Nur 004 Actual Exam Questions and
Answers| Updated 2025 (answers
highlighted)
The emergency department nurse is triaging clients. Which client is a priority
for diagnostic workup and definitive care?
1. Fell, twisting the right knee; heard a "pop"
2. History of glomerulonephritis; has "iced tea"-colored urine
3. Pain 10/10 in reddened eye; wears contact lens
4. Took a handful of amitriptyline tablets after a fight with spouse
4
The nurse receives report on 4 clients. Which client should the nurse see first?
1. Client 2 hours post foot amputation surgery has a surgical dressing saturated
with bright red blood
2. Client scheduled for whirlpool bath in 20 minutes has the dressing on the
infected foot ulcer fall off
3. Client with arteriovenous graft for hemodialysis access has new-onset pain and
redness at graft site
4. Client with urinary retention and infection receiving antibiotics is confused
and trying to pull out Foley catheter
1
A Spanish-speaking client is admitted for a small bowel obstruction. The surgeon explains
to the client's child, who speaks both Spanish and English, that an exploratory
laparotomy is needed to determine the cause of the obstruction and possible causes
include intestinal adhesions and ovarian or colon cancer. The surgeon asks the child to
translate this information for the client and assist with translating the consent form.
,Which is the most appropriate action by the nurse?
1. Act as a witness for the informed consent process
2. Provide additional information about what the client can expect
3. Report the surgeon to the ethics board for using an inappropriate consent process
4. Talk to the surgeon privately about using a trained Spanish-language
medical interpreter
4
Which client should the charge nurse assign to the room closest to the nurses' station?
1. Client with a Salem sump tube to continuous suction who is deaf
2. Client with gastroenteritis and dementia who wanders
3. Client with herpes zoster under airborne isolation precautions
4. Client with sickle cell crisis who requires frequent intravenous opioids
2
The day nurse gets the following hand-off report from the night nurse. The nurse
should assess which client first?
1. Client with cellulitis, medicated with hydromorphone IV 1 hour ago, reports pain of
6 on a scale of 0-10
2. Client with chronic kidney disease with hemoglobin 8 g/dL (80 g/L) and
hematocrit 24% (0.24), is short of breath with activity
3. Client with heart failure and bilateral pleural effusions with serum sodium of 133
mEq/L (133 mmol/L), is scheduled for a thoracentesis this morning
4. Client with pneumonia and reactive airway disease, developed increased
shortness of breath and high-pitched wheezing 10 minutes ago
4
,There has been a community disaster with multiple victims. Stable clients must be
released to make room for the victims. Which clients would the nurse recommend
as stable for discharge? Select all that apply.
1. Acute head injury with Glasgow Coma Scale of 12
2. Admitted with cirrhosis of liver with oozing esophageal varices
3. Asthma exacerbation with peak flow at 85% of personal best
4. Deep venous thrombosis on IV heparin with platelets 40,000/mm3 (40 × 109/L)
5. Myasthenia gravis with ptosis in the evening
3,5
Multiple clients present to the emergency department. Which client should the
triage nurse prioritize for additional diagnostic testing and definitive treatment?
1. Client at 11 weeks gestation with productive yellow phlegm cough but
no abdominal pain
2. Client with Alzheimer disease who developed restlessness and confusion today
3. Client with deformed forearm who has normal circulation, movement,
and sensation; pain rated "8"
4. Client with epilepsy who had a seizure at work today but is now alert and oriented
2
The nurse receives a report on 4 clients. Which client should the nurse assess first?
1. A 29-year-old heroin user admitted for arm cellulitis 24 hours ago has
abdominal cramps and is restless
2. A 34-year-old admitted with femur fracture 24 hours ago is confused and has SpO2
of 91%
3. A 65-year-old admitted with serum sodium of 125 mEq/L (125 mmol/L) 8 hours ago
is confused
, 4. A 78-year-old admitted for urinary tract infection 6 hours ago is disoriented to
time and place
2
A housekeeping employee tells the staff nurse of having a headache and asks
for acetaminophen. How should the nurse respond?
1. Ask about liver disease and give acetaminophen from the nurse's personal supply
2. Assess the employee's blood pressure
3. Check for allergies to drugs before giving acetaminophen from hospital stock
4. Refer employee to the employee health provider
4
Which of these clients should the nurse assess first?
1. A client who has shortness of breath from moderate pleural effusion and is
waiting for thoracentesis
2. A client who just had a long leg cast applied and has severe pain despite a dose
of morphine
3. A client with cellulitis who is receiving a first dose of IV antibiotics and has
throat tightness
4. A sickle cell crisis client who has severe bone pain despite a dose of morphine
3
The clinic nurse receives multiple phone calls regarding client status. Which call
should the nurse return first?
1. A 3-year-old diagnosed with Kawasaki disease 2 weeks ago developed skin peeling
2. A 7-year-old has had a high fever, cough, and sore throat for the past 2 days
3. A 14-year-old with asthma controlled with a corticosteroid inhaler developed oral
Answers| Updated 2025 (answers
highlighted)
The emergency department nurse is triaging clients. Which client is a priority
for diagnostic workup and definitive care?
1. Fell, twisting the right knee; heard a "pop"
2. History of glomerulonephritis; has "iced tea"-colored urine
3. Pain 10/10 in reddened eye; wears contact lens
4. Took a handful of amitriptyline tablets after a fight with spouse
4
The nurse receives report on 4 clients. Which client should the nurse see first?
1. Client 2 hours post foot amputation surgery has a surgical dressing saturated
with bright red blood
2. Client scheduled for whirlpool bath in 20 minutes has the dressing on the
infected foot ulcer fall off
3. Client with arteriovenous graft for hemodialysis access has new-onset pain and
redness at graft site
4. Client with urinary retention and infection receiving antibiotics is confused
and trying to pull out Foley catheter
1
A Spanish-speaking client is admitted for a small bowel obstruction. The surgeon explains
to the client's child, who speaks both Spanish and English, that an exploratory
laparotomy is needed to determine the cause of the obstruction and possible causes
include intestinal adhesions and ovarian or colon cancer. The surgeon asks the child to
translate this information for the client and assist with translating the consent form.
,Which is the most appropriate action by the nurse?
1. Act as a witness for the informed consent process
2. Provide additional information about what the client can expect
3. Report the surgeon to the ethics board for using an inappropriate consent process
4. Talk to the surgeon privately about using a trained Spanish-language
medical interpreter
4
Which client should the charge nurse assign to the room closest to the nurses' station?
1. Client with a Salem sump tube to continuous suction who is deaf
2. Client with gastroenteritis and dementia who wanders
3. Client with herpes zoster under airborne isolation precautions
4. Client with sickle cell crisis who requires frequent intravenous opioids
2
The day nurse gets the following hand-off report from the night nurse. The nurse
should assess which client first?
1. Client with cellulitis, medicated with hydromorphone IV 1 hour ago, reports pain of
6 on a scale of 0-10
2. Client with chronic kidney disease with hemoglobin 8 g/dL (80 g/L) and
hematocrit 24% (0.24), is short of breath with activity
3. Client with heart failure and bilateral pleural effusions with serum sodium of 133
mEq/L (133 mmol/L), is scheduled for a thoracentesis this morning
4. Client with pneumonia and reactive airway disease, developed increased
shortness of breath and high-pitched wheezing 10 minutes ago
4
,There has been a community disaster with multiple victims. Stable clients must be
released to make room for the victims. Which clients would the nurse recommend
as stable for discharge? Select all that apply.
1. Acute head injury with Glasgow Coma Scale of 12
2. Admitted with cirrhosis of liver with oozing esophageal varices
3. Asthma exacerbation with peak flow at 85% of personal best
4. Deep venous thrombosis on IV heparin with platelets 40,000/mm3 (40 × 109/L)
5. Myasthenia gravis with ptosis in the evening
3,5
Multiple clients present to the emergency department. Which client should the
triage nurse prioritize for additional diagnostic testing and definitive treatment?
1. Client at 11 weeks gestation with productive yellow phlegm cough but
no abdominal pain
2. Client with Alzheimer disease who developed restlessness and confusion today
3. Client with deformed forearm who has normal circulation, movement,
and sensation; pain rated "8"
4. Client with epilepsy who had a seizure at work today but is now alert and oriented
2
The nurse receives a report on 4 clients. Which client should the nurse assess first?
1. A 29-year-old heroin user admitted for arm cellulitis 24 hours ago has
abdominal cramps and is restless
2. A 34-year-old admitted with femur fracture 24 hours ago is confused and has SpO2
of 91%
3. A 65-year-old admitted with serum sodium of 125 mEq/L (125 mmol/L) 8 hours ago
is confused
, 4. A 78-year-old admitted for urinary tract infection 6 hours ago is disoriented to
time and place
2
A housekeeping employee tells the staff nurse of having a headache and asks
for acetaminophen. How should the nurse respond?
1. Ask about liver disease and give acetaminophen from the nurse's personal supply
2. Assess the employee's blood pressure
3. Check for allergies to drugs before giving acetaminophen from hospital stock
4. Refer employee to the employee health provider
4
Which of these clients should the nurse assess first?
1. A client who has shortness of breath from moderate pleural effusion and is
waiting for thoracentesis
2. A client who just had a long leg cast applied and has severe pain despite a dose
of morphine
3. A client with cellulitis who is receiving a first dose of IV antibiotics and has
throat tightness
4. A sickle cell crisis client who has severe bone pain despite a dose of morphine
3
The clinic nurse receives multiple phone calls regarding client status. Which call
should the nurse return first?
1. A 3-year-old diagnosed with Kawasaki disease 2 weeks ago developed skin peeling
2. A 7-year-old has had a high fever, cough, and sore throat for the past 2 days
3. A 14-year-old with asthma controlled with a corticosteroid inhaler developed oral
