1
EMERGENCY NURSING TRIAGE AND ASSESSMENT
EXAM WITH REAL EXAM STUDY GUIDE TIPS QS & AS
Note: answers key provided
1. Michael works as a triage nurse, and four clients arrive at the emergency
department at the same time. List the order in which he will assess these
clients from first to last.
• 1. A 50-year-old female with moderate abdominal pain and
occasional vomiting.
• 2. A 35-year-old jogger with a twisted ankle, having a pedal pulse and
no deformity.
• 3. An ambulatory dazed 25-year-old male with a bandaged head
wound.
• 4. An irritable infant with a fever, petechiae, and nuchal rigidity.
A. 1, 2, 3, 4
B. 2, 1, 3, 4
C. 4, 3, 1, 2
D. 3, 4, 2, 1
,2
2. In conducting a primary survey on a trauma patient, which of the following
is considered one of the priority elements of the primary survey?
A. Initiation of pulse oximetry.
B. Complete set of vital signs.
C. Client’s allergy history.
D. Brief neurologic assessment.
3. A 65-year-old patient arrived at the triage area with complaints of
diaphoresis, dizziness, and left-sided chest pain. This patient should be
prioritized into which category?
A. Non-urgent.
B. Urgent.
C. Emergent.
D. High urgent.
4. You respond to a call for help from the ED waiting room. There is an elderly
patient lying on the floor. List the order for the actions that you must perform.
• 1. Call for help and activate the code team.
• 2. Instruct a nursing assistant to get the emergency cart.
• 3. Initiate cardiopulmonary resuscitation (CPR).
• 4. Perform the chin lift or jaw thrust maneuver.
• 5. Establish unresponsiveness.
A. 5, 2, 4, 3, 1
B. 1, 5, 2, 4, 3
C. 1, 2, 5, 4, 3
D. 5, 1, 4, 3, 2
5. In caring for a victim of sexual assault, which task is most appropriate for an
LPN/LVN?
,3
A. Provide emotional support and supportive communication.
B. Assess immediate emotional state and physical injuries.
C. Ensure that the “chain of custody” is maintained.
D. Collect hair samples, saliva swabs, and scrapings beneath fingernails.
6. You are caring for a client with a frostbite on the feet. Place the following
interventions in the correct order.
• 1. Immerse the feet in warm water 100° F to 105° F (40.6º C to 46.1°
C).
• 2. Remove the victim from the cold environment.
• 3. Monitor for signs of compartment syndrome.
• 4. Apply a loose, sterile, bulky dressing.
• 5. Administer a pain medication.
A. 5, 2, 1, 3, 4
B. 2, 5, 1, 4, 3
C. 2, 1, 5, 3, 4
D. 3, 2, 1, 4, 5
7. Following an emergency endotracheal intubation, nurses must verify tube
placement and secure the tube. List in order the steps that are required to
perform this function?
• 1. Obtain an order for a chest x-ray to document tube placement.
• 2. Confirm that the breath sounds are equal and bilateral.
• 3. Auscultate the chest during assisted ventilation.
• 4. Secure the tube in place.
A. 1, 2, 3, 4
B. 4, 3, 2, 1
C. 3, 2, 4, 1
D. 4, 1, 2, 3
, 4
8. A 15-year-old male client arrives at the emergency department. He is
conscious, coherent and ambulatory, but his shirt and pants are covered with
blood. He and his hysterical friends are yelling and trying to explain that they
were goofing around and he got poked in the abdomen with a stick. Which of
the following comments should be given first consideration?
A. “He’s a diabetic, so he needs attention right away.”
B. “There was a lot of blood and we used three bandages.”
C. “The stick was really dirty and covered with mud.”
D. “He pulled the stick out, just now, because it was hurting him.”
9. A prisoner, with a known history of alcohol abuse, has been in police
custody for 48 hours. Initially, anxiety, sweating, and tremors were noted.
Now, disorientation, hallucination, and hyper-reactivity are observed. The
medical diagnosis is delirium tremens. What is the priority nursing diagnosis?
A. Risk for Situational Low Self-esteem related to police custody.
B. Risk for Nutritional Deficit related to chronic alcohol abuse.
C. Risk for Injury related to seizures.
D. Risk for Other-Directed Violence related to hallucinations.
10. In relation to submersion injuries, which task is most appropriate to
delegate to an LPN/LVN?
A. Talk to a community group about water safety issues.
B. Stabilize the cervical spine for an unconscious drowning victim.
C. Remove wet clothing and cover the victim with a warm blanket.
D. Monitor an asymptomatic near-drowning victim.
11. You are assessing a patient who has sustained a cat bite to the left hand.
The cat is up-to-date immunizations. The date of the patient’s last tetanus shot
is unknown. Which of the following is the priority nursing diagnosis?
EMERGENCY NURSING TRIAGE AND ASSESSMENT
EXAM WITH REAL EXAM STUDY GUIDE TIPS QS & AS
Note: answers key provided
1. Michael works as a triage nurse, and four clients arrive at the emergency
department at the same time. List the order in which he will assess these
clients from first to last.
• 1. A 50-year-old female with moderate abdominal pain and
occasional vomiting.
• 2. A 35-year-old jogger with a twisted ankle, having a pedal pulse and
no deformity.
• 3. An ambulatory dazed 25-year-old male with a bandaged head
wound.
• 4. An irritable infant with a fever, petechiae, and nuchal rigidity.
A. 1, 2, 3, 4
B. 2, 1, 3, 4
C. 4, 3, 1, 2
D. 3, 4, 2, 1
,2
2. In conducting a primary survey on a trauma patient, which of the following
is considered one of the priority elements of the primary survey?
A. Initiation of pulse oximetry.
B. Complete set of vital signs.
C. Client’s allergy history.
D. Brief neurologic assessment.
3. A 65-year-old patient arrived at the triage area with complaints of
diaphoresis, dizziness, and left-sided chest pain. This patient should be
prioritized into which category?
A. Non-urgent.
B. Urgent.
C. Emergent.
D. High urgent.
4. You respond to a call for help from the ED waiting room. There is an elderly
patient lying on the floor. List the order for the actions that you must perform.
• 1. Call for help and activate the code team.
• 2. Instruct a nursing assistant to get the emergency cart.
• 3. Initiate cardiopulmonary resuscitation (CPR).
• 4. Perform the chin lift or jaw thrust maneuver.
• 5. Establish unresponsiveness.
A. 5, 2, 4, 3, 1
B. 1, 5, 2, 4, 3
C. 1, 2, 5, 4, 3
D. 5, 1, 4, 3, 2
5. In caring for a victim of sexual assault, which task is most appropriate for an
LPN/LVN?
,3
A. Provide emotional support and supportive communication.
B. Assess immediate emotional state and physical injuries.
C. Ensure that the “chain of custody” is maintained.
D. Collect hair samples, saliva swabs, and scrapings beneath fingernails.
6. You are caring for a client with a frostbite on the feet. Place the following
interventions in the correct order.
• 1. Immerse the feet in warm water 100° F to 105° F (40.6º C to 46.1°
C).
• 2. Remove the victim from the cold environment.
• 3. Monitor for signs of compartment syndrome.
• 4. Apply a loose, sterile, bulky dressing.
• 5. Administer a pain medication.
A. 5, 2, 1, 3, 4
B. 2, 5, 1, 4, 3
C. 2, 1, 5, 3, 4
D. 3, 2, 1, 4, 5
7. Following an emergency endotracheal intubation, nurses must verify tube
placement and secure the tube. List in order the steps that are required to
perform this function?
• 1. Obtain an order for a chest x-ray to document tube placement.
• 2. Confirm that the breath sounds are equal and bilateral.
• 3. Auscultate the chest during assisted ventilation.
• 4. Secure the tube in place.
A. 1, 2, 3, 4
B. 4, 3, 2, 1
C. 3, 2, 4, 1
D. 4, 1, 2, 3
, 4
8. A 15-year-old male client arrives at the emergency department. He is
conscious, coherent and ambulatory, but his shirt and pants are covered with
blood. He and his hysterical friends are yelling and trying to explain that they
were goofing around and he got poked in the abdomen with a stick. Which of
the following comments should be given first consideration?
A. “He’s a diabetic, so he needs attention right away.”
B. “There was a lot of blood and we used three bandages.”
C. “The stick was really dirty and covered with mud.”
D. “He pulled the stick out, just now, because it was hurting him.”
9. A prisoner, with a known history of alcohol abuse, has been in police
custody for 48 hours. Initially, anxiety, sweating, and tremors were noted.
Now, disorientation, hallucination, and hyper-reactivity are observed. The
medical diagnosis is delirium tremens. What is the priority nursing diagnosis?
A. Risk for Situational Low Self-esteem related to police custody.
B. Risk for Nutritional Deficit related to chronic alcohol abuse.
C. Risk for Injury related to seizures.
D. Risk for Other-Directed Violence related to hallucinations.
10. In relation to submersion injuries, which task is most appropriate to
delegate to an LPN/LVN?
A. Talk to a community group about water safety issues.
B. Stabilize the cervical spine for an unconscious drowning victim.
C. Remove wet clothing and cover the victim with a warm blanket.
D. Monitor an asymptomatic near-drowning victim.
11. You are assessing a patient who has sustained a cat bite to the left hand.
The cat is up-to-date immunizations. The date of the patient’s last tetanus shot
is unknown. Which of the following is the priority nursing diagnosis?
