Emergency Nursing NCLEX
Home / Nursing & Allied Health Certifications / NCLEX PN / Emergency and Disaster Nursing
Question 1 of 5.
The nurse writes a nursing diagnosis of 'risk for injury as a result of physical abuse by spouse' for a client. Which is an appropriate goal for this client?
A. The client will learn not to trust anyone.
B. The client will admit the abuse is happening and get help.
C. The client will discuss the nurse's suspicions with the spouse.
D. The client will choose to stay with the spouse.
Explanation: Admitting abuse and seeking help is a realistic goal to reduce injury risk. Distrust, confronting the spouse, or staying are unsafe or neutral.
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.
Related Questions