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1. Which action should the nurse perform first?
A. Obtain a complete health history.
B. Administer prescribed analgesics.
C. Place the client on a cardiac monitor and obtain vital signs.
D. Encourage the client to rest quietly.
Answer: C. Place the client on a cardiac monitor and obtain vital signs.
Rationale: The priority is rapid assessment of airway, breathing, circulation (ABCs), and
cardiac status. Continuous cardiac monitoring and vital signs help identify life-threatening
dysrhythmias and hemodynamic instability. A complete history and pain management are
important but follow stabilization.
2. A triage nurse assesses four clients. Which client should be seen first?
A. A client with a sore throat for 3 days.
B. A client with a closed wrist fracture.
C. A client with crushing chest pain radiating to the left arm.
D. A client requesting a medication refill.
Answer: C. A client with crushing chest pain radiating to the left arm.
Rationale: Chest pain suggestive of acute myocardial infarction is an emergency requiring
immediate evaluation and intervention. The remaining conditions are urgent or nonurgent
but are less immediately life-threatening.
3. A client is brought to the emergency department following a motor vehicle collision.
Which assessment takes priority?
,A. Inspecting the abdomen.
B. Evaluating airway patency.
C. Assessing bowel sounds.
D. Reviewing medication history.
Answer: B. Evaluating airway patency.
Rationale: Trauma care follows the ABCDE approach. Airway management is always the
first priority because airway obstruction can rapidly become fatal.
4. Which finding indicates hypovolemic shock?
A. Warm, flushed skin.
B. Bradycardia.
C. Cool, clammy skin with tachycardia.
D. Bounding peripheral pulses.
Answer: C. Cool, clammy skin with tachycardia.
Rationale: Hypovolemic shock causes sympathetic stimulation, producing tachycardia,
cool clammy skin, hypotension, decreased urine output, and delayed capillary refill.
5. Which laboratory value is most important to review before administering
intravenous potassium?
A. Hemoglobin.
B. Platelet count.
C. Serum potassium level.
D. White blood cell count.
Answer: C. Serum potassium level.
Rationale: Administering potassium without verifying the current potassium level may
result in dangerous hyperkalemia. Potassium should never be administered without
confirming the need.
6. A client with anaphylaxis is experiencing severe respiratory distress. Which
medication should the nurse anticipate administering first?
, A. Diphenhydramine.
B. Epinephrine.
C. Prednisone.
D. Famotidine.
Answer: B. Epinephrine.
Rationale: Intramuscular epinephrine is the first-line treatment for anaphylaxis because it
rapidly reverses airway edema, bronchospasm, and hypotension.
7. A client presents with suspected stroke symptoms that began 45 minutes ago.
Which action is the priority?
A. Offer oral fluids.
B. Arrange an immediate head CT scan.
C. Encourage ambulation.
D. Administer aspirin immediately.
Answer: B. Arrange an immediate head CT scan.
Rationale: Rapid neuroimaging differentiates ischemic from hemorrhagic stroke and
determines eligibility for thrombolytic therapy. Aspirin should not be administered until
hemorrhage is excluded.
8. A trauma client has absent breath sounds on the right side, tracheal deviation to the
left, and severe respiratory distress. Which condition is most likely?
A. Pulmonary edema.
B. Simple pneumothorax.
C. Tension pneumothorax.
D. Pleural effusion.
Answer: C. Tension pneumothorax.
Rationale: Tracheal deviation, unilateral absent breath sounds, hypotension, and
respiratory distress are classic findings of tension pneumothorax, requiring immediate
decompression.