EMERGENCY QUESTION FROM NCLEX
11. A patient arrives at the emergency
department complaining of mid-sternal chest pain. Which of the following
nursing action should take priority?
A.
A complete history with emphasis on
preceding events.
B.
An electrocardiogram.
C.
Careful assessment of vital signs.
D.
Chest exam with auscultation.
22. Patient has been hospitalized with
pneumonia and is about to be discharged. A nurse provides discharge
instructions to a patient and his family. Which misunderstanding by the family
indicates the need for more detailed information?
A. The patient may resume normal home
activities as tolerated but should avoid physical exertion and get adequate
rest.
B. The patient should resume a normal
diet with emphasis on nutritious, healthy foods.
C. The patient may discontinue the
prescribed course of oral antibiotics once the symptoms have completely
resolved.
D. The patient should continue use of the
incentive spirometer to keep airways open and free of secretions.
33. A nurse is caring for an elderly
Vietnamese patient in the terminal stages of lung cancer. Many family members
are in the room around the clock performing unusual rituals and bringing ethnic
foods. Which of the following actions should the nurse take?
A. Restrict visiting hours and ask the
family to limit visitors to two at a time.
B. Notify visitors with a sign on the
door that the patient is limited to clear fluids only with no solid food
allowed.
C. If possible, keep the other bed in the room
unassigned to provide privacy and comfort to the family.
D. Contact the physician to report the unusual
rituals and activities.
44. The charge nurse on the cardiac unit
is planning assignments for the day. Which of the following is the most
appropriate assignment for the float nurse that has been reassigned from labor
and delivery?
A. A one-week postoperative coronary
bypass patient, who is being evaluated for placement of a pacemaker prior to
discharge.
B. A suspected myocardial infarction
patient on telemetry, just admitted from the Emergency Department and scheduled
for an angiogram.
C. A patient with unstable angina being
closely monitored for pain and medication titration.
D. A post-operative valve replacement patient who
was recently admitted to the unit because all surgical beds were filled.
55. A newly diagnosed 8-year-old child
with type I diabetes mellitus and his mother are receiving diabetes education
prior to discharge. The physician has prescribed Glucagon for emergency use.
The mother asks the purpose of this medication. Which of the following
statements by the nurse is correct?
A. Glucagon enhances the effect of insulin in
case the blood sugar remains high one hour after injection.
B. Glucagon treats hypoglycemia resulting from
insulin overdose.
C. Glucagon treats lipoatrophy from insulin
injections.
D. Glucagon prolongs the effect of insulin,
allowing fewer injections.
66. A patient on the cardiac telemetry
unit unexpectedly goes into ventricular fibrillation. The advanced cardiac life
support team prepares to defibrillate. Which of the following choices indicates
the correct placement of the conductive gel pads?
A.
The left clavicle and right lower
sternum.
B.
Right of midline below the bottom rib and the
left shoulder.
C.
The upper and lower halves of the
sternum.
D.
The right side of the sternum just below the
clavicle and left of the precordium.
77. The nurse performs an initial
abdominal assessment on a patient newly admitted for abdominal pain. The nurse
hears what she describes as "clicks and gurgles in all four
quadrants" as well as "swishing or buzzing sound heard in one or two
quadrants." Which of the following statements is correct?
A. The frequency and intensity of bowel
sounds varies depending on the phase of digestion.
B. In the presence of intestinal obstruction,
bowel sounds will be louder and higher pitched.
C. A swishing or buzzing sound may represent the
turbulent blood flow of a bruit and is not normal.
D. All of the above.
78. A patient arrives in the emergency
department and reports splashing concentrated household cleaner in his eye.
Which of the following nursing actions is a priority?
A.
Irrigate the eye repeatedly with
normal saline solution.
B.
Place fluorescein drops in the eye.
C.
Patch the eye.
D.
Test visual acuity.
99. A nurse is caring for a patient who
has had hip replacement. The nurse should be most concerned about which of the
following findings?
A.
Complaints of pain during
repositioning.
B.
Scant bloody discharge on the surgical
dressing.
C.
Complaints of pain following physical
therapy.
D.
Temperature of 101.8 F (38.7 C).
10. A child is admitted to the hospital
with an uncontrolled seizure disorder. The admitting physician writes orders
for actions to be taken in the event of a seizure. Which of the following
actions would NOT be included?
A.
Notify the physician.
B.
Restrain the patient's limbs.
C.
Position the patient on his/her side
with the head flexed forward.
D.
Administer rectal diazepam.
11.
Emergency department triage is an
important nursing function. A nurse working the evening shift is presented with
four patients at the same time. Which of the following patients should be
assigned the highest priority?
A.
A patient with low-grade fever,
headache, and myalgias for the past 72 hours.
B.
A patient who is unable to bear weight on the
left foot, with swelling and bruising following a running accident.
C.
A patient with abdominal and chest pain following
a large, spicy meal.
D.
A child with a one-inch bleeding
laceration on the chin but otherwise well after falling while jumping on his
bed.
12.
A patient is admitted to the hospital
with a calcium level of 6.0 mg/dL. Which of the following symptoms would you
NOT expect to see in this patient?
A.
Numbness in hands and feet.
B.
Muscle cramping.
C.
Hypoactive bowel sounds.
D.
Positive Chvostek's sign.
13.
A nurse cares for a patient who has a
nasogastric tube attached to low suction because of a suspected bowel
obstruction. Which of the following arterial blood gas results might be
expected in this patient?
A.
pH 7.52, PCO2 54 mm Hg.
B.
pH 7.42, PCO2 40 mm Hg.
C.
pH 7.25, PCO2 25 mm Hg.
D.
pH 7.38, PCO2 36 mm Hg.
14.
A patient is admitted to the hospital
for routine elective surgery. Included in the list of current medications is
Coumadin (warfarin) at a high dose. Concerned about the possible effects of the
drug, particularly in a patient scheduled for surgery, the nurse anticipates
which of the following actions?
A.
Draw a blood sample for prothrombin
(PT) and international normalized ratio (INR) level.
B.
Administer vitamin K.
C.
Draw a blood sample for type and
crossmatch and request blood from the blood bank.
D.
Cancel the surgery after the patient
reports stopping the Coumadin one week previously.
15.
The follow lab results are received
for a patient. Which of the following results are abnormal? Note: More than one
answer may be correct.
A.
Hemoglobin 10.4 g/dL.
B.
Total cholesterol 340 mg/dL.
C.
Total serum protein 7.0 g/dL.
D.
Glycosylated hemoglobin A1C 5.4%.
16.
A nurse is performing routine
assessment of an IV site in a patient receiving both IV fluids and medications
through the line. Which of the following would indicate the need for
discontinuation of the IV line as the next nursing action?
A.
The patient complains of pain on
movement.
B.
The area proximal to the insertion
site is reddened, warm, and painful.
C.
The IV solution is infusing too
slowly, particularly when the limb is elevated.
D.
A hematoma is visible in the area of
the IV insertion site.
17.
A hospitalized patient has received
transfusions of 2 units of blood over the past few hours. A nurse enters the
room to find the patient sitting up in bed, dyspneic and uncomfortable. On
assessment, crackles are heard in the bases of both lungs, probably indicating
that the patient is experiencing a complication of transfusion. Which of the
following complications is most likely the cause of the patient's symptoms?
A.
Febrile non-hemolytic reaction.
B.
Allergic transfusion reaction.
C.
Acute hemolytic reaction.
D.
Fluid overload.
18.
A patient in labor and delivery has
just received an amniotomy. Which of the following is correct? Note: More than
one answer may be correct.
A.
Frequent checks for cervical dilation
will be needed after the procedure.
B.
Contractions may rapidly become
stronger and closer together after the procedure.
C.
The FHR (fetal heart rate) will be
followed closely after the procedure due to the possibility of cord
compression.
D.
The procedure is usually painless and
is followed by a gush of amniotic fluid.
19.
A nurse is counseling the mother of a
newborn infant with hyperbilirubinemia. Which of the following instructions by
the nurse is NOT correct?
A.
Continue to breastfeed frequently, at
least every 2-4 hours.
B.
Follow up with the infant's physician
within 72 hours of discharge for a recheck of the serum bilirubin and exam.
C.
Watch for signs of dehydration,
including decreased urinary output and changes in skin turgor.
D.
Keep the baby quiet and swaddled, and
place the bassinet in a dimly lit area.
20.
A nurse is giving discharge instructions
to the parents of a healthy newborn. Which of the following instructions should
the nurse provide regarding car safety and the trip home from the hospital?
A.
The infant should be restrained in an
infant car seat, properly secured in the back seat in a rear-facing position.
B.
The infant should be restrained in an
infant car seat, properly secured in the front passenger seat.
C.
The infant should be restrained in an
infant car seat facing forward or rearward in the back seat.
D.
For the trip home from the hospital, the
parent may sit in the back seat and hold the newborn.
21. Rhea, confused and short breath,
is brought to the emergency department by a family member. The medical history
reveals chronic bronchitis and hypertension. To learn more about the current
respiratory problem, the doctor orders a chest x-ray and arterial blood gas
(ABG) analysis. When reviewing the ABG report, the nurses sees many
abbreviations. What does a lowercase “a” in ABG value present?
A.
Acid-base balance
B.
Arterial Blood
C.
Arterial oxygen saturation
D.
Alveoli
22.
An emergency room nurse is assessing a male client who has
sustained a blunt injury to the chest wall. Which of these signs would indicate
the presence of a pneumothorax in this client?
A.
A low respiratory rate
B.
Diminished breath sounds
C.
The presence of a barrel chest
D.
A sucking sound at the site of
injury
23.
A black client with asthma seeks emergency care
for acute respiratory distress. Because of this client’s dark skin, the nurse
should assess for cyanosis by inspecting the:
A.
Lips.
B.
Mucous membranes.
C.
Nail beds.
D.
Earlobes.
24.
At 11 p.m., a male client is admitted to the emergency department.
He has a respiratory rate of 44 breaths/minute. He’s anxious, and wheezes are
audible. The client is immediately given oxygen by face mask and methylprednisolone
(Depo-medrol) I.V. At 11:30 p.m., the client’s arterial blood oxygen saturation
is 86% and he’s still wheezing. The nurse should plan to administer:
A.
Alprazolam (Xanax).
B.
Propranolol (Inderal)
C.
Morphine.
D.
Albuterol (Proventil).
25. A client is admitted to the emergency
department following an overdose of barbiturates. What should the nurse do
first?
A.
Assess and assist ventilation.
B.
Monitor the BP.
C.
Prepare to administer blood products.
D.
Place the client in the trendelenburg
position.
26. A male client who is 76 years of age
comes to the emergency department with sudden onset of severe pain in his back,
flank and abdomen. He reports feeling weak and his BP is 68/31 mmhg. Urine
output is absent. Bilateral leg pulses are weak, although bruit and pulsation are
noted at the umbilicus. The nurse should first:
A.
Obtain consent for emergency surgery.
B.
Assess leg pulses with a Doppler test.
C.
Palpate the abdomen for presence of a
mass.
D.
Start an IV infusion.
27. An alert client is admitted to the
emergency department with a severe laceration of his arm with heavy bleeding.
What action should the nurse take first?
A.
Apply a tourniquet above the wound.
B.
Assess pulse and nerve functioning of
the arm.
C.
Cover the wound with a dressing and
apply firm pressure.
D.
Start an IV infusion.
28. A small airplane has crashed in a
neighbourhood of 10 houses. One of the victims appears to have a cervical spine
injury. First aid for this victim includes which of the following?
A.
Establish an airway with head tilt.
B.
Immobilize the spine.
C.
Logroll the victim to a side-lying
position.
D.
Elevate the feet 6 inches.
29. Several clients come to the emergency
department suspected contamination by the Ebola virus. The nurse should do
which of the following? Select all that apply.
A.
Call in extra staff to assist with the
possibility more clients with the same condition.
B.
Isolate all the suspected clients in
the emergency department in one area.
C.
Obtain diluted household bleach from
housekeeping services.
D.
Restrict visitors from the emergency
department.
E.
Request that the emergency department
be closed to other client.
30. The nurse in the immediate care clinic
is assessing a client who is 80 years of age and lives with his son’s family.
The client is scald burns on his hands and both foramens (10% first-degree
burns). The nurse should do first:
A.
Cleanse the wounds with warm water.
B.
Apply antibiotic cream.
C.
Call for transport to a burn centre.
D.
Cover all the burns with sterile
dressing.
31. A client who is 16 years of age is
seen in an emergency department following the rape. The management of a rape
victim should primarily be directed toward:
A.
Relieving physical discomfort.
B.
Maintain self-esteem.
C.
Assessing for sources of infection
resulting from the rape.
D.
Teaching the victim how to prevent
future attacks.
A nurse who witnesses a motor vehicle
accident stops to provide emergency assistance to the injured motorists.
32. When the nurses assess a victim who
has been thrown from the vehicle, which assessment finding is most suggestive
of the serious head injury?
A.
The victim has a bad head injury.
B.
The victim asks the nurse, “What
happened?”
C.
The victim is hesitant to move.
D.
The client has clear fluid draining
from the ears.
The
accidents victim is taken to the emergency department for evaluation.
33. While waiting for the physician to
examine the client, how should the nurse position the client?
A.
Dorsal recumbent with the legs
elevated.
B.
Supine with head slightly elevated.
C.
Flat with neck immobilizer in place.
D.
Right lateral with the neck flexed.
