EMERGENCY NURSING COMPREHENSIVE EXAM
QUESTIONS AND ANSWERS GRADED A+
✔✔10. A triage nurse is talking to a patient when the patient begins choking on his
lunch. The patient is coughing forcefully. What should the nurse do?
A) Stand him up and perform the abdominal thrust maneuver from behind.
B) Lay him down, straddle him, and perform the abdominal thrust maneuver.
C) Leave him to get assistance.
D) Stay with him and encourage him, but not intervene at this time. - ✔✔ans: D
Feedback: If the patient is coughing, he should be able to dislodge the object or cause a
complete obstruction. If complete obstruction occurs, the nurse should perform the
abdominal thrust maneuver with the patient standing. If the patient is unconscious, the
nurse should lay the patient down. A nurse should never leave a choking patient alone.
✔✔11. You are a floor nurse caring for a patient with alcohol withdrawal syndrome.
What would be an appropriate nursing action to minimize the potential for
hallucinations? A) Engage the patient in a process of health education. B) Administer
opioid analgesics as ordered. C) Place the patient in a private, well-lit room. D) Provide
television or a radio as therapeutic distraction - ✔✔: C Feedback: The patient should be
placed in a quiet single room with lights on and in a calm nonstressful environment. TV
and radio stimulation should be avoided. Analgesics are not normally necessary, and
would potentially contribute to hallucinations. Health education would be inappropriate
while the patient is experiencing acute withdrawal.
✔✔12. An obtunded patient is admitted to the ED after ingesting bleach. The nurse
should prepare to assist with what intervention?
A) Prompt administration of an antidote
B) Gastric lavage
C) Administration of activated charcoal
D) Helping the patient drink large amounts of water - ✔✔ans: D Feedback: The patient
who has ingested a corrosive poison, such as bleach, is given water or milk to drink for
dilution. Gastric lavage is not used to treat ingestion of corrosives and activated
charcoal is ineffective. There is no antidote for a corrosive substance such as bleach.
✔✔13. A 6-year-old is admitted to the ED after being rescued from a pond after falling
through the ice while ice skating. What action should the nurse perform while rewarming
the patient? A) Assessing the patients oral temperature frequently B) Ensuring
continuous ECG monitoring C) Massaging the patients skin surfaces to promote
circulation D) Administering bronchodilators by nebulizer - ✔✔: B Feedback: A
hypothermic patient requires continuous ECG monitoring and assessment of core
temperatures with an esophageal probe, bladder, or rectal thermometer. Massage is not
performed and bronchodilators would normally be insufficient to meet the patients
respiratory needs.
, ✔✔14. A male patient with multiple injuries is brought to the ED by ambulance. He has
had his airway stabilized and is breathing on his own. The ED nurse does not see any
active bleeding, but should suspect internal hemorrhage based on what finding? A)
Absence of bruising at contusion sites B) Rapid pulse and decreased capillary refill C)
Increased BP with narrowed pulse pressure D) Sudden diaphoresis - 1355 - ✔✔: B
Feedback: The nurse would anticipate that the pulse would increase and BP would
decrease. Urine output would also decrease. An absence of bruising and the presence
of diaphoresis would not suggest internal hemorrhage.
✔✔15. A 13-year-old is being admitted to the ED after falling from a roof and sustaining
blunt abdominal injuries. To assess for internal injury in the patients peritoneum, the
nurse should anticipate what diagnostic test? A) Radiograph B) Computed tomography
(CT) scan C) Complete blood count (CBC) D) Barium swallow - ✔✔: B Feedback: CT
scan of the abdomen, diagnostic peritoneal lavage, and abdominal ultrasound are
appropriate diagnostic tools to assess intra-abdominal injuries. X-rays do not yield
sufficient data and a CBC would not reveal the presence of intraperitoneal injury.
✔✔16. A patient is brought to the ER in an unconscious state. The physician notes that
the patient is in need of emergency surgery. No family members are present, and the
patient does not have identification. What action by the nurse is most important
regarding consent for treatment? A) Ask the social worker to come and sign the
consent. B) Contact the police to obtain the patients identity. C) Obtain a court order to
treat the patient. D) Clearly document LOC and health status on the patients chart. -
✔✔: D Feedback: When patients are unconscious and in critical condition, the condition
and situation should be - 1356 documented to administer treatment quickly and timely
when no consent can be obtained by usual routes. A social worker is not asked to sign
the consent. Finding the patients identity is not a priority. Obtaining a court order would
take too long.
✔✔17. A patient is experiencing respiratory insufficiency and cannot maintain
spontaneous respirations. The nurse suspects that the physician will perform which of
the following actions? A) Insert an oropharyngeal airway. B) Perform the jaw thrust
maneuver. C) Perform endotracheal intubation. D) Perform a cricothyroidotomy. - ✔✔:
C Feedback: Endotracheal tubes are used in cases when the patient cannot be
ventilated with an oropharyngeal airway, which is used in patients who are breathing
spontaneously. The jaw thrust maneuver does not establish an airway and
cricothyroidotomy would be performed as a last resort.
✔✔18. A patient is brought by friends to the ED after being involved in a motor vehicle
accident. The patient sustained blunt trauma to the abdomen. What nursing action
would be most appropriate for this patient? A) Ambulate the patient to expel flatus. B)
Place the patient in a high Fowlers position. C) Immobilize the patient on a backboard.
D) Place the patient in a left lateral position. - ✔✔: C Feedback: When admitted for blunt
trauma, patients must be immobilized until spinal injury is ruled out. Ambulation, side-
lying, and upright positioning would be contraindicated until spinal injury is ruled out.
QUESTIONS AND ANSWERS GRADED A+
✔✔10. A triage nurse is talking to a patient when the patient begins choking on his
lunch. The patient is coughing forcefully. What should the nurse do?
A) Stand him up and perform the abdominal thrust maneuver from behind.
B) Lay him down, straddle him, and perform the abdominal thrust maneuver.
C) Leave him to get assistance.
D) Stay with him and encourage him, but not intervene at this time. - ✔✔ans: D
Feedback: If the patient is coughing, he should be able to dislodge the object or cause a
complete obstruction. If complete obstruction occurs, the nurse should perform the
abdominal thrust maneuver with the patient standing. If the patient is unconscious, the
nurse should lay the patient down. A nurse should never leave a choking patient alone.
✔✔11. You are a floor nurse caring for a patient with alcohol withdrawal syndrome.
What would be an appropriate nursing action to minimize the potential for
hallucinations? A) Engage the patient in a process of health education. B) Administer
opioid analgesics as ordered. C) Place the patient in a private, well-lit room. D) Provide
television or a radio as therapeutic distraction - ✔✔: C Feedback: The patient should be
placed in a quiet single room with lights on and in a calm nonstressful environment. TV
and radio stimulation should be avoided. Analgesics are not normally necessary, and
would potentially contribute to hallucinations. Health education would be inappropriate
while the patient is experiencing acute withdrawal.
✔✔12. An obtunded patient is admitted to the ED after ingesting bleach. The nurse
should prepare to assist with what intervention?
A) Prompt administration of an antidote
B) Gastric lavage
C) Administration of activated charcoal
D) Helping the patient drink large amounts of water - ✔✔ans: D Feedback: The patient
who has ingested a corrosive poison, such as bleach, is given water or milk to drink for
dilution. Gastric lavage is not used to treat ingestion of corrosives and activated
charcoal is ineffective. There is no antidote for a corrosive substance such as bleach.
✔✔13. A 6-year-old is admitted to the ED after being rescued from a pond after falling
through the ice while ice skating. What action should the nurse perform while rewarming
the patient? A) Assessing the patients oral temperature frequently B) Ensuring
continuous ECG monitoring C) Massaging the patients skin surfaces to promote
circulation D) Administering bronchodilators by nebulizer - ✔✔: B Feedback: A
hypothermic patient requires continuous ECG monitoring and assessment of core
temperatures with an esophageal probe, bladder, or rectal thermometer. Massage is not
performed and bronchodilators would normally be insufficient to meet the patients
respiratory needs.
, ✔✔14. A male patient with multiple injuries is brought to the ED by ambulance. He has
had his airway stabilized and is breathing on his own. The ED nurse does not see any
active bleeding, but should suspect internal hemorrhage based on what finding? A)
Absence of bruising at contusion sites B) Rapid pulse and decreased capillary refill C)
Increased BP with narrowed pulse pressure D) Sudden diaphoresis - 1355 - ✔✔: B
Feedback: The nurse would anticipate that the pulse would increase and BP would
decrease. Urine output would also decrease. An absence of bruising and the presence
of diaphoresis would not suggest internal hemorrhage.
✔✔15. A 13-year-old is being admitted to the ED after falling from a roof and sustaining
blunt abdominal injuries. To assess for internal injury in the patients peritoneum, the
nurse should anticipate what diagnostic test? A) Radiograph B) Computed tomography
(CT) scan C) Complete blood count (CBC) D) Barium swallow - ✔✔: B Feedback: CT
scan of the abdomen, diagnostic peritoneal lavage, and abdominal ultrasound are
appropriate diagnostic tools to assess intra-abdominal injuries. X-rays do not yield
sufficient data and a CBC would not reveal the presence of intraperitoneal injury.
✔✔16. A patient is brought to the ER in an unconscious state. The physician notes that
the patient is in need of emergency surgery. No family members are present, and the
patient does not have identification. What action by the nurse is most important
regarding consent for treatment? A) Ask the social worker to come and sign the
consent. B) Contact the police to obtain the patients identity. C) Obtain a court order to
treat the patient. D) Clearly document LOC and health status on the patients chart. -
✔✔: D Feedback: When patients are unconscious and in critical condition, the condition
and situation should be - 1356 documented to administer treatment quickly and timely
when no consent can be obtained by usual routes. A social worker is not asked to sign
the consent. Finding the patients identity is not a priority. Obtaining a court order would
take too long.
✔✔17. A patient is experiencing respiratory insufficiency and cannot maintain
spontaneous respirations. The nurse suspects that the physician will perform which of
the following actions? A) Insert an oropharyngeal airway. B) Perform the jaw thrust
maneuver. C) Perform endotracheal intubation. D) Perform a cricothyroidotomy. - ✔✔:
C Feedback: Endotracheal tubes are used in cases when the patient cannot be
ventilated with an oropharyngeal airway, which is used in patients who are breathing
spontaneously. The jaw thrust maneuver does not establish an airway and
cricothyroidotomy would be performed as a last resort.
✔✔18. A patient is brought by friends to the ED after being involved in a motor vehicle
accident. The patient sustained blunt trauma to the abdomen. What nursing action
would be most appropriate for this patient? A) Ambulate the patient to expel flatus. B)
Place the patient in a high Fowlers position. C) Immobilize the patient on a backboard.
D) Place the patient in a left lateral position. - ✔✔: C Feedback: When admitted for blunt
trauma, patients must be immobilized until spinal injury is ruled out. Ambulation, side-
lying, and upright positioning would be contraindicated until spinal injury is ruled out.
