NCLEX Medical-Surgical Nursing Exam for Emergencies In Text Mode: All questions and answers are given for reading and answering at your own pace.
Question 1. In caring for a victim of sexual assault, which task is most appropriate for an LPN/LVN?
A). Collect hair samples, saliva swabs, and scrapings beneath fingernails..
B). Ensure that the “chain of custody” is maintained..
C). Assess immediate emotional state and physical injuries.
D). Provide emotional support and supportive communication..
Question 1 Answer: D). Provide emotional support and supportive communication..
Question 1 Explanation: The LPN/LVN is able to listen and provide emotional support for her patients. 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.
Question 2. You are preparing a child for IV conscious sedation prior to repair of a facial laceration. What information should you immediately report to the physician?
A). The parent declines the IV conscious sedation..
B). The parent is unsure about the child’s tetanus immunization status..
C). The child is upset and pulls out the IV..
D). The parent wants information about the IV conscious sedation..
Question 2 Answer: A). The parent declines the IV conscious sedation..
Question 2 Explanation: Parent refusal is an absolute contraindication; therefore, the physician must be notified. Tetanus status can be addressed later. The RN can restart the IV and provide information about conscious sedation; if the parent still notsatisfied, the physician can give more information.
Question 3. 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 patient’s last tetanus shot is unknown. Which of the following is the priority nursing diagnosis?
A). Ineffective Health Maintenance related to immunization status.
B). Risk for Infection related to organisms specific to cat bites.
C). Impaired Skin Integrity related to puncture wounds.
D). Risk for Impaired Mobility related to potential tendon damage.
Question 3 Answer: B). Risk for Infection related to organisms specific to cat bites.
Question 3 Explanation: Cat’s mouths contain a virulent organism, Pasteurella multocida, that can lead to septic arthritis or bacteremia. There is also a risk for tendon damage due to deep puncture wounds. These wounds are usually not sutured. A tetanus shot can be given before discharge.
Question 4. A tearful parent brings a child to the ED for taking an unknown amount of children’s chewable vitamins at an unknown time. The child is currently alert and asymptomatic. What information should be immediately reported to the physician?
A). The child has been treated several times for ingestion of toxic substances..
B). The ingested children’s chewable vitamins contain iron..
C). The child has been treated several times for accidental injuries..
D). The child was nauseated and vomited once at home..
Question 4 Answer: B). The ingested children’s chewable vitamins contain iron..
Question 4 Explanation: Iron is a toxic substance that can lead to massive hemorrhage, coma, shock, and hepatic failure. Deferoxame is an antidote that can be used for severe cases of iron poisoning. Other information needs additional investigation, but will not change the immediate diagnostic testing or treatment plan.
Question 5. 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.
Perform the chin lift or jaw thrust maneuver.
Initiate cardiopulmonary resuscitation (CPR).
Call for help and activate the code team.
Instruct a nursing assistant to get the crash cart.
C). B, D, A, C, E.
Question 5 Answer: C). B, D, A, C, E.
Question 5 Explanation: 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.
Question 6. When an unexpected death occurs in the ED, which of the following tasks is most appropriate to delegate to the nursing assistant?
A). Escort the family to a place of privacy..
B). Assist with postmortem care..
C). Go with the organ donor specialist to talk to the family..
D). Assist the family to collect belongings..
Question 6 Answer: B). Assist with postmortem care..
Question 6 Explanation: Postmortem care requires some turning, cleaning, lifting, etc., and the nursing assistant is able to assist with these duties. The RN should take responsibility for the other tasks to help the family begin the grieving process. In cases of questionable death, belongings may be retained for evidence, so the chain of custody would have to be maintained.
Question 7. 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). IV carbamazepam.
B). IV magnesium sulfate.
C). PO phenytoin and carbamazepine.
D). IV lorazepam (Ativan).
Question 7 Answer: D). IV lorazepam (Ativan).
Question 7 Explanation: IV Lorazepam (Ativan) is the drug of choice for status epilepticus. Tegretol is used in the management of generalized tonic-clonic, absence or mixed type seizures, but it does not come in an IV form. PO (per os) medications are inappropriate for this emergency situation. Magnesium sulfate is given to control seizures in toxemia of pregnancy.
Question 8. In the work setting, what is your primary responsibility in preparing for disaster management that includes natural disasters or bioterrorism incidents?
A). Awareness of the signs and symptoms for potential agnets of bioterrorism.
B). Knowledge of how and what to report to the CDC.
C). Ethical decision-making about exposing self to potentially lethal substances.
D). Knowledge of the agency’s emergency response plan.
Question 8 Answer: D). Knowledge of the agency’s emergency response plan.
Question 8 Explanation: In preparing for disasters, the RN should be aware of the emergency response plan. The plan gives guidance that includes roles of team members, responsibilities, and mechanisms of reporting. Signs and symptoms of many agents will mimic common complaints, such as flu-like symptoms. Discussions with colleagues and supervisors may help the individual nurse to sort through ethical dilemmas related to potential danger to self.
Question 9. The emergency medical service (EMS) 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 no palpable pulse. Which task is appropriate to delegate to the nursing assistant?
A). Bag-valve mask ventilation.
B). Assisting with oral intubation.
C). Chest compressions.
D). Placing the defibrillator pads.
Question 9 Answer: C). Chest compressions.
Question 9 Explanation: Nursing assistants are trained in basic cardiac life support and can perform chest compressions. The use of the bag-valve mask requires practice and usually a respiratory therapist will perform this function. The nurse or the respiratory therapist should provide PRN assistance during intubation. 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.
Question 10. You are assigned to telephone triage. A patient who was stung by a common honey bee calls for advice, reports pain and localized swelling, but denies any respiratory distress or other systemic signs of anaphylaxis. What is the action that you should direct the caller to perform?
A). Apply a cool compress..
B). Call 911..
C). Take an oral antihistamine.
D). Remove the stinger by scraping..
Question 10 Answer: D). Remove the stinger by scraping..
Question 10 Explanation: The stinger will continue to release venom into the skin, so prompt removal of the stinger is advised. Cool compresses and antihistamines can follow. The caller should be further advised about symptoms that require 911 assistance.
Question 11. 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 Nutritional Deficit related to chronic alcohol abuse.
B). Risk for Other-Directed Violence related to hallucinations.
C). Risk for Situational Low Self-esteem related to police custody.
D). Risk for Injury related to seizures.
Question 11 Answer: D). Risk for Injury related to seizures.
Question 11 Explanation: The patient demonstrates 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. The other diagnoses are pertinent but not as immediate.
Question 12. In a multiple-trauma victim, which assessment finding signals the most serious and life-threatening condition?
A). Gross deformity in a lower extremity.
C). Decreased bowel sounds.
D). A deviated trachea.
Question 12 Answer: D). A deviated trachea.
Question 12 Explanation: A deviated trachea is a symptoms of tension pneumothorax. All of the other symptoms need to be addressed, but are of lesser priority.
Question 13. You are working in the triage area of an ED, and four patients approach the triage desk at the same time. List the order in which you will assess these patients.
An ambulatory, dazed 25-year-old male with a bandaged head wound
An irritable infant with a fever, petechiae, and nuchal rigidity
A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity
A 50-year-old female with moderate abdominal pain and occasional vomiting
C). B, A, D, C.
Question 13 Answer: C). B, A, D, C.
Question 13 Explanation: 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, medical evaluation can be delayed 24 – 48 hours if necessary.
Question 14. In relation to submersion injuries, which task is most appropriate to delegate to an LPN/LVN?
A). Remove wet clothing and cover the victim with a warm blanket..
B). Talk to a community group about water safety issues..
C). Stabilize the cervical spine for an unconscious drowning victim..
D). Monitor an asymptomatic near-drowning victim..
Question 14 Answer: D). Monitor an asymptomatic near-drowning victim..
Question 14 Explanation: The asymptomatic patient is currently stable but should be observed for delayed pulmonary edema, cerebral edema, or pneumonia. Teaching and care of critical patients is an RN responsibility. Removing clothing can be delegated to a nursing assistant.
Question 15. These patients present to the ED complaining of acute abdominal pain. Prioritize them in order of severity.
A 35-year-old male complaining of severe, intermittent cramps with three episodes of watery diarrhea, 2 hours after eating
A 11-year-old boy with a low-grade fever, left lower quadrant tenderness, nausea, and anorexia for the past 2 days
A 40-year-old female with moderate left upper quadrant pain, vomiting small amounts of yellow bile, and worsening symptoms over the past week
A 56-year-old male with a pulsating abdominal mass and sudden onset of pressure-like pain in the abdomen and flank within the past hour
D). D, B, C, A.
Question 15 Answer: D). D, B, C, A.
Question 15 Explanation: The patient with a pulsating mass has an abdominal aneurysm that may rupture and he may decompensate suddenly. The 11-year-old boy needs evaluation to rule out appendicitis. The woman needs evaluation for gallbladder problems that appear to be worsening. The 35-year-old man has food poisoning, which is usually self-limiting.
Question 16. A teenager arrives by private car. He is alert and ambulatory, but this shirt and pants are covered with blood. He and his hysterical friends are yelling and trying to explain that 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). “There was a lot of blood and we used three bandages.”.
B). “He’s a diabetic, so he needs attention right away.”.
C). “The stick was really dirty and covered with mud.”.
D). “He pulled the stick out, just now, because it was hurting him.”.
Question 16 Answer: D). “He pulled the stick out, just now, because it was hurting him.”.
Question 16 Explanation: 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 plan, but can be addressed later.
Question 17. A patient in a one-car rollover presents with multiple injuries. Prioritize the interventions that must be initiated for this patient.
Secure/start two large-bore IVs with normal saline
Use the chin lift or jaw thrust method to open the airway.
Assess for spontaneous respirations
Give supplemental oxygen per mask.
Obtain a full set of vital signs.
Remove patient’s clothing.
Insert a Foley catheter if not contraindicated.
A). C, B, D, A, E, F, G.
Question 17 Answer: A). C, B, D, A, E, F, G.
Question 17 Explanation: For a multiple trauma victim, many 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 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.
Question 18. An intoxicated patient presents with slurred speech, mild confusion, and uncooperative behavior. The patient is a poor historian but admits to “drinking a few on the weekend.” What is the priority nursing action for this patient?
A). Administer IV fluid support with supplemental thiamine as ordered..
B). Administer naloxone (Narcan) 2 – 4 mg as ordered..
C). Obtain an order for a blood alcohol level..
D). Contact the family to obtain additional history and baseline information..
Question 18 Answer: A). Administer IV fluid support with supplemental thiamine as ordered..
Question 18 Explanation: The patient presents with symptoms of alcohol abuse and there is a risk for Wernicke’s syndrome, which is caused by a thiamine deficiency. Multiples drug abuse is not uncommon; however, there is nothing in the question that suggests an opiate overdose that requires naloxone. Additional information or the results of the blood alcohol level are part of the total treatment plan but should not delay the immediate treatment.
Question 19. A 56-year-old patient presents in triage with left-sided chest pain, diaphoresis, and dizziness. This patient should be prioritized into which category?
B). High urgent.
Question 19 Answer: D). Emergent.
Question 19 Explanation: Chest pain is considered an emergent priority, which is defined as potentially life-threatening. Patients with urgent priority need treatment within 2 hours of triage (e.g. kidney stones). Non-urgent conditions can wait for hours or even days. (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 lapsing prior to treatment).
Question 20. It is the summer season, and patients with signs and symptoms of heat-related illness present in the ED. Which patient needs attention first?
A). An elderly person complains of dizziness and syncope after standing in the sun for several hours to view a parade.
B). A previously healthy homemaker reports broken air conditioner for days. Tachypnea, hypotension, fatigue, and profuse diaphoresis are observed..
C). A homeless person, poor historian, presents with altered mental status, poor muscle coordination, and hot, dry, ashen skin. Duration of exposure is unknown..
D). A marathon runner complains of severe leg cramps and nausea. Tachycardia, diaphoresis, pallor, and weakness are observed..
Question 20 Answer: C). A homeless person, poor historian, presents with altered mental status, poor muscle coordination, and hot, dry, ashen skin. Duration of exposure is unknown..
Question 20 Explanation: The homeless person has symptoms of heat stroke, a medical emergency, which increases risk for brain damage. Elderly patients are at risk for heat syncope and should be educated to rest in cool area and avoid future similar situations. The runner is having heat crams, which can be managed with rest and fluids. The housewife is experiencing heat exhaustion, and management includes fluids (IV or parenteral) and cooling measures. The prognosis for recovery is good.
Question 21. Following emergency endotracheal intubation, you must verify tube placement and secure the tube. List in order the steps that are required to perform this function?
Obtain an order for a chest x-ray to document tube placement.
Secure the tube in place.
Auscultate the chest during assisted ventilation.
Confirm that the breath sounds are equal and bilateral.
C). C, D, B, A.
Question 21 Answer: C). C, D, B, A.
Question 21 Explanation: 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.
Question 22. You are the charge nurse in an emergency department (ED) and must assign two staff members to cover the triage area. Which team is the most appropriate for this assignment?
A). An experienced LPN/LVN and an inexperienced RN.
B). An advanced practice nurse and an experienced LPN/LVN.
C). An experienced RN and a nursing assistant.
D). An experienced RN and an inexperienced RN.
Question 22 Answer: D). An experienced RN and an inexperienced RN.
Question 22 Explanation: Triage requires at least one experienced RN. Pairing an experienced RN with inexperienced RN provides opportunities for mentoring. Advanced practice nurses are qualified to perform triage; however, their services are usually required in other areas of the ED. An LPN/LVN is not qualified to perform the initial patient assessment or decision making. Pairing an experienced RN with a nursing assistant is the second best option, because the assistant can obtain vital signs and assist in transporting.
Question 23. A patient sustains an amputation of the first and second digits in a chainsaw accident. Which task should be delegated to the LPN/LVN?
A). Wrap the amputated digits in sterile gauze moistened with saline..
B). Gently cleanse the amputated digits with Betadine solution..
C). Store the amputated digits in a solution of sterile normal saline..
D). Place the amputated digits directly into ice slurry..
Question 23 Answer: A). Wrap the amputated digits in sterile gauze moistened with saline..
Question 23 Explanation: The digits should be gently cleansed with normal saline, wrapped in sterile gauze moistened with saline, and placed in a plastic bag or container. The container is then placed on ice.
Question 24. The nursing manager decides to form a committee to address the issue of violence against ED personnel. Which combination of employees is best suited to fulfill this assignment?
A). At least one representative from each group of ED personnel.
B). Experienced RNs and experienced paramedics.
C). ED physicians and charge nurses.
D). RNs, LPN/LVNs, and nursing assistants.
Question 24 Answer: A). At least one representative from each group of ED personnel.
Question 24 Explanation: At least one representative from each group should be included because all employees are potential targets fro violence in the ED.
Question 25. An anxious 24-year-old college student complains of tingling sensations, palpitations, and chest tightness. Deep, rapid breathing and carpal spasms are noted. What priority nursing action should you take?
A). Have the student breathe into a paper bag..
B). Administer supplemental oxygen..
C). Notify the physician immediately..
D). Obtain an order for an anxiolytic medication..
Question 25 Answer: A). Have the student breathe into a paper bag..
Question 25 Explanation: The patient is hyperventilating secondary to anxiety, and breathing into a paper bag will allow rebreathing of carbon dioxide. Also, encouraging slow breathing will help. Other treatments such as oxygen and medication may be needed if other causes are identified.
Question 26. You are caring for a victim of frostbite to the feet. Place the following interventions in the correct order.
Apply a loose, sterile, bulky dressing.
Give pain medication.
Remove the victim from the cold environment.
Immerse the feet in warm water 100o F to 105o F (40.6o C to 46.1o C)
C). C, B, D, A.
Question 26 Answer: C). C, B, D, A.
Question 26 Explanation: 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 warmed water.
Question 27. The physician has ordered cooling measures for a child with fever who is likely to be discharged when the temperature comes down. Which of the following would be appropriate to delegate to the nursing assistant?
A). Explain the need for cool fluids..
B). Assist the child to remove outer clothing..
C). Prepare and administer a tepid bath..
D). Advise the parent to use acetaminophen instead of aspirin..
Question 27 Answer: B). Assist the child to remove outer clothing..
Question 27 Explanation: The nursing assistant can assist with the removal of the outer clothing, which allows the heat to dissipate from the child’s skin. Advising and explaining are teaching functions that are the responsibility of the RN. Tepid baths are not usually performed because of potential for rebound and shivering.
Question 28. You are giving discharge instructions to a woman who has been treated for contusions and bruises sustained during an episode of domestic violence. What is your priority intervention for this patient?
A). Referral to a counselor.
B). Follow-up appointment for injuries.
C). Transportation arrangements to a safe house.
D). Advise about contacting the police.
Question 28 Answer: C). Transportation arrangements to a safe house.
Question 28 Explanation: Safety is a priority for this patient, and she should not return to a place where violence could reoccur. The other options are important for the long term management of this care.
Question 29. An experienced traveling nurse has been assigned to work in the ED; however, this is the nurse’s first week on the job. Which area of the ED is the most appropriate assignment for the nurse?
A). Ambulatory or fats track clinic.
C). Trauma team.
D). Pediatric medicine team.
Question 29 Answer: A). Ambulatory or fats track clinic.
Question 29 Explanation: The fast track clinic will deal with relatively stable patients. Triage, trauma, and pediatric medicine should be staffed with experienced nurses who know the hospital routines and policies and can rapidly locate equipment.
Question 30. 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). Brief neurologic assessment.
B). Initiation of pulse oximetry.
C). Palpation and auscultation of the abdomen.
D). Complete set of vital signs.
Question 30 Answer: A). Brief neurologic assessment.
Question 30 Explanation: A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. Vital signs, assessment of the abdomen, and initiation of pulse oximetry are considered part of the secondary survey.