NCLEX: Emergency Nursing Exam Questions AND Correct
Answers
1. The nurse working on a medical unit finds the client
unresponsive in the bed. After establishing the client is not
breathing and giving two rescue breaths with a mask, which
action should the nurse implement next?
1. Check the client for airway obstruction.
2. Assess the carotid artery for a pulse.
3. Begin chest compressions.
4. Call a code via the call light. - ✔✔Correct answer 4: Call a
code via the call light.
The nurse should notify the code team to come to the room so
that a defibrillator is brought to the bedside. The earlier the
client is defib- rillated, the better the chance of success. Then,
the nurse should assess for a carotid pulse and then start
compressions. The nurse has already checked for airway
obstruction before giving the two rescue breaths.
Content-Emergency; Category of Health Alteration-
Cardiovascular; Integrated Process-Implementation; Client
,Needs-Safe Effective Care Environment, Manage- ment of
Care; Cognitive Level-Synthesis.
8. Which statement explains the scientific rationale for
administering epinephrine, a catecholamine, to a client during
a code?
1. It will prevent gastric distention resulting from
overventilation with the ambu-bag.
2. Epinephrine will treat any potential anaphylactic reaction to
the medications administered.
3. Epinephrine dries secretions and makes it easier for the HCP
to intubate the client.
4. It vasoconstricts the peripheral circulation and shunts the
blood to the central circulation. - ✔✔4. It vasoconstricts the
peripheral circulation and shunts the blood to the central
circulation.
Epinephrine is a potent vasocon- strictor that keeps the blood
in the central circulationof the heart, lungs, and brain. It is
given in allergic reac- tions, but this client has no pulse or
respirations and is not having an allergic reaction.
,A 23-year-old male was brought to the emergency
department after trying to kill himself by drinking motor oil.
Which HCP order should the nurse question?
1. Initiate intravenous fluids with a 20-gauge angiocatheter.
2. Insert an indwelling urinary catheter with a urometer.
3. Place a nasogastric tube and perform gastric lavage.
4. Monitor the client's cardiac status on telemetry. - ✔✔3.
Place a nasogastric tube and perform gastric lavage.
Gastric lavage should not be attempted with ingestion of
caustic agents such as high-viscosity petroleum products.
Intravenous fluids, monitoring intake and output, and
monitoring the cardiac status are appropriate interventions.
A gastric lavage has been ordered for a comatose client who
ingested a full bottle of sleeping pills in an attempt to commit
suicide. Which interventions should the nurse implement?
Select all that apply.
1. Place the client supine with the head of the bed flat.
2. Insert a large-bore gastric tube into the client's mouth.
, 3. Make sure there is standby suction at the bedside.
4. Withdraw all stomach contents and then instill irritating
solution.
5. Use gloves to dispose all stomach contents into the
commode. - ✔✔2, 3, 4
A large-bore tube is used with a comatose client; suction is to
prevent aspiration; and removing stomach contents before
the lavage helps to prevent overdistention of the stomach.
The client should be placed on the left side to allow the gastric
contents to pool in the stomach, decreasing passage of fluid
into the duodenum during lavage. Samples are sent to the lab
to be analyzed for chemical compounds.
A potential chemical spill has occurred on the medical floor.
Which intervention should the charge nurse implement first?
1. Instruct the staff to evacuate the immediate area.
2. Contain the area where the chemical spill occurred.
3. Notify the hazard management team.
4. Contact the hospital shift supervisor. - ✔✔2. Contain the
area where the chemical spill occurred.
Answers
1. The nurse working on a medical unit finds the client
unresponsive in the bed. After establishing the client is not
breathing and giving two rescue breaths with a mask, which
action should the nurse implement next?
1. Check the client for airway obstruction.
2. Assess the carotid artery for a pulse.
3. Begin chest compressions.
4. Call a code via the call light. - ✔✔Correct answer 4: Call a
code via the call light.
The nurse should notify the code team to come to the room so
that a defibrillator is brought to the bedside. The earlier the
client is defib- rillated, the better the chance of success. Then,
the nurse should assess for a carotid pulse and then start
compressions. The nurse has already checked for airway
obstruction before giving the two rescue breaths.
Content-Emergency; Category of Health Alteration-
Cardiovascular; Integrated Process-Implementation; Client
,Needs-Safe Effective Care Environment, Manage- ment of
Care; Cognitive Level-Synthesis.
8. Which statement explains the scientific rationale for
administering epinephrine, a catecholamine, to a client during
a code?
1. It will prevent gastric distention resulting from
overventilation with the ambu-bag.
2. Epinephrine will treat any potential anaphylactic reaction to
the medications administered.
3. Epinephrine dries secretions and makes it easier for the HCP
to intubate the client.
4. It vasoconstricts the peripheral circulation and shunts the
blood to the central circulation. - ✔✔4. It vasoconstricts the
peripheral circulation and shunts the blood to the central
circulation.
Epinephrine is a potent vasocon- strictor that keeps the blood
in the central circulationof the heart, lungs, and brain. It is
given in allergic reac- tions, but this client has no pulse or
respirations and is not having an allergic reaction.
,A 23-year-old male was brought to the emergency
department after trying to kill himself by drinking motor oil.
Which HCP order should the nurse question?
1. Initiate intravenous fluids with a 20-gauge angiocatheter.
2. Insert an indwelling urinary catheter with a urometer.
3. Place a nasogastric tube and perform gastric lavage.
4. Monitor the client's cardiac status on telemetry. - ✔✔3.
Place a nasogastric tube and perform gastric lavage.
Gastric lavage should not be attempted with ingestion of
caustic agents such as high-viscosity petroleum products.
Intravenous fluids, monitoring intake and output, and
monitoring the cardiac status are appropriate interventions.
A gastric lavage has been ordered for a comatose client who
ingested a full bottle of sleeping pills in an attempt to commit
suicide. Which interventions should the nurse implement?
Select all that apply.
1. Place the client supine with the head of the bed flat.
2. Insert a large-bore gastric tube into the client's mouth.
, 3. Make sure there is standby suction at the bedside.
4. Withdraw all stomach contents and then instill irritating
solution.
5. Use gloves to dispose all stomach contents into the
commode. - ✔✔2, 3, 4
A large-bore tube is used with a comatose client; suction is to
prevent aspiration; and removing stomach contents before
the lavage helps to prevent overdistention of the stomach.
The client should be placed on the left side to allow the gastric
contents to pool in the stomach, decreasing passage of fluid
into the duodenum during lavage. Samples are sent to the lab
to be analyzed for chemical compounds.
A potential chemical spill has occurred on the medical floor.
Which intervention should the charge nurse implement first?
1. Instruct the staff to evacuate the immediate area.
2. Contain the area where the chemical spill occurred.
3. Notify the hazard management team.
4. Contact the hospital shift supervisor. - ✔✔2. Contain the
area where the chemical spill occurred.
