Q.01. A nurse receives a telephone call from the post-anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to do which of the following first on arrival of the client?
a) check tubes or drains for patency
b) check the dressing to assess for bleeding
c) assess the vital signs to compare with preoperative measurements.
d) assess the patency of the airway
Q.02. A nurse on the day shift walks into a client's room and finds the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. The next nursing action is which of the following?
a) give the client oxygen
b) start chest compressions
c) open the airway
d) ventilate with a mouth-to-mask device
Q.03. A nurse is caring for a pregnant client with preeclampsia. The nurse prepares a plan of care for the client and documents in the plan that if the client progresses for preeclampsia to eclampsia, the nurse's first action should be to:
a) clear and maintain an open airway
b) administer oxygen by face mask
c) administer magnesium sulfate intravenously
d) assess the blood pressure and fetal heart rate
Q.04. A patient arrives at the emergency department complaining of mid-sternal chest pain. Which of the following nursing action should take priority?
a. Careful assessment of vital signs.
b. A complete history with emphasis on preceding events.
c. An electrocardiogram.
d. Chest exam with auscultation.
Q.05. A patient arrives in the emergency department and reports splashing concentrated household cleaner in his eye. Which of the following nursing actions is a priority?
a. Place fluorescein drops in the eye.
b. Patch the eye.
c. Test visual acuity.
d. Irrigate the eye repeatedly with normal saline solution.
Q.06. A patient arrives at the emergency department with severe lower leg pain after a fall in a touch football game. Following routine triage, which of the following is the appropriate next step in assessment and treatment?
A. Apply heat to the painful area.
B. Apply an elastic bandage to the leg.
c. Give pain medication.
d. X-ray the leg.
Q.07. A patient arrives at the emergency department complaining of back pain. He reports taking at least 3 acetaminophen tablets every three hours for the past week without relief. Which of the following symptoms suggests acetaminophen toxicity?
A. Tinnitus.
b. Hepatic damage.
C. Hypertension.
d. Diarrhea.
Q.08. A patient is brought to the emergency department after a bee sting. The family reports a history of severe allergic reaction, and the patient appears to have some oral swelling. Which of the following is the most urgent nursing action?
a. Consult a physician.
b. Administer epinephrine subcutaneously.
c. Administer diphenhydramine (Benadryl) orally.
d. Maintain a patent airway.
Q.09. A nurse enters a room and finds a client lying on the floor. Which action should the nurse perform first?
a) call for help to get the client back in bed
b) assist the client back to bed
c) ask the client what happened
d) establish whether the client is responsive
Q.10. A client presents to the emergency room with dyspnea, chest pain, and syncope. The nurse assesses the client and notes that the client is pale and diaphoretic with blood pressure 94/60, respiration 32. The client is anxious, fearing death. Which action should the nurse take first?
a) administer oxygen per nasal cannula
b) administer pain medication
c) administer IV fluids
d) administer dopamine
Q.11. The nurse is providing care in the emergency department to the client with chest pain. Which action is most important for the nurse to do first?
a) perform venipuncture and start an IV line
b) start lidocaine (xylocaine) infusion
c) administer oxygen via nasal cannula
d) administer morphine sulfate intravenously
Answer & Rational
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