Emergency & Trauma Nursing NCLEX:Questions and Answers
A nurse is caring for clients in a busy emergency department. Which actions should the nurse take to ensure
client and staff safety? (SATA)
a. Leave the stretcher in the lowest position with rails down so that the client can access the bathroom.
b. Use two identifiers before each intervention and before mediation administration.
c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors.
d. Search the belongings of clients with altered mental status to gain essential medical information.
e. Isolate clients who have immune suppression disorders to prevent hospital-acquired infections. - ansB, C, D ~
To ensure client and staff safety, nurses should use two identifiers per The Joint Commissions National Patient
Safety Goals; follow the hospitals security plan, including de-escalation strategies for people who demonstrate
aggressive or violent tendencies; and search belongings to identify essential medical information. Nurses
should also use standard fall prevention interventions, including leaving stretchers in the lowest position with
rails up, and isolating clients who present with signs and symptoms of contagious infectious disorders.
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 clients
c. Level III Located in rural communities and provides only basic care to clients
d. Level IV Located in large teaching hospitals and provides a full continuum of trauma care for all clients - ansB
~ Level I trauma centers are usually located in large teaching hospital systems and provide a full continuum of
trauma care for all clients. Both Level II and Level III facilities are usually located in community hospitals. These
trauma centers provide care for most clients and transport to Level I centers when client needs exceed
resource capabilities. Level IV trauma centers are usually located in rural and remote areas. These centers
provide basic care, stabilization, and advanced life support while transfer arrangements to higher-level trauma
centers are made.
A nurse is triaging clients in the emergency department (ED). Which client should 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 - ansB ~ A client
experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to
a treatment room in the ED. The other clients are more stable.
A nurse is triaging clients in the emergency department. Which client should 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
d. A 50-year-old male with new-onset confusion and slurred speech - ansC ~ A client with a cough and a
temperature of 102 F is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in
an immediately life-threatening situation. The client with a chest stab wound and tachycardia and the client
with new-onset confusion and slurred speech should be triaged as emergent. The client with a skin rash and a
sore throat is not at risk for deterioration and would be triaged as nonurgent.
A nurse is triaging clients in the emergency department. Which client should 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 - ansC ~ A client in a nonurgent category can tolerate waiting
several hours for health care services without a significant risk of clinical deterioration. The client with a simple
arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and
would be considered nonurgent. The client with chest pain and diaphoresis and the client with chest trauma
are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a
high fever may be stable now but also has a risk of deterioration.
A nurse prepares to discharge an older adult client home from the emergency department (ED). Which actions
should the nurse take to prevent future ED visits? (SATA)
a. Provide medical supplies to the family.
b. Consult a home health agency.
c. Encourage participation in community activities.
d. Screen for depression and suicide.
A nurse is caring for clients in a busy emergency department. Which actions should the nurse take to ensure
client and staff safety? (SATA)
a. Leave the stretcher in the lowest position with rails down so that the client can access the bathroom.
b. Use two identifiers before each intervention and before mediation administration.
c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors.
d. Search the belongings of clients with altered mental status to gain essential medical information.
e. Isolate clients who have immune suppression disorders to prevent hospital-acquired infections. - ansB, C, D ~
To ensure client and staff safety, nurses should use two identifiers per The Joint Commissions National Patient
Safety Goals; follow the hospitals security plan, including de-escalation strategies for people who demonstrate
aggressive or violent tendencies; and search belongings to identify essential medical information. Nurses
should also use standard fall prevention interventions, including leaving stretchers in the lowest position with
rails up, and isolating clients who present with signs and symptoms of contagious infectious disorders.
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 clients
c. Level III Located in rural communities and provides only basic care to clients
d. Level IV Located in large teaching hospitals and provides a full continuum of trauma care for all clients - ansB
~ Level I trauma centers are usually located in large teaching hospital systems and provide a full continuum of
trauma care for all clients. Both Level II and Level III facilities are usually located in community hospitals. These
trauma centers provide care for most clients and transport to Level I centers when client needs exceed
resource capabilities. Level IV trauma centers are usually located in rural and remote areas. These centers
provide basic care, stabilization, and advanced life support while transfer arrangements to higher-level trauma
centers are made.
A nurse is triaging clients in the emergency department (ED). Which client should 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 - ansB ~ A client
experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to
a treatment room in the ED. The other clients are more stable.
A nurse is triaging clients in the emergency department. Which client should 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
d. A 50-year-old male with new-onset confusion and slurred speech - ansC ~ A client with a cough and a
temperature of 102 F is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in
an immediately life-threatening situation. The client with a chest stab wound and tachycardia and the client
with new-onset confusion and slurred speech should be triaged as emergent. The client with a skin rash and a
sore throat is not at risk for deterioration and would be triaged as nonurgent.
A nurse is triaging clients in the emergency department. Which client should 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 - ansC ~ A client in a nonurgent category can tolerate waiting
several hours for health care services without a significant risk of clinical deterioration. The client with a simple
arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and
would be considered nonurgent. The client with chest pain and diaphoresis and the client with chest trauma
are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a
high fever may be stable now but also has a risk of deterioration.
A nurse prepares to discharge an older adult client home from the emergency department (ED). Which actions
should the nurse take to prevent future ED visits? (SATA)
a. Provide medical supplies to the family.
b. Consult a home health agency.
c. Encourage participation in community activities.
d. Screen for depression and suicide.
