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Exam (elaborations)

NCLEX ED and Disaster Questions and Answers MAY 2022-100% GRADE A+

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1. An emergency room nurse assesses a patient who has been raped. With which healthcare team member would the nurse collaborate when planning this patient’s care? A. Emergency medicine physician B. Case manager C. Forensic nurse examiner D. Psychiatric crisis nurse 2. The emergency department team is performing cardiopulmonary resuscitation on a patient when the patient’s spouse arrives at the emergency department. Which action would the nurse take first? A. Request that the patient’s spouse sit in the waiting room. B. Ask the spouse if he wishes to be present during the resuscitation. C. Suggest that the spouse begin to pray for the patient. D. Refer the patient’s spouse to the hospital’s crisis team. 3. An emergency room nurse is triaging victims of a multi-casualty event. Which patient would receive care first? A. A 30-year-old distraught mother holding her crying child B. A 65-year-old conscious male with a head laceration C. A 26-year-old male who has pale, cool, clammy skin D. A 48-year-old with a simple fracture of the lower leg 4. While triaging patients in a crowded emergency department, a nurse assesses a patient who presents with symptoms of tuberculosis. Which action would the nurse take first? A. Apply oxygen via nasal cannula. B. Administer intravenous 0.9% saline solution. C. Transfer the patient to a negative-pressure room. D. Obtain a sputum culture and sensitivity. 5. A nurse is triaging patients in the emergency department (ED). Which patient would the nurse prioritize to receive care first? A. A 22-year-old with a painful and swollen right wrist B. A 45-year-old reporting chest pain and diaphoresis C. A 60-year-old reporting difficulty swallowing and nausea D. An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101° F (38.8° C) 6. A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center? A. Level I—located within remote areas and provides advanced life support within resource capabilities B. Level II—located within community hospitals and provides care to most injured patients C. Level III—located in rural communities and provides only basic care to patients D. Level IV—located in large teaching hospitals and provides a full continuum of trauma care for all patients 7. Emergency medical technicians arrive at the emergency department with an unresponsive patient who has an oxygen mask in place. Which action would the nurse take first? A. Assess that the patient is breathing adequately. B. Insert a large-bore intravenous line. C. Place the patient on a cardiac monitor. D. Assess for the best neurologic response. 8. A trauma patient with multiple open wounds is brought to the emergency department in cardiac arrest. Which action would the nurse take prior to providing advanced cardiac life support? A. Contact the on-call orthopedic surgeon. B. Don personal protective equipment. C. Notify the Rapid Response Team. D. Obtain a complete history from the paramedic. 9. A nurse is triaging patients in the emergency department. Which patient would be considered “urgent”? A. A 20-year-old female with a chest stab wound and tachycardia B. A 45-year-old homeless man with a skin rash and sore throat C. A 75-year-old female with a cough and a temperature of 102° F (38.9° C) D. A 50-year-old male with new-onset confusion and slurred speech 10. An emergency department nurse is caring for a patient who has died from a suspected homicide. Which action does the nurse take? A. Remove all tubes and wires in preparation for the medical examiner. B. Limit the number of visitors to minimize the family’s trauma. C. Consult the bereavement committee to follow up with the grieving family. D. Communicate the patient’s death to the family in a simple and concrete manner. 11. An emergency department (ED) case manager is consulted for a patient who is homeless. Which intervention would the case manager provide? A. Communicate patient needs and restrictions to support staff. B. Prescribe low-cost antibiotics to treat community-acquired infection. C. Provide referrals to subsidized community-based health clinics. D. Offer counseling for substance abuse and mental health disorders. 12. An emergency department nurse is caring for a patient who is homeless. Which action would the nurse take to gain the patient’s trust? A. Speak in a quiet and monotone voice. B. Avoid eye contact with the patient. C. Listen to the patient’s concerns and needs. D. Ask security to store the patient’s belongings. 13. A nurse is triaging patients in the emergency department. Which patient would the nurse classify as “nonurgent?” A. A 44-year-old with chest pain and diaphoresis B. A 50-year-old with chest trauma and absent breath sounds C. A 62-year-old with a simple fracture of the left arm D. A 79-year-old with a temperature of 104° F (40.0° C) 14. What is the primary goal of a triage system used by the nurse with patients presenting to the emergency department? A. Determine the acuity of the patient’s condition to determine priority of care. B. Assess the status of the airway, breathing, circulation, or presence of deficits. C. Determine whether the patient is responsive enough to provide needed information. D. Evaluate the emergency department’s resources to adequately treat the patient. 15. An elderly patient who has fallen from a roof is transported to the emergency department by ambulance. The patient was unconscious at the scene but is conscious on arrival and is triaged as urgent. What is the priority assessment the nurse includes during the primary survey of the patient? A. A full set of vital signs B. Cardiac rhythm C. Neurological status D. Patient history

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