Emergency Nursing Practice Questions With
Verified Answers
The client diagnosed with hypovolemic shock has a BP of 100/60. Fifteen
minutes later the BP is 88/64. How much narrowing of the client's pulse
pressure has occurred between the two readings? ✔️Ans - Answer: 16
mmHg pulse pressure
The pulse pressure is the systolic BP minus the diastolic BP.
100 - 60 = 40 mmHg pulse pressure in first BP reading
88 - 64 = 24 mmHg pulse pressure in second reading
40 - 24 = 16 mmHg pulse pressure narrowing.
A narrowing or decreased pulse pressure is an earlier indicator of shock than
a decrease in systolic blood pressure.
TEST-TAKING HINT: If the test taker is not aware of how to obtain a pulse
pressure, the only numbers provided in the stem are systolic and diastolic
blood pressures. The test taker should do something with the numbers.
The client is admitted into the emergency department with diaphoresis, pale
clammy skin, and BP of 90/70. Which intervention should the nurse
implement first?
1. Start an IV with an 18-gauge catheter.
2. Administer intravenous dopamine infusion.
3. Obtain arterial blood gases (ABGs).
4. Insert an indwelling urinary catheter. ✔️Ans - Answer: 1
1. There are many types of shock, but the one common intervention that
should be done first in all types of shock is to establish an intravenous line
with a large-bore catheter. The low blood pressure and cold, clammy skin
indicate shock.
2. This blood pressure does not require dopamine; fluid resuscitation is first.
3. The client may need ABGs monitored, but this is not the first intervention.
4. An indwelling catheter may need to be inserted for accurate measurement
of output, but it is not the first intervention.
,TEST-TAKING HINT: This question asks for the first intervention, which
means all options may be appropriate interventions for the client, but only
one should be implemented first. Remember: When the client is in distress, do
not assess.
The nurse is caring for a client diagnosed with septic shock. Which assessment
data warrant immediate intervention by the nurse?
1. Vital signs T 100.4°F, P 104, R 26, and BP 102/60.
2. A white blood cell count of 18,000/mm^3.
3. Urinary output of 90 mL in the last 4 hours.
4. The client reports being thirsty. ✔️Ans - Answer: 3
1. These vital signs are expected in a client diagnosed with septic shock.
2. An elevated WBC count indicates an infection, which is the definition of
sepsis.
3. The client must have a urinary output of at least 30 mL/hr, so 90 mL in the
last 4 hours indicates impaired renal perfusion, which is a sign of worsening
shock.
4. The client being thirsty is not an uncommon issue for a client diagnosed
with septic shock. This warrants immediate intervention.
TEST-TAKING HINT: The words "warrant immediate intervention" mean the
nurse must do something, which frequently can be notifying the HCP. Any
client diagnosed with shock will have clinical manifestations requiring the
nurse to intervene. In this question, the test taker must determine priority and
which data require immediate intervention.
The client diagnosed with septicemia has the following health-care provider
(HCP) orders. Which HCP order has the highest priority?
1. Provide clear liquid diet.
2. Initiate IV antibiotic therapy.
3. Obtain a STAT chest x-ray.
4. Perform hourly glucometer checks. ✔️Ans - Answer: 2
1. The client's diet is not a priority when transcribing orders.
2. An IV antibiotic is the priority medication for the client diagnosed with an
infection, which is the definition of sepsis—a systemic bacterial infection of
,the blood. A new order for an IV antibiotic should be implemented within 1
hour of receiving the order.
3. Diagnostic tests are important but not priority over intervening in a
potentially life-threatening situation such as septic shock.
4. There is no indication in the stem of the question that this client has
diabetes, and glucose levels are not associated with clinical manifestations of
septicemia.
TEST-TAKING HINT: Remember, if the test taker can rule out two answers—
options "1" and "4"—and cannot determine the right answer between options
"2" and "3," select the option directly affecting or treating the client, which is
antibiotics. Diagnostic tests do not treat the client.
The client is diagnosed with neurogenic shock. Which clinical manifestations
should the nurse assess in this client? Select all that apply.
1. Cool, moist skin.
2. Bradycardia.
3. Wheezing.
4. Decreased bowel sounds.
5. Hypotension. ✔️Ans - Answer: 2, 5
1. The client diagnosed with neurogenic shock will have dry, warm skin,
rather than cool, moist skin, as seen in hypovolemic shock.
2. The client will have bradycardia instead of tachycardia, which is seen in
other forms of shock.
3. Wheezing is associated with anaphylactic shock.
4. Decreased bowel sounds occur in the hyper-dynamic phase of septic shock.
5. Hypotension is a clinical manifestation of most types of shock.
TEST-TAKING HINT: The test taker should identify the body system the
question is addressing. In this case, neuro- indicates the question relates to
the neurological system. With this information only, the test taker could
possibly rule out option "4," which refers to the gastrointestinal system, and
option "3," which refers to the respiratory system. Although bradycardia is in
the cardiac system, the pulse rate is controlled by the brain.
The nurse in the emergency department administered an intramuscular
antibiotic in the left ventrogluteal muscle to the client diagnosed with
, pneumonia being discharged home. Which intervention should the nurse
implement?
1. Ask the client about drug allergies.
2. Obtain a sterile sputum specimen.
3. Have the client wait for 30 minutes.
4. Place a warm washcloth on the client's left hip. ✔️Ans - Answer: 3
1. It is too late to ask the client about drug allergies because the medication
has already been administered.
2. Obtaining a specimen after the antibiotic has been initiated will skew the
culture and sensitivity results. It must be obtained before the antibiotic is
started.
3. Anytime a nurse administers a medication for the first time, the client
should be observed for a possible anaphylactic reaction, especially with
antibiotics.
4. The client is being discharged, and the nurse can encourage the client to do
this at home, but it is not appropriate to do in the emergency department.
TEST-TAKING HINT: The test taker must be observant of information in the
stem. The nurse has already administered the medication, and checking for
allergies after the fact will not affect the client's outcome. This is a violation of
the five rights; this medication cannot be the right medication if the client is
allergic to it.
The nurse caring for a client diagnosed with sepsis writes the client diagnosis
of "alteration in comfort R/T chills and fever." Which intervention should be
included in the plan of care?
1. Ambulate the client in the hallway every shift.
2. Monitor urinalysis, creatinine level, and BUN level.
3. Apply sequential compression devices to the lower extremities.
4. Administer an antipyretic medication every 4 hours PRN. ✔️Ans -
Answer: 4
1. Ambulating the client in the hall will not address the etiology of the client's
chills and fever; in fact, this could increase the client's discomfort.
2. Monitoring these laboratory data does not address the etiology of the
client's diagnosis.
Verified Answers
The client diagnosed with hypovolemic shock has a BP of 100/60. Fifteen
minutes later the BP is 88/64. How much narrowing of the client's pulse
pressure has occurred between the two readings? ✔️Ans - Answer: 16
mmHg pulse pressure
The pulse pressure is the systolic BP minus the diastolic BP.
100 - 60 = 40 mmHg pulse pressure in first BP reading
88 - 64 = 24 mmHg pulse pressure in second reading
40 - 24 = 16 mmHg pulse pressure narrowing.
A narrowing or decreased pulse pressure is an earlier indicator of shock than
a decrease in systolic blood pressure.
TEST-TAKING HINT: If the test taker is not aware of how to obtain a pulse
pressure, the only numbers provided in the stem are systolic and diastolic
blood pressures. The test taker should do something with the numbers.
The client is admitted into the emergency department with diaphoresis, pale
clammy skin, and BP of 90/70. Which intervention should the nurse
implement first?
1. Start an IV with an 18-gauge catheter.
2. Administer intravenous dopamine infusion.
3. Obtain arterial blood gases (ABGs).
4. Insert an indwelling urinary catheter. ✔️Ans - Answer: 1
1. There are many types of shock, but the one common intervention that
should be done first in all types of shock is to establish an intravenous line
with a large-bore catheter. The low blood pressure and cold, clammy skin
indicate shock.
2. This blood pressure does not require dopamine; fluid resuscitation is first.
3. The client may need ABGs monitored, but this is not the first intervention.
4. An indwelling catheter may need to be inserted for accurate measurement
of output, but it is not the first intervention.
,TEST-TAKING HINT: This question asks for the first intervention, which
means all options may be appropriate interventions for the client, but only
one should be implemented first. Remember: When the client is in distress, do
not assess.
The nurse is caring for a client diagnosed with septic shock. Which assessment
data warrant immediate intervention by the nurse?
1. Vital signs T 100.4°F, P 104, R 26, and BP 102/60.
2. A white blood cell count of 18,000/mm^3.
3. Urinary output of 90 mL in the last 4 hours.
4. The client reports being thirsty. ✔️Ans - Answer: 3
1. These vital signs are expected in a client diagnosed with septic shock.
2. An elevated WBC count indicates an infection, which is the definition of
sepsis.
3. The client must have a urinary output of at least 30 mL/hr, so 90 mL in the
last 4 hours indicates impaired renal perfusion, which is a sign of worsening
shock.
4. The client being thirsty is not an uncommon issue for a client diagnosed
with septic shock. This warrants immediate intervention.
TEST-TAKING HINT: The words "warrant immediate intervention" mean the
nurse must do something, which frequently can be notifying the HCP. Any
client diagnosed with shock will have clinical manifestations requiring the
nurse to intervene. In this question, the test taker must determine priority and
which data require immediate intervention.
The client diagnosed with septicemia has the following health-care provider
(HCP) orders. Which HCP order has the highest priority?
1. Provide clear liquid diet.
2. Initiate IV antibiotic therapy.
3. Obtain a STAT chest x-ray.
4. Perform hourly glucometer checks. ✔️Ans - Answer: 2
1. The client's diet is not a priority when transcribing orders.
2. An IV antibiotic is the priority medication for the client diagnosed with an
infection, which is the definition of sepsis—a systemic bacterial infection of
,the blood. A new order for an IV antibiotic should be implemented within 1
hour of receiving the order.
3. Diagnostic tests are important but not priority over intervening in a
potentially life-threatening situation such as septic shock.
4. There is no indication in the stem of the question that this client has
diabetes, and glucose levels are not associated with clinical manifestations of
septicemia.
TEST-TAKING HINT: Remember, if the test taker can rule out two answers—
options "1" and "4"—and cannot determine the right answer between options
"2" and "3," select the option directly affecting or treating the client, which is
antibiotics. Diagnostic tests do not treat the client.
The client is diagnosed with neurogenic shock. Which clinical manifestations
should the nurse assess in this client? Select all that apply.
1. Cool, moist skin.
2. Bradycardia.
3. Wheezing.
4. Decreased bowel sounds.
5. Hypotension. ✔️Ans - Answer: 2, 5
1. The client diagnosed with neurogenic shock will have dry, warm skin,
rather than cool, moist skin, as seen in hypovolemic shock.
2. The client will have bradycardia instead of tachycardia, which is seen in
other forms of shock.
3. Wheezing is associated with anaphylactic shock.
4. Decreased bowel sounds occur in the hyper-dynamic phase of septic shock.
5. Hypotension is a clinical manifestation of most types of shock.
TEST-TAKING HINT: The test taker should identify the body system the
question is addressing. In this case, neuro- indicates the question relates to
the neurological system. With this information only, the test taker could
possibly rule out option "4," which refers to the gastrointestinal system, and
option "3," which refers to the respiratory system. Although bradycardia is in
the cardiac system, the pulse rate is controlled by the brain.
The nurse in the emergency department administered an intramuscular
antibiotic in the left ventrogluteal muscle to the client diagnosed with
, pneumonia being discharged home. Which intervention should the nurse
implement?
1. Ask the client about drug allergies.
2. Obtain a sterile sputum specimen.
3. Have the client wait for 30 minutes.
4. Place a warm washcloth on the client's left hip. ✔️Ans - Answer: 3
1. It is too late to ask the client about drug allergies because the medication
has already been administered.
2. Obtaining a specimen after the antibiotic has been initiated will skew the
culture and sensitivity results. It must be obtained before the antibiotic is
started.
3. Anytime a nurse administers a medication for the first time, the client
should be observed for a possible anaphylactic reaction, especially with
antibiotics.
4. The client is being discharged, and the nurse can encourage the client to do
this at home, but it is not appropriate to do in the emergency department.
TEST-TAKING HINT: The test taker must be observant of information in the
stem. The nurse has already administered the medication, and checking for
allergies after the fact will not affect the client's outcome. This is a violation of
the five rights; this medication cannot be the right medication if the client is
allergic to it.
The nurse caring for a client diagnosed with sepsis writes the client diagnosis
of "alteration in comfort R/T chills and fever." Which intervention should be
included in the plan of care?
1. Ambulate the client in the hallway every shift.
2. Monitor urinalysis, creatinine level, and BUN level.
3. Apply sequential compression devices to the lower extremities.
4. Administer an antipyretic medication every 4 hours PRN. ✔️Ans -
Answer: 4
1. Ambulating the client in the hall will not address the etiology of the client's
chills and fever; in fact, this could increase the client's discomfort.
2. Monitoring these laboratory data does not address the etiology of the
client's diagnosis.
