Emergency Nursing NCLEX
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Question 1 of 5.
The nurse is teaching a class about rape prevention to a group of women at a community center. Which information is not a myth about rape?
A. Women who are raped asked for it by dressing provocatively.
B. If a woman says no, it is a come on and she really does not mean it.
C. Rape is an attempt to exert power and control over the client.
D. All victims of sexual assault are women; men can't be raped.
Explanation: Rape is about power and control, not sexual desire, a fact. Provocative dressing, misinterpreting 'no,' and excluding male victims are myths.
Question 2 of 5.
The client is admitted into the emergency department with diaphoresis, pale clammy skin, and BP of 90/70. Which intervention should the nurse implement first?
A. Start an IV with an 18-gauge catheter.
B. Administer dopamine intravenous infusion.
C. Obtain arterial blood gases (ABGs).
D. Insert an indwelling urinary catheter.
Explanation: Hypovolemic shock (suggested by symptoms) requires immediate IV access for fluid resuscitation. Dopamine requires IV access, ABGs are diagnostic, and urinary catheter monitors output but is secondary.
Question 3 of 5.
The client is diagnosed with neurogenic shock. Which signs/symptoms should the nurse assess in this client?
A. Cool, moist skin.
B. Bradycardia.
C. Wheezing.
D. Decreased bowel sounds.
Explanation: Neurogenic shock causes bradycardia due to loss of sympathetic tone. Cool, moist skin is typical of hypovolemic shock, wheezing suggests anaphylaxis, and decreased bowel sounds are non-specific.
Question 4 of 5.
The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients on a medical floor. Which action by the UAP warrants intervention by the nurse?
A. The UAP places a urine specimen in a biohazard bag in the hallway.
B. The UAP uses the alcohol foam hand cleanser after removing gloves.
C. The UAP puts soiled linen in a plastic bag in the client's room.
D. The UAP obtains a disposable stethoscope for a client in an isolation room.
Explanation: Urine specimens are not biohazardous unless visibly bloody; placing in a biohazard bag is incorrect and requires intervention. Hand cleansing, linen handling, and stethoscope use are appropriate.
Question 5 of 5.
The client diagnosed with septicemia is receiving a broad-spectrum antibiotic. Which laboratory data require the nurse to notify the health-care provider?
A. The client's potassium level is 3.8 mEq/L.
B. The urine culture indicates high sensitivity to the antibiotic.
C. The client's pulse oximeter reading is 94%.
D. The culture and sensitivity is resistant to the client's antibiotic.
Explanation: Antibiotic resistance requires immediate HCP notification to adjust therapy. Normal potassium, sensitive cultures, and 94% SpO2 are not urgent.
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