EMERGENCY NURSING UPDATED EXAM SCRIPT
QUESTIONS AND ANSWERS GRADED A+
✔✔A patient presents to the ED following a motor vehicle collision. The patient is
suspected of having internal hemorrhage. The nurse assesses the patient for signs and
symptoms of shock. Signs and symptoms of shock include which of the following?
Select all that apply. - ✔✔Cool, moist skin
Decreasing blood pressure
Increasing heart rate
Delayed capillary refill
✔✔A nurse is completing her annual cardiopulmonary resuscitation training. The class
instructor tells her that a client has fallen off a ladder and is lying on his back; he is
unconscious and isn't breathing. What maneuver should the nurse use to open his
airway? - ✔✔Jaw-thrust
✔✔Which of the following data is most important for the nurse to record while assessing
a patient with an open wound? - ✔✔Time when the patient last received a tetanus
immunization
✔✔A female patient was sexually assaulted when leaving work. When assisting with the
physical examination, what nursing interventions should be provided? (Select all that
apply.) - ✔✔Assess and document any bruises and lacerations.
Record a history of the event, using the patient's own words.
Label all torn or bloody clothes and place each item in a separate brown bag so that any
evidence can be given to the police.
✔✔A client is brought to the emergency department by ambulance. The client is
seriously ill and unconscious. No family or friends are present. Which of the following
would be most appropriate to do? - ✔✔Document the client's condition and absence of
friends or family for obtaining consent to treatment.
✔✔A nurse is providing an educational program for a group of occupational health
nurses working in chemical facilities. Which of the following would the nurse include as
the priority in the case of a chemical burn? - ✔✔Rinsing the area with copious amounts
of water
✔✔A client is in hypovolemic shock. To determine the effectiveness of fluid replacement
therapy, the nurse should monitor the client's: - ✔✔Blood pressure
, ✔✔What is the most frequently injured solid organ in a penetrating trauma? - ✔✔Liver
✔✔A client with depression and behavioral changes is transferred from a local assisted
living center to the emergency department. The nurse notes that the client cries out
when she approaches. When the nurse gains the client's confidence and performs an
assessment, the nurse notes bruising of the labia and a lateral laceration in the perineal
area. When the nurse asks the client about the injury, the client shakes her head and
begins to cry "don't tell, don't tell." The nurse suspects sexual abuse. How should the
nurse proceed? - ✔✔Attend to the client's physiological needs.
✔✔A nurse is assessing a patient who is suspected of having a partial airway
obstruction. Which of the following would the nurse expect to find? - ✔✔Spontaneous
coughing
✔✔A patient has experienced blunt abdominal trauma from a motor vehicle crash. The
nurse assesses the patient, knowing that which organ is the most frequently injured
solid abdominal organ? - ✔✔Liver
✔✔Nursing students are reviewing the categories of intra-abdominal injuries. The
students demonstrate understanding of the information when they identify which of the
following as examples of penetrating trauma? Select all that apply. - ✔✔Gunshot wound
Knife-stab wound
✔✔A nurse is caring for a client who is experiencing alcohol withdrawal. Which
statement best indicates that the client understands the need for long-term treatment? -
✔✔The client agrees to detoxification, rehabilitation, and participation in an aftercare
program.
✔✔A homeless patient presents to the ED. Upon assessment, the patient is
experiencing hypothermia. The nurse will plan to complete which of the following priority
interventions during the rewarming process? - ✔✔Attach a cardiac monitor.
✔✔A patient is brought to the emergency department and diagnosed with
decompression sickness. The nurse interprets this as indicating that the patient most
likely has been involved with which of the following? - ✔✔Diving in an ocean
✔✔A nurse is providing care to an older adult client who has frostbite of the feet. Which
action would be least appropriate? - ✔✔Massaging the feet
QUESTIONS AND ANSWERS GRADED A+
✔✔A patient presents to the ED following a motor vehicle collision. The patient is
suspected of having internal hemorrhage. The nurse assesses the patient for signs and
symptoms of shock. Signs and symptoms of shock include which of the following?
Select all that apply. - ✔✔Cool, moist skin
Decreasing blood pressure
Increasing heart rate
Delayed capillary refill
✔✔A nurse is completing her annual cardiopulmonary resuscitation training. The class
instructor tells her that a client has fallen off a ladder and is lying on his back; he is
unconscious and isn't breathing. What maneuver should the nurse use to open his
airway? - ✔✔Jaw-thrust
✔✔Which of the following data is most important for the nurse to record while assessing
a patient with an open wound? - ✔✔Time when the patient last received a tetanus
immunization
✔✔A female patient was sexually assaulted when leaving work. When assisting with the
physical examination, what nursing interventions should be provided? (Select all that
apply.) - ✔✔Assess and document any bruises and lacerations.
Record a history of the event, using the patient's own words.
Label all torn or bloody clothes and place each item in a separate brown bag so that any
evidence can be given to the police.
✔✔A client is brought to the emergency department by ambulance. The client is
seriously ill and unconscious. No family or friends are present. Which of the following
would be most appropriate to do? - ✔✔Document the client's condition and absence of
friends or family for obtaining consent to treatment.
✔✔A nurse is providing an educational program for a group of occupational health
nurses working in chemical facilities. Which of the following would the nurse include as
the priority in the case of a chemical burn? - ✔✔Rinsing the area with copious amounts
of water
✔✔A client is in hypovolemic shock. To determine the effectiveness of fluid replacement
therapy, the nurse should monitor the client's: - ✔✔Blood pressure
, ✔✔What is the most frequently injured solid organ in a penetrating trauma? - ✔✔Liver
✔✔A client with depression and behavioral changes is transferred from a local assisted
living center to the emergency department. The nurse notes that the client cries out
when she approaches. When the nurse gains the client's confidence and performs an
assessment, the nurse notes bruising of the labia and a lateral laceration in the perineal
area. When the nurse asks the client about the injury, the client shakes her head and
begins to cry "don't tell, don't tell." The nurse suspects sexual abuse. How should the
nurse proceed? - ✔✔Attend to the client's physiological needs.
✔✔A nurse is assessing a patient who is suspected of having a partial airway
obstruction. Which of the following would the nurse expect to find? - ✔✔Spontaneous
coughing
✔✔A patient has experienced blunt abdominal trauma from a motor vehicle crash. The
nurse assesses the patient, knowing that which organ is the most frequently injured
solid abdominal organ? - ✔✔Liver
✔✔Nursing students are reviewing the categories of intra-abdominal injuries. The
students demonstrate understanding of the information when they identify which of the
following as examples of penetrating trauma? Select all that apply. - ✔✔Gunshot wound
Knife-stab wound
✔✔A nurse is caring for a client who is experiencing alcohol withdrawal. Which
statement best indicates that the client understands the need for long-term treatment? -
✔✔The client agrees to detoxification, rehabilitation, and participation in an aftercare
program.
✔✔A homeless patient presents to the ED. Upon assessment, the patient is
experiencing hypothermia. The nurse will plan to complete which of the following priority
interventions during the rewarming process? - ✔✔Attach a cardiac monitor.
✔✔A patient is brought to the emergency department and diagnosed with
decompression sickness. The nurse interprets this as indicating that the patient most
likely has been involved with which of the following? - ✔✔Diving in an ocean
✔✔A nurse is providing care to an older adult client who has frostbite of the feet. Which
action would be least appropriate? - ✔✔Massaging the feet
