NCLEX RN Emergency Nursing Practice
Exam 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026
Question 1
A client arrives in the emergency department after a motor vehicle collision.
The client is unconscious and has noisy respirations. What is the nurse’s priority
action?
A. Obtain the client’s blood pressure
B. Assess the pupils
C. Open and maintain the airway
D. Insert a urinary catheter
Answer: C. Open and maintain the airway
Rationale: Airway management is the first priority in emergency assessment.
An unconscious client with noisy respirations may have an obstructed airway
and requires immediate airway intervention.
Question 2
A client with suspected spinal cord injury is being transferred from the
ambulance stretcher. Which intervention is most important?
A. Flex the client’s neck
B. Maintain spinal alignment
C. Place the client in high-Fowler’s position
D. Encourage active range-of-motion exercises
Answer: B. Maintain spinal alignment
,Rationale: Maintaining spinal alignment prevents additional neurologic
injury in clients with possible spinal trauma.
Question 3
A client arrives with severe chest pain, diaphoresis, and nausea. Which
assessment should the nurse perform first?
A. Obtain a 12-lead ECG
B. Ask about family history
C. Assess dietary intake
D. Obtain a urine specimen
Answer: A. Obtain a 12-lead ECG
Rationale: A 12-lead ECG should be obtained rapidly in suspected acute
coronary syndrome to identify myocardial ischemia or infarction and guide
treatment.
Question 4
A client presents with anaphylaxis after receiving an antibiotic. Which
medication should the nurse administer first?
A. Diphenhydramine
B. Methylprednisolone
C. Epinephrine
D. Famotidine
Answer: C. Epinephrine
Rationale: Epinephrine is the first-line treatment for anaphylaxis because it
rapidly reverses airway edema, bronchoconstriction, and cardiovascular
collapse.
Question 5
A client arrives after a house fire with facial burns and singed nasal hairs.
Which finding requires the most immediate attention?
A. Blisters on the arms
B. Hoarse voice
,C. Pain rated 9/10
D. Redness of the chest
Answer: B. Hoarse voice
Rationale: Hoarseness may indicate inhalation injury and impending airway
edema. Airway compromise can progress rapidly after a thermal injury.
Question 6
A client with suspected stroke arrives in the emergency department. Which
information is most important to determine?
A. Last oral intake
B. Time symptoms were last known to be normal
C. Previous vaccination history
D. Usual sleep pattern
Answer: B. Time symptoms were last known to be normal
Rationale: The time of symptom onset or last-known-well time is critical in
determining eligibility for time-sensitive stroke therapies.
Question 7
A client with hypovolemic shock is pale, restless, tachycardic, and hypotensive.
Which intervention should the nurse anticipate?
A. Restrict fluids
B. Administer isotonic IV fluids
C. Place the client in a warm bath
D. Administer oral fluids
Answer: B. Administer isotonic IV fluids
Rationale: Rapid administration of isotonic IV fluids is commonly used to
restore circulating volume in hypovolemic shock while the underlying cause is
treated.
Question 8
A client arrives after ingesting an unknown quantity of a household chemical.
Which action should the nurse take first?
, A. Induce vomiting
B. Give activated charcoal immediately
C. Assess airway, breathing, and circulation
D. Give milk
Answer: C. Assess airway, breathing, and circulation
Rationale: Emergency poisoning management begins with stabilization of
airway, breathing, and circulation before specific decontamination measures
are considered.
Question 9
A client has a penetrating chest wound with a sucking sound. Which
intervention is appropriate?
A. Apply a sterile occlusive dressing secured on three sides
B. Remove any visible foreign object
C. Apply a dry gauze dressing only
D. Place the client flat with the legs elevated
Answer: A. Apply a sterile occlusive dressing secured on three sides
Rationale: A three-sided occlusive dressing helps prevent air from entering
the pleural space while allowing trapped air to escape, reducing the risk of
tension pneumothorax.
Question 10
A client arrives with severe shortness of breath and unilateral absent breath
sounds after chest trauma. The trachea is deviated away from the injured side.
What condition should the nurse suspect?
A. Pulmonary edema
B. Tension pneumothorax
C. Simple rib fracture
D. Pleural effusion
Answer: B. Tension pneumothorax
Exam 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026
Question 1
A client arrives in the emergency department after a motor vehicle collision.
The client is unconscious and has noisy respirations. What is the nurse’s priority
action?
A. Obtain the client’s blood pressure
B. Assess the pupils
C. Open and maintain the airway
D. Insert a urinary catheter
Answer: C. Open and maintain the airway
Rationale: Airway management is the first priority in emergency assessment.
An unconscious client with noisy respirations may have an obstructed airway
and requires immediate airway intervention.
Question 2
A client with suspected spinal cord injury is being transferred from the
ambulance stretcher. Which intervention is most important?
A. Flex the client’s neck
B. Maintain spinal alignment
C. Place the client in high-Fowler’s position
D. Encourage active range-of-motion exercises
Answer: B. Maintain spinal alignment
,Rationale: Maintaining spinal alignment prevents additional neurologic
injury in clients with possible spinal trauma.
Question 3
A client arrives with severe chest pain, diaphoresis, and nausea. Which
assessment should the nurse perform first?
A. Obtain a 12-lead ECG
B. Ask about family history
C. Assess dietary intake
D. Obtain a urine specimen
Answer: A. Obtain a 12-lead ECG
Rationale: A 12-lead ECG should be obtained rapidly in suspected acute
coronary syndrome to identify myocardial ischemia or infarction and guide
treatment.
Question 4
A client presents with anaphylaxis after receiving an antibiotic. Which
medication should the nurse administer first?
A. Diphenhydramine
B. Methylprednisolone
C. Epinephrine
D. Famotidine
Answer: C. Epinephrine
Rationale: Epinephrine is the first-line treatment for anaphylaxis because it
rapidly reverses airway edema, bronchoconstriction, and cardiovascular
collapse.
Question 5
A client arrives after a house fire with facial burns and singed nasal hairs.
Which finding requires the most immediate attention?
A. Blisters on the arms
B. Hoarse voice
,C. Pain rated 9/10
D. Redness of the chest
Answer: B. Hoarse voice
Rationale: Hoarseness may indicate inhalation injury and impending airway
edema. Airway compromise can progress rapidly after a thermal injury.
Question 6
A client with suspected stroke arrives in the emergency department. Which
information is most important to determine?
A. Last oral intake
B. Time symptoms were last known to be normal
C. Previous vaccination history
D. Usual sleep pattern
Answer: B. Time symptoms were last known to be normal
Rationale: The time of symptom onset or last-known-well time is critical in
determining eligibility for time-sensitive stroke therapies.
Question 7
A client with hypovolemic shock is pale, restless, tachycardic, and hypotensive.
Which intervention should the nurse anticipate?
A. Restrict fluids
B. Administer isotonic IV fluids
C. Place the client in a warm bath
D. Administer oral fluids
Answer: B. Administer isotonic IV fluids
Rationale: Rapid administration of isotonic IV fluids is commonly used to
restore circulating volume in hypovolemic shock while the underlying cause is
treated.
Question 8
A client arrives after ingesting an unknown quantity of a household chemical.
Which action should the nurse take first?
, A. Induce vomiting
B. Give activated charcoal immediately
C. Assess airway, breathing, and circulation
D. Give milk
Answer: C. Assess airway, breathing, and circulation
Rationale: Emergency poisoning management begins with stabilization of
airway, breathing, and circulation before specific decontamination measures
are considered.
Question 9
A client has a penetrating chest wound with a sucking sound. Which
intervention is appropriate?
A. Apply a sterile occlusive dressing secured on three sides
B. Remove any visible foreign object
C. Apply a dry gauze dressing only
D. Place the client flat with the legs elevated
Answer: A. Apply a sterile occlusive dressing secured on three sides
Rationale: A three-sided occlusive dressing helps prevent air from entering
the pleural space while allowing trapped air to escape, reducing the risk of
tension pneumothorax.
Question 10
A client arrives with severe shortness of breath and unilateral absent breath
sounds after chest trauma. The trachea is deviated away from the injured side.
What condition should the nurse suspect?
A. Pulmonary edema
B. Tension pneumothorax
C. Simple rib fracture
D. Pleural effusion
Answer: B. Tension pneumothorax
