for hypervigilance.
d. Offer the client food every three to four hours.

6. The client diagnosed with Addison’s disease is admitted to the emergency department
after a day at the lake. The client is lethargic, forgetful, and weak. Which intervention
should be the emergency department nurse’s first action?
a. Start an IV with an 18-gauge needle and infuse NS rapidly.
b. Have the client wait in the waiting room until a bed is available.
c. Perform a complete head-to-toe assessment.
d. Collect urinalysis and blood samples for a CBC and calcium level.

7. The nurse caring for a client diagnosed with cancer of the pancreas writes the nursing
diagnosis of “risk for altered skin integrity related to pruritus.” Which interventions
should the nurse implement?
a. Assess tissue turgor.
b. Apply antifungal creams.
c. Monitor bony prominences for breakdown.
d. Have the client keep the fingernails short.

8. The client diagnosed with cancer of the head of the pancreas is two (2) days
postpancreatoduodenectomy (Whipple’s procedure). Which nursing problem has the
highest priority?
a. Anticipatory grieving.
b. Fluid volume imbalance.
c. Acute incisional pain.
d. Altered nutrition.

9. The client is diagnosed with cancer of the head of the pancreas. When assessing the
patient, which signs and symptoms would the nurse expect to find?
a. Clay-colored stools and dark urine.
b. Night sweats and fever.
c. Left lower abdominal cramps and tenesmus.
d. Nausea and coffee-ground emesis.

10. The client admitted to rule out pancreatic islet tumors complains of feeling weak,
shaky, and sweaty. Which should be the first intervention implemented by the nurse?
a. Start an IV with D5W.
b. Notify the health-care provider.
c. Perform a bedside glucose check.
d. Give the client some orange juice.

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Nursing Board Sample Review Answers in Emergency

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Answers, Emergency Questions
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Nursing Board Exam Review Questions in Emergency Part 3/20

(ANSWER KEY)

1. Answer: D
Rationale: Presence of abdominal drains for several days after surgery
Drains are usually inserted into the splenic bed to facilitate removal of fluid in the area
that could lead to abscess formation.

2. Answer: A
Rationale: to establish the sufficiency of fluid resuscitation, urine output totals an index
of renal perfusion. Urine output totals an index of renal perfusion, urine output totals of
30-50 ml/hour have been used as resuscitation goals. Other indicators of adequate fluid
replacement are systolic blood pressure exceeding 100 mmHg, a pulse rate less than110
beats/min or both.

3. Answer: B
Rationale: Emergent surgery is performed, immediately without delay to maintain life,
limb or organ, remove damage and stop bleeding. Urgent surgery requires prompt
attention and is done few hours but within 24 to 48 hours. Required surgery is done
within a few weeks as surgery is important. Elective surgery is scheduled and done at the
convenience of client as failure to have surgery is not catastrophic. Optional surgeries are
done by preference only.

4. Answer: A
Rationale: Introducing self initiates the nurse-patient interaction, relationship and the
purpose of being with the client. This prevents confusion and let the client know what to
expect, thereby reducing anxiety.

5. Answer: A
Rationale: Awakening the client every 2 hours allows the identification of headache,
dizziness, lethargy, irritability, and anxiety—all signs of post-concussion syndrome—that
would warrant the significant other’s taking the client back to the emergency department.

6. Answer: A
Rationale: This client has been exposed to wind and sun at the lake during the hours
prior to being admitted to the emergency department. This predisposes the client to
dehydration and an Addisonian crisis. Rapid IV fluid replacement is necessary.

7. Answer: D
Rationale: Keeping the fingernails short will reduce the chance of breaks in the skin from
scratching.
8. Answer: B
Rationale: This is a major abdominal surgery, and there are massive fluid volume shifts
that occur when this type of trauma is experienced by the body. Maintaining the
circulatory system without overloading it requires extremely close monitoring.

9. Answer: A
Rationale: The client will have jaundice, clay-colored stools, and tea-colored urine
resulting from blockage of the bile drainage.

10. Answer: C
Rationale: These are symptoms of an insulin reaction (hypoglycemia). A bedside glucose
check should be done. Pancreatic islet tumors can produce hyperinsulinemia or
hypoglycemia.

1 Which nursing intervention would be appropriate when caring for a client who has
sustained an electrical burn?
a. Applying ice to the burned area
b. Flushing the burn area with large amounts of water
c. Monitoring the client with cardiac telemetry
d. Preparing to administer the chemical antidote

2. Eddie, 40 years old, is brought to the emergency room after the crash of his private
plane. He has suffered multiple crushing wounds of the chest, abdomen and legs. It is
feared his leg may have to be amputated.
When Eddie arrives in the emergency room, the assessment that assume the greatest
priority are:
a. Level of consciousness and pupil size
b. Abdominal contusions and other wounds
c. Pain, Respiratory rate and blood pressure
d. Quality of respirations and presence of pulses.

3. An emergency treatment for an acute asthmatic attack is Adrenaline 1:1000 given

hypodermically. This is given to:
a. increase BP
b. decrease mucosal swelling
c. relax the bronchial smooth muscle
d. decrease bronchial secretions

4. Intervention for a pt. who has swallowed a Muriatic Acid includes all of the following
except
a. administering an irritant that will stimulate vomiting
b. aspirating secretions from the pharynx if respirations are affected
c. neutralizing the chemical
d. washing the esophagus with large volumes of water via gastric lavage
5. John, 16 years old, is brought to the ER after a vehicular accident. He is pronounced
dead on arrival. When his parents arrive at the hospital, the nurse should:
a. ask them to stay in the waiting area until she can spend time alone with them
b. speak to both parents together and encourage them to support each other and express
their emotions freely
c. Speak to one parent at a time so that each can ventilate feelings of loss without
upsetting the other
d. ask the MD to medicate the parents so they can stay calm to deal with their son’s
death.

6. A nurse is eating in the hospital cafeteria when a toddler at a nearby table chokes on a
piece of food and appears slightly blue. The appropriate initial action should be to
a. Begin mouth to mouth resuscitation
b. Give the child water to help in swallowing
c. Perform 5 abdominal thrusts
d. Call for the emergency response team

7. A client is admitted from the emergency department with severe-pain and edema in the
right foot. His diagnosis is gouty arthritis. When developing a plan of care, which action
would have the highest priority?
a. Apply hot compresses to the affected joints.
b. Stress the importance of maintaining good posture to prevent deformities.
c. Administer salicylates to minimize the inflammatory reaction.
d. Ensure an intake of at least 3000 ml of fluid per day.

8. The Heimlich maneuver (abdominal thrust), for acute airway obstruction, attempts to:
a. Force air out of the lungs
b. Increase systemic circulation
c. Induce emptying of the stomach
d. Put pressure on the apex of the heart

9. A nurse is performing CPR on an adult patient. When performing chest compressions,

the nurse understands the correct hand placement is located over the
a. upper half of the sternum
b. upper third of the sternum
c. lower half of the sternum
d. lower third of the sternum

10. John, 16 years old, is brought to the ER after a vehicular accident. He is pronounced
dead on arrival. When his parents arrive at the hospital, the nurse should:
a. ask them to stay in the waiting area until she can spend time alone with them
b. speak to both parents together and encourage them to support each other and express
their emotions freely
c. Speak to one parent at a time so that each can ventilate feelings of loss without
upsetting the other
d. ask the MD to medicate the parents so they can stay calm to deal with their son’s
death.

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Nursing Board Exam Review Answers in Emergency

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Nursing Board Exam Review Questions in Emergency Part 2/20

(ANSWER KEY)

1. Answer: C
Rationale: Because of the effects of the electrical current on the cardiovascular system,
all clients experiencing electrical burns should be placed on a cardiac monitor. Applying
ice is inappropriate for any type of burn. Only chemical burns should be flushed with
large amounts of water. Chemical antidotes may be used for chemical burns for which an
antidote has been identified.

2. Answer: D
Rationale: Respiratory and cardiovascular functions are essential for oxygenation. These
are top priorities to trauma management. Basic life functions must be maintained or
reestablished

3. Answer: C
Rationale: Acute asthmatic attack is characterized by severe bronchospasm which can be
relieved by the immediate administration of bronchodilators. Adrenaline or Epinephrine
is an adrenergic agent that causes bronchial dilation by relaxing the bronchial smooth
muscles.

4. Answer: A
Rationale: Swallowing of corrosive substances causes severe irritation and tissue
destruction of the mucous membrane of the GI tract. Measures are taken to immediately
remove the toxin or reduce its absorption. For corrosive poison ingestion, such as in
muriatic acid where burn or perforation of the mucosa may occur, gastric emptying
procedure is immediately instituted, This includes gastric lavage and the administration
of activated charcoal to absorb the poison. Administering an irritant with the concomitant
vomiting to remove the swallowed poison will further cause irritation and damage to the
mucosal lining of the digestive tract. Vomiting is only indicated when non-corrosive
poison is swallowed.
5. Answer: B
Rationale: Sudden death of a family member creates a state of shock on the family. They
go into a stage of denial and anger in their grieving. Assisting them with information they
need to know, answering their questions and listening to them will provide the needed
support for them to move on and be of support to one another.

6. Answer: C
Rationale: Perform 5 abdominal thrusts. At this age, the most effective way to clear the
airway of food is to perform abdominal thrusts.

7. Answer: D
Rationale: Ensure an intake of at least 3000 ml of fluid per day. Gouty arthritis is a
metabolic disease marked by urate deposits that cause painful arthritic joints. The patient
should be urged to increase his fluid intake to prevent the development of urinary uric
acid stones.

8. Answer: A
Rationale: The Heimlich maneuver is used to assist a person choking on a foreign object.
The pressure from the thrusts lifts the diaphragm, forces air out of the lungs and creates
an artificial cough that expels the aspirated material.

9. Answer: C
Rationale: The exact and safe location to do cardiac compression is the lower half of the
sternum. Doing it at the lower third of the sternum may cause gastric compression which
can lead to a possible aspiration.

10. Answer: B
Rationale: Sudden death of a family member creates a state of shock on the family. They
go into a stage of denial and anger in their grieving. Assisting them with information they
need to know, answering their questions and listening to them will provide the needed
support for them to move on and be of support to one another.