Category Archives: Emergency Nursing

Emergency Nursing & Triage Q 1

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?   … Read More »

Emergency Nursing & Triage Q 2

The nursing manager decides to form a committee to address the issue of violence against ED personnel. Which combination of employees would be best suited to fulfill this assignment?        A. ED physicians and charge nurses     B. RNs, LPNs, and nursing assistants     C. Experienced RNs and experienced paramedics     D. At least one… Read More »

Emergency Nursing & Triage Q 3

In relation to submersion injuries, which task is most appropriate to delegate to an LPN/LVN?        A. Stabilize the cervical spine for an unconscious drowning victim     B. Talk to a community group about water safety issues     C. Monitor an asymptomatic near-drowning victim     D. Remove wet clothing and cover the victim with a… Read More »

Emergency Nursing & Triage Q 4

A client suffered an amputation of the first and second digits in a chainsaw accident. Which task should be delegated to an LPN/LVN?        A. Cleansing the amputated digits and placing them directly into an ice slurry     B. Wrapping the cleansed digits in saline-moistened gauze, sealing in a plastic container, and placing it in… Read More »

Emergency Nursing & Triage Q 5

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?        A. Impaired Skin Integrity related to puncture wounds     B. Ineffective Health Maintenance related to… Read More »

Emergency Nursing & Triage Q 6

A client arrives in the emergency unit and reports that a concentrated household cleaner was splashed in both eyes. Which of the following nursing actions is a priority?        A. Examine the client’s visual acuity     B. Patch the eye     C. Use Restasis (Allergan) drops in the eye     D. Flush the eye repeatedly… Read More »

Emergency Nursing & Triage Q 7

A client was brought to the emergency department after suffering a closed head injury and lacerations around the face due to a hit-run accident. The client is unconscious and has a minimal response to noxious stimuli. Which of the following assessment findings if observed after few hours, should be reported to the physician immediately?   … Read More »

Emergency Nursing & Triage Q 8

A 33-year-old patient with a history of seizures and medication compliance of phenytoin (Dilantin) and carbamazepine (Tegretol) is brought to the ED by the MS personnel for repetitive seizure activity that started 45 minutes prior to arrival. You anticipate that the physician will order which drug for status epilepticus?        A. Phenytoin and Carbamazepine PO… Read More »

Emergency Nursing & Triage Q 9

A 5-year-old client was admitted to the emergency unit due to the ingestion of an unknown amount of chewable vitamins for children at an unknown time. Upon assessment, the child is alert and with no symptoms. Which of the following information should be reported to the physician immediately?        A. The child was nauseated and… Read More »

Emergency Nursing & Triage Q 10

A client arrived at the emergency department after suffering multiple physical injuries including a fractured pelvis from a vehicular accident. Upon assessment, the client is incoherent, pale, and diaphoretic. With vital signs as follows: temperature of 97°F (36.11° C), blood pressure of 60/40 mm Hg, heart rate of 143 beats/minute, and a respiratory rate of… Read More »