Emergency Nursing & Triage NCLEX Practice (Part
1: 20 Questions)
1. 1. Question
Nurse Ejay is assigned to telephone triage. A client called who was
stung by a honeybee and is asking for help. The client reports pain and
localized swelling but has no respiratory distress or other symptoms of
anaphylactic shock. What is the appropriate initial action that the
nurse should direct the client to perform?
o A. Removing the stinger by scraping it
o B. Applying a cold compress
o C. Taking an oral antihistamine
o D. Calling 911
Incorrect
Correct Answer: A. Removing the stinger by scraping it.
Since the stinger will continue to release venom into the skin,
removing the stinger should be the first action that the nurse should
direct to the client. Within the first few minutes after the sting, the
stinger should be removed via scraping with a credit card rather than
squeezing/tweezing to avoid further venom exposure.
Option B: Uncomplicated local reactions can be treated with
supportive care (ice packs, NSAIDs/APAP for pain, H1/H2 blocker).
Cold compress follows the administration of antihistamine. Large
local reactions should also be treated with supportive care along
with glucocorticoids (usually a burst course of prednisone 40 to
60 mg per day for 3 to 5 days) to decrease the inflammatory
response and improve symptoms.
Option C: After removing the stinger, an antihistamine is
administered. H1 and H2 antagonists block the effects of
histamine decreasing pruritus, erythema, and urticaria.
Corticosteroids (prednisone, methylprednisolone,
dexamethasone) act to decrease inflammation and immune
response to the antigen.
, Option D: The caller should be further advised about symptoms
that require 911 assistance. Systemic reactions (anaphylaxis) are
life-threatening and should be managed as such. ABCs first. The
airway can be lost within seconds to minutes, so intubate early.
As with any anaphylactic reaction, epinephrine, corticosteroids,
H1 and H2 antagonists, and intravenous (IV) fluids should be
given immediately.
2. 2. Question
Nurse Anna is an experienced travel nurse who was recently employed
and is assigned to the emergency unit. In her first week of the job,
which of the following area is the most appropriate assignment for
her?
A. Triage
B. Ambulatory section
C. Trauma team
D. Psychiatric care
Incorrect
Correct Answer: B. Ambulatory section
The ambulatory section deals with clients with relatively stable
conditions. The decision of whether or not to delegate or assign is
based upon the RN’s judgment concerning the condition of the patient,
the competence of all members of the nursing team and the degree of
supervision that will be required of the RN if a task is delegated.
Option A: The RN delegates only those tasks for which he or she
believes the other health care worker has the knowledge and skill
to perform, taking into consideration training, cultural
competence, experience and facility/agency policies and
procedures.
Option C: This area should be filled with nurses who are
experienced with hospital routines and policies and have the
ability to locate equipment immediately. There is both individual
accountability and organizational accountability for delegation.
Organizational accountability for delegation relates to providing
sufficient resources, including sufficient staffing with an
appropriate staff mix.
Option D: Few places are more hectic than a Hospital
, Emergency Room. Clearly, delegating important nursing tasks is
the only plausible way for short-staffed emergency rooms to
meet the challenges of providing quality patient care. All
decisions related to delegation and assignment are based on the
fundamental principles of protection of the health, safety, and
welfare of the public.”
3. 3. Question
A client arrives at the emergency department who suffered multiple
injuries from a head-on car collision. Which of the following assessment
should take the highest priority to take?
A. Unequal pupils
B. Irregular pulse
C. Ecchymosis in the flank area
D. A deviated trachea
Incorrect
Correct Answer: D. A deviated trachea
A deviated trachea is a symptom of tension pneumothorax, which will
result in respiratory distress if left untreated. The first question in the
ESI triage algorithm for triage nurses asks whether “the patient
requires immediate life-saving interventions” or simply “is the patient
dying?” The nurse determines this by looking to see if the patient has a
patent airway, if the patient is breathing, and does the patient has a
pulse.
Option A: Another scale used by nurses in the assessment is if
the patient is meeting criteria for a true level 1 trauma is the
AVPU (alert, verbal, pain, unresponsive) scale. The scale is used
to evaluate if the patient had a recent or sudden change in the
level of consciousness and needs immediate intervention.
Option B: The nurse evaluates the patient, checking pulse,
rhythm, rate, and airway patency. Is there concern for
inadequate oxygenation? Is this person hemodynamically stable?
Does the patient need any immediate medication or interventions
to replace volume or blood loss? Does this patient have
pulselessness, apnea, severe respiratory distress, oxygen
saturation below 90, acute mental status changes, or
unresponsiveness?
1: 20 Questions)
1. 1. Question
Nurse Ejay is assigned to telephone triage. A client called who was
stung by a honeybee and is asking for help. The client reports pain and
localized swelling but has no respiratory distress or other symptoms of
anaphylactic shock. What is the appropriate initial action that the
nurse should direct the client to perform?
o A. Removing the stinger by scraping it
o B. Applying a cold compress
o C. Taking an oral antihistamine
o D. Calling 911
Incorrect
Correct Answer: A. Removing the stinger by scraping it.
Since the stinger will continue to release venom into the skin,
removing the stinger should be the first action that the nurse should
direct to the client. Within the first few minutes after the sting, the
stinger should be removed via scraping with a credit card rather than
squeezing/tweezing to avoid further venom exposure.
Option B: Uncomplicated local reactions can be treated with
supportive care (ice packs, NSAIDs/APAP for pain, H1/H2 blocker).
Cold compress follows the administration of antihistamine. Large
local reactions should also be treated with supportive care along
with glucocorticoids (usually a burst course of prednisone 40 to
60 mg per day for 3 to 5 days) to decrease the inflammatory
response and improve symptoms.
Option C: After removing the stinger, an antihistamine is
administered. H1 and H2 antagonists block the effects of
histamine decreasing pruritus, erythema, and urticaria.
Corticosteroids (prednisone, methylprednisolone,
dexamethasone) act to decrease inflammation and immune
response to the antigen.
, Option D: The caller should be further advised about symptoms
that require 911 assistance. Systemic reactions (anaphylaxis) are
life-threatening and should be managed as such. ABCs first. The
airway can be lost within seconds to minutes, so intubate early.
As with any anaphylactic reaction, epinephrine, corticosteroids,
H1 and H2 antagonists, and intravenous (IV) fluids should be
given immediately.
2. 2. Question
Nurse Anna is an experienced travel nurse who was recently employed
and is assigned to the emergency unit. In her first week of the job,
which of the following area is the most appropriate assignment for
her?
A. Triage
B. Ambulatory section
C. Trauma team
D. Psychiatric care
Incorrect
Correct Answer: B. Ambulatory section
The ambulatory section deals with clients with relatively stable
conditions. The decision of whether or not to delegate or assign is
based upon the RN’s judgment concerning the condition of the patient,
the competence of all members of the nursing team and the degree of
supervision that will be required of the RN if a task is delegated.
Option A: The RN delegates only those tasks for which he or she
believes the other health care worker has the knowledge and skill
to perform, taking into consideration training, cultural
competence, experience and facility/agency policies and
procedures.
Option C: This area should be filled with nurses who are
experienced with hospital routines and policies and have the
ability to locate equipment immediately. There is both individual
accountability and organizational accountability for delegation.
Organizational accountability for delegation relates to providing
sufficient resources, including sufficient staffing with an
appropriate staff mix.
Option D: Few places are more hectic than a Hospital
, Emergency Room. Clearly, delegating important nursing tasks is
the only plausible way for short-staffed emergency rooms to
meet the challenges of providing quality patient care. All
decisions related to delegation and assignment are based on the
fundamental principles of protection of the health, safety, and
welfare of the public.”
3. 3. Question
A client arrives at the emergency department who suffered multiple
injuries from a head-on car collision. Which of the following assessment
should take the highest priority to take?
A. Unequal pupils
B. Irregular pulse
C. Ecchymosis in the flank area
D. A deviated trachea
Incorrect
Correct Answer: D. A deviated trachea
A deviated trachea is a symptom of tension pneumothorax, which will
result in respiratory distress if left untreated. The first question in the
ESI triage algorithm for triage nurses asks whether “the patient
requires immediate life-saving interventions” or simply “is the patient
dying?” The nurse determines this by looking to see if the patient has a
patent airway, if the patient is breathing, and does the patient has a
pulse.
Option A: Another scale used by nurses in the assessment is if
the patient is meeting criteria for a true level 1 trauma is the
AVPU (alert, verbal, pain, unresponsive) scale. The scale is used
to evaluate if the patient had a recent or sudden change in the
level of consciousness and needs immediate intervention.
Option B: The nurse evaluates the patient, checking pulse,
rhythm, rate, and airway patency. Is there concern for
inadequate oxygenation? Is this person hemodynamically stable?
Does the patient need any immediate medication or interventions
to replace volume or blood loss? Does this patient have
pulselessness, apnea, severe respiratory distress, oxygen
saturation below 90, acute mental status changes, or
unresponsiveness?
