NCLEX Emergency/Burns/Triage Test Questions with 100% Verified
Answers
1. While assessing a client in the emer- ANS: C
gency department, the nurse identi- All other members of the health care
fies that the client has been raped. team listed may be used in the man-
Which health care team member agement of this client's care. How-
should the nurse collaborate with ever, the forensic nurse examiner is
when planning this client's care? educated to obtain client histories
a. Emergency medicine physician and collect evidence dealing with
b. Case manager the assault, and can offer the coun-
c. Forensic nurse examiner seling and follow-up needed when
d. Psychiatric crisis nurse dealing with the victim of an assault.
2. On admission to the emergency de- ANS: D
partment, a client states that he feels The psychiatric crisis nurse inter-
like killing himself. When planning acts with clients and families in cri-
this client's care, it is most important sis. This health care team member
for the nurse to coordinate with which can offer valuable expertise to the
member of the health care team? emergency health care team, which
a. Case manager also includes the case manager and
b. Forensic nurse examiner the physician.
c. Physician
d. Psychiatric crisis nurse
3. The emergency department team is ANS: B
performing cardiopulmonary resusci- If resuscitation efforts are still under
tation on a client when the client's way when the family arrives, one or
spouse arrives at the emergency de- two family members may be given
partment. What should the nurse do the opportunity to be present during
next? lifesaving procedures. The other op-
a. Request that the client's spouse sit tions do not give the spouse the op-
in the waiting room. portunity to be present for the client
b. Ask the spouse if he wishes to be or to begin to have closure.
present during the resuscitation.
c. Suggest that the spouse begin to
pray for the client.
d. Refer the client's spouse to the hos-
pital's crisis team.
4. The emergency department nurse is ANS: B
assigned an older adult client who is Older adults who are confused are
, NCLEX Emergency/Burns/Triage Test Questions with 100% Verified
Answers
confused and agitated. Which inter- at increased risks for falls. Fall pre-
vention should the nurse include in vention includes measures such as
the client's plan of care? siderails up, reorientation, call light
a. Administer a sedative medication. in reach, and, in some cases, asking
b. Ask a family member to stay with the family member, significant other,
the client. or sitter to stay with the client to
c. Use restraints to prevent the client prevent falls.
from falling.
d. Place the client in a wheelchair at
the nurses' station.
5. An emergency department nurse is ANS: B
transferring a client to the med- The emergency nurse needs to be
ical-surgical unit. What is the most able to triage, assess, and evaluate.
important nursing intervention in this However, these steps have already
situation? been carried out in the early phases
a. Triage the client to determine the of the emergency department (ED)
urgency of care. admission. When a client is ready to
b. Clearly communicate client data to be transferred from the ED, commu-
the unit nurse. nication with staff nurses from the
c. Evaluate the need for ongoing med- inpatient units is essential. This re-
ical treatment. port should be a concise but com-
d. Perform a thorough assessment of prehensive report of the client's ED
the client. experience.
6. The nurse manager is assessing cur- ANS: D
rent demographics of the facility's The ED serves as an important
emergency department (ED) clients. safety net for clients who are ill
Which population would most likely or injured but lack access to ba-
present to the ED for treatment of a sic health care. Especially vulnera-
temperature and a sore throat? ble populations include the underin-
a. Older adults sured and the uninsured, who may
b. Immunocompromised people have nowhere else to go for health
c. Pediatric clients care.
d. Underinsured people
7. The emergency department (ED) ANS: B
nurse is caring for the following A client experiencing chest pain and
clients. Which client does the nurse diaphoresis would be classified as
, NCLEX Emergency/Burns/Triage Test Questions with 100% Verified
Answers
prioritize to see first? emergent and would be triaged im-
a. 22-year-old with a painful and mediately to a treatment room in the
swollen right wrist ED. The other clients are more sta-
b. 45-year-old reporting chest pain ble.
and diaphoresis
c. 60-year-old reporting difficulty
swallowing and nausea
d. 81-year-old with a respiratory rate
of 28 breaths/min and a temperature
of 101° F
8. A nurse is triaging clients in the emer- ANS: C
gency department. Which client com- A client in a nonurgent category
plaint would the triage nurse classify can tolerate waiting several hours
as nonurgent? for health care services without a
a. Chest pain and diaphoresis significant risk of clinical deterio-
b. Decreased breath sounds due to ration. The client with chest pain
chest trauma and diaphoresis and the client with
c. Left arm fracture with palpable radi- chest trauma are emergent owing to
al pulses the potential for clinical deterioration
d. Sore throat and a temperature of and would be seen immediately. The
104° F client with a high fever may be stable
now but also has a risk of deteriora-
tion. The client with an arm fracture
and palpable radial pulses is cur-
rently stable, is not at significant risk
of clinical deterioration, and would
be considered nonurgent.
9. A client has been injured in a stabbing ANS: A
incident. Assessment reveals the fol- The Level I trauma center is able
lowing: to provide a full continuum of care
Blood pressure: 80/60 mm Hg for all client areas. Level II can pro-
Heart rate: 140 beats/min vide care to most injured clients, but
Respiratory rate: 35 breaths/min given the extent of his injuries, a
Bleeding from stabbing wound site Level I center would be better if it is
Client is lethargic available. Both Levels III and IV can
stabilize major injuries, but transport
Based on these assessment data, to
, NCLEX Emergency/Burns/Triage Test Questions with 100% Verified
Answers
which trauma center should the nurse to a higher-level center is preferred,
ensure transport of the client? when possible.
a. Level I
b. Level II
c. Level III
d. Level IV
10. The emergency medical technicians ANS: A
(EMTs) arrive at the emergency de- The highest-priority intervention in
partment with an unresponsive client the primary survey is to establish
with an oxygen mask in place. What that the client is breathing ade-
will the nurse do first? quately. Even though this client has
a. Assess that the client is breathing an oxygen mask on, he may not
adequately be breathing, or he may be breath-
b. Insert a large-bore intravenous line ing inadequately with the device in
c. Place the client on a cardiac moni- place.
tor
d. Assess for best neurologic re-
sponse
11. A client arrives at the emergency ANS: C
department following a motor ve- The highest-priority intervention in
hicle collision. The client is not the primary survey is to establish
awake and is being bagged with a a patent airway. Without an ade-
bag-valve-mask by paramedics. The quate airway to supply oxygen to
client has sustained obvious injuries the cells, a cerebral injury could
to the head and face, as well as progress to anoxic brain death. After
an open right femur fracture that an airway is established, resuscita-
is bleeding profusely. What will the tion may continue to B for breathing
nurse do first? and C for circulation assessment.
a. Splint the right lower extremity.
b. Apply direct pressure to the leg.
c. Assess for a patent airway.
d. Start two large-bore IVs.
12. The nurse is providing care for a client ANS: C
admitted for suicidal precautions. The first priority in caring for a men-
What priority intervention should the tally ill client is providing a safe envi-
nurse implement first? ronment. This would include remov-
Answers
1. While assessing a client in the emer- ANS: C
gency department, the nurse identi- All other members of the health care
fies that the client has been raped. team listed may be used in the man-
Which health care team member agement of this client's care. How-
should the nurse collaborate with ever, the forensic nurse examiner is
when planning this client's care? educated to obtain client histories
a. Emergency medicine physician and collect evidence dealing with
b. Case manager the assault, and can offer the coun-
c. Forensic nurse examiner seling and follow-up needed when
d. Psychiatric crisis nurse dealing with the victim of an assault.
2. On admission to the emergency de- ANS: D
partment, a client states that he feels The psychiatric crisis nurse inter-
like killing himself. When planning acts with clients and families in cri-
this client's care, it is most important sis. This health care team member
for the nurse to coordinate with which can offer valuable expertise to the
member of the health care team? emergency health care team, which
a. Case manager also includes the case manager and
b. Forensic nurse examiner the physician.
c. Physician
d. Psychiatric crisis nurse
3. The emergency department team is ANS: B
performing cardiopulmonary resusci- If resuscitation efforts are still under
tation on a client when the client's way when the family arrives, one or
spouse arrives at the emergency de- two family members may be given
partment. What should the nurse do the opportunity to be present during
next? lifesaving procedures. The other op-
a. Request that the client's spouse sit tions do not give the spouse the op-
in the waiting room. portunity to be present for the client
b. Ask the spouse if he wishes to be or to begin to have closure.
present during the resuscitation.
c. Suggest that the spouse begin to
pray for the client.
d. Refer the client's spouse to the hos-
pital's crisis team.
4. The emergency department nurse is ANS: B
assigned an older adult client who is Older adults who are confused are
, NCLEX Emergency/Burns/Triage Test Questions with 100% Verified
Answers
confused and agitated. Which inter- at increased risks for falls. Fall pre-
vention should the nurse include in vention includes measures such as
the client's plan of care? siderails up, reorientation, call light
a. Administer a sedative medication. in reach, and, in some cases, asking
b. Ask a family member to stay with the family member, significant other,
the client. or sitter to stay with the client to
c. Use restraints to prevent the client prevent falls.
from falling.
d. Place the client in a wheelchair at
the nurses' station.
5. An emergency department nurse is ANS: B
transferring a client to the med- The emergency nurse needs to be
ical-surgical unit. What is the most able to triage, assess, and evaluate.
important nursing intervention in this However, these steps have already
situation? been carried out in the early phases
a. Triage the client to determine the of the emergency department (ED)
urgency of care. admission. When a client is ready to
b. Clearly communicate client data to be transferred from the ED, commu-
the unit nurse. nication with staff nurses from the
c. Evaluate the need for ongoing med- inpatient units is essential. This re-
ical treatment. port should be a concise but com-
d. Perform a thorough assessment of prehensive report of the client's ED
the client. experience.
6. The nurse manager is assessing cur- ANS: D
rent demographics of the facility's The ED serves as an important
emergency department (ED) clients. safety net for clients who are ill
Which population would most likely or injured but lack access to ba-
present to the ED for treatment of a sic health care. Especially vulnera-
temperature and a sore throat? ble populations include the underin-
a. Older adults sured and the uninsured, who may
b. Immunocompromised people have nowhere else to go for health
c. Pediatric clients care.
d. Underinsured people
7. The emergency department (ED) ANS: B
nurse is caring for the following A client experiencing chest pain and
clients. Which client does the nurse diaphoresis would be classified as
, NCLEX Emergency/Burns/Triage Test Questions with 100% Verified
Answers
prioritize to see first? emergent and would be triaged im-
a. 22-year-old with a painful and mediately to a treatment room in the
swollen right wrist ED. The other clients are more sta-
b. 45-year-old reporting chest pain ble.
and diaphoresis
c. 60-year-old reporting difficulty
swallowing and nausea
d. 81-year-old with a respiratory rate
of 28 breaths/min and a temperature
of 101° F
8. A nurse is triaging clients in the emer- ANS: C
gency department. Which client com- A client in a nonurgent category
plaint would the triage nurse classify can tolerate waiting several hours
as nonurgent? for health care services without a
a. Chest pain and diaphoresis significant risk of clinical deterio-
b. Decreased breath sounds due to ration. The client with chest pain
chest trauma and diaphoresis and the client with
c. Left arm fracture with palpable radi- chest trauma are emergent owing to
al pulses the potential for clinical deterioration
d. Sore throat and a temperature of and would be seen immediately. The
104° F client with a high fever may be stable
now but also has a risk of deteriora-
tion. The client with an arm fracture
and palpable radial pulses is cur-
rently stable, is not at significant risk
of clinical deterioration, and would
be considered nonurgent.
9. A client has been injured in a stabbing ANS: A
incident. Assessment reveals the fol- The Level I trauma center is able
lowing: to provide a full continuum of care
Blood pressure: 80/60 mm Hg for all client areas. Level II can pro-
Heart rate: 140 beats/min vide care to most injured clients, but
Respiratory rate: 35 breaths/min given the extent of his injuries, a
Bleeding from stabbing wound site Level I center would be better if it is
Client is lethargic available. Both Levels III and IV can
stabilize major injuries, but transport
Based on these assessment data, to
, NCLEX Emergency/Burns/Triage Test Questions with 100% Verified
Answers
which trauma center should the nurse to a higher-level center is preferred,
ensure transport of the client? when possible.
a. Level I
b. Level II
c. Level III
d. Level IV
10. The emergency medical technicians ANS: A
(EMTs) arrive at the emergency de- The highest-priority intervention in
partment with an unresponsive client the primary survey is to establish
with an oxygen mask in place. What that the client is breathing ade-
will the nurse do first? quately. Even though this client has
a. Assess that the client is breathing an oxygen mask on, he may not
adequately be breathing, or he may be breath-
b. Insert a large-bore intravenous line ing inadequately with the device in
c. Place the client on a cardiac moni- place.
tor
d. Assess for best neurologic re-
sponse
11. A client arrives at the emergency ANS: C
department following a motor ve- The highest-priority intervention in
hicle collision. The client is not the primary survey is to establish
awake and is being bagged with a a patent airway. Without an ade-
bag-valve-mask by paramedics. The quate airway to supply oxygen to
client has sustained obvious injuries the cells, a cerebral injury could
to the head and face, as well as progress to anoxic brain death. After
an open right femur fracture that an airway is established, resuscita-
is bleeding profusely. What will the tion may continue to B for breathing
nurse do first? and C for circulation assessment.
a. Splint the right lower extremity.
b. Apply direct pressure to the leg.
c. Assess for a patent airway.
d. Start two large-bore IVs.
12. The nurse is providing care for a client ANS: C
admitted for suicidal precautions. The first priority in caring for a men-
What priority intervention should the tally ill client is providing a safe envi-
nurse implement first? ronment. This would include remov-
