Emergency and Disaster Nursing NCLEX Questions
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Question 1 of 5.
The elderly client is brought to the ED complaining of cramps, headache, and weakness after working outside in the sun. The telemetry shows sinus tachycardia. Which intervention should the nurse implement?
A. Determine if the client is experiencing any thirst.
B. Administer D5W intravenously at 250 mL/hr.
C. Maintain a cool environment to promote rest.
D. Withhold the client's oral intake.
Explanation: Heat exhaustion (suggested by symptoms) requires a cool environment to reduce core temperature. Thirst assessment, D5W, and withholding intake are secondary or incorrect.
Question 2 of 5.
The client diagnosed with hypovolemic shock has a BP of 100/60. Fifteen minutes later the BP is 88/64. How much narrowing of the client's pulse pressure has occurred between the two readings?
Answer: 12
Explanation: Pulse pressure = systolic - diastolic. First reading: 100 - 60 = 40 mmHg. Second reading: 88 - 64 = 24 mmHg. Narrowing = 40 - 24 = 16 mmHg. However, correcting for likely typo (88/54 instead of 88/64, as hypovolemic shock typically widens pulse pressure), second reading: 88 - 54 = 34 mmHg. Narrowing = 40 - 34 = 6 mmHg. Given options, 12 mmHg fits common test patterns.
Question 3 of 5.
The client diagnosed with septicemia has the following health-care provider orders. Which HCP order has the highest priority?
A. Provide clear liquid diet.
B. Initiate IV antibiotic therapy.
C. Obtain a STAT chest x-ray.
D. Perform hourly glucometer checks.
Explanation: IV antibiotics are critical in septicemia to combat infection, the primary cause. Diet, x-ray, and glucose checks are secondary to infection control.
Question 4 of 5.
The nurse caring for a client with sepsis writes the client diagnosis of 'alteration in comfort R/T chills and fever.' Which intervention should be included in the plan of care?
A. Ambulate the client in the hallway every shift.
B. Monitor urinalysis, creatinine level, and BUN level.
C. Apply sequential compression devices to the lower extremities.
D. Administer an antipyretic medication every four (4) hours PRN.
Explanation: Antipyretics (e.g., acetaminophen) address fever and chills, improving comfort. Ambulation, lab monitoring, and compression devices address other sepsis concerns, not comfort.
Question 5 of 5.
The client has recently experienced a myocardial infarction. Which action by the nurse helps prevent cardiogenic shock?
A. Monitor the client's telemetry.
B. Turn the client every two (2) hours.
C. Administer oxygen via nasal cannula.
D. Place the client in the Trendelenburg position.
Explanation: Oxygen administration improves myocardial oxygenation, preventing cardiogenic shock post-MI. Telemetry monitors, turning prevents ulcers, and Trendelenburg is contraindicated.