,NSG 233 Exam 1 Medical-Surgical Nursing III Questions And
Answers 2026/2027 Herzing University
Q1. Which triage category is the highest priority in the Emergency Severity
Index (ESI)?
A) Level 1
B) Level 2
C) Level 3
D) Level 5
Correct Answer: A) Level 1
Rationale: ESI level 1 identifies clients requiring immediate life-saving
intervention.
Q2. Which client should the emergency department triage nurse assess first?
A) Client with a sprained ankle and stable vital signs
B) Client with a superficial laceration and controlled bleeding
C) Client with severe respiratory distress and cyanosis
D) Client requesting a prescription refill
Correct Answer: C) Client with severe respiratory distress and cyanosis
Rationale: Airway and breathing problems that threaten life take priority
over stable injuries and nonurgent conditions.
Q3. Which action is a primary responsibility of the ED triage nurse?
A) Assign clients according to urgency and resource needs
B) Complete all definitive diagnoses
C) Perform surgery
D) Discharge every stable client
Correct Answer: A) Assign clients according to urgency and resource needs
Rationale: Triage prioritizes clients based on acuity and anticipated
treatment needs so the most urgent conditions receive immediate attention.
Q4. A client arrives at the emergency department with a minor ankle sprain
and stable vital signs. Which triage level is most appropriate if the client
requires minimal resources?
A) ESI level 1
B) ESI level 2
C) ESI level 4
D) ESI level 5
Correct Answer: D) ESI level 5
Rationale: ESI level 5 applies to clients who are stable and are expected to
require no resources beyond examination and assessment.
, Q5. Which client is most appropriately classified as emergent?
A) Client with mild nausea for 2 days
B) Client with a life-threatening airway obstruction
C) Client with a chronic rash
D) Client requesting a routine medication refill
Correct Answer: B) Client with a life-threatening airway obstruction
Rationale: A threatened airway is an immediate life-threatening condition
requiring immediate intervention.
Q6. Which safety measure is most appropriate when an ED client becomes
physically aggressive?
A) Stand directly within grabbing distance.
B) Maintain an exit route and summon assistance.
C) Turn away from the client.
D) Remove all security personnel.
Correct Answer: B) Maintain an exit route and summon assistance.
Rationale: Staff safety is a priority when violence is possible. Maintaining
distance, an escape route, and adequate support reduces injury risk.
Q7. Which intervention should be attempted when a potentially violent client
can still be verbally redirected?
A) Immediate physical restraint in every situation
B) Calm communication and reduction of environmental stimulation
C) Isolation without assessment
D) Physical confrontation
Correct Answer: B) Calm communication and reduction of environmental
stimulation
Rationale: Nonphysical de-escalation should be attempted when clinically
safe before restrictive interventions.
Q8. A violent client requires restraints. Which nursing responsibility is
essential?
A) Apply restraints and never reassess them.
B) Monitor the client and document the reason, response, and ongoing need.
C) Use restraints as punishment.
D) Leave the restrained client unattended.
Correct Answer: B) Monitor the client and document the reason, response,
and ongoing need.
Rationale: Restrictive interventions require ongoing monitoring, appropriate
documentation, and reassessment for continued necessity.
Answers 2026/2027 Herzing University
Q1. Which triage category is the highest priority in the Emergency Severity
Index (ESI)?
A) Level 1
B) Level 2
C) Level 3
D) Level 5
Correct Answer: A) Level 1
Rationale: ESI level 1 identifies clients requiring immediate life-saving
intervention.
Q2. Which client should the emergency department triage nurse assess first?
A) Client with a sprained ankle and stable vital signs
B) Client with a superficial laceration and controlled bleeding
C) Client with severe respiratory distress and cyanosis
D) Client requesting a prescription refill
Correct Answer: C) Client with severe respiratory distress and cyanosis
Rationale: Airway and breathing problems that threaten life take priority
over stable injuries and nonurgent conditions.
Q3. Which action is a primary responsibility of the ED triage nurse?
A) Assign clients according to urgency and resource needs
B) Complete all definitive diagnoses
C) Perform surgery
D) Discharge every stable client
Correct Answer: A) Assign clients according to urgency and resource needs
Rationale: Triage prioritizes clients based on acuity and anticipated
treatment needs so the most urgent conditions receive immediate attention.
Q4. A client arrives at the emergency department with a minor ankle sprain
and stable vital signs. Which triage level is most appropriate if the client
requires minimal resources?
A) ESI level 1
B) ESI level 2
C) ESI level 4
D) ESI level 5
Correct Answer: D) ESI level 5
Rationale: ESI level 5 applies to clients who are stable and are expected to
require no resources beyond examination and assessment.
, Q5. Which client is most appropriately classified as emergent?
A) Client with mild nausea for 2 days
B) Client with a life-threatening airway obstruction
C) Client with a chronic rash
D) Client requesting a routine medication refill
Correct Answer: B) Client with a life-threatening airway obstruction
Rationale: A threatened airway is an immediate life-threatening condition
requiring immediate intervention.
Q6. Which safety measure is most appropriate when an ED client becomes
physically aggressive?
A) Stand directly within grabbing distance.
B) Maintain an exit route and summon assistance.
C) Turn away from the client.
D) Remove all security personnel.
Correct Answer: B) Maintain an exit route and summon assistance.
Rationale: Staff safety is a priority when violence is possible. Maintaining
distance, an escape route, and adequate support reduces injury risk.
Q7. Which intervention should be attempted when a potentially violent client
can still be verbally redirected?
A) Immediate physical restraint in every situation
B) Calm communication and reduction of environmental stimulation
C) Isolation without assessment
D) Physical confrontation
Correct Answer: B) Calm communication and reduction of environmental
stimulation
Rationale: Nonphysical de-escalation should be attempted when clinically
safe before restrictive interventions.
Q8. A violent client requires restraints. Which nursing responsibility is
essential?
A) Apply restraints and never reassess them.
B) Monitor the client and document the reason, response, and ongoing need.
C) Use restraints as punishment.
D) Leave the restrained client unattended.
Correct Answer: B) Monitor the client and document the reason, response,
and ongoing need.
Rationale: Restrictive interventions require ongoing monitoring, appropriate
documentation, and reassessment for continued necessity.
