Emergency and Prioritization

1. The nurse is assessing Minda, patient who sustained a partial thickness burn over half of her body.
Which of the following manifestations should alert the nurse?
a. The patient is in intense thirst
b. Moderate to severe pain
c. Urine output of 65 ml in one hour
d. Hoarseness of voice when talking
2. Mila , who is the charge nurse on duty, is formulating a client care assignment. Which of the
following client is she going to assign to a practical nurse?
a. Stable 7 month old with pulmonary problem
b. A newly admitted 2 months old with severe bronchitis
c. A newly admitted 16 year old with severe hyperglycemia
d. A 14 year old admitted for here chemotherapy session
3. A nurse is assigned to care for four clients. In planning clients rounds, which client should the nurse
assess first?
a. A client scheduled for chest x-ray
b. A client requiring daily dressing changes
c. A postoperative client preparing for discharge
d. A client receiving nasal oxygen who had difficulty breathing during the previous shift
4. Daryll, registered nurse, has received the assignment for the day shift. After making initial rounds
and checking all the assigned clients, which client will the registered nurse plan to care for first?
a. A client who is ambulatory
b. A client scheduled for physical therapy at 1PM
c. A client with fever who is diaphoretic and restless
d. A postoperative client who has just received pain medication
5. When performing an assessment, Nurse Gene identifies the following signs and symptoms: impaired
coordination, decreased muscle strength, limited range of motion, and reluctance to move. These
signs and symptoms indicate which nursing diagnosis?
a. Health-seeking behaviors
b. Impaired physical mobility
c. Disturbed sensory perception
d. Deficient knowledge
6. When prioritizing a patient’s care plan based on Maslow’s hierarchy of needs, the nurse’s first
priority would be:
a. allowing the family to see a newly admitted patient
b. ambulating the patient in the hallway
c. administering pain medication
d. using two nurses to transfer the patient.
7. When planning the implementation of evidence-based practices to prevent falls, which of the
following steps should the nurse take first?
a. Identify the common causes of falls
b. Gather and review currently existing literature and guidelines for the prevention of falls
c. Identify fall prevention practices that are applicable to the patient care setting
d. Gather data to identify the effectiveness of the new practice guidelines.
8. Nurse Klemence is caring for the patient following removal of a large posterior oral lesion. Which of
the following is the priority nursing measure?
a. Maintain a patent airway
b. Perform meticulous oral care every 2 hours
c. Ensure that the incisional area is kept as dry as possible
d. Assess the client frequently for pain
9. The Nurse Venz is making assignments for the day. After accepting the assignment to a client with
leukemia, the nurse tells the charge nurse that her child has chickenpox. Which initial response
should the charge nurse take?
a. Change the nurse’s assignment to another client
b. Explain to the nurse that there is no risk to the client
c. Ask the nurse if the chickenpox has scabbed
d. Ask the nurse if she has ever had the chickenpox
10. Nurse Julius is teaching a group of new graduates about the safety needs of the client receiving
chemotherapy. Before administering chemotherapy, which of the following will receive highest
priority?
a. Administer a bolus of IV fluids
b. Administer pain medication
c. Administer an antiemetic
d. Allow the patient a chance to eat
11. Nurse Ivan is making assignments for the day. To which client he will assign the pregnant nurse?
a. The client receiving linear radiation therapy for lung cancer
b. The client with a radium implant for cervical cancer
c. The client who has just been administered soluble brachytherapy for thyroid cancer
d. The client who returned from placement of iridium seeds for prostate cancer
12. The client returns to the unit from surgery with a blood pressure 90/50, pulse 132, respiration 30.
Which action by the nurse should receive priority?
a. Continue to monitor the vital signs
b. Contact the physician
c. Ask the client how he feels
d. Ask the practical nurse to continue the post op care
13. The nurse has just received the change of shift report. Which client should the nurse assess first?
a. A client 2 hours post lobectomy with 150 ml drainage
b. A client 2 days post gastrectomy with scanty drainage
 c. A client with pneumonia with an oral temperature of 102 F
d. A client with a fractured hip in Buck’s traction
14. The nurse employed in the emergency room is responsible for triage of four clients injured in a
motor vehicle accident. Which of the following clients receive priority in care?
a. A 10 year old with lacerations of the face
b. A 15 year old with sterna bruises
c. A 34 year old with a fractured femur
d. A 50 year old with dislocation of the elbow
15. The nurse is working with another nurse and a patient care assistant. Which of the following clients
should be assigned to the registered nurse?
a. A client 2 days post appendectomy
b. A client 1 week post thyroidectomy
c. A client 3 days post splenectomy
d. A client 2 days post thoracotomy
16. The nurse is working in the emergency room when a client arrives with severe burns of the left arm,
hands, face and neck. Which action should receive priority?
a. Starting an IV
b. Applying oxygen
c. Obtaining blood gases
d. Medicating the client for pain
17. The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respiration 30.
Which action by the nurse should receive priority?
a. Document the finding
b. Contact the physician
c. Elevate the head of the bed
d. Administer a pain medication
18. The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to
share a room in the emergency department during the disaster?
a. A schizophrenic client having visual and auditory hallucination and the client with ulcerative
colitis
b. The client who is six months pregnant with abdominal pain and the client with facial
lacerations and a broken arm
c. A child whose pupils are fixed and dilated and his parents and a client with a frontal head
injury
d. The client who arrives with a large puncture wound to the abdomen and the client with
chest pain
19. A client with AIDS was admitted with a diagnosis of pneumocystis carinii pneumonia. Shortly after
his admission, he becomes confused and disoriented. He attempts to pull out his IV and refuses to
wear an oxygen mask. Based upon his mental status, the priority nursing diagnosis is:
a. Social isolation
 b. Risk for injury
c. Ineffective coping
d. Anxiety
20. Romeo, the charge nurse on duty, is formulating a discharge teaching plan for a client with mild
preeclampsia. The nurse should give priority to:
a. Teaching the client to report a nosebleed
b. Instructing the client to maintain strict bed rest
c. Telling the client to notify the doctor of pedal edema
d. Advising the client to avoid sodium source in the diet
21. The blood alcohol concentration of a client admitted following a motor vehicle accident is 420
mg/dl. The nurse should give priority in monitoring the client for:
a. Loss of coordination
b. Respiratory depression
c. Visual hallucination
d. Tachycardia
22. Rafael, an ICU nurse, is assessing client following a coronary artery bypass graft. Which of the
following should be given highest priority by the nurse?
a. Chest drainage of 150 ml in the past hour
b. Confusion and restlessness
c. Pallor and coolness of skin
d. Urinary output of 40 ml/hour
23. A client with schizophrenia is started on Zyprexa. Three weeks later, the client develops severe
muscle rigidity and elevated temperature. The nurse should give priority to:
a. Withholding all morning medications
b. Ordering a CBC and CPK
c. Administering prescribed anti-Parkinsonian medication
d. Transferring the client to a medical unit
24. A 24 year old woman is diagnosed with post traumatic stressed disorder following a rape by an
unknown assailant. The nurse should give priority to:
a. Providing a supportive environment
b. Controlling the client’s feelings of anger
c. Discussing the details of the attack
d. Administering a hypnotic for sleep
25. Which of the following nursing interventions has the highest priority for the client scheduled who is
scheduled for intravenous pyelogram?
a. Providing the client with a favorite meal for dinner
b. Asking if the client has allergies to shellfish
c. Encouraging fluids the evening before the test
d. Telling the client what to expect during the test
26. A 45 year old government employee with an esophageal tamponade develops symptoms of
respiratory distress, including inspiratory stridor. Which of the following should be given highest
priority?
a. Apply oxygen at 4 LPM via nasal cannula
b. Removing the tube after deflating the balloons
c. Elevating the head of the bed to 45 degrees
d. Increasing the pressure in the esophageal balloon
27. A College Professor with Addison’s disease asks the nurse what he needs to know to manage his
condition. The nurse should give priority to:
a. Emphasizing the need for strict adherence to his medication regimen
b. Teaching the client to avoid lotions and skin preparations containing alcohol
c. Explaining the need to avoid extremes of temperature
d. Assisting the client to choose a diet that contains adequate protein, fat and carbohydrates
28. Mario, the nurse on duty, is caring for a client with amytropic lateral sclerosis. The nurse should
give priority to:
a. assessing the client’s respiratory status
b. providing an alternate means of communication
c. referring the client and family to a community support groups
d. instituting a routine of active range of motion exercises
29. Nurse Arnold is planning care for a client with adrenal insufficiency. Which of the following diagnosis
should be given highest priority?
a. Fluid volume deficit
b. Sleep pattern disturbance
c. Altered nutrition
d. Alterations in body image
30. A 25 year old male is admitted in sickle cell crisis. Which of the following interventions would be of
highest priority?
a. Taking hourly blood pressures with mechanical cuff
b. Encouraging fluid intake at least 200 ml per hour
c. Position in high fowler’s with knee gatch raised
d. Administering Tylenol as ordered
31. A newly admitted client has a sickle cell crisis. He is complaining pain in his feet and hands. The
nurse’s assessment findings include a pulse oximetry of 92%. Assuming that all the following
interventions are ordered, which should be done first?
a. Adjust the room temperature
b. Give a bolus of IV fluids
c. Start O2
d. Administer meperidine (Demerol) 75 mg IV push
32. The client with a history of diabetes insipidus is admitted with polyuria, polydipsia and mental
confusion. The priority intervention for this client is:
 a. Measure the urinary output
b. Check the vital signs
c. Encourage increased fluid intake
d. Weigh the client
33. A 32 year old mother of three is brought to the clinic. Her pulse is 52, there is weight gain of 30
pounds in 4 months and the client is wearing two sweaters. The client is diagnosed with
hypothyroidism. Which of the following nursing diagnosis is of highest priority?
a. Impaired physical mobility related to decreased endurance
b. Hypothermia related to decreased metabolic rate
c. Disturbed thought processes related to interstitial edema
d. Decreased cardiac output related to bradycardia
34. A client returns from surgery with a total knee replacement. Which of the following findings requires
immediate nursing intervention?
a. Bloody drainage of 30 ml from the Davol drain is present
b. The CPM is set on 90 degree flexion
c. The client is unable to ambulate to the bathroom
d. The client is complaining of muscle spasms
35. A 21 year old male with Hodgkin’s lymphoma is a senior at the local university. He is engaged to be
married and is to begin a new job upon graduation. Which of the following diagnoses would be a
priority for this client?
a. Sexual dysfunction related to radiation therapy
b. Anticipatory grieving related to terminal illness
c. Tissue integrity related to prolonged bed rest
d. Fatigue related to chemotherapy
36. A client is admitted to the emergency room with a gunshot wound to the right arm. After dressing
the wound and administering the prescribed antibiotic, the nurse should:
a. Ask the client if he has any medication allergies
b. Check the client’s immunization record
c. Apply a splint to immobilize the arm
d. Administer medication for pain
37. Nurse Peter is assessing a patient that was rushed to the emergency room with diagnosis of
duodenal ulcer. Which finding should be reported to the doctor immediately?
a. BP 82/60, pulse 120
b. Pulse 68, respirations 24
c. BP 110/88, pulse 56
d. Pulse 82, respirations 16
38. Nurse Ara is developing a plan of care for a client with an ileostomy. What would be the priority
nursing diagnosis for this client?
a. Fluid volume deficit
b. Alteration in body image
 c. Impaired oxygen exchange
d. Alteration in elimination
39. A male client who is dehydrated has urinary incontinence and excoriation in the perineal area.
Which of the following actions would be a priority?
a. Keeping the perineal area clean and dry
b. Offering the urinal every 3 hours
c. Maintaining a fluid intake of 1L/day
d. Applying moist, warm compress to the client’s groin
40. The patient was rushed into the emergency department suspected with cancer of the bladder.
Which one of the following factors is most significant in the client’s diagnosis?
a. Smoking a pack of cigarettes a day for 30 years
b. Use of nonsteroidal anti inflammatory
c. Eating foods with preservatives
d. Past employment involving asbestos
41. Nurse Vincent is assessing a client following the removal of a pituitary tumor. The nurse notes that
the urinary output has increased and that the urine is very dilute. The nurse should give priority to:
a. Notifying the doctor immediately
b. Documenting the finding in the chart
c. Decreasing the rate of IV fluids
d. Administering vasopressive medication
42. A 75 year old male client with schizophrenia has been taking Clozaril for the past 6 months. This
morning the client’s temperature was elevated to 102 F. the nurse should give priority to:
a. Placing a note in the chart for the doctor
b. Rechecking the temperature in 4 hours
c. Notifying the physician immediately
d. Asking the client if he has been feeling sick
43. Nurse Denver is the first person to person at the scene of a motor vehicle accident. When rendering
aid to the victim, the nurse should give priority to:
a. Establishing a patent airway
b. Checking the quality of respirations
c. Observing for signs of active bleeding
d. Determining the level of consciousness
44. An obstetrical client has just been diagnosed with cardiac disease. The nurse should give priority to:
a. Instructing the client to remain on strict bed rest
b. Telling the client to monitor her pulse and respirations
c. Instructing the client to check her temperature in the evening
d. Telling the client to weigh herself monthly
45. Four clients are to receive their due medications. Which client should receive the medication first?
a. A client with apical; pulse of 72 receiving Lanoxin PO daily
 b. A client with abdominal surgery receiving Phenergan IM every 4 hours PRN for nausea and
vomiting
c. A client with labored respirations receiving a stat dose of IV Lasix
d. A client with pneumonia receiving Ampicillin IV every 6 hours
46. A 64 year old client is admitted with a diagnosis of renal calculi. Which of the following should be
given highest priority?
a. Initiating an intravenous infusion
b. Encouraging oral fluids
c. Administering pain medication
d. Straining the urine
47. Nurse John Paul is constructing a nursing care plan for a client post-operative open
cholecystectomy. Which nursing diagnosis would be the priority for this client?
a. Risk for ineffective airway clearance
b. Activity intolerance
c. Risk for urinary retention
d. Acute pain
48. Nurse Jayson is caring for a client with cerebrovascular accident who is complaining of being
nauseated and is requesting an emesis basin. Which action would the nurse take first?
a. Administer an ordered antiemetic
b. Obtain an ice bag and apply to the client’s throat
c. Turn the client to one side
d. Notify the physician
49. Nurse Dave is caring for a client after a laryngectomy. The client is anxious, with a respiratory rate of
32 and an oxygen saturation of 88. The nurse’s first action should be to:
a. Suction the client
b. Increase the oxygen flow rate
c. Notify the physician
d. Recheck the oxygen saturation
50. Nurse Carlo is caring for a 70 year old client with hypovolemia who is receiving a blood transfusion.
Assessment findings reveal crackles on chest auscultation and distended neck veins. What is the
nurse’s initial action?
a. Slow the transfusion
b. Document the finding as the only action
c. Stop the blood transfusion and turn on the normal saline
d. Assess the client’s pupils
51. Nurse Reynan is caring for a client after a motor vehicle accident. The client has a fractured tibia
and bone is noted protruding through the skin. Which action is priority?
a. Provide manual traction above and below the leg
b. Cover the bone area with a sterile dressing
c. Apply a bandage around the entire lower limb
 d. Place the client in the prone position
52. A female client with a stroke and malnutrition has been placed on total parenteral nutrition. The
nurse notes air entering the client via the central line. Which initial action is most appropriate?
a. Notify the physician
b. Elevate the head of the bed
c. Place the client in the left lateral decubitus position
d. Stop the TPN and hang D5 ½ Normal Saline
53. Upon admission to the hospital, a client reports having “the worst headache I’ve ever had”. The
nurse should give highest priority to:
a. Administering pain medication
b. Starting oxygen
c. Performing neuro checks
d. Inserting a foley catheter
54. Nurse Van is caring for a client with an acoustic neuroma brain tumor. The location of this tumor
warrants which of the following nursing diagnosis as the highest priority?
a. High risk for constipation
b. Fluid volume deficit
c. Ineffective coping
d. High risk for injury