BCIT NSER 7110 Emergency Nursing Theory 1 Final Exam
Questions and Answers
QUESTION 1
A patient arrives in the emergency department with crushing chest pain radiating to the left
arm. Which nursing action should be given the highest priority?
A. Administer nitroglycerin sublingually.
B. Obtain a 12-lead ECG.
C. Establish IV access.
D. Assess airway, breathing, and circulation.
CORRECT ANSWER: D
RATIONALE: Airway, breathing, and circulation (ABCs) always take precedence in emergency
care. While ECG and medication administration are critical, stabilization of basic life functions
must occur first.
QUESTION 2
Which of the following findings is the earliest indicator of hypovolemic shock?
A. Hypotension
B. Bradycardia
C. Narrowed pulse pressure
D. Decreased urine output
CORRECT ANSWER: C
RATIONALE: A narrowing pulse pressure reflects falling stroke volume and is an early sign.
Hypotension and reduced urine output occur later.
QUESTION 3
When performing triage during a mass casualty event, which patient should the nurse assign
the highest priority (red tag)?
A. A 25-year-old with an open femur fracture
B. A 46-year-old with severe shortness of breath and cyanosis
,C. A 70-year-old with minor abrasions
D. A 15-year-old who is unresponsive with fixed dilated pupils
CORRECT ANSWER: B
RATIONALE: The red tag indicates immediate care required for life-threatening but potentially
survivable conditions. Respiratory distress and cyanosis signify airway compromise.
QUESTION 4
Which electrolyte imbalance is most commonly associated with cardiac arrest following major
burns?
A. Hyperkalemia
B. Hypokalemia
C. Hypercalcemia
D. Hypernatremia
CORRECT ANSWER: A
RATIONALE: Cellular destruction from burns releases potassium into circulation, causing
hyperkalemia, which may lead to cardiac dysrhythmias and arrest.
QUESTION 5
For a trauma patient with suspected spinal cord injury, what is the most appropriate method of
airway management?
A. Head tilt–chin lift
B. Jaw thrust maneuver
C. Oral airway insertion
D. Bag-valve-mask ventilation without stabilization
CORRECT ANSWER: B
RATIONALE: The jaw thrust maneuver opens the airway without moving the cervical spine,
preventing further injury.
QUESTION 6
Which assessment finding indicates increased intracranial pressure (ICP)?
,A. Bradycardia, irregular respirations, and widened pulse pressure
B. Tachycardia, shallow respirations, and hypotension
C. Fever and nuchal rigidity
D. Dilated pupils with brisk reaction
CORRECT ANSWER: A
RATIONALE: This classic triad—Cushing’s triad—reflects a late compensatory response to
markedly increased ICP.
QUESTION 7
During rapid sequence intubation, which drug is administered immediately before the paralytic
agent?
A. Fentanyl
B. Etomidate
C. Succinylcholine
D. Rocuronium
CORRECT ANSWER: B
RATIONALE: Etomidate is a sedative-hypnotic given to induce unconsciousness prior to
administration of a paralytic like succinylcholine.
QUESTION 8
A patient has a systolic BP of 80 mmHg after major trauma. What is the first fluid resuscitation
choice?
A. 0.9% Normal saline
B. Lactated Ringer’s solution
C. 5% Dextrose
D. Packed red blood cells
CORRECT ANSWER: B
RATIONALE: Balanced crystalloids like Lactated Ringer’s are first-line in hypovolemic shock; blood
is added if hemorrhage persists.
QUESTION 9
, Which of the following best describes Beck’s triad in cardiac tamponade?
A. Hypotension, muffled heart sounds, jugular venous distension
B. Hypertension, bradycardia, bounding pulses
C. Chest pain, tachypnea, diaphoresis
D. Palpitations, lightheadedness, fatigue
CORRECT ANSWER: A
RATIONALE: This triad characterizes cardiac tamponade, indicating impaired ventricular filling
due to pericardial fluid accumulation.
QUESTION 10
Following a motor vehicle collision, a patient presents with absent breath sounds on the right
and tracheal deviation to the left. What is the immediate nursing action?
A. Prepare for needle decompression
B. Obtain a chest x-ray
C. Start a large bore IV
D. Apply 100% oxygen via nonrebreather
CORRECT ANSWER: A
RATIONALE: The presentation indicates tension pneumothorax, a life-threatening emergency
relieved by immediate needle decompression.
QUESTION 11
A patient with suspected stroke presents to the emergency department. What is the first
diagnostic test that should be ordered to determine eligibility for thrombolytic therapy?
A. MRI of the brain
B. CT scan of the head without contrast
C. Carotid Doppler
D. Lumbar puncture
CORRECT ANSWER: B
RATIONALE: A CT scan without contrast rapidly differentiates ischemic from hemorrhagic stroke,
guiding safe administration of thrombolytics.
QUESTION 12
Questions and Answers
QUESTION 1
A patient arrives in the emergency department with crushing chest pain radiating to the left
arm. Which nursing action should be given the highest priority?
A. Administer nitroglycerin sublingually.
B. Obtain a 12-lead ECG.
C. Establish IV access.
D. Assess airway, breathing, and circulation.
CORRECT ANSWER: D
RATIONALE: Airway, breathing, and circulation (ABCs) always take precedence in emergency
care. While ECG and medication administration are critical, stabilization of basic life functions
must occur first.
QUESTION 2
Which of the following findings is the earliest indicator of hypovolemic shock?
A. Hypotension
B. Bradycardia
C. Narrowed pulse pressure
D. Decreased urine output
CORRECT ANSWER: C
RATIONALE: A narrowing pulse pressure reflects falling stroke volume and is an early sign.
Hypotension and reduced urine output occur later.
QUESTION 3
When performing triage during a mass casualty event, which patient should the nurse assign
the highest priority (red tag)?
A. A 25-year-old with an open femur fracture
B. A 46-year-old with severe shortness of breath and cyanosis
,C. A 70-year-old with minor abrasions
D. A 15-year-old who is unresponsive with fixed dilated pupils
CORRECT ANSWER: B
RATIONALE: The red tag indicates immediate care required for life-threatening but potentially
survivable conditions. Respiratory distress and cyanosis signify airway compromise.
QUESTION 4
Which electrolyte imbalance is most commonly associated with cardiac arrest following major
burns?
A. Hyperkalemia
B. Hypokalemia
C. Hypercalcemia
D. Hypernatremia
CORRECT ANSWER: A
RATIONALE: Cellular destruction from burns releases potassium into circulation, causing
hyperkalemia, which may lead to cardiac dysrhythmias and arrest.
QUESTION 5
For a trauma patient with suspected spinal cord injury, what is the most appropriate method of
airway management?
A. Head tilt–chin lift
B. Jaw thrust maneuver
C. Oral airway insertion
D. Bag-valve-mask ventilation without stabilization
CORRECT ANSWER: B
RATIONALE: The jaw thrust maneuver opens the airway without moving the cervical spine,
preventing further injury.
QUESTION 6
Which assessment finding indicates increased intracranial pressure (ICP)?
,A. Bradycardia, irregular respirations, and widened pulse pressure
B. Tachycardia, shallow respirations, and hypotension
C. Fever and nuchal rigidity
D. Dilated pupils with brisk reaction
CORRECT ANSWER: A
RATIONALE: This classic triad—Cushing’s triad—reflects a late compensatory response to
markedly increased ICP.
QUESTION 7
During rapid sequence intubation, which drug is administered immediately before the paralytic
agent?
A. Fentanyl
B. Etomidate
C. Succinylcholine
D. Rocuronium
CORRECT ANSWER: B
RATIONALE: Etomidate is a sedative-hypnotic given to induce unconsciousness prior to
administration of a paralytic like succinylcholine.
QUESTION 8
A patient has a systolic BP of 80 mmHg after major trauma. What is the first fluid resuscitation
choice?
A. 0.9% Normal saline
B. Lactated Ringer’s solution
C. 5% Dextrose
D. Packed red blood cells
CORRECT ANSWER: B
RATIONALE: Balanced crystalloids like Lactated Ringer’s are first-line in hypovolemic shock; blood
is added if hemorrhage persists.
QUESTION 9
, Which of the following best describes Beck’s triad in cardiac tamponade?
A. Hypotension, muffled heart sounds, jugular venous distension
B. Hypertension, bradycardia, bounding pulses
C. Chest pain, tachypnea, diaphoresis
D. Palpitations, lightheadedness, fatigue
CORRECT ANSWER: A
RATIONALE: This triad characterizes cardiac tamponade, indicating impaired ventricular filling
due to pericardial fluid accumulation.
QUESTION 10
Following a motor vehicle collision, a patient presents with absent breath sounds on the right
and tracheal deviation to the left. What is the immediate nursing action?
A. Prepare for needle decompression
B. Obtain a chest x-ray
C. Start a large bore IV
D. Apply 100% oxygen via nonrebreather
CORRECT ANSWER: A
RATIONALE: The presentation indicates tension pneumothorax, a life-threatening emergency
relieved by immediate needle decompression.
QUESTION 11
A patient with suspected stroke presents to the emergency department. What is the first
diagnostic test that should be ordered to determine eligibility for thrombolytic therapy?
A. MRI of the brain
B. CT scan of the head without contrast
C. Carotid Doppler
D. Lumbar puncture
CORRECT ANSWER: B
RATIONALE: A CT scan without contrast rapidly differentiates ischemic from hemorrhagic stroke,
guiding safe administration of thrombolytics.
QUESTION 12
