POST TEST - EMERGENCY NURSING

1. After gardening, the elderly client is brought into the Emergency Department complaining of cramps,
headache, and weakness [heatstroke]. The nurse applies the cardiac monitor and notes tachycardia. Which
should the nurse include in the assessment?
A. Determine if the client is experiencing any thirst.
B. Administer D5W intravenously at 250 mL per hour.
C. Maintain a cool environment to promote rest.
D. Withhold the client’s oral intake.

2. The nurse is working in the Emergency Department and is assigned a client who suffered a near-
drowning [decrease ang o2]. Which expected outcome should the nurse include in the plan of care for this
client?
A. Maintain cardiac function, including tachycardia.
B. Promote a continued decrease in lung surfactant.
C. Warm rapidly to minimize the effects of hypothermia.
D. Keep the oxygen saturation level above 95%. [normal: 95-100%]

3. A nurse is at the lake when a person experiences a near-drowning event. People at the scene remove
the victim from the water. After breathing, which should the nurse assess first?
A. Possibility of drug use.
B. Spinal cord injury.
C. Airway obstruction. Principle of ABCs
D. Amount of alcohol

4. The nurse is working the triage position in the ED. Which client should be treated first?
A. A client who has multiple injuries from a motor-vehicle accident.
B. A client complaining of epigastric pain and nausea after eating.
C. An elderly client who fell and fractured the left femoral neck. -yellow ain’t life threatening
D. The client suffering from a migraine headache and nausea.

5. The nurse is teaching the client home care instructions for a re-implanted finger after a traumatic
amputation. Which information should the nurse include?
A. Perform range-of-motion exercises weekly.
B. Smoking may be resumed if it does not causing nausea.
C. Protect the finger and be careful not to re-injure the finger.
D. An elevated temperature is the only reason to call the HCP.

6. The ED nurse is caring for a client diagnosed with frostbite of the feet. Which intervention should the
nurse implement?
A. Massage the feet vigorously.
B. Soak the feet in warm water.
C. Apply a heating pad to feet.
D. Apply petroleum jelly to the feet.

7. The client has been brought to the ED by ambulance following a motor-vehicle accident and has suffered
a chest injury. Which intervention should the nurse implement first?
A. Start a large bore intravenous access.
B. Apply the cardiac monitor to the client.
C. Assess the client’s airway and breathing.
D. Assess the cardiac rhythm on the monitor.
8. The emergency room nurse admits a child who experienced a seizure at school. The father comments
that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the
nurse?
A. "Do not worry. Epilepsy can be treated with medications."
B. "The seizure may or may not mean your child has epilepsy."
C. "Since this was the first convulsion, it may not happen again."
D. "Long term treatment will prevent future seizures."

9. A nurse attempts to relieve an airway obstruction on a 3-year-old conscious child. The nurse performs
this maneuver by placing his or her hands between the:
A. Groin and the abdomen.
B. Umbilicus and the groin.
C. Lower abdomen and the chest.
D. Umbilicus and the xiphoid process.

10. A client comes to the emergency room following an assault and is extremely agitated, trembling, and
hyperventilating. The appropriate initial nursing action would be to:
A. Encourage the client to discuss the assault.
B. Place the client in a quiet room alone to decrease stimulation.
C. Remain with the client until the anxiety decreases.
D. Begin to teach relaxation techniques.

11. A client presents to the emergency department with upper gastrointestinal (GI) bleeding and is in
moderate distress. In planning care, which nursing action would be the first priority for this client?
A. Thorough investigation of precipitating events
B. Insertion of a nasogastric tube and Hematest of emesis
C. Complete abdominal examination
D. Assessment of vital signs

12. A client is being seen in the Emergency Room. A diagnosis of Congestive Heart Failure is made. Upon
auscultating the client's lungs the nurse hears crackling sounds bilaterally at the bases. In documenting
these findings, the nurse would state that which of the following was heard:
A. Rhonchi
B. Wheezing
C. Rales/Crackles
D. Atelectasis

13. A homeless individual is brought to the Emergency Room after having been out in subfreezing
temperatures for three to four days. The toes of the patient's right foot appear hard and cold with
mottling, and are unresponsive to touch. Which of the following would not be included in the initial
management of this patient by the Emergency Room nurse?
A. Rewarm the extremity with controlled and rapid rewarming
B. Wrap the affected extremity in a blanket and apply moist heat
C. Place sterile gauze between the affected digits
D. Elevate the affected extremity

14. Which of the following findings is the best indication that fluid replacement for the client with
hypovolemic shock is adequate?
A. Urine output greater than 30ml/hr
B. Respiratory rate of 25 breaths/minute
C. Diastolic blood pressure lesser than 80 mmhg
D. Systolic blood pressure lesser than 110 mmhg
15. A client presents in the emergency department with fever 102°F, malaise, and a productive cough.
Which of the following should be done first?
A. Administer the prescribed antibiotic.
B. Obtain a sputum culture.
C. Administer acetaminophen to lower fever.
D. Teach client the importance of hand washing.

16. Which of the following terms is used to describe minor injuries or illnesses requiring first-aid level of
management?
A. Triage
B. Non- Urgent
C. Emergent
D. Immediate

17. When field triage has occurred and the patient is admitted to the ED with a yellow tag, the ED nurse
recognizes that the tag indicates that the patient requires which type of care?
A. Emergent
B. Immediate
C. Non- Urgent
D. Psychological support

18. An Emergency Department nurse is preparing to assess a male client who reported being sexually
abused by a woman. The nurse’s best response would be:
A. “You are too strong to be abused by a woman.”
B. “What did you do to provoke the woman?”
C. “Please describe what happened.”
D. “Is your preference heterosexual, homosexual or bisexual?”

19. The client diagnosed with septicemia is receiving a broad-spectrum antibiotic. Which laboratory data
require the nurse to notify the health-care provider?
A. The client’s potassium level is 3.8 mEq/L.
B. The urine culture indicates high sensitivity to the antibiotic.
C. The client’s pulse oximeter reading is 94%.
D. The culture and sensitivity is resistant to the client’s antibiotic.

20. When initiating care for a client in the emergency department with an estimated blood loss of 2 L from
a chain saw injury, for which factor should the nurse assess first?
A. Hypovolemia
B. Pain
C. Impaired cognition
D. Peripheral paresthesias

21. The child has fractured extremity after playing in the park. The nurse is trying to assess deformity. What
is the best method that the nurse can perform?
A. Compare the affected extremity to the unaffected side
B. Ask the child about the injury
C. Perform a neurologic assessment
D. Assess if pulse is absent

22. An emergency happened in the ER. A client was on cardiac arrest upon arrival. E-cart was prepared.
The physician asked for PNSS to be given to the patient immediately. The nurse will open which drawer?
A. Drawer 5
B. Drawer 4
C. Drawer 3 -fluids
D. Drawer 2

23. Emergency drugs was also requested by the physician during the code. Which drawer will the nurse
open?
A. Drawer 1-Meds
B. Drawer 2
C. Drawer 3
D. Drawer 4

24. The nurse assesses the GCS of the patient under motor movement. The patient obeys the nurse’s
commands. The nurse scores this as?
A. 6
B. 5
C. 4
D. 3

25. Which equipment must be immediately brought to the client's bedside when a code is called for a
client who has experienced a cardiac arrest?*
A. A Ventilator
B. An Emergency cart
C. A face mask
D. Portable Oxygen

26. The nurse have assessed the patient GCS. The following data were gathered: patient obeys command,
eye movement is spontaneous and patient is alert and coherent. What is the GCS Score of the patient?
A. 14
B. 15
C. 13
D. 12

27. The client is experiencing hemorrhage after being stab 12 times in a bar fight. Which of the following
management is correct?
A. The nurse will infuse packed RBC’s immediately
B. Administer an O + blood type instantly
C. Prepare 2 large bore IV cannula for fluid and blood replacement
D. Hypertonic solutions will be given fast drip

28. The patient was given Digoxin to increase cardiac output. Which of the following patient statements
would alert the nurse?
A. I have color changes in my vision
B. My appetite increases when I take the drug
C. There is mild difficulty in performing my ADL’s
D. My heart is 86bpm
Signs of toxicity*** NAVDA
-NAUSEA
-ANOREXIA
-VISUAL DISTURBANCES
-DIARRHEA
-ABDOMINAL CRAMPS
29. Which of the following interventions is correct when performing wound cleansing?
A. LRS is used to irrigate wound
B. General anesthetics are used
C. Hair around the wound should be shaved
D. Betadine can be used to deep wounds without cleansing

30. A patient with anaphylactic reaction is rushed to the ER. Which of the following interventions is top
priority?
A. Establish airway by early intubation
B. Administration of epinephrine
C. Perform tracheostomy immediately
D. Antihistamines should be delayed