NUR 265 Emergency Nursing and Patient Care Exam 4 Questions with Verified Answers (2026)

NUR 265 Emergency Nursing and Patient Care Exam 4 Questions with Verified Answers (2026) 1. Penetrating Trauma - ANSWER Object pierces the skin and enters the body creating open wound Most common in the US are gunshot and stab wounds Primary assessment to maintain ABCs Control bleeding and evaluate neurologic status Head trauma has high mortality rate 2. Emergency vs Mass Casualty Incident (MCI) - ANSWER MCIs usually involve large numbers of victims, physical and emotional suffering MCIs always require assistance from resources outside the affected community First responders triage and designate injury's seriousness: Red (life-threatening) Yellow (urgent but not life-threatening) Green (minor injuries) 3. Important goals of emergency nursing - ANSWER Recognition of life-threatening illness or injury Reverse or prevent crisis Prompt identification of patients who need immediate treatment Triage - ANSWER The process of rapidly determining patient acuity Life-threatening problems are treated first TRIAGE SYSTEM Identifies and categorizes patients Emergency severity index 4. The nurse working in the ED has triaged a client who presented with chest pain, sob, a productive cough and reports or night sweats. The client has a health hx of AIDS and recents labs show a low CD4+ count. Which of the following actions should the nurse take next? - Initiate airborne precautions - Check the clients temp - Assess the client for shingles - Obtain a throat culture - ANSWER Initiate airborne precautions 5. The newly hired nurse is developing a plan of care for a client who has acquired AIDS and was just diagnosed with PJP. Which of the following interventions should the nurse preceptor question? - Offering the client foods high in calories and protein - Instructing the client to drink at least 2-3L of fluid throughout the day - Wearing a surgical mask when standing within 3 ft of the client - Auscultating the client's breath sounds for crackles at least once per shift - ANSWER Wearing a surgical mask when standing within 3 ft of the client. 6. The nurse is caring for a patient who has AIDS and has just been diagnosed with toxoplasmosis encephalitis. Which of the following actions should the nurse take? - Thicken the pt's liquids to honey consistency - Initiate airborne precautions for the next 72 hrs - Ask the client if they ingested undercooked meat - Monitor the client's level of orientation - ANSWER Ask the client if they ingested undercooked meat. 7. The nurse working in a community health center has instructed a group of clients who have AIDS about ways to prevent infection. Which of the following statements by a client indicated the need for additional teaching? - I should clean my toothbrush by running it through the dishwasher once a week - I will avoid eating undercooked fruits and veggies - I will notify my provider if my temp is greater than 101 F - I will avoid drinking water that has been standing for longer than an hour. - ANSWER I will notify my primary healthcare provider if my temp is greater than 101 F 8. The nurse is admitting a client who has AIDS and has developed an infection caused by cryptosporidium. Which of the following client statements is consistent with the diagnosis? - "I have lost 5 lbs this past week" - "I have developed a persistent dry cough" - "I have noticed that my speech has become slurred" -"I have noticed that my food does not taste the same" - ANSWER "I have noticed that my speech has become slurred" 9. The nurse is caring for a client who had a heart transplant 10 years ago. Which findings from the box below require follow-up by the nurse? Prolonged prothrombin time (PT) Activity intolerance Weight gain of 3 lbs Shortness of breath Hypotension Irritability - ANSWER 2. Activity intolerance 10. The nurse attended a conference about kidney transplantations. Which of the following clients who had end-stage renal disease (ESRD) does the nurse recognize as being a transplant candidate? - a 35 yr old client who is reporting burning with urination and is receiving abdominal radiation - a 42 yr old client who is sobbing after receiving a new diagnosis of ovarian cancer - a 24 yr old client who is receiving neck radiation and is reporting xerostomia - a 56 yr old client who is receiving chest radiation and has developed changes in taste. - ANSWER A 35 yr old client who is reporting burning with urination and is receiving abdominal radiation 11. The nurse is caring for a client who has a liver transplant 48 hours ago. It is a priority for the nurse to notify the PHCP if the client has - An increasing bilirubin level - Scant amounts of serosanguinous drainage from the incision - A urine output that has decreased from 65 to 45mL/ Hr since surgery - An increase in BP from 115/68 to 122/74 - ANSWER An increasing bilirubin level 12. The nurse is caring for a client who had a lung transplant 10 days ago. It is a priority for the nurse to notify the PHCP if the client has - Only used the incentive spirometer once since last evening - Developed sputum that is yellow-tinged - A pain rating of 7/10 when taking a deep-breath - Refused high- frequency chest wall oscillation for the past 24 hrs. - ANSWER Developed sputum that is yellow-tinged 13. The nurse is caring for a client who had a kidney transplant 2 week ago. Which findings from the box below should the nurse correlate to possible organ rejection? Blood pressure of 116/66 Serum creatinine lvl of 2.5 Urinalysis is positive for protein Serum potassium level of 5.8 14. Blood urea nitrogen (BUN) levl of 30. - ANSWER 2. Serum creatinine lvl of 2.5 4. Serum potassium level of 5.8 Blood urea nitrogen (BUN) levl of 30. 15. The nurse working in the PHCP office has just administered a routine immunization to a client. The client is asked to wait in the waiting room for the next 15 minutes. five minutes later, the client develops swlling of the eyes and reports feeling anxious, SOB, and dizzy. Which of the following actions should the nurse take first? - Elevate the client's feet and legs - Perform a respiratory assessment - Prepare tp administer diphenhydramine - Obtain a full set of vital signs. - ANSWER Perform a respiratory assessment 16. The nurse working in the emergency department (ED) is admitting a client who presents with stridor, dyspnea, and bronchospasm after being stung by a bee. After notifying the ED health care provider, which of the following action should the nurse take next? -Administer an Albuterol nebulizer treatment. -Initiate oxygen via a nonrebreather mask. -Remove the bee sting from the site of the sting. -Prepare to administer a corticosteroid. - ANSWER Initiate oxygen via a nonrebreather mask. 17. The newly hired nurse has attended a continuing education conference regarding anaphylaxis with allergen exposure. Which of the following statements by the newly hired nurse indicates a need for further education? -"The client may present with widespread hives and hypoxia." -"The client may present with swollen lips and tongue". -"The client may report new-onset abdominal cramping with hyperreflexia." -"The client may have audible wheezes and cyanosis." - ANSWER "The client may report new-onset abdominal cramping with hyperreflexia."