Emergency Nursing Test Bank(NCLEX reviewer and practice questions WITH RATIONALE)

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Emergency Nursing Test Bank




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Emergency Nursing & Triage NCLEX Challenge Exam (Quiz #1: 20 Questions)




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1.​ 1. Question




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1 point(s)




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Nurse Ejay is assigned to telephone triage. A client called who was stung by a

honeybee and is asking for help. The client reports pain and localized swelling




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but has no respiratory distress or other symptoms of anaphylactic shock. What is




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the appropriate initial action that the nurse should direct the client to perform?




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○​ A. Removing the stinger by scraping it




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○​ B. Applying a cold compress




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○​ C. Taking an oral antihistamine




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○​ D. Calling 911


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Correct Answer: A. Removing the stinger by scraping it.


Since the stinger will continue to release venom into the skin, removing the

stinger should be the first action that the nurse should direct to the client. Within

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the first few minutes after the sting, the stinger should be removed via scraping

with a credit card rather than squeezing/tweezing to avoid further venom

exposure.


○​ Option B: Uncomplicated local reactions can be treated with




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supportive care (ice packs, NSAIDs/APAP for pain, H1/H2 blocker).




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Cold compress follows the administration of antihistamine. Large




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local reactions should also be treated with supportive care along




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with glucocorticoids (usually a burst course of prednisone 40 to 60




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mg per day for 3 to 5 days) to decrease the inflammatory response

and improve symptoms.




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○​ Option C: After removing the stinger, an antihistamine is




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administered. H1 and H2 antagonists block the effects of histamine




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decreasing pruritus, erythema, and urticaria. Corticosteroids




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(prednisone, methylprednisolone, dexamethasone) act to decrease

inflammation and immune response to the antigen.




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○​ Option D: The caller should be further advised about symptoms that




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require 911 assistance. Systemic reactions (anaphylaxis) are

life-threatening and should be managed as such. ABCs first. The

airway can be lost within seconds to minutes, so intubate early. As

with any anaphylactic reaction, epinephrine, corticosteroids, H1 and

H2 antagonists, and intravenous (IV) fluids should be given

immediately.

2.​ 2. Question

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1 point(s)


Nurse Anna is an experienced travel nurse who was recently employed and is

assigned to the emergency unit. In her first week of the job, which of the

following area is the most appropriate assignment for her?




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○​ A. Triage

○​ B. Ambulatory section




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○​ C. Trauma team




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○​ D. Psychiatric care




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Correct




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Correct Answer: B. Ambulatory section




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The ambulatory section deals with clients with relatively stable conditions. The

decision of whether or not to delegate or assign is based upon the RN’s judgment




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concerning the condition of the patient, the competence of all members of the




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nursing team and the degree of supervision that will be required of the RN if a




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task is delegated.




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○​ Option A: The RN delegates only those tasks for which he or she

believes the other health care worker has the knowledge and skill to

perform, taking into consideration training, cultural competence,

experience and facility/agency policies and procedures.

○​ Option C: This area should be filled with nurses who are experienced

with hospital routines and policies and have the ability to locate

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equipment immediately. There is both individual accountability and

organizational accountability for delegation. Organizational

accountability for delegation relates to providing sufficient

resources, including sufficient staffing with an appropriate staff mix.​




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Option D: Few places are more hectic than a Hospital Emergency




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Room. Clearly, delegating important nursing tasks is the only




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plausible way for short-staffed emergency rooms to meet the

challenges of providing quality patient care. All decisions related to




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delegation and assignment are based on the fundamental principles




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of protection of the health, safety, and welfare of the public.”




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3.​ 3. Question




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1 point(s)




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A client arrives at the emergency department who suffered multiple injuries from




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a head-on car collision. Which of the following assessment should take the




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highest priority to take?




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○​ A. Unequal pupils




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○​ B. Irregular pulse

○​ C. Ecchymosis in the flank area

○​ D. A deviated trachea


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Correct Answer: D. A deviated trachea