Emergency Nursing NCLEX Questions
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Question 1 of 5.
The nurse is responding to a disaster call from home following a multivehicle motor-vehicle accident. Which action should the nurse take first?
A. Go to the emergency department to triage the clients coming in.
B. Assist the charge nurse to identify clients who could be discharged.
C. Report to the command center for assignment.
D. Pack a bag to be able to stay until the emergency is over.
Explanation: Reporting to the command center ensures coordinated assignment per disaster protocol. Triaging, discharging, or packing are secondary.
Question 2 of 5.
The nurse is caring for a client diagnosed with septic shock. Which assessment data warrant immediate intervention by the nurse?
A. Vital signs T 100.4°F, P 104, R 26, and BP 102/60.
B. A white blood cell count of 18,000/mm3.
C. A urinary output of 90 mL in the last four (4) hours.
D. The client complains of being thirsty.
Explanation: Urinary output of 90 mL/4 hours = 22.5 mL/hour, below 30 mL/hour, indicating renal hypoperfusion, requiring immediate intervention. Fever, tachycardia, and elevated WBC are expected; thirst is less urgent.
Question 3 of 5.
The nurse in the emergency department administered an intramuscular antibiotic in the left gluteal muscle to the client with pneumonia who is being discharged home. Which intervention should the nurse implement?
A. Ask the client about drug allergies.
B. Obtain a sterile sputum specimen.
C. Have the client wait for 30 minutes.
D. Place a warm washcloth on the client's left hip.
Explanation: Waiting 30 minutes post-antibiotic monitors for allergic reactions, critical for safety. Allergies should be checked pre-administration, sputum is diagnostic, and warm washcloths are not standard.
Question 4 of 5.
The elderly female client with vertebral fractures who has been self-medicating with ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), presents to the ED complaining of abdominal pain, is pale and clammy, and has a P of 110 and a BP of 92/60. Which type of shock should the nurse suspect?
A. Cardiogenic shock.
B. Hypovolemic shock.
C. Neurogenic shock.
D. Septic shock.
Explanation: NSAID-induced gastrointestinal bleeding can cause hypovolemic shock, indicated by tachycardia, hypotension, and pale, clammy skin. Cardiogenic involves cardiac failure, neurogenic involves bradycardia, and septic involves fever.
Question 5 of 5.
The nurse is caring for a client diagnosed with septic shock who has hypotension, decreased urine output, and cool, pale skin. Which phase of septic shock is the client experiencing?
A. The hypodynamic phase.
B. The compensatory phase.
C. The hyperdynamic phase.
D. The progressive phase.
Explanation: The hypodynamic (cold) phase of septic shock involves hypotension, low urine output, and cool, pale skin due to vasoconstriction. Compensatory is early, hyperdynamic is warm, and progressive involves organ failure.