Emergency nursing 1

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.
C. Facilitate meeting between the family and the organ donor specialist.
D. Escorting the family to a place of privacy.

7. The physician has ordered cooling measures for a child with a fever who is likely to be discharged
when the temperature comes down. Which task would be appropriate to delegate to a nursing
assistant?

A. Prepare and administer a tepid sponge bath.

B. Explain the need for giving cool fluids.
C. Assist the child in removing outer clothing.
D. Advise the parent to use acetaminophen (Tylenol) instead of aspirin.

8. You are preparing a child for IV conscious sedation before the repair of a facial laceration. What
information should you report immediately to the physician?

A. The parent wants information about the IV conscious sedation.

B. The parent is not sure regarding the child’s tetanus immunization status.
C. The child suddenly pulls out the IV.
D. The parent’s refusal of the administration of the IV sedation.

9. The emergency medical service has transported a client with severe chest pain. As the client is being
transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and
unpalpable pulse. Which of the following task is appropriate to delegate to the nursing assistant?

A. Assisting with the intubation.

B. Placing the defibrillator pads.
C. Doing chest compressions.
D. Initiating bag valve mask ventilation.

10. The nursing manager decides to form a committee to address the issue of violence against ED
personnel. Which combination of employees would be best suited to fulfill this assignment?

A. RNs, LPNs, and nursing assistants.

B. At least one representative from each group of ED personnel.
C. Experienced RNs and experienced paramedics.
D. ED physicians and charge nurses.

11. A client suffered an amputation of the first and second digits in a chainsaw accident. Which task
should be delegated to an LPN/LVN?

A. Cleansing the amputated digits and placing them directly into an ice slurry.
B. Cleansing the digits with sterile normal saline and placing in a sterile cup with sterile normal saline.
C. Gently cleansing the amputated digits and the hand with povidone-iodine.
D. Wrapping the cleansed digits in saline-moistened gauze, sealing in a plastic container, and placing it in
an ice.

12. A client arrives in the emergency unit and reports that a concentrated household cleaner was
splashed in both eyes. Which of the following nursing actions is a priority?

A. Use Restasis (Allergan) drops in the eye.

B. Flush the eye repeatedly using sterile normal saline.
C. Examine the client’s visual acuity.
D. Patch the eye.

13. 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. The client is unconscious and has minimal
response to noxious stimuli. Which of the following assessment findings if observed after few hours,
should be reported to the physician immediately?

A. Bleeding around the lacerations.

B. Withdrawal of the client in response to painful stimuli.
C. Bruises and minimal edema of the eyelids.
D. Drainage of a clear fluid from the client’s nose.

14. 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. Upon assessment, the child is alert and with no
symptoms. Which of the following information should be reported to the physician immediately?

A. The child has been treated multiple times for injuries caused by accidents.
B. The vitamin that was ingested contains iron.
C. The child was nauseated and vomited once at home.
D. The child has been treated several times for toxic substance ingestion.

15. The following clients come at the emergency department complaining of acute abdominal pain.
Prioritize them for care in order of the severity of the conditions.

1. A 27-year-old woman complaining of lightheadedness and severe sharp left lower quadrant pain who
reports she is possibly pregnant.
2. 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.
3. A 15-year-old boy with a low-grade fever, right lower quadrant pain, vomiting, nausea, and loss of
appetite for the past few days.
4. A 57-year-old woman who complains of a sore throat and gnawing midepigastric pain that is worse
between meals and during the night.
5. A 59-year-old man with a pulsating abdominal mass and sudden onset of persistent abdominal or
back pain, which can be described as a tearing sensation within the past hour.
A. 2,5,3,4,1
B. 3,1,4,5,2
C. 5,1,3,2,4
D. 2,5,1,4,3
16. The following clients are presented with signs and symptoms of heat-related illness. Which of them
needs to be attended first?

A. A relatively healthy homemaker who reports that the air conditioner has been broken for days and
who manifest fatigue, hypotension, tachypnea, and profuse sweating.
B. An elderly person who complains of dizziness and syncope after standing in the sun for several hours
to view a parade.
C. A homeless person who is a poor historian; has altered mental status, poor muscle coordination, and
hot, dry ashen skin; and whose duration of heat exposure is unknown.
D. A marathon runner who complains of severe leg cramps and nausea, and manifests weakness, pallor,
diaphoresis, and tachycardia.

17. An anxious female client complains of chest tightness, tingling sensations, and palpitations. Deep,
rapid breathing, and carpal spasms are noted. Which of the following priority action should the nurse do
first?

A. Provide oxygen therapy.

B. Notify the physician immediately.
C. Administer anxiolytic medication as ordered.
D. Have the client breathe into a brown paper bag.

18. An intoxicated client comes into the emergency unit with an uncooperative behavior, mild
confusion, and with slurred speech. The client is unable to provide a good history but he verbalizes that
he has been drinking a lot. Which of the following is a priority action of the nurse?

A. Administer IV fluid incorporated with Vitamin B1 as ordered.

B. Administer Naloxone (Narcan) 4 mg as ordered.
C. Contact the family to get information of the client.
D. Obtain an order for the determination of blood alcohol level.

19. A nurse is providing discharge instruction to a woman who has been treated for contusions and
bruises due to a domestic violence. What is the priority intervention for this client?

A. Making a referral to a counselor.

B. Making an appointment to follow up on the injuries.
C. Advising the client about contacting the police.
D. Arranging transportation to a safe house.

20. In the work setting, what is the primary responsibility of the nurse in preparation for disaster
management, that includes natural disasters and bioterrorism incidents?

A. Being aware of the signs and symptoms of potential agents of bioterrorism.

B. Making ethical decisions regarding exposing self to potentially lethal substances.
C. Being aware of the agency’s emergency response plan.
D. Being aware of what and how to report to the Centers for Disease Control and Prevention.
Answers and Rationale

1. Answer: A. Removing the stinger by scraping it.

Since the stinger will continue to release venom into the skin, removing the stinger should be the first
action that the nurse should direct to the client.

Options B and C: After removing the stinger, Antihistamine and cold compress follow.
Option D: The caller should be further advised about symptoms that require 911 assistance.

2. Answer: B. Ambulatory section.

The ambulatory section deals with clients with relatively stable conditions.

Options A, C, 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.

3. Answer: C. A deviated trachea.

A deviated trachea is a symptom of tension pneumothorax, which will result in respiratory distress if left
untreated.

4. Answer: D. Administer oxygen therapy via nasal cannula.

The priority goal is to increase myocardial oxygenation.

Options A, B, and C: These actions are also appropriate and should be performed immediately.

5. Answer: A. Direct the clients to the decontamination area.

Decontamination in a specified area is the priority.

Option B: The clients must undergo decontamination before entering cold or clean areas.
Options C and D: Performing assessments and moving others delays contamination and does not protect
the total environment.
Option E: Personnel should don personal protective equipment before assisting with decontamination
or assessing the clients.

6. Answer: B. Assisting with postmortem care.

Postmortem care requires some turning, cleaning, lifting, and so on, and the nursing assistant is able to
assist with these duties.

Option A: In cases of questionable death, belongings may be retained for evidence, so the chain of
custody would have to be maintained.
Options C and D: A licensed nurse should take responsibility for the other tasks to help the family begin
the grieving process.
7. Answer: C. Assist the child in removing outer clothing.

The nursing assistant can help with the removal of outer clothing, which allows the heat to dissipate
from the child’s skin.

Option A: Tepid baths are not usually given because of the possibility of shivering and rebound.
Options B and D: Explaining and Advising are teaching functions that are a responsibility of the
registered nurse.

8. Answer: D. The parent’s refusal of the administration of the IV sedation.

The refusal of the parents is an absolute contraindication; therefore the physician must be notified.

Options A and C: The RN can reestablish the IV access and provide information about conscious
sedation.
Option B: Tetanus status can be addressed later.

9. Answer: C. Doing chest compressions.

Performing chest compressions are within the training of a nurse assistant.

Option A: The use of the bag valve mask requires practice, and usually a respiratory therapist will
perform the function.
Option B: 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.

10. Answer: B. At least one representative from each group of ED personnel.

At least one representative from each group of ED personnel should be included because all employees
are potential targets for violence in the ED.

11. Answer: D. Wrapping the cleansed digits in saline-moistened gauze, sealing in a plastic container,
and placing it in an ice.

12. Answer: B. Flush the eye repeatedly using sterile normal saline.

Initial emergency action during a chemical splash to the eye includes immediate continuous irrigation of
the affected eye with normal saline.

Option A: Restasis (Allergan) drops are used to treat dry eyes.

Option C: Patching the eye is not part of the first line treatment of a chemical splash.
Option D: After irrigation, visual acuity then is assessed.

13. Answer: D. Drainage of a clear fluid from the client’s nose.

Clear drainage from the client’s nose indicates that there is a leakage of CSF and should be reported to
the physician immediately.
14. Answer: B. The vitamin that was ingested contains iron.

Iron is a toxic substance that can lead to massive hemorrhage, shock, coma, and kidney failure.

Options A, C, and D: These information needs further investigation but will not change the immediate
diagnostic testing or treatment plan.

15. Answer: C. 5,1,3,2,4

The client with a pulsating mass has an abdominal aneurysm that may rupture and he may
decompensate easily. The woman with lower left quadrant pain is at risk for a life-threatening ectopic
pregnancy. The 15-year-old boy needs evaluation to rule out appendicitis. The woman with vomiting
needs evaluation for gallbladder problems, which appear to be worsening. Lastly, the woman with mid
epigastric pain is suffering from an ulcer, but follow-up diagnostic testing can be scheduled with a
primary care provider.

16. Answer: C. A homeless person who is a poor historian; has altered mental status, poor muscle
coordination, and hot, dry ashen skin; and whose duration of heat exposure is unknown.

The signs and symptoms manifested by the homeless person indicate that a heat stroke is happening, a
medical emergency, which can lead to brain damage.

Option A: The homemaker is experiencing heat exhaustion, which can be managed by fluids and cooling
measures.
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.
Option D: The runner is experiencing heat cramps, which can be managed with fluid and rest.

17. Answer: D. Have the client breathe into a brown paper bag.

The client is suffering from hyperventilation secondary from anxiety, the initial action is to let the client
breathe in a paper bag that will allow the rebreathing of carbon dioxide.

18. Answer: A. Administer IV fluid incorporated with Vitamin B1 as ordered.

The client has symptoms of alcohol abuse and there is a risk for Wernicke syndrome, which is caused by
a deficiency in Vitamin B.

Option B: Multiple drug abuse is not uncommon; however, there is currently nothing to suggest an
opiate overdose that requires the administration of naloxone.
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.

19. Answer: D. Arranging transportation to a safe house.

Safety is a priority for this client and she should not return to a place where violence could recur.

Options A, B, and C: These are important for the long-term management of this case.
20. Answer: C. Being aware of the agency’s emergency response plan.

In disasters preparedness, the nurse should know the emergency response plan. This gives guidance that
includes the roles of the team members, responsibilities and mechanism of reporting.