Emergency Nursing NCLEX Practice Quiz #2 (20 Questions)

  • October 12, 2020/

Take this 20-item examination that will review and challenge your knowledge about emergency nursing! Feel the rush and raucousness (not guaranteed) of the ER department in these questions that will absolutely traumatize you.

Knowing is not enough; we must apply. Willing is not enough; we must do.

-Johann Wolfgang von Goethe


Topics or concepts included in this exam are:

  • Biological Agent.
  • Emergency nursing.
  • Triage.
  • Prioritization.
  • Delegation.
  • Disaster management.


Follow the guidelines below:

  • Read each question carefully and choose the best answer.
  • You are given one minute per question. Spend your time wisely!
  • Answers and rationales (if any) are given below. Be sure to read them.
  • If you need more clarifications, please direct them to the comments section.


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Practice Mode

Practice Mode: This is an interactive version of the Text Mode. All questions are given in a single page and correct answers, rationales or explanations (if any) are immediately shown after you have selected an answer. No time limit for this exam.

Text Mode

In Text Mode: All questions and answers are given for reading and answering at your own pace. You can also copy this exam and make a printout.

1. Michael works as a triage nurse, and four clients arrive at the emergency department at the same time. List the order in which he will assess these clients from first to last.

  • 1. A 50-year-old female with moderate abdominal pain and occasional vomiting.
  • 2. A 35-year-old jogger with a twisted ankle, having a pedal pulse and no deformity.
  • 3. An ambulatory dazed 25-year-old male with a bandaged head wound.
  • 4. An irritable infant with a fever, petechiae, and nuchal rigidity.

A. 1, 2, 3, 4
B. 2, 1, 3, 4
C. 4, 3, 1, 2
D. 3, 4, 2, 1

2. 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. Initiation of pulse oximetry.
B. Complete set of vital signs.
C. Client’s allergy history.
D. Brief neurologic assessment.

3. A 65-year-old patient arrived at the triage area with complaints of diaphoresis, dizziness, and left-sided chest pain. This patient should be prioritized into which category?

A. Non-urgent.
B. Urgent.
C. Emergent.
D. High urgent.

4. 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.

  • 1. Call for help and activate the code team.
  • 2. Instruct a nursing assistant to get the emergency cart.
  • 3. Initiate cardiopulmonary resuscitation (CPR).
  • 4. Perform the chin lift or jaw thrust maneuver.
  • 5. Establish unresponsiveness.

A. 5, 2, 4, 3, 1
B. 1, 5, 2, 4, 3
C. 1, 2, 5, 4, 3
D. 5, 1, 4, 3, 2

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

A. Provide emotional support and supportive communication.
B. Assess immediate emotional state and physical injuries.
C. Ensure that the “chain of custody” is maintained.
D. Collect hair samples, saliva swabs, and scrapings beneath fingernails.

6. You are caring for a client with a frostbite on the feet. Place the following interventions in the correct order.

  • 1. Immerse the feet in warm water 100° F to 105° F (40.6º C to 46.1° C).
  • 2. Remove the victim from the cold environment.
  • 3. Monitor for signs of compartment syndrome.
  • 4. Apply a loose, sterile, bulky dressing.
  • 5. Administer a pain medication.

A. 5, 2, 1, 3, 4
B. 2, 5, 1, 4, 3
C. 2, 1, 5, 3, 4
D. 3, 2, 1, 4, 5

7. Following an emergency endotracheal intubation, nurses must verify tube placement and secure the tube. List in order the steps that are required to perform this function?

  • 1. Obtain an order for a chest x-ray to document tube placement.
  • 2. Confirm that the breath sounds are equal and bilateral.
  • 3. Auscultate the chest during assisted ventilation.
  • 4. Secure the tube in place.

A. 1, 2, 3, 4
B. 4, 3, 2, 1
C. 3, 2, 4, 1
D. 4, 1, 2, 3

8. A 15-year-old male client arrives at the emergency department. He is conscious, coherent and ambulatory, but his shirt and pants are covered with blood. He and his hysterical friends are yelling and trying to explain 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. “He’s a diabetic, so he needs attention right away.”
B. “There was a lot of blood and we used three bandages.”
C. “The stick was really dirty and covered with mud.”
D. “He pulled the stick out, just now, because it was hurting him.”

9. 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 Situational Low Self-esteem related to police custody.
B. Risk for Nutritional Deficit related to chronic alcohol abuse.
C. Risk for Injury related to seizures.
D. Risk for Other-Directed Violence related to hallucinations.

10. 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.

11. 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 Impaired Mobility related to potential tendon damage.
B. Risk for Infection related to organisms specific to cat bites.
C. Ineffective Health Maintenance related to immunization status.
D. Impaired Skin Integrity related to puncture wounds.

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

  • 1. Assess for spontaneous respirations.
  • 2. Give supplemental oxygen per mask.
  • 3. Insert a Foley catheter if not contraindicated.
  • 4. Obtain a full set of vital signs.
  • 5. Remove patient’s clothing.
  • 6. Secure/start two large-bore IVs with normal saline.
  • 7. Use the chin lift or jaw thrust method to open the airway.

A. 1, 7, 2, 6, 4, 5, 3
B. 7, 1, 4, 2, 3, 5, 6
C. 4, 1, 5, 7, 6, 3, 2
D. 5, 4, 1, 7, 2, 6, 3

13. 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. Lorazepam (Ativan) IV.
B. Magnesium sulfate IV.
C. Carbamazepine (Tegretol) IV.
D. Phenytoin and Carbamazepine PO.

14. A client arrived at the emergency department after suffering multiple physical injuries including a fractured pelvis from a vehicular accident. Upon assessment, the client is incoherent, pale, and diaphoretic. With vital signs as follows: temperature of 97°F (36.11° C), blood pressure of 60/40 mm Hg, heart rate of 143 beats/minute, and a respiratory rate of 30 breaths/minute. The client is mostly suffering from which of the following shock?

A. Cardiogenic.
B. Distributive.
C. Hypovolemic.
D. Obstructive.

15. Which of these is not classified as a Category A biologic agent?

A. Staphylococcus enterotoxin B (SEB).
B. Clostridium botulinum toxin (botulism).
C. Bacillus anthracis (anthrax).
D. Francisella tularensis (tularemia).

16. A 15-year-old male client was sent to the emergency unit following a small laceration on the forehead. The client says that he can’t move his legs. Upon assessment, respiratory rate of 20, strong pulses, and capillary refill time of less than 2 seconds. Which triage category would this client be assigned to?

A. Black.
B. Green.
C. Red.
D. Yellow.

17. An ER nurse is handling a 50-year-old woman complaining of dizziness and palpitations that occur from time to time. ECG confirms the diagnosis of paroxysmal supraventricular tachycardia. The client seems worried about it. Which of the following is an appropriate response of the nurse?

A. “You can be discharged now; this is a probable sign of anxiety.”
B. “You have to stay here for a few hours to undergo blood tests to rule out myocardial infarction.”
C. “We’ll need to keep you for further assessment; you may develop blood clots.”
D. “The physician will prescribe you blood-thinning medications to lessen the episodes of palpitations.”

18. A client was brought to the ED due to an abdominal trauma caused by a motorcycle accident. During the assessment, the client complains of epigastric pain and back pain. Which of the following is true regarding the diagnosis of pancreatic injury?

A. Redness and bruising may indicate the site of the injury in blunt trauma.
B. The client is symptom-free during the early post-injury period.
C. Signs of peritoneal irritation may indicate pancreatic injury.
D. All of the above.

19. A 20-year-old male client was brought to the emergency department with a gunshot wound to the chest. In obtaining a history of the incident to determine possible injuries, the nurse should ask which of the following?

A. “What was the initial first aid done?”
B. “Where did the incident happen?”
C. “What direction did the bullet enter into the body?”
D. “How long ago did the incident occur?”

20. When attending a client with a head and neck trauma following a vehicular accident, the nurse’s initial action is to?

A. Do oral and nasal suctioning.
B. Provide oxygen therapy.
C. Initiate intravenous access.
D. Immobilize the cervical area.

Answers and Rationale

Below are the answers and rationale for the questions above. If you think the answers are wrong, please comment below.

1. Answer: C. 4, 3, 1, 2

An irritable infant with fever and petechiae should be further assessed for other meningeal signs. The patient with the head wound needs additional history and assessment for intracranial pressure. The patient with moderate abdominal pain is uncomfortable, but not unstable at this point. For the ankle injury, a medical evaluation can be delayed 24 – 48 hours if necessary.

2. Answer: D. Brief neurologic assessment.

A brief neurologic assessment to determine the level of consciousness and pupil reaction is part of the primary survey. Vital signs, client’s allergy, and initiation of pulse oximetry are considered part of the secondary survey.

3. Answer: C. Emergent.

Chest pain is considered an emergent priority, which is defined as potentially life-threatening.

  • Option B: Clients with urgent priority need treatment within 2 hours of triage (e.g. kidney stones).
  • Option A: Non-urgent conditions can wait for hours or even days.
  • Option D: High urgent is not commonly used; however, in 5-tier triage systems, High urgent patients fall between emergent and urgent in terms of the time elapsing prior to treatment.

4. Answer: D. 5, 1, 4, 3, 2

Establish unresponsiveness first. (The patient may have fallen and sustained a minor injury.) If the patient is unresponsive, get help and have someone initiate the code. Performing the chin lift or jaw thrust maneuver opens the airway. The nurse is then responsible for starting CPR. CPR should not be interrupted until the patient recovers or it is determined that heroic efforts have been exhausted. A crash cart should be at the site when the code team arrives; however, basic CPR can be effectively performed until the team arrives.

5. Answer: A. Provide emotional support and supportive communication.

The LPN/LVN is able to listen and provide emotional support for her patients.

  • Options B, C, and D: The other tasks are the responsibility of an RN or, if available, a SANE (sexual assault nurse examiner) who has received training to assess, collect and safeguard evidence, and care for these victims.

6. Answer: B. 2, 5, 1, 4, 3

The victim should be removed from the cold environment first, and then the rewarming process can be initiated. It will be painful, so give pain medication prior to immersing the feet in a warmed water.

7. Answer: C. 3, 2, 4, 1

Auscultating and confirming equal bilateral breath sounds should be performed in rapid succession. If the sounds are not equal or if the sounds are heard over the mid-epigastric area, tube placement must be corrected immediately. Securing the tube is appropriate while waiting for the x-ray study.

8. Answer: D. “He pulled the stick out, just now, because it was hurting him.”

An impaled object may be providing a tamponade effect, and removal can precipitate sudden hemodynamic decompensation. Additional history including a more definitive description of the blood loss, depth of penetration, and medical history should be obtained. Other information, such as the dirt on the stick or history of diabetes, is important in the overall treatment

  • Options A and C: Other information, such as the dirt on the stick or history of diabetes, is important in the overall treatment plan, but can be addressed later.

9. Answer: C. Risk for Injury related to seizures.

The client shows neurologic hyperactivity and is on the verge of a seizure. Patient safety is the priority. The patient needs chlordiazepoxide (Librium) to decrease neurologic irritability and phenytoin (Dilantin) for seizures. Thiamine and haloperidol (Haldol) will also be ordered to address the other problems.

  • Options A, B, and D: The other diagnoses are pertinent but not as immediate.

10. Answer: D. Monitor an asymptomatic near-drowning victim.

The asymptomatic patient is currently stable but should be observed for delayed pulmonary edema, cerebral edema, or pneumonia.

  • Options A and B: Teaching and care of critical patients are an RN responsibility.
  • Option C: Removing clothing can be delegated to a nursing assistant.

11. Answer: B. Risk for Infection related to organisms specific to cat bites.

Cat’s mouths contain a virulent organism, Pasteurella multocida, that can lead to septic arthritis or bacteremia.

  • Options A and D: There is also a risk for tendon damage due to deep puncture wounds. These wounds are usually not sutured.
  • Option C: A tetanus shot can be given before discharge.

12. Answer: A. 1, 7, 2, 6, 4, 5, 3

For multiple trauma victims, a lot of interventions will occur simultaneously as team members assist in the resuscitation. Methods to open the airway such as the chin lift or jaw thrust can be used simultaneously while assessing for spontaneous respirations. However, airway and oxygenation are a priority. Starting IVs for fluid resuscitation is part of supporting circulation. (EMS will usually establish at least one IV in the field.) Nursing assistants can be directed to take vitals and remove clothing. Foley catheter is necessary to closely monitor output.

13. Answer: A. Lorazepam (Ativan) IV.

IV Lorazepam (Ativan) is the drug of choice for status epilepticus.

  • Option B: Magnesium sulfate is given to control seizures in toxemia of pregnancy.
  • Option C: Tegretol is used in the management of generalized tonic-clonic, absence or mixed type seizures, but it does not come in an IV form.
  • Option D: PO (per os) medications are inappropriate for this emergency situation.

14. Answer: C. Hypovolemic. 

Hypovolemic shock occurs when the volume of the circulatory system is too depleted to allow adequate circulation to the tissues of the body. A fractured pelvis will lose about one liter of blood hence symptoms such as hypotension, tachycardia, and tachypnea will occur.

  • Option A: Causes of cardiogenic include massive myocardial infarction or other cause of primary cardiac (pump) failure.
  • Option B: Distributive shock results from a relative inadequate intravascular volume caused by arterial or venous vasodilation.
  • Option D: Obstructive shock is a form of shock associated with physical obstruction of the major vessels or the heart itself.

15. Answer: A. Staphylococcus enterotoxin B (SEB).

Staphylococcus enterotoxin B (SEB) belongs to the category B priority pathogen.

16. Answer: D. Yellow.

The client is possibly suffering from a spinal injury but otherwise, has a stable status and can communicate so the appropriate tag is YELLOW.

17. Answer: C. “You have to stay to undergo an electrophysiology study as per doctor’s advice.”

Paroxysmal supraventricular tachycardia (PSVT) is characterized by episodes of rapid heart rate that occurs periodically and stops on its own. PSVT decreases the cardiac output and can result to a thrombus. These clots could turn into an embolus, which could eventually lead to a stroke.

18. Answer: D. All of the above

Blunt injury resulting from vehicular accidents could cause pancreatic injury. Redness, bruising in the flank and severe peritoneal irritation are signs of a pancreatic injury. The client is usually pain-free during the early post-injury period, hence a comprehensive assessment and monitoring should be done.

19. Answer: C. “What direction did the bullet enter into the body?”

The entry point and direction of the bullet will predict the involve injuries of the client.

  • Options A, B, and D: The other information is not as useful in determining which diagnostic studies and care are needed immediately.

20. Answer: D. Immobilize the cervical area.

Clients with suspected or possible cervical spine injury must have their neck immobilized until formal assessment occurs.

  • Options A, B, and C: Suctioning, oxygen therapy, and intravenous access are also done after the cervical spine is immobilized.

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