Medical-Surgical Nursing Exam 15:

Emergency Nursing (30 Items)

1. 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 advanced practice nurse and an experienced LPN/LVN

b. An experienced LPN/LVN and an inexperienced RN
c. An experienced RN and an inexperienced RN
d. An experienced RN and a nursing assistant

2. 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.

a. An ambulatory, dazed 25-year-old male with a bandaged head wound

b. An irritable infant with a fever, petechiae, and nuchal rigidity
c. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity
d. A 50-year-old female with moderate abdominal pain and occasional vomiting
__B___, __A___, _D____, __C___

3. 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. Complete set of vital signs

b. Palpation and auscultation of the abdomen
c. Brief neurologic assessment
d. Initiation of pulse oximetry

4. A 56-year-old patient presents in triage with left-sided chest pain, diaphoresis, and
dizziness. This patient should be prioritized into which category?

a. High urgent
b. Urgent
c. Non-urgent
d. Emergent

5. 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. Assist the child to remove outer clothing.

b. Advise the parent to use acetaminophen instead of aspirin.
c. Explain the need for cool fluids.
d. Prepare and administer a tepid bath.

6. 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 marathon runner complains of severe leg cramps and nausea. Tachycardia, diaphoresis,

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pallor, and weakness are observed.
c. A previously healthy homemaker reports broken air conditioner for days. Tachypnea,
hypotension, fatigue, and profuse diaphoresis are observed.
d. A homeless person, poor historian, presents with altered mental status, poor muscle
coordination, and hot, dry, ashen skin. Duration of exposure is unknown.

7. 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.

a. Perform the chin lift or jaw thrust maneuver.

b. Establish unresponsiveness.
c. Initiate cardiopulmonary resuscitation (CPR).
d. Call for help and activate the code team.
e. Instruct a nursing assistant to get the crash cart.
__B___, __D___, _A____, __C___, __E___

8. 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. Chest compressions
b. Bag-valve mask ventilation
c. Assisting with oral intubation
d. Placing the defibrillator pads

9. 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. Notify the physician immediately.

b. Administer supplemental oxygen.
c. Have the student breathe into a paper bag.
d. Obtain an order for an anxiolytic medication.

10.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. Trauma team
b. Triage
c. Ambulatory or fats track clinic
d. Pediatric medicine team

11.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 ingested children’s chewable vitamins contain iron.

b. The child has been treated several times for ingestion of toxic substances.
c. The child has been treated several times for accidental injuries.
d. The child was nauseated and vomited once at home.

12.In caring for a victim of sexual assault, which task is most appropriate for an LPN/LVN?

a. Assess immediate emotional state and physical injuries

b. Collect hair samples, saliva swabs, and scrapings beneath fingernails.
c. Provide emotional support and supportive communication.
d. Ensure that the “chain of custody” is maintained.

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13.You are caring for a victim of frostbite to the feet. Place the following interventions in the
correct order.

a. Apply a loose, sterile, bulky dressing.

b. Give pain medication.
c. Remove the victim from the cold environment.
d. Immerse the feet in warm water 100o F to 105o F (40.6o C to 46.1o C)
_____, _____, _____, _____

14.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. Gently cleanse the amputated digits with Betadine solution.

b. Place the amputated digits directly into ice slurry.
c. Wrap the amputated digits in sterile gauze moistened with saline.
d. Store the amputated digits in a solution of sterile normal saline.

15.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. PO phenytoin and carbamazepine

b. IV lorazepam (Ativan)
c. IV carbamazepam
d. IV magnesium sulfate

16.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 is unsure about the child’s tetanus immunization status.

b. The child is upset and pulls out the IV.
c. The parent declines the IV conscious sedation.
d. The parent wants information about the IV conscious sedation.

17.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. Obtain an order for a blood alcohol level.

b. Contact the family to obtain additional history and baseline information.
c. Administer naloxone (Narcan) 2 – 4 mg as ordered.
d. Administer IV fluid support with supplemental thiamine as ordered.

18.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. Go with the organ donor specialist to talk to the family.
c. Assist with postmortem care.
d. Assist the family to collect belongings.

19.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?

a. Obtain an order for a chest x-ray to document tube placement.

b. Secure the tube in place.
c. Auscultate the chest during assisted ventilation.

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d. Confirm that the breath sounds are equal and bilateral.
_C,__D__, ___B__,_A__

20.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 pulled the stick out, just now, because it was hurting him.”
c. “The stick was really dirty and covered with mud.”
d. “He’s a diabetic, so he needs attention right away.”

21.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 Injury related to seizures

b. Risk for Other-Directed Violence related to hallucinations
c. Risk for Situational Low Self-esteem related to police custody
d. Risk for Nutritional Deficit related to chronic alcohol abuse

22.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. Call 911.
b. Remove the stinger by scraping.
c. Apply a cool compress.
d. Take an oral antihistamine.

23.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.

24.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. Risk for Infection related to organisms specific to cat bites

b. Impaired Skin Integrity related to puncture wounds
c. Ineffective Health Maintenance related to immunization status
d. Risk for Impaired Mobility related to potential tendon damage

25.These patients present to the ED complaining of acute abdominal pain. Prioritize them in
order of severity.

a. A 35-year-old male complaining of severe, intermittent cramps with three episodes of

watery diarrhea, 2 hours after eating
b. A 11-year-old boy with a low-grade fever, left lower quadrant tenderness, nausea, and
anorexia for the past 2 days
c. A 40-year-old female with moderate left upper quadrant pain, vomiting small amounts of

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yellow bile, and worsening symptoms over the past week
d. 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___, ___B__, ___C__, ___A__

26.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. ED physicians and charge nurses

b. Experienced RNs and experienced paramedics
c. RNs, LPN/LVNs, and nursing assistants
d. At least one representative from each group of ED personnel

27.In a multiple-trauma victim, which assessment finding signals the most serious and life-
threatening condition?

a. A deviated trachea
b. Gross deformity in a lower extremity
c. Decreased bowel sounds
d. Hematuria

28.A patient in a one-car rollover presents with multiple injuries. Prioritize the interventions
that must be initiated for this patient.

a. Secure/start two large-bore IVs with normal saline

b. Use the chin lift or jaw thrust method to open the airway.
c. Assess for spontaneous respirations
d. Give supplemental oxygen per mask.
e. Obtain a full set of vital signs.
f. Remove patient’s clothing.
g. Insert a Foley catheter if not contraindicated.
__C_B__, __D__A_, ___E_, ____F_, __G__, ____, ____

29.In the work setting, what is your primary responsibility in preparing for disaster
management that includes natural disasters or bioterrorism incidents?

a. Knowledge of the agency’s emergency response plan

b. Awareness of the signs and symptoms for potential agnets of bioterrorism
c. Knowledge of how and what to report to the CDC
d. Ethical decision-making about exposing self to potentially lethal substances

30.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. Transportation arrangements to a safe house

b. Referral to a counselor
c. Advise about contacting the police
d. Follow-up appointment for injuries