Florida NCLEX Exam Emergency Nursing Care Updated Exam 2026
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Questions (Actual Exam 2026-2027) Correct Detailed & Verified
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1. A client arrives in the emergency department with severe chest pain. What is the nurse's
priority action?
A. Obtain a complete health history.
B. Perform a rapid assessment of airway, breathing, and circulation.
C. Administer oral pain medication.
D. Ask the client to complete admission paperwork.
Answer: B. Perform a rapid assessment of airway, breathing, and circulation.
Rationale: Emergency nursing follows the ABC (Airway, Breathing, Circulation) approach.
Immediate identification and correction of life-threatening problems take priority over history
taking or paperwork. Chest pain may indicate myocardial infarction, pulmonary embolism, or
aortic dissection, all of which require prompt assessment and intervention.
2. A triage nurse assigns a client with active chest pain and diaphoresis to which Emergency
Severity Index (ESI) level?
A. Level 5
B. Level 4
C. Level 2
D. Level 3
Answer: C. Level 2
Rationale: ESI Level 2 is assigned to high-risk clients who require rapid evaluation due to the
potential for rapid deterioration. Active chest pain with diaphoresis strongly suggests acute
coronary syndrome.
3. Which assessment finding indicates complete airway obstruction?
,A. Loud wheezing
B. Strong cough
C. Inability to speak with absent breath sounds
D. Hoarse voice
Answer: C. Inability to speak with absent breath sounds
Rationale: Complete airway obstruction prevents airflow, resulting in inability to speak, cough,
or breathe. Immediate intervention, such as abdominal thrusts or advanced airway management,
is required.
4. Which client should the emergency nurse assess first?
A. Stable ankle fracture
B. Child with fever of 101°F (38.3°C)
C. Adult with sudden onset facial drooping and slurred speech
D. Client requesting medication refill
Answer: C. Adult with sudden onset facial drooping and slurred speech
Rationale: Sudden neurological deficits indicate a possible acute stroke. Time-sensitive
interventions such as thrombolytic therapy depend on rapid recognition and evaluation.
5. A trauma client has absent breath sounds on the left side and tracheal deviation to the right.
Which condition is most likely?
A. Pulmonary edema
B. Tension pneumothorax
C. Pleural effusion
D. Asthma attack
Answer: B. Tension pneumothorax
Rationale: Tension pneumothorax causes air to accumulate under pressure in the pleural space,
leading to tracheal deviation, absent breath sounds, hypotension, and respiratory distress.
Immediate needle decompression is required.
6. Which intervention has the highest priority for a client with severe external bleeding?
, A. Apply direct pressure to the wound.
B. Elevate the extremity.
C. Administer antibiotics.
D. Clean the wound.
Answer: A. Apply direct pressure to the wound.
Rationale: Direct pressure is the first-line intervention to control hemorrhage. Prompt bleeding
control reduces the risk of hypovolemic shock.
7. Which finding suggests hypovolemic shock?
A. Bradycardia and hypertension
B. Warm flushed skin
C. Tachycardia and hypotension
D. Bounding pulses
Answer: C. Tachycardia and hypotension.
Rationale: As blood volume decreases, the body compensates with tachycardia. Persistent blood
loss eventually leads to hypotension and poor tissue perfusion.
8. A client with suspected cervical spine injury arrives in the emergency department. Which
action is appropriate?
A. Remove the cervical collar immediately.
B. Maintain cervical spine immobilization.
C. Place the client in high Fowler's position.
D. Encourage neck movement.
Answer: B. Maintain cervical spine immobilization.
Rationale: Spinal precautions prevent additional neurological injury until cervical spine injury
has been ruled out through imaging and clinical evaluation.
9. Which laboratory value is most important to monitor in a client receiving massive blood
transfusions?
A. Calcium level
B. Cholesterol level
WITH Recent Newest Verified And Well Analyzed Exam
Questions (Actual Exam 2026-2027) Correct Detailed & Verified
ANSWERS (100% Accurate Solutions) ALREADY GRADED
A+||NEWEST VERSION Of The Exam Guarantee Pass!!
1. A client arrives in the emergency department with severe chest pain. What is the nurse's
priority action?
A. Obtain a complete health history.
B. Perform a rapid assessment of airway, breathing, and circulation.
C. Administer oral pain medication.
D. Ask the client to complete admission paperwork.
Answer: B. Perform a rapid assessment of airway, breathing, and circulation.
Rationale: Emergency nursing follows the ABC (Airway, Breathing, Circulation) approach.
Immediate identification and correction of life-threatening problems take priority over history
taking or paperwork. Chest pain may indicate myocardial infarction, pulmonary embolism, or
aortic dissection, all of which require prompt assessment and intervention.
2. A triage nurse assigns a client with active chest pain and diaphoresis to which Emergency
Severity Index (ESI) level?
A. Level 5
B. Level 4
C. Level 2
D. Level 3
Answer: C. Level 2
Rationale: ESI Level 2 is assigned to high-risk clients who require rapid evaluation due to the
potential for rapid deterioration. Active chest pain with diaphoresis strongly suggests acute
coronary syndrome.
3. Which assessment finding indicates complete airway obstruction?
,A. Loud wheezing
B. Strong cough
C. Inability to speak with absent breath sounds
D. Hoarse voice
Answer: C. Inability to speak with absent breath sounds
Rationale: Complete airway obstruction prevents airflow, resulting in inability to speak, cough,
or breathe. Immediate intervention, such as abdominal thrusts or advanced airway management,
is required.
4. Which client should the emergency nurse assess first?
A. Stable ankle fracture
B. Child with fever of 101°F (38.3°C)
C. Adult with sudden onset facial drooping and slurred speech
D. Client requesting medication refill
Answer: C. Adult with sudden onset facial drooping and slurred speech
Rationale: Sudden neurological deficits indicate a possible acute stroke. Time-sensitive
interventions such as thrombolytic therapy depend on rapid recognition and evaluation.
5. A trauma client has absent breath sounds on the left side and tracheal deviation to the right.
Which condition is most likely?
A. Pulmonary edema
B. Tension pneumothorax
C. Pleural effusion
D. Asthma attack
Answer: B. Tension pneumothorax
Rationale: Tension pneumothorax causes air to accumulate under pressure in the pleural space,
leading to tracheal deviation, absent breath sounds, hypotension, and respiratory distress.
Immediate needle decompression is required.
6. Which intervention has the highest priority for a client with severe external bleeding?
, A. Apply direct pressure to the wound.
B. Elevate the extremity.
C. Administer antibiotics.
D. Clean the wound.
Answer: A. Apply direct pressure to the wound.
Rationale: Direct pressure is the first-line intervention to control hemorrhage. Prompt bleeding
control reduces the risk of hypovolemic shock.
7. Which finding suggests hypovolemic shock?
A. Bradycardia and hypertension
B. Warm flushed skin
C. Tachycardia and hypotension
D. Bounding pulses
Answer: C. Tachycardia and hypotension.
Rationale: As blood volume decreases, the body compensates with tachycardia. Persistent blood
loss eventually leads to hypotension and poor tissue perfusion.
8. A client with suspected cervical spine injury arrives in the emergency department. Which
action is appropriate?
A. Remove the cervical collar immediately.
B. Maintain cervical spine immobilization.
C. Place the client in high Fowler's position.
D. Encourage neck movement.
Answer: B. Maintain cervical spine immobilization.
Rationale: Spinal precautions prevent additional neurological injury until cervical spine injury
has been ruled out through imaging and clinical evaluation.
9. Which laboratory value is most important to monitor in a client receiving massive blood
transfusions?
A. Calcium level
B. Cholesterol level
