**Title:** **Emergency Nursing & Triage: NCLEX-
RN Critical Care Scenarios**
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### Question 1 of 88
A nurse in the ED is triaging clients after a mass casualty event. Which client should receive immediate
(red tag) treatment?
A) Partial-thickness burns to 30% TBSA, conscious and talking
B) Open femur fracture with palpable distal pulses
C) Unconscious with respiratory rate 8 breaths/min
D) Sucking chest wound, alert, SpO2 91%
💫RATIONALE✔️✔️: Unconscious with RR 8 (C) has airway/breathing compromise, life-threatening. Red
tag. Others are stable or can wait.
💫ANSWER✔️✔️: C) Unconscious with respiratory rate 8 breaths/min
---
### Question 2 of 88
A nurse is caring for a client with carbon monoxide poisoning. Which finding is most consistent?
A) Cherry-red skin color
B) Cyanosis of lips and nail beds
,C) Jaundice of the sclera
D) Pallor and diaphoresis
💫RATIONALE✔️✔️: Carbon monoxide causes cherry-red skin color (A) due to carboxyhemoglobin.
💫ANSWER✔️✔️: A) Cherry-red skin color
---
### Question 3 of 88
**Select-All-That-Apply (SATA):** A nurse is assessing a client with tension pneumothorax after blunt
chest trauma. Which findings should the nurse expect? (Select all that apply.)
A) Absent breath sounds on affected side
B) Tracheal deviation toward affected side
C) Hypotension
D) Jugular vein distention
E) Hyperresonance on percussion
💫RATIONALE✔️✔️: Tension pneumothorax: absent breath sounds (A), hypotension (C), JVD (D),
hyperresonance (E). Tracheal deviation away from affected side.
💫ANSWER✔️✔️: A, C, D, E
---
### Question 4 of 88
A nurse in the ICU is caring for a client with a pulmonary artery catheter. PAWP is 4 mmHg. Which
condition should the nurse suspect?
,A) Hypervolemia
B) Left ventricular failure
C) Hypovolemia
D) Pulmonary hypertension
💫RATIONALE✔️✔️: Normal PAWP 4-12 mmHg. PAWP 4 is low normal trending toward hypovolemia (C).
💫ANSWER✔️✔️: C) Hypovolemia
---
### Question 5 of 88
A nurse is caring for a client with new ARDS. Which finding is expected in the early phase?
A) Severe hypoxemia that does not improve with oxygen
B) Hypercapnia and respiratory acidosis
C) Normal chest x-ray
D) Bradycardia and hypotension
💫RATIONALE✔️✔️: Early ARDS causes refractory hypoxemia (A) from intrapulmonary shunting.
💫ANSWER✔️✔️: A) Severe hypoxemia that does not improve with oxygen
---
### Question 6 of 88
A nurse is providing discharge teaching to a client after hip replacement with new enoxaparin (Lovenox).
Which statement indicates understanding?
, A) "I will inject this into my thigh muscle."
B) "I will take ibuprofen for pain."
C) "I will not rub the injection site."
D) "I will stop this if I see bruising."
💫RATIONALE✔️✔️: Do not rub injection site (C) to prevent bleeding. Subcutaneous in abdomen. Avoid
NSAIDs. Bruising expected.
💫ANSWER✔️✔️: C) "I will not rub the injection site."
---
### Question 7 of 88
**Select-All-That-Apply (SATA):** A nurse is caring for a client with status epilepticus. Which actions
should the nurse take first? (Select all that apply.)
A) Administer lorazepam (Ativan)
B) Place client in lateral position
C) Insert padded tongue blade
D) Establish IV access
E) Apply oxygen
💫RATIONALE✔️✔️: Lateral position (B), establish IV (D), benzodiazepines (A), oxygen (E) correct. Tongue
blades contraindicated.
💫ANSWER✔️✔️: A, B, D, E
---
### Question 8 of 88
RN Critical Care Scenarios**
---
### Question 1 of 88
A nurse in the ED is triaging clients after a mass casualty event. Which client should receive immediate
(red tag) treatment?
A) Partial-thickness burns to 30% TBSA, conscious and talking
B) Open femur fracture with palpable distal pulses
C) Unconscious with respiratory rate 8 breaths/min
D) Sucking chest wound, alert, SpO2 91%
💫RATIONALE✔️✔️: Unconscious with RR 8 (C) has airway/breathing compromise, life-threatening. Red
tag. Others are stable or can wait.
💫ANSWER✔️✔️: C) Unconscious with respiratory rate 8 breaths/min
---
### Question 2 of 88
A nurse is caring for a client with carbon monoxide poisoning. Which finding is most consistent?
A) Cherry-red skin color
B) Cyanosis of lips and nail beds
,C) Jaundice of the sclera
D) Pallor and diaphoresis
💫RATIONALE✔️✔️: Carbon monoxide causes cherry-red skin color (A) due to carboxyhemoglobin.
💫ANSWER✔️✔️: A) Cherry-red skin color
---
### Question 3 of 88
**Select-All-That-Apply (SATA):** A nurse is assessing a client with tension pneumothorax after blunt
chest trauma. Which findings should the nurse expect? (Select all that apply.)
A) Absent breath sounds on affected side
B) Tracheal deviation toward affected side
C) Hypotension
D) Jugular vein distention
E) Hyperresonance on percussion
💫RATIONALE✔️✔️: Tension pneumothorax: absent breath sounds (A), hypotension (C), JVD (D),
hyperresonance (E). Tracheal deviation away from affected side.
💫ANSWER✔️✔️: A, C, D, E
---
### Question 4 of 88
A nurse in the ICU is caring for a client with a pulmonary artery catheter. PAWP is 4 mmHg. Which
condition should the nurse suspect?
,A) Hypervolemia
B) Left ventricular failure
C) Hypovolemia
D) Pulmonary hypertension
💫RATIONALE✔️✔️: Normal PAWP 4-12 mmHg. PAWP 4 is low normal trending toward hypovolemia (C).
💫ANSWER✔️✔️: C) Hypovolemia
---
### Question 5 of 88
A nurse is caring for a client with new ARDS. Which finding is expected in the early phase?
A) Severe hypoxemia that does not improve with oxygen
B) Hypercapnia and respiratory acidosis
C) Normal chest x-ray
D) Bradycardia and hypotension
💫RATIONALE✔️✔️: Early ARDS causes refractory hypoxemia (A) from intrapulmonary shunting.
💫ANSWER✔️✔️: A) Severe hypoxemia that does not improve with oxygen
---
### Question 6 of 88
A nurse is providing discharge teaching to a client after hip replacement with new enoxaparin (Lovenox).
Which statement indicates understanding?
, A) "I will inject this into my thigh muscle."
B) "I will take ibuprofen for pain."
C) "I will not rub the injection site."
D) "I will stop this if I see bruising."
💫RATIONALE✔️✔️: Do not rub injection site (C) to prevent bleeding. Subcutaneous in abdomen. Avoid
NSAIDs. Bruising expected.
💫ANSWER✔️✔️: C) "I will not rub the injection site."
---
### Question 7 of 88
**Select-All-That-Apply (SATA):** A nurse is caring for a client with status epilepticus. Which actions
should the nurse take first? (Select all that apply.)
A) Administer lorazepam (Ativan)
B) Place client in lateral position
C) Insert padded tongue blade
D) Establish IV access
E) Apply oxygen
💫RATIONALE✔️✔️: Lateral position (B), establish IV (D), benzodiazepines (A), oxygen (E) correct. Tongue
blades contraindicated.
💫ANSWER✔️✔️: A, B, D, E
---
### Question 8 of 88
