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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.

D. D. C. LPNs. Which task should be delegated to an LPN/LVN? A. You are preparing a child for IV conscious sedation before the repair of a facial laceration. 9. B. A client arrives in the emergency unit and reports that a concentrated household cleaner was splashed in both eyes. ED physicians and charge nurses. Cleansing the digits with sterile normal saline and placing in a sterile cup with sterile normal saline. Which task would be appropriate to delegate to a nursing assistant? A. Cleansing the amputated digits and placing them directly into an ice slurry. Which of the following task is appropriate to delegate to the nursing assistant? A. and nursing assistants. Wrapping the cleansed digits in saline-moistened gauze. C. 11. B. B. D. The physician has ordered cooling measures for a child with a fever who is likely to be discharged when the temperature comes down. sealing in a plastic container. C. The emergency medical service has transported a client with severe chest pain. What information should you report immediately to the physician? A. RNs. Assist the child in removing outer clothing. and unpalpable pulse. D. Assisting with the intubation. Explain the need for giving cool fluids. Advise the parent to use acetaminophen (Tylenol) instead of aspirin.C. Escorting the family to a place of privacy. C. and placing it in an ice. B. . The parent is not sure regarding the child’s tetanus immunization status. 12. B. Prepare and administer a tepid sponge bath. D. The child suddenly pulls out the IV. At least one representative from each group of ED personnel. Which of the following nursing actions is a priority? A. A client suffered an amputation of the first and second digits in a chainsaw accident. Facilitate meeting between the family and the organ donor specialist. Use Restasis (Allergan) drops in the eye. As the client is being transferred to the emergency stretcher. The parent’s refusal of the administration of the IV sedation. Gently cleansing the amputated digits and the hand with povidone-iodine. 10. you note unresponsiveness. Flush the eye repeatedly using sterile normal saline. 7. Doing chest compressions. Which combination of employees would be best suited to fulfill this assignment? A. B. cessation of breathing. Initiating bag valve mask ventilation. The nursing manager decides to form a committee to address the issue of violence against ED personnel. The parent wants information about the IV conscious sedation. 8. Placing the defibrillator pads. Experienced RNs and experienced paramedics. D. C.

Which of the following assessment findings if observed after few hours. 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. B.  2. should be reported to the physician immediately? A. A homeless person who is a poor historian. Bleeding around the lacerations. poor musclecoordination.  3.C.1. . The vitamin that was ingested contains iron.5. The client is unconscious and has minimal response to noxious stimuli. B. C.5.5. Which of them needs to be attended first? A. The following clients are presented with signs and symptoms of heat-related illness. B. Withdrawal of the client in response to painful stimuli. The child was nauseated and vomited once at home. A. Examine the client’s visual acuity. A 15-year-old boy with a low-grade fever.1 B.2 C. 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. Which of the following information should be reported to the physician immediately? A. hypotension. 13.4. 5. The child has been treated multiple times for injuries caused by accidents.  5. has altered mental status.4.2. Prioritize them for care in order of the severity of the conditions. Upon assessment. vomiting. the child is alert and with no symptoms. 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. C. 15. A 27-year-old woman complaining of lightheadedness and severe sharp left lower quadrant pain who reports she is possibly pregnant.3. D. A 59-year-old man with a pulsating abdominal mass and sudden onset of persistent abdominal or back pain. 14.3. 2.  1. C. nausea. The child has been treated several times for toxic substance ingestion. which can be described as a tearing sensation within the past hour. D.4 D. D. 2.3 16. An elderly person who complains of dizziness and syncope after standing in the sun for several hours to view a parade. A 57-year-old woman who complains of a sore throat and gnawing midepigastric pain that is worse between meals and during the night. The following clients come at the emergency department complaining of acute abdominal pain. Drainage of a clear fluid from the client’s nose. right lower quadrant pain. and profuse sweating. 3. Bruises and minimal edema of the eyelids.4.1.1. and loss of appetite for the past few days. Patch the eye. A relatively healthy homemaker who reports that the air conditioner has been broken for days and who manifest fatigue.  4. tachypnea.

20. tingling sensations. 18. An anxious female client complains of chest tightness. Contact the family to get information of the client. Answers and Rationale Here are the answers and rationale for the NCLEX quiz. that includes natural disasters and bioterrorism incidents? A. Answer: A. A marathon runner who complains of severe leg cramps and nausea. An intoxicated client comes into the emergency unit with an uncooperative behavior. C. and carpal spasms are noted. D. and with slurred speech. and manifests weakness. . Deep. Since the stinger will continue to release venom into the skin. B. Answer: B. Being aware of the signs and symptoms of potential agents of bioterrorism. C. Obtain an order for the determination of blood alcohol level. Making an appointment to follow up on the injuries. D. Provide oxygen therapy. A nurse is providing discharge instruction to a woman who has been treated for contusions and bruises due to a domestic violence. and tachycardia. B. what is the primary responsibility of the nurse in preparation for disaster management.  Option D: The caller should be further advised about symptoms that require 911 assistance. Antihistamine and cold compress follow. Administer Naloxone (Narcan) 4 mg as ordered. 1. Being aware of the agency’s emergency response plan. Administer anxiolytic medication as ordered. B. D.  Options B and C: After removing the stinger. dry ashen skin. What is the priority intervention for this client? A. pallor. Which of the following priority action should the nurse do first? A. 19. and palpitations. 17. mild confusion. In the work setting. D. Which of the following is a priority action of the nurse? A. D. B. Advising the client about contacting the police. diaphoresis. Making a referral to a counselor. 2. Arranging transportation to a safe house. rapid breathing. Have the client breathe into a brown paper bag. Ambulatory section. Making ethical decisions regarding exposing self to potentially lethal substances. C. Administer IV fluid incorporated with Vitamin B1 as ordered. Being aware of what and how to report to the Centers for Disease Control and Prevention. C.and hot. removing the stinger should be the first action that the nurse should direct to the client. and whose duration of heat exposure is unknown. The client is unable to provide a good history but he verbalizes that he has been drinking a lot. Notify the physician immediately. Removing the stinger by scraping it.

B.  Option A: Tepid baths are not usually given because of the possibility of shivering and rebound. and C: These actions are also appropriate and should be performed immediately. Assisting with postmortem care. Answer: A. The parent’s refusal of the administration of the IV sedation. Direct the clients to the decontamination area. Administer oxygen therapy via nasal cannula. Assist the child in removing outer clothing. 5. 7. Answer: D. Answer: D.  Options A. 6. Answer: C. The refusal of the parents is an absolute contraindication. A deviated trachea.  Options B and D: Explaining and Advising are teaching functions that are a responsibility of the registered nurse. lifting. 8.  Option E: Personnel should don personal protective equipment before assisting with decontamination or assessing the clients. Answer: C. The priority goal is to increase myocardial oxygenation. Decontamination in a specified area is the priority. The nursing assistant can help with the removal of outer clothing.  Option B: The clients must undergo decontamination before entering cold or clean areas. and the nursing assistant is able to assist with these duties.  Options C and D: A licensed nurse should take responsibility for the other tasks to help the family begin the grieving process. 4. so the chain of custody would have to be maintained.  Options A and C: The RN can reestablish the IV access and provide information about conscious sedation. which will result in respiratory distress if left untreated. 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.  Options A. A deviated trachea is a symptom of tension pneumothorax. therefore the physician must be notified. which allows the heat to dissipate from the child’s skin. Postmortem care requires some turning.  Options C and D: Performing assessments and moving others delays contamination and does not protect the total environment. C. and so on.The ambulatory section deals with clients with relatively stable conditions. cleaning.  Option A: In cases of questionable death. . 3. belongings may be retained for evidence. Answer: B.

C. which appear to be worsening. 14. and placing it in an ice. dry ashen skin. visual acuity then is assessed.  Option C: Patching the eye is not part of the first line treatment of a chemical splash. A homeless person who is a poor historian. Answer: C. At least one representative from each group of ED personnel should be included because all employees are potential targets for violence in the ED. Clear drainage from the client’s nose indicates that there is a leakage of CSF and should be reported to the physician immediately.  Options A. Answer: B.4 The client with a pulsating mass has an abdominal aneurysm that may rupture and he may decompensate easily.3. Doing chest compressions. The woman with lower left quadrant pain is at risk for a life- threatening ectopic pregnancy. Wrapping the cleansed digits in saline-moistened gauze. Answer: C. Answer: C. Answer: D. and D: These information needs further investigation but will not change the immediate diagnostic testing or treatment plan. At least one representative from each group of ED personnel. the woman with mid epigastric pain is suffering from an ulcer. Answer: B. and hot.  Option B: The defibrillator pads are clearly marked. 10. and usually a respiratory therapist will perform the function. sealing in a plastic container.1. Answer: D. however placement should be done by the RN or physician because of the potential for skin damage and electrical arcing. Flush the eye repeatedly using sterile normal saline. The vitamin that was ingested contains iron. Performing chest compressions are within the training of a nurse assistant.  Option A: The use of the bag valve mask requires practice. and kidney failure. . Drainage of a clear fluid from the client’s nose. 13. coma. 16. 12. poor muscle coordination. 11.  Option B: Tetanus status can be addressed later. but follow-up diagnostic testing can be scheduled with a primary care provider. The 15-year-old boy needs evaluation to rule out appendicitis. Initial emergency action during a chemical splash to the eye includes immediate continuous irrigation of the affected eye with normal saline.2. 5. 9.  Option D: After irrigation.  Option A: Restasis (Allergan) drops are used to treat dry eyes. Answer: B. The woman with vomiting needs evaluation for gallbladder problems. Iron is a toxic substance that can lead to massive hemorrhage. 15. Lastly. has altered mental status. and whose duration of heat exposure is unknown. shock.

17.  Option A: The homemaker is experiencing heat exhaustion. Arranging transportation to a safe house. Answer: C. and C: These are important for the long-term management of this case. Answer: A. which can be managed by fluids and cooling measures. Administer IV fluid incorporated with Vitamin B1 as ordered. This gives guidance that includes the roles of the team members. a medical emergency. there is currently nothing to suggest an opiate overdose that requires the administration of naloxone. . Have the client breathe into a brown paper bag. which can be managed with fluid and rest.  Option D: The runner is experiencing heat cramps.  Option B: Multiple drug abuse is not uncommon. Answer: D. Answer: D.  Options A. In disasters preparedness. The client is suffering from hyperventilation secondary from anxiety. The client has symptoms of alcohol abuse and there is a risk for Wernicke syndrome.The signs and symptoms manifested by the homeless person indicate that a heat stroke is happening.  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. the initial action is to let the client breathe in a paper bag that will allow the rebreathing of carbon dioxide. Safety is a priority for this client and she should not return to a place where violence could recur. the nurse should know the emergency response plan. responsibilities and mechanism of reporting. 19.  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. which is caused by a deficiency in Vitamin B. 20. which can lead to brain damage. B. however. 18. Being aware of the agency’s emergency response plan.