NCLEX Emergency Nursing & Triage Practice Exam
- A 60-year-old patient arrives at the emergency department (ED) with chest pain radiating to the left arm. Which action should the nurse take first?
- A. Obtain a complete medical history.
- B. Administer sublingual nitroglycerin.
- C. Apply oxygen via nasal cannula.
- D. Perform a 12-lead ECG.
- What is the most appropriate intervention for a patient experiencing hypoglycemia?
- A. Administer glucagon IM.
- B. Provide a high-protein snack.
- C. Administer 1 ampule of D50 IV.
- D. Give 500 mL of D5W.
- A triage nurse should prioritize which of the following patients?
- A. A 25-year-old with a swollen ankle after a fall.
- B. A 40-year-old with shortness of breath and diaphoresis.
- C. A 50-year-old with a minor hand laceration.
- D. A 10-year-old with a minor nosebleed.
- In emergency triage, what does the “red tag” signify?
- A. Deceased.
- B. Minor injury.
- C. Immediate attention required.
- D. Delayed treatment.
- A patient with suspected spinal cord injury should be managed by which of the following interventions?
- A. Perform a head-to-toe physical exam.
- B. Immobilize the spine.
- C. Perform a Glasgow Coma Scale (GCS) assessment.
- D. Place the patient in a semi-Fowler’s position.
- A burn patient presents with blisters and severe pain. Which type of burn does the patient likely have?
- A. Superficial.
- B. Full-thickness.
- C. Partial-thickness.
- D. Fourth-degree.
- During cardiac arrest, which rhythm is most appropriate for defibrillation?
- A. Asystole.
- B. Ventricular fibrillation.
- C. Sinus bradycardia.
- D. Atrial fibrillation.
- What is the initial treatment for a patient with an open chest wound?
- A. Cover the wound with a sterile dressing.
- B. Apply a three-sided occlusive dressing.
- C. Administer high-flow oxygen.
- D. Place the patient in a prone position.
- In a patient with suspected sepsis, which of the following is the nurse’s priority?
- A. Administer broad-spectrum antibiotics.
- B. Draw blood cultures.
- C. Start fluid resuscitation.
- D. Monitor urine output.
- What is the most critical nursing intervention during a hypertensive crisis?
- A. Administer antihypertensive medication.
- B. Insert a Foley catheter.
- C. Elevate the patient’s legs.
- D. Provide high-flow oxygen.
- A patient presents with acute anaphylaxis. What is the priority intervention?
- A. Establish an airway.
- B. Administer IV fluids.
- C. Provide diphenhydramine.
- D. Administer epinephrine IM.
- Which medication is most appropriate for a patient with acute opioid overdose?
- A. Naloxone.
- B. Flumazenil.
- C. Atropine.
- D. Activated charcoal.
- In assessing a patient with head trauma, which finding requires immediate intervention?
- A. Vomiting.
- B. Glasgow Coma Scale (GCS) of 15.
- C. Unequal pupil size.
- D. Headache.
- A patient arrives with frostbite on both feet. What is the priority intervention?
- A. Rub the affected areas vigorously.
- B. Immerse the feet in warm water (37–40°C).
- C. Administer pain medication.
- D. Apply ice packs to the area.
- Which lab finding is most concerning for a patient with trauma?
- A. Hemoglobin of 14 g/dL.
- B. Platelet count of 90,000/mm³.
- C. White blood cell count of 11,000/mm³.
- D. Serum sodium of 140 mEq/L.
- The nurse identifies which of the following as a symptom of carbon monoxide poisoning?
- A. Cyanosis.
- B. Cherry-red skin.
- C. Jaundice.
- D. Petechiae.
- In managing a patient with a tension pneumothorax, the nurse should prepare for which intervention?
- A. Chest tube insertion.
- B. Bronchoscopy.
- C. Endotracheal intubation.
- D. Needle decompression.
- A patient in the ED exhibits signs of acute stroke. What is the priority intervention?
- A. Administer aspirin.
- B. Perform a CT scan of the head.
- C. Check blood glucose levels.
- D. Administer tissue plasminogen activator (tPA).
- Which intervention is most critical for a patient with a snakebite?
- A. Elevate the affected limb.
- B. Apply a tourniquet.
- C. Immobilize the affected limb.
- D. Administer corticosteroids.
- For a patient with heatstroke, what is the initial nursing intervention?
- A. Administer antipyretics.
- B. Initiate rapid cooling measures.
- C. Provide oral fluids.
- D. Place the patient in a Trendelenburg position.
- A patient arrives at the ED with a suspected stroke. Which time-sensitive intervention is most critical?
- A. Start IV fluids.
- B. Perform a head CT scan without contrast.
- C. Draw blood for coagulation studies.
- D. Administer aspirin immediately.
- A patient presents to triage with complaints of abdominal pain rated 9/10, accompanied by hypotension and tachycardia. What is the nurse’s priority?
- A. Initiate IV fluids.
- B. Administer pain medication.
- C. Obtain a urine sample.
- D. Prepare for an ultrasound.
- Which finding suggests airway obstruction in a patient?
- A. Stridor.
- B. Wheezing.
- C. Crackles.
- D. Rhonchi.
- A nurse triaging during a mass casualty event assigns which priority level to a patient with a minor laceration on the arm?
- A. Red tag.
- B. Yellow tag.
- C. Green tag.
- D. Black tag.
- In a patient with severe sepsis, which lab result would concern the nurse the most?
- A. Elevated white blood cell count.
- B. Blood glucose of 120 mg/dL.
- C. Serum lactate of 5 mmol/L.
- D. Platelet count of 250,000/mm³.
- What is the appropriate nursing intervention for a patient with a suspected cervical spine injury?
- A. Perform a chin-lift maneuver.
- B. Logroll the patient when moving.
- C. Remove the cervical collar to assess.
- D. Elevate the head of the bed to 45 degrees.
- A patient is admitted with diabetic ketoacidosis (DKA). What is the first intervention the nurse should implement?
- A. Administer IV insulin.
- B. Start fluid resuscitation.
- C. Check blood glucose.
- D. Administer potassium supplements.
- A nurse suspects a tension pneumothorax in a trauma patient. Which clinical sign supports this suspicion?
- A. Bilateral crackles.
- B. Tracheal deviation to the unaffected side.
- C. Bradycardia.
- D. Hyperresonance on the affected side.
- A child presents with a febrile seizure in the ED. What is the nurse’s priority action?
- A. Administer antipyretics.
- B. Ensure a patent airway.
- C. Apply seizure precautions.
- D. Start an IV for fluid resuscitation.
- A patient with suspected meningitis requires which intervention first?
- A. Administer IV antibiotics.
- B. Perform a lumbar puncture.
- C. Start seizure precautions.
- D. Assess the patient’s Glasgow Coma Scale (GCS).
- A patient presents with signs of an acute asthma exacerbation. What is the priority intervention?
- A. Administer oxygen via nasal cannula.
- B. Administer a short-acting beta-agonist (SABA).
- C. Provide oral corticosteroids.
- D. Obtain arterial blood gases (ABGs).
- A patient involved in a motor vehicle accident is bleeding profusely from the leg. What is the nurse’s initial action?
- A. Apply a tourniquet above the injury site.
- B. Start an IV and administer fluids.
- C. Elevate the affected leg.
- D. Apply direct pressure to the wound.
- A nurse is caring for a patient with acute alcohol withdrawal. What is the priority intervention?
- A. Administer thiamine.
- B. Monitor for seizures.
- C. Administer IV fluids.
- D. Provide a calming environment.
- A child with a high fever presents with a barking cough and stridor. What is the likely diagnosis?
- A. Bronchiolitis.
- B. Croup.
- C. Asthma.
- D. Pneumonia.
- A patient presents with a chemical burn to the eyes. What is the first action the nurse should take?
- A. Administer analgesics.
- B. Flush the eyes with copious amounts of water.
- C. Apply a sterile eye patch.
- D. Check visual acuity.
- During a code situation, a patient is found to be in pulseless electrical activity (PEA). What is the nurse’s priority action?
- A. Administer epinephrine IV.
- B. Perform defibrillation.
- C. Check for a pulse.
- D. Start chest compressions.
- A nurse is triaging patients during a disaster. Which patient should receive a “black tag”?
- A. A 65-year-old with a head injury and unresponsive to stimuli.
- B. A 45-year-old with a femur fracture.
- C. A 10-year-old with a minor abrasion on the leg.
- D. A 30-year-old with shortness of breath.
- A patient with a snakebite is brought to the ED. What should the nurse avoid?
- A. Immobilizing the affected limb.
- B. Removing tight clothing near the bite site.
- C. Applying ice to the bite area.
- D. Monitoring for signs of shock.
- A patient arrives with symptoms of cyanide poisoning. What is the priority treatment?
- A. Administer amyl nitrite.
- B. Start IV fluids.
- C. Provide high-flow oxygen.
- D. Perform gastric lavage.
- A nurse is assessing a patient with a traumatic brain injury. Which finding suggests increasing intracranial pressure?
- A. Hypotension.
- B. Bradycardia.
- C. Tachypnea.
- D. Hyperthermia.
- A patient experiencing status epilepticus is admitted to the ED. What is the priority intervention?
- A. Administer lorazepam IV.
- B. Place the patient in the supine position.
- C. Monitor oxygen saturation.
- D. Obtain a stat CT scan.
- A patient presents with symptoms of acute appendicitis. What should the nurse avoid doing?
- A. Administering IV fluids.
- B. Applying a heating pad to the abdomen.
- C. Monitoring for signs of peritonitis.
- D. Administering pain medication as prescribed.
- Which sign is a key indicator of hypovolemic shock?
- A. Hypertension.
- B. Bounding peripheral pulses.
- C. Cool, clammy skin.
- D. Slow capillary refill.
- A patient with a suspected basilar skull fracture should not have which intervention performed?
- A. Neurological assessment.
- B. Application of a cervical collar.
- C. Nasogastric tube insertion.
- D. Administration of IV fluids.
- In a patient presenting with hyperkalemia, what is the priority intervention?
- A. Administer sodium bicarbonate.
- B. Administer calcium gluconate.
- C. Start insulin and glucose infusion.
- D. Monitor cardiac rhythm.
- A child with a febrile illness develops a purpuric rash. What is the nurse’s priority?
- A. Administer acetaminophen.
- B. Obtain a blood culture.
- C. Administer IV antibiotics immediately.
- D. Provide supportive care for fever.
- A patient is admitted with a suspected opioid overdose. What is the primary symptom the nurse should monitor?
- A. Hyperactivity.
- B. Pinpoint pupils.
- C. Severe agitation.
- D. Increased respiratory rate.
- What is the initial nursing intervention for a patient with a suspected pulmonary embolism?
- A. Administer anticoagulants.
- B. Provide oxygen therapy.
- C. Position the patient in Trendelenburg.
- D. Encourage ambulation.
- A nurse is providing care for a patient experiencing hypothermia. What intervention is most appropriate?
- A. Rapidly warm the patient with a hot water bath.
- B. Administer warm IV fluids.
- C. Massage extremities to increase circulation.
- D. Provide oral warm fluids.
- A patient presents with severe abdominal pain and a pulsatile mass in the abdomen. What is the nurse’s priority action?
- A. Monitor blood pressure.
- B. Prepare the patient for surgery.
- C. Administer pain medication.
- D. Place the patient in the prone position.
- A patient is brought to the ED with suspected carbon monoxide poisoning. What is the priority intervention?
- A. Administer 100% oxygen via non-rebreather mask.
- B. Perform intubation.
- C. Administer a bronchodilator.
- D. Monitor arterial blood gases.
- A nurse is assessing a patient with a suspected spinal cord injury. What is the most critical first step?
- A. Perform a complete neurological exam.
- B. Immobilize the spine.
- C. Assess for motor weakness.
- D. Administer IV fluids.
- A patient with chest pain rates their discomfort as 8/10. The ECG shows ST elevation. What is the nurse’s priority?
- A. Start an IV line for medication administration.
- B. Prepare the patient for percutaneous coronary intervention (PCI).
- C. Administer morphine for pain relief.
- D. Administer sublingual nitroglycerin.
- A patient arrives with suspected anaphylaxis. What is the first medication the nurse should administer?
- A. IV fluids.
- B. Epinephrine IM.
- C. Diphenhydramine IV.
- D. Albuterol via nebulizer.
- In a patient presenting with acute decompensated heart failure, which finding requires immediate intervention?
- A. Crackles in the lungs.
- B. Pink, frothy sputum.
- C. Peripheral edema.
- D. Jugular vein distention.
- A trauma patient has a Glasgow Coma Scale (GCS) score of 6. What does this indicate?
- A. Mild head injury.
- B. Moderate head injury.
- C. Severe head injury.
- D. Normal neurological function.
- A patient with a deep puncture wound presents with redness and swelling at the site. What is the most appropriate initial nursing intervention?
- A. Administer antibiotics.
- B. Clean the wound with sterile saline.
- C. Apply a sterile dressing.
- D. Obtain a wound culture.
- During a mass casualty event, a nurse triages a patient with a sucking chest wound. What is the correct priority tag for this patient?
- A. Green.
- B. Yellow.
- C. Red.
- D. Black.
- A patient in the ED is diagnosed with hyperglycemic hyperosmolar syndrome (HHS). What is the nurse’s priority intervention?
- A. Administer IV insulin.
- B. Begin aggressive fluid replacement.
- C. Monitor potassium levels.
- D. Obtain blood glucose readings every hour.
- A patient with suspected acute pancreatitis presents with severe abdominal pain. Which position is most likely to provide relief?
- A. Supine.
- B. Sitting upright, leaning forward.
- C. Side-lying with knees flexed.
- D. Trendelenburg.
- A nurse is assessing a patient with suspected acute kidney injury (AKI). Which lab result is most concerning?
- A. Elevated serum creatinine.
- B. Decreased hemoglobin.
- C. Elevated potassium.
- D. Decreased serum calcium.
- A patient presents with a tension pneumothorax. What intervention should the nurse anticipate?
- A. Chest tube insertion.
- B. Administration of bronchodilators.
- C. Needle decompression.
- D. Endotracheal intubation.
- A patient with severe hypothermia is admitted to the ED. Which finding requires immediate intervention?
- A. Core temperature of 89°F (31.6°C).
- B. Slow, irregular pulse.
- C. Altered level of consciousness.
- D. Shivering.
- A patient with burns over 40% of their body surface area arrives in the ED. What is the priority nursing action?
- A. Assess airway and breathing.
- B. Begin fluid resuscitation.
- C. Administer pain medication.
- D. Cover burns with sterile dressings.
- A patient presents with acute epiglottitis. What is the nurse’s priority intervention?
- A. Administer antibiotics.
- B. Prepare for intubation.
- C. Obtain a throat culture.
- D. Place the patient in a supine position.
- A nurse is caring for a patient with a suspected myocardial infarction. Which lab value confirms this diagnosis?
- A. Elevated white blood cell count.
- B. Elevated troponin levels.
- C. Decreased platelet count.
- D. Elevated serum sodium.
- A child is admitted with suspected dehydration. Which assessment finding indicates severe dehydration?
- A. Dry mucous membranes.
- B. Capillary refill of 4 seconds.
- C. Slightly sunken fontanel.
- D. Moderate tachycardia.
- A nurse is caring for a patient experiencing a thyroid storm. What is the priority intervention?
- A. Administer beta-blockers.
- B. Provide cooling measures.
- C. Administer antithyroid medications.
- D. Monitor for cardiac dysrhythmias.
- A patient with a suspected pelvic fracture complains of severe abdominal pain. What is the nurse’s priority action?
- A. Palpate the abdomen for tenderness.
- B. Immobilize the pelvis.
- C. Start IV fluids.
- D. Administer pain medication.
- A nurse is caring for a patient with a suspected heatstroke. What is the first intervention?
- A. Provide oral rehydration.
- B. Administer antipyretics.
- C. Begin active cooling measures.
- D. Apply oxygen.
- A patient presents with symptoms of acute stroke. What is the priority action?
- A. Administer oxygen.
- B. Prepare the patient for a CT scan.
- C. Establish IV access.
- D. Monitor vital signs.
- A patient in the ED develops ventricular fibrillation. What is the immediate intervention?
- A. Start CPR and prepare for defibrillation.
- B. Administer amiodarone IV.
- C. Check for a pulse.
- D. Administer epinephrine IV.
- In a patient experiencing septic shock, which clinical finding requires immediate intervention?
- A. Elevated temperature.
- B. Hypotension unresponsive to fluids.
- C. Increased heart rate.
- D. Increased respiratory rate.
- A patient presents with a possible open fracture. What is the priority nursing action?
- A. Administer pain medications.
- B. Cover the wound with a sterile dressing.
- C. Immobilize the affected limb.
- D. Start IV antibiotics.
- A patient presents with severe respiratory distress and tracheal deviation to the left. What is the nurse’s priority?
- A. Prepare for needle decompression.
- B. Administer oxygen.
- C. Obtain a chest x-ray.
- D. Insert a chest tube.
- A nurse is caring for a patient with suspected acute appendicitis. Which assessment finding is most concerning?
- A. Rebound tenderness in the lower right quadrant.
- B. Elevated white blood cell count.
- C. Sudden relief of pain.
- D. Low-grade fever.
- A nurse is assessing a patient with third-degree burns. What is the highest priority?
- A. Pain management.
- B. Monitoring urine output.
- C. Assessing airway and breathing.
- D. Initiating fluid resuscitation.
- A trauma patient is hypotensive and tachycardic. What type of shock is most likely?
- A. Cardiogenic shock.
- B. Hypovolemic shock.
- C. Septic shock.
- D. Neurogenic shock.
- In a patient presenting with acute asthma exacerbation, which intervention should the nurse prioritize?
- A. Administer corticosteroids.
- B. Initiate oxygen therapy.
- C. Provide a nebulized beta-agonist.
- D. Obtain arterial blood gases.
- A patient with a head injury presents with unequal pupils. What is the most likely cause?
- A. Increased intracranial pressure.
- B. Basilar skull fracture.
- C. Concussion.
- D. Orbital fracture.
- A nurse is triaging patients in the ED. Which patient should be seen first?
- A. A patient with a sprained ankle.
- B. A patient with a migraine and nausea.
- C. A patient with shortness of breath and chest tightness.
- D. A patient with abdominal pain.
- A nurse receives a patient with suspected meningitis. What is the priority nursing action?
- A. Start antibiotics after a lumbar puncture.
- B. Initiate droplet precautions.
- C. Monitor neurological status.
- D. Administer IV fluids.
- A patient presents with hypothermia and shivering. What is the most appropriate intervention?
- A. Administer warmed IV fluids.
- B. Apply external heating pads.
- C. Perform rapid rewarming.
- D. Encourage physical activity.
- A child arrives in the ED after ingesting an unknown substance. What is the nurse’s priority?
- A. Administer activated charcoal.
- B. Contact Poison Control.
- C. Assess airway, breathing, and circulation.
- D. Monitor for signs of toxicity.
- A patient with a gunshot wound to the abdomen is hypotensive. What is the nurse’s priority action?
- A. Administer IV fluids rapidly.
- B. Apply a sterile dressing to the wound.
- C. Perform a neurological assessment.
- D. Prepare the patient for surgery.
- A patient presents with diabetic ketoacidosis (DKA). What is the priority nursing intervention?
- A. Administer insulin IV.
- B. Monitor potassium levels.
- C. Administer fluids to correct dehydration.
- D. Monitor for signs of cerebral edema.
- A nurse is preparing to defibrillate a patient in ventricular tachycardia. What is the correct first step?
- A. Ensure the patient is connected to a cardiac monitor.
- B. Place the defibrillator pads on the chest.
- C. Ensure the patient has no pulse.
- D. Charge the defibrillator to the correct joules.
- A patient presents with an open chest wound. What is the immediate intervention?
- A. Apply a sterile occlusive dressing.
- B. Perform a needle thoracostomy.
- C. Insert a chest tube.
- D. Administer IV antibiotics.
- A patient with a suspected pulmonary embolism is admitted. What is the nurse’s priority?
- A. Administer heparin.
- B. Place the patient in a high Fowler’s position.
- C. Provide oxygen therapy.
- D. Obtain a D-dimer test.
- A patient presents with signs of heat exhaustion. Which intervention is most appropriate?
- A. Immerse the patient in ice water.
- B. Administer IV fluids.
- C. Apply cool packs to the neck and groin.
- D. Provide oral rehydration.
- A patient presents with severe anaphylaxis. What is the priority intervention?
- A. Administer IV fluids.
- B. Administer epinephrine IM.
- C. Apply oxygen therapy.
- D. Administer diphenhydramine.
- A trauma patient has a Glasgow Coma Scale (GCS) score of 8. What is the immediate action?
- A. Administer mannitol IV.
- B. Perform endotracheal intubation.
- C. Monitor intracranial pressure.
- D. Perform a CT scan.
- A patient arrives in the ED with a suspected myocardial infarction. What is the priority intervention?
- A. Administer nitroglycerin.
- B. Obtain a 12-lead ECG.
- C. Administer aspirin.
- D. Start oxygen therapy.
- A nurse is triaging multiple patients after a bus accident. Which patient should be treated first?
- A. A patient with a femur fracture.
- B. A patient with a scalp laceration.
- C. A patient with an open chest wound and respiratory distress.
- D. A patient with a dislocated shoulder.
- A patient presents with acute pancreatitis. Which assessment finding requires immediate intervention?
- A. Severe epigastric pain.
- B. Cullen’s sign (periumbilical discoloration).
- C. Decreased urine output.
- D. Elevated serum lipase levels.
- A patient in the ED is suspected of having a tension pneumothorax. What is the nurse’s priority intervention?
- A. Insert a chest tube.
- B. Prepare for needle decompression.
- C. Perform a chest x-ray.
- D. Administer oxygen therapy.
- A patient with a spinal cord injury at C5 presents with shallow respirations. What is the nurse’s priority?
- A. Monitor oxygen saturation.
- B. Prepare for intubation.
- C. Assess for urinary retention.
- D. Administer corticosteroids.
- A child presents with a high fever, drooling, and stridor. What is the nurse’s immediate action?
- A. Start IV antibiotics.
- B. Assess for nuchal rigidity.
- C. Prepare for endotracheal intubation.
- D. Perform a throat culture.
- A patient in hypovolemic shock has cool, clammy skin and a blood pressure of 80/50 mmHg. What is the priority intervention?
- A. Administer a vasopressor.
- B. Administer IV fluids rapidly.
- C. Monitor central venous pressure.
- D. Administer oxygen therapy.
- A patient presents with crushing chest pain and nausea. Which lab test should the nurse prioritize?
- A. Serum potassium.
- B. Troponin levels.
- C. Complete blood count (CBC).
- D. D-dimer test.
- A nurse is assessing a patient with suspected meningitis. Which sign would confirm this diagnosis?
- A. Positive Trousseau’s sign.
- B. Positive Kernig’s sign.
- C. Positive Babinski reflex.
- D. Positive Homan’s sign.
- A patient presents with acute abdominal pain and guarding. Which intervention should the nurse perform first?
- A. Administer pain medication.
- B. Perform a focused abdominal assessment.
- C. Place the patient in a supine position.
- D. Obtain a complete blood count (CBC).
- A patient with diabetic ketoacidosis has a potassium level of 3.2 mEq/L. What is the nurse’s priority intervention?
- A. Administer IV potassium before insulin.
- B. Administer a rapid-acting insulin.
- C. Initiate fluid resuscitation.
- D. Monitor cardiac telemetry.
- A patient with a suspected basilar skull fracture is in the ED. Which assessment finding is most concerning?
- A. Battle’s sign (bruising behind the ear).
- B. Clear fluid drainage from the nose.
- C. Periorbital ecchymosis (raccoon eyes).
- D. Altered level of consciousness.
- A patient presents with symptoms of heatstroke. What is the most appropriate intervention?
- A. Administer IV fluids.
- B. Provide ice packs to the neck and groin.
- C. Immerse the patient in cold water.
- D. Offer oral electrolyte solutions.
- A nurse is assessing a patient with suspected opioid overdose. What is the nurse’s priority?
- A. Administer naloxone.
- B. Initiate IV fluids.
- C. Obtain a urine toxicology screen.
- D. Monitor respiratory rate.
- A patient with suspected septic shock presents with fever and low blood pressure. Which lab test is most critical?
- A. Blood cultures.
- B. Arterial blood gases (ABG).
- C. Serum lactate.
- D. Complete blood count (CBC).
- A child arrives in the ED with burns on 15% of their body surface area. What is the nurse’s priority intervention?
- A. Administer IV fluids.
- B. Cover the burns with a sterile dressing.
- C. Administer pain medication.
- D. Assess for signs of infection.
- A patient presents with facial trauma and is bleeding heavily. What is the nurse’s first action?
- A. Assess airway patency.
- B. Apply direct pressure to stop bleeding.
- C. Prepare for intubation.
- D. Obtain a CT scan of the face.
- A patient with a penetrating abdominal wound is hypotensive. What is the nurse’s priority?
- A. Start IV fluids.
- B. Prepare for emergency surgery.
- C. Cover the wound with a sterile dressing.
- D. Assess for bowel sounds.
- A patient presents to the ED with severe respiratory distress and a tracheostomy tube that is dislodged. What is the nurse’s priority intervention?
- A. Attempt to reinsert the tracheostomy tube.
- B. Call the respiratory therapist.
- C. Provide bag-valve-mask ventilation.
- D. Apply an oxygen mask.
- A patient is brought to the ED after being struck by lightning. Which symptom is most concerning?
- A. Burns at the entry and exit sites.
- B. Loss of consciousness.
- C. Cardiac arrhythmias.
- D. Temporary paralysis of limbs.
- A patient with suspected carbon monoxide poisoning presents to the ED. Which oxygen delivery method is most effective?
- A. Nasal cannula at 6 L/min.
- B. Non-rebreather mask at 15 L/min.
- C. High-flow nasal cannula.
- D. BiPAP ventilation.
- A patient in the ED is exhibiting signs of acute stroke. What is the nurse’s priority intervention?
- A. Assess blood glucose levels.
- B. Obtain a CT scan of the head.
- C. Administer aspirin.
- D. Start thrombolytic therapy.
- A patient presents with a suspected ectopic pregnancy. Which assessment finding is most concerning?
- A. Abdominal pain and spotting.
- B. Referred shoulder pain.
- C. Positive pregnancy test.
- D. Serum beta-hCG levels.
- A nurse is assessing a patient with suspected compartment syndrome. What is the most critical assessment finding?
- A. Edema at the injury site.
- B. Pain that is unrelieved by opioids.
- C. Decreased range of motion.
- D. Bruising around the site.
- A patient presents to the ED after ingesting a large amount of acetaminophen. What is the priority intervention?
- A. Administer activated charcoal.
- B. Start IV fluids.
- C. Administer N-acetylcysteine.
- D. Obtain liver function tests.
- A patient arrives in the ED with a stab wound to the chest. They exhibit signs of decreased cardiac output. What is the most likely condition?
- A. Cardiac tamponade.
- B. Tension pneumothorax.
- C. Hemothorax.
- D. Pulmonary embolism.
- A nurse is caring for a patient with status epilepticus. What is the first medication the nurse should anticipate administering?
- A. Lorazepam IV.
- B. Phenytoin IV.
- C. Midazolam IM.
- D. Levetiracetam PO.
- A patient presents to the ED with a suspected opioid overdose and pinpoint pupils. What is the priority action?
- A. Administer naloxone.
- B. Insert a nasopharyngeal airway.
- C. Start IV fluids.
- D. Place the patient on a cardiac monitor.
- A patient is brought to the ED after a motorcycle accident. They are unresponsive and hypotensive with a distended abdomen. What should the nurse suspect?
- A. Internal hemorrhage.
- B. Spinal cord injury.
- C. Pelvic fracture.
- D. Tension pneumothorax.
- A patient with a suspected overdose has a prolonged QT interval on their ECG. Which medication should the nurse anticipate administering?
- A. Magnesium sulfate.
- B. Sodium bicarbonate.
- C. Calcium gluconate.
- D. Atropine.
- A patient with a head injury has clear fluid draining from their ears. What test should the nurse anticipate to confirm cerebrospinal fluid (CSF)?
- A. CT scan of the head.
- B. Blood glucose test.
- C. Halo test.
- D. Lumbar puncture.
- A patient presents with third-degree burns over 40% of their body. What is the priority nursing intervention?
- A. Administer IV pain medication.
- B. Begin fluid resuscitation.
- C. Assess for infection.
- D. Apply antibiotic ointment to the burns.
- A child presents with bradycardia and signs of shock. What is the first medication the nurse should anticipate?
- A. Epinephrine IV.
- B. Atropine IV.
- C. Adenosine IV.
- D. Dopamine IV.
- A nurse is triaging patients during a mass casualty event. Which patient should be tagged as “black” (expectant)?
- A. A patient with severe burns over 80% of their body.
- B. A patient with a femur fracture and stable vitals.
- C. A patient with penetrating chest trauma and stable vitals.
- D. A patient with minor abrasions.
- A patient with acute alcohol withdrawal is admitted to the ED. Which symptom is most concerning?
- A. Tremors.
- B. Hallucinations.
- C. Seizures.
- D. Agitation.
- A patient presents with facial swelling, hives, and difficulty breathing after eating shellfish. What is the priority intervention?
- A. Administer diphenhydramine.
- B. Administer epinephrine IM.
- C. Start an IV line.
- D. Apply oxygen therapy.
- A patient in the ED is in hypovolemic shock. Which type of IV fluid should the nurse administer first?
- A. 5% dextrose in water.
- B. 0.9% sodium chloride.
- C. Lactated Ringer’s solution.
- D. Albumin.
- A patient is brought in after a motor vehicle accident. They have jugular vein distention and hypotension. What condition should the nurse suspect?
- A. Cardiac tamponade.
- B. Tension pneumothorax.
- C. Pulmonary embolism.
- D. Aortic dissection.
- A patient presents with a penetrating abdominal wound and eviscerated bowel loops. What is the nurse’s priority action?
- A. Push the bowel loops back into the abdomen.
- B. Cover the exposed organs with a sterile, moist dressing.
- C. Apply a pressure dressing to control bleeding.
- D. Place the patient in a semi-Fowler’s position.
- A patient with suspected spinal cord injury is brought to the ED. What is the first action the nurse should take?
- A. Assess for sensation and motor function.
- B. Immobilize the cervical spine.
- C. Obtain vital signs.
- D. Start IV fluids.
- A patient with suspected sepsis has a blood pressure of 85/50 mmHg and a lactate level of 5 mmol/L. What is the nurse’s priority intervention?
- A. Administer broad-spectrum antibiotics.
- B. Start norepinephrine infusion.
- C. Administer a fluid bolus of 30 mL/kg.
- D. Obtain blood cultures.
- A patient with a gunshot wound to the chest has an open sucking wound. What is the nurse’s priority action?
- A. Cover the wound with a non-porous dressing taped on three sides.
- B. Apply pressure to the wound with a sterile gauze.
- C. Intubate the patient immediately.
- D. Perform a needle decompression.
- A patient arrives after ingesting an unknown substance. They are unconscious and have a respiratory rate of 6 breaths/min. What is the first action?
- A. Administer naloxone.
- B. Insert an oropharyngeal airway.
- C. Prepare for gastric lavage.
- D. Draw blood for toxicology screening.
- A patient presents with chemical burns to the eyes. What is the immediate nursing intervention?
- A. Apply cool compresses.
- B. Flush the eyes with copious amounts of saline.
- C. Apply antibiotic eye drops.
- D. Patch the affected eye.
- A patient in the ED is experiencing chest pain and shortness of breath. An ECG shows ST elevation in the anterior leads. What is the next priority intervention?
- A. Administer oxygen at 2 L/min via nasal cannula.
- B. Prepare the patient for PCI (percutaneous coronary intervention).
- C. Administer sublingual nitroglycerin.
- D. Obtain blood for cardiac enzymes.
- A patient is brought to the ED after being found unresponsive in a hot car. Their rectal temperature is 41°C (105.8°F). What is the priority action?
- A. Administer antipyretics.
- B. Start rapid cooling measures.
- C. Administer IV fluids.
- D. Assess blood glucose levels.
- A child is brought to the ED after choking on a small toy. They are conscious but unable to speak or cough. What is the nurse’s immediate action?
- A. Perform abdominal thrusts.
- B. Encourage the child to cough forcefully.
- C. Begin back blows and chest thrusts.
- D. Prepare for intubation.
- A patient presents with hypothermia and a core temperature of 32°C (89.6°F). What is the priority intervention?
- A. Administer warm IV fluids.
- B. Place the patient in a heated blanket.
- C. Perform continuous ECG monitoring.
- D. Encourage oral warm fluids.
- A patient with a suspected basal skull fracture has raccoon eyes and clear nasal drainage. What is the priority action?
- A. Test the drainage for glucose.
- B. Insert a nasogastric tube.
- C. Prepare the patient for surgery.
- D. Apply pressure to stop the drainage.
- A patient presents with an acute asthma exacerbation and is not responding to albuterol. What is the next medication the nurse should anticipate?
- A. Ipratropium bromide nebulizer.
- B. Epinephrine subcutaneous injection.
- C. IV methylprednisolone.
- D. IV magnesium sulfate.
- A patient has just undergone rapid sequence intubation in the ED. What is the nurse’s next priority?
- A. Assess tube placement using end-tidal CO2.
- B. Secure the endotracheal tube.
- C. Begin mechanical ventilation.
- D. Administer sedatives.
- A patient with a history of diabetes presents with altered mental status and a blood glucose of 24 mg/dL. What is the priority intervention?
- A. Administer IV dextrose 50%.
- B. Start an insulin drip.
- C. Provide oral glucose.
- D. Obtain a full set of vital signs.
- A patient with a suspected pelvic fracture is hypotensive and tachycardic. What is the nurse’s priority intervention?
- A. Immobilize the pelvis with a binder.
- B. Start IV fluids.
- C. Perform a FAST (focused assessment with sonography for trauma).
- D. Administer blood products.
- A patient with a high-voltage electrical burn is admitted to the ED. What is the priority nursing intervention?
- A. Assess cardiac rhythm.
- B. Perform a thorough head-to-toe assessment.
- C. Apply burn dressings to affected areas.
- D. Administer tetanus prophylaxis.
- A patient presents to the ED with a suspected overdose of tricyclic antidepressants. What ECG finding would the nurse expect?
- A. Prolonged PR interval.
- B. Widened QRS complex.
- C. ST elevation.
- D. T wave inversion.
- A patient presents with epistaxis that has not resolved after 20 minutes of direct pressure. What is the next intervention?
- A. Apply a nasal balloon tamponade.
- B. Insert a nasopharyngeal airway.
- C. Administer IV tranexamic acid.
- D. Apply a cold compress to the neck.
- A patient is found unresponsive with pinpoint pupils and shallow breathing. The nurse suspects opioid overdose. After administering naloxone, what is the next action?
- A. Place the patient in a recovery position.
- B. Prepare for a second dose of naloxone.
- C. Start an IV for fluid resuscitation.
- D. Monitor for sudden agitation or withdrawal.
- A patient with acute pancreatitis presents with severe epigastric pain radiating to the back. What is the most appropriate initial intervention?
- A. Administer IV fluids.
- B. Insert a nasogastric tube.
- C. Administer IV opioids.
- D. Provide oral pancreatic enzymes.
- A patient is brought to the ED after a motor vehicle collision and is in shock. The patient’s skin is cool and clammy, blood pressure is 90/60 mmHg, and heart rate is 120 bpm. What is the priority intervention?
- A. Administer IV fluids.
- B. Administer vasopressors.
- C. Apply warm blankets.
- D. Intubate the patient.
- A patient with a head injury presents with a Glasgow Coma Scale (GCS) of 8. What is the nurse’s priority action?
- A. Intubate the patient.
- B. Administer IV fluids.
- C. Prepare for a CT scan.
- D. Assess for bleeding.
- A patient is brought to the ED after a burn injury. The patient has burns on the chest, arms, and face, and is alert and oriented. What is the priority action?
- A. Start IV fluids to prevent shock.
- B. Administer pain medication.
- C. Remove the patient’s clothing.
- D. Apply cooling to the affected areas.
- A child presents with a fever of 39.5°C (103.1°F) and a persistent sore throat. What is the priority intervention?
- A. Obtain a throat culture for group A streptococcus.
- B. Administer antipyretics to reduce fever.
- C. Provide fluids to prevent dehydration.
- D. Administer antibiotics.
- A patient with suspected appendicitis is complaining of pain in the lower right quadrant. What additional sign is most suggestive of appendicitis?
- A. Positive Murphy’s sign.
- B. Rebound tenderness.
- C. Guarding of the left upper quadrant.
- D. Pain radiating to the left shoulder.
- A patient presents with a laceration to the leg that is bleeding profusely. What is the nurse’s first action?
- A. Apply direct pressure to the wound.
- B. Elevate the leg.
- C. Apply a tourniquet.
- D. Clean the wound with saline.
- A patient is in the ED after a fall and is suspected to have a pelvic fracture. What assessment finding is most concerning?
- A. Blood pressure of 110/70 mmHg.
- B. Hematuria.
- C. Pain upon palpation of the pelvis.
- D. Tachycardia.
- A patient with a history of hypertension presents with severe headache, nausea, and vomiting. What is the nurse’s priority intervention?
- A. Administer antihypertensive medication.
- B. Perform a neurological assessment.
- C. Obtain a CT scan of the head.
- D. Administer antiemetic medication.
- A patient with an open fracture is being treated in the ED. What is the nurse’s priority action?
- A. Administer pain medication.
- B. Clean and dress the wound.
- C. Immobilize the affected limb.
- D. Start IV antibiotics.
- A patient presents with acute renal failure and hyperkalemia. Which of the following interventions is the priority?
- A. Administer calcium gluconate IV.
- B. Administer sodium bicarbonate.
- C. Administer hemodialysis.
- D. Administer potassium-sparing diuretics.
- A patient presents with signs of heatstroke, including confusion, hot dry skin, and a temperature of 41.1°C (106°F). What is the priority nursing intervention?
- A. Administer antipyretics.
- B. Apply cool packs to the axillae and groin.
- C. Place the patient in a cold water bath.
- D. Provide oral hydration with electrolytes.
- A patient with a gunshot wound to the abdomen has a BP of 80/40 mmHg, and tachycardia. What is the nurse’s priority action?
- A. Apply a pressure dressing.
- B. Insert an NG tube.
- C. Administer IV fluids.
- D. Prepare for exploratory surgery.
- A patient is brought in with a suspected overdose of acetaminophen. The patient is asymptomatic but has a blood level of 300 µg/mL. What is the next step in management?
- A. Administer activated charcoal.
- B. Administer N-acetylcysteine (NAC).
- C. Obtain a liver function test.
- D. Monitor the patient for 24 hours.
- A patient presents with an acute asthma attack and is not responding to bronchodilators. What medication should the nurse anticipate administering next?
- A. Oral prednisone.
- B. Intravenous magnesium sulfate.
- C. Intravenous terbutaline.
- D. Epinephrine subcutaneously.
- A child presents to the ED with anaphylaxis after eating peanuts. What is the priority treatment?
- A. Administer diphenhydramine.
- B. Administer corticosteroids.
- C. Administer epinephrine.
- D. Apply oxygen.
- A patient with a history of heart failure presents with shortness of breath, jugular vein distention, and bilateral crackles on auscultation. What is the priority intervention?
- A. Administer diuretics.
- B. Administer oxygen.
- C. Administer morphine.
- D. Prepare for intubation.
- A patient in the ED is suspected of having a pneumothorax. What is the most definitive diagnostic test?
- A. Chest X-ray.
- B. CT scan of the chest.
- C. Arterial blood gas.
- D. MRI of the chest.
- A patient presents with suspected fractured ribs after a fall. What is the priority intervention?
- A. Provide pain medication.
- B. Apply a rib belt.
- C. Monitor for signs of pneumothorax.
- D. Administer IV fluids.
- A patient presents to the ED with acute alcohol intoxication. What is the nurse’s priority action?
- A. Administer a benzodiazepine.
- B. Monitor vital signs frequently.
- C. Provide fluids for hydration.
- D. Prepare for intubation.
- A patient with a massive stroke is unresponsive and has a GCS score of 4. What is the nurse’s priority action?
- A. Assess the airway and provide respiratory support.
- B. Administer thrombolytics.
- C. Prepare for a CT scan.
- D. Administer antihypertensives.
Questions and Answers for Study Guide
Discuss the priority interventions for a patient who is brought to the emergency department with signs and symptoms of shock. What is the role of the nurse in managing shock, and how would you prioritize interventions for a patient in this condition?
Answer:
Shock is a critical condition that requires rapid intervention to prevent organ failure and death. The primary goals in managing shock are to restore tissue perfusion, address the underlying cause, and prevent complications. The nurse’s role is crucial in providing initial stabilization and guiding the patient through the resuscitative process.
The priority interventions for a patient in shock are as follows:
- Assessment and Monitoring: The nurse should quickly assess the patient’s vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation. Monitoring should be continuous to assess the effectiveness of interventions.
- IV Access and Fluid Resuscitation: The first line of treatment for shock, especially in hypovolemic shock, is the administration of intravenous fluids. Crystalloids, such as normal saline or lactated Ringer’s solution, are often used to expand intravascular volume and improve perfusion.
- Oxygen Administration: Ensuring adequate oxygenation is vital. Supplemental oxygen or even mechanical ventilation may be required depending on the severity of the shock and the patient’s oxygen saturation levels.
- Vasoactive Medications: If fluid resuscitation does not adequately restore blood pressure, vasoactive drugs such as norepinephrine or dopamine may be administered to support the cardiovascular system.
- Identifying and Treating the Underlying Cause: Depending on the type of shock (hypovolemic, cardiogenic, distributive, or obstructive), the underlying cause must be addressed. For example, bleeding should be controlled in hypovolemic shock, while antibiotics may be required in septic shock.
Nurses must prioritize the stabilization of the patient’s airway, breathing, and circulation (the ABCs) and continuously assess their response to interventions, adjusting care as needed to ensure optimal outcomes.
Explain the role of triage in emergency nursing, and how would you approach the triage process for patients in an overcrowded emergency department?
Answer:
Triage is the process of sorting patients based on the severity of their condition to ensure that those who need immediate care receive it without delay. The goal of triage in emergency nursing is to prioritize care efficiently, particularly when resources are limited or in high-stress situations, such as during mass casualty incidents or overcrowded emergency departments (EDs).
The triage process is typically guided by established systems, such as the Emergency Severity Index (ESI) or START (Simple Triage and Rapid Treatment), which categorize patients into levels based on the urgency of their medical needs.
The role of the nurse in triage involves:
- Initial Assessment: Quickly and accurately assessing the patient’s condition upon arrival. This includes evaluating vital signs, airway and breathing status, level of consciousness, and the chief complaint.
- Categorizing Patients: Assigning a triage level based on the severity of the condition:
- Level 1 (Resuscitation): Patients with life-threatening conditions requiring immediate intervention (e.g., cardiac arrest, severe trauma).
- Level 2 (Emergent): Patients who require prompt attention but are not in immediate danger of death (e.g., chest pain, severe pain).
- Level 3 (Urgent): Patients with conditions that need care but can wait for a short period without significant risk (e.g., minor fractures).
- Level 4 (Less urgent): Conditions that can be treated with a longer wait time (e.g., mild fever, minor injuries).
- Level 5 (Non-urgent): Patients with minimal or no risk to health (e.g., routine check-ups, cold symptoms).
- Managing Overcrowding: When the ED is overcrowded, the nurse must utilize the triage system to prioritize life-threatening conditions while ensuring timely treatment for all patients. Effective communication with the healthcare team is vital to coordinate care efficiently. Non-urgent patients may be asked to wait longer or referred to urgent care centers if appropriate.
- Reassessment: Triage is an ongoing process. Patients should be reassessed frequently to determine if their condition has worsened, which may require re-prioritization.
Nurses must be skilled in quickly identifying critical conditions while maintaining a calm, organized approach to manage multiple patients efficiently.
A patient in the emergency department presents with signs of a myocardial infarction (MI). What are the key nursing interventions in the acute phase of a myocardial infarction, and how would you manage the patient during this time?
Answer:
Myocardial infarction (MI) is a medical emergency that requires immediate and aggressive intervention to limit myocardial damage and improve outcomes. The nurse plays a critical role in both the initial management and ongoing monitoring of the patient with MI.
Key nursing interventions in the acute phase of a myocardial infarction include:
- Initial Assessment: Upon presentation, the nurse should perform a rapid assessment, focusing on the patient’s level of consciousness, chest pain (character, duration, radiation), and vital signs. The nurse should also assess for signs of heart failure, such as shortness of breath or edema, and gather information on the patient’s medical history, risk factors, and symptoms.
- Administer Oxygen: Oxygen therapy is often given to ensure adequate oxygenation of the heart muscle and reduce myocardial ischemia. This is especially important in patients with low oxygen saturation levels.
- Pain Management: Chest pain is a hallmark symptom of MI, and the nurse should administer analgesics such as nitroglycerin and morphine, as prescribed, to reduce pain and decrease myocardial oxygen demand. Nitroglycerin can help dilate coronary arteries and improve blood flow, while morphine reduces pain and anxiety.
- Monitor Vital Signs: Continuous monitoring of blood pressure, heart rate, and respiratory rate is essential to assess the patient’s response to treatment. Cardiac monitoring is critical to detect arrhythmias, which are common during an MI.
- Administer Antiplatelet and Anticoagulant Medications: Medications like aspirin and heparin may be given to reduce clot formation and prevent further obstruction of coronary arteries.
- Prepare for Intervention: The nurse should prepare the patient for possible interventions, such as percutaneous coronary intervention (PCI) or thrombolytic therapy, depending on the hospital’s capabilities and the time elapsed since symptom onset. The nurse should educate the patient about the procedure and what to expect.
- Psychological Support: MI can be an overwhelming experience for patients, and anxiety is common. Nurses should provide reassurance and emotional support, addressing any concerns about the diagnosis and treatment.
- Patient Education: In the acute phase, education should be focused on the importance of lifestyle changes, medication adherence, and follow-up care once the patient is stabilized.
Nurses must be vigilant in monitoring for complications such as arrhythmias, heart failure, or shock and be prepared to implement emergency interventions as needed.
Describe the management and nursing interventions for a patient presenting with acute respiratory distress syndrome (ARDS) in the emergency department.
Answer:
Acute Respiratory Distress Syndrome (ARDS) is a life-threatening condition characterized by severe hypoxemia and bilateral pulmonary infiltrates without evidence of left-sided heart failure. It may occur after trauma, pneumonia, sepsis, or aspiration, and requires prompt recognition and management.
Nursing interventions for a patient with ARDS include:
- Initial Assessment: The nurse should perform a comprehensive assessment to confirm the signs of ARDS, which include rapid breathing, hypoxia, and crackles on auscultation. Vital signs should be continuously monitored, and the patient’s oxygen saturation levels should be carefully observed.
- Oxygen Therapy: The cornerstone of ARDS management is oxygenation. Supplemental oxygen, administered via a non-rebreather mask or mechanical ventilation, is typically required to maintain adequate oxygen levels. In severe cases, positive pressure ventilation, including the use of mechanical ventilation with high levels of positive end-expiratory pressure (PEEP), is essential to open collapsed alveoli and improve oxygenation.
- Mechanical Ventilation: If the patient’s condition deteriorates, intubation and mechanical ventilation may be necessary. The nurse plays a role in ensuring the proper settings for mechanical ventilation, monitoring for complications such as barotrauma, and supporting the patient during the ventilation process.
- Fluid Management: Careful fluid management is critical. In ARDS, excessive fluid administration can worsen pulmonary edema, so the nurse must carefully monitor input and output, and the physician may prescribe fluid restriction or diuretics as appropriate.
- Positioning: Prone positioning (turning the patient onto their stomach) is often used in ARDS to improve oxygenation. The nurse should work with the respiratory therapy team to ensure proper positioning and monitor for skin breakdown.
- Monitoring for Complications: The nurse should closely monitor for complications such as ventilator-associated pneumonia (VAP), barotrauma, or pneumothorax, and communicate any changes in the patient’s condition to the medical team.
- Sedation and Pain Management: Mechanical ventilation and the associated discomfort may require sedation and analgesia. The nurse should assess pain levels and provide medications as prescribed to ensure comfort and cooperation with the ventilator.
- Patient and Family Education: In the critical phase, educating the patient’s family about the severity of the condition and the treatment plan is important. The nurse should also provide psychological support to help manage the stress of an extended ICU stay.
Describe the management and nursing interventions for a patient presenting with a traumatic brain injury (TBI) in the emergency department.
Answer:
Traumatic brain injury (TBI) is a medical emergency that requires immediate intervention to prevent secondary brain damage and improve patient outcomes. The nurse plays a crucial role in the initial management, assessment, and ongoing care of patients with TBI.
Key nursing interventions for TBI include:
- Initial Assessment: A rapid assessment of the patient’s airway, breathing, and circulation (ABCs) is the first priority. The nurse should assess the Glasgow Coma Scale (GCS) score to evaluate the level of consciousness. Any signs of severe head injury, such as bleeding from the ears, nose, or mouth, should be noted immediately.
- Airway Management: Patients with severe TBI are at high risk for airway compromise. The nurse should ensure that the airway is clear and provide oxygen as needed. In cases of severe injury, intubation and mechanical ventilation may be required.
- Monitoring Vital Signs: Continuous monitoring of vital signs is essential. A patient with TBI may develop increased intracranial pressure (ICP), which can lead to further brain damage. The nurse should monitor blood pressure, heart rate, respiratory rate, and oxygen saturation frequently.
- Preventing Increased Intracranial Pressure (ICP): ICP can increase in TBI patients, leading to brain herniation. The nurse should elevate the head of the bed to 30 degrees to reduce ICP and avoid actions that increase pressure, such as sudden movements or coughing.
- Fluid Management: Careful fluid management is important in preventing both dehydration and cerebral edema. Hypertonic saline or mannitol may be administered as ordered to reduce cerebral swelling and maintain appropriate fluid balance.
- Neuroimaging: The nurse should prepare the patient for a CT scan or MRI to assess the extent of the brain injury and identify any bleeding, fractures, or swelling. This is essential for determining the next steps in care.
- Pain and Sedation Management: Head injuries often cause significant pain. The nurse should administer analgesics and sedatives as prescribed to maintain patient comfort while also preventing agitation, which can increase ICP.
- Patient Education: Once the patient is stabilized, the nurse should educate both the patient and their family on the signs of complications, such as worsening headache, vomiting, confusion, or changes in consciousness, which require immediate medical attention.
What is the role of the nurse in the management of a patient presenting with a severe allergic reaction, including anaphylaxis, in the emergency department?
Answer:
Severe allergic reactions, including anaphylaxis, are life-threatening conditions that require rapid intervention. The nurse’s role is to quickly identify the symptoms of an allergic reaction, provide emergency treatment, and ensure that the patient is stabilized.
Key nursing interventions in managing an allergic reaction or anaphylaxis include:
- Initial Assessment: The nurse should assess for signs of anaphylaxis, which can include difficulty breathing, swelling of the face or throat, hives, dizziness, and hypotension. Immediate recognition is crucial for successful intervention.
- Administer Epinephrine: Epinephrine is the first-line treatment for anaphylaxis. The nurse should administer intramuscular epinephrine as soon as possible, typically in the lateral thigh. This medication helps to reverse bronchoconstriction, vasodilation, and angioedema, which are common symptoms of anaphylaxis.
- Oxygen Therapy: The nurse should administer oxygen to ensure adequate oxygenation and support the patient’s respiratory function, particularly if the airway is compromised due to swelling or bronchoconstriction.
- IV Access and Fluid Resuscitation: IV fluids, typically normal saline, are essential to treat hypotension and restore circulatory volume. The nurse should start an intravenous line and administer fluids as prescribed.
- Antihistamines and Corticosteroids: In addition to epinephrine, antihistamines (e.g., diphenhydramine) and corticosteroids (e.g., prednisone) may be given to reduce inflammation and further allergic response. The nurse should administer these medications as ordered and monitor for any adverse effects.
- Monitoring Vital Signs and Airway: The nurse should closely monitor the patient’s vital signs, including blood pressure, heart rate, and respiratory rate, to assess for signs of worsening anaphylaxis. Continuous monitoring of oxygen saturation is also necessary to ensure that the patient remains adequately oxygenated.
- Prepare for Advanced Airway Management: If the patient’s condition worsens and respiratory failure is imminent, the nurse should prepare for advanced airway management, including intubation. This may be required if the patient is unable to maintain their airway due to swelling or laryngeal obstruction.
- Education and Prevention: Once the patient is stabilized, the nurse should educate them about the potential causes of their allergic reaction and provide instructions on how to use an epinephrine auto-injector (e.g., EpiPen) in case of future reactions. Additionally, the nurse should emphasize the importance of avoiding allergens and seeking immediate medical attention in the event of another allergic reaction.
What are the key nursing interventions for a patient presenting with a stroke, and how would you manage the patient during the acute phase?
Answer:
Stroke is a medical emergency that requires immediate assessment and intervention to minimize brain damage and improve patient outcomes. The nurse plays a vital role in the early identification, management, and ongoing care of stroke patients.
Key nursing interventions for a patient presenting with a stroke include:
- Initial Assessment: The nurse should perform a rapid neurological assessment to determine the type and severity of the stroke. The FAST (Face drooping, Arm weakness, Speech difficulty, Time to call emergency services) mnemonic is often used to quickly identify signs of a stroke.
- Airway and Breathing Management: Maintaining the patient’s airway and ensuring adequate oxygenation is crucial, especially in patients with decreased level of consciousness or respiratory compromise. The nurse should administer oxygen if needed and monitor the patient’s respiratory status.
- IV Access and Medications: IV access should be established immediately. If the patient is a candidate for thrombolytic therapy (e.g., tissue plasminogen activator [tPA]), the nurse should ensure that the medication is administered within the appropriate time window (usually within 3–4.5 hours of symptom onset) to improve the chances of recovery.
- Blood Pressure Management: The nurse should monitor and manage the patient’s blood pressure, as elevated blood pressure can worsen stroke outcomes. Medications may be prescribed to control hypertension if necessary.
- Neurological Monitoring: Continuous neurological assessment is essential to monitor for changes in the patient’s condition. This includes monitoring the Glasgow Coma Scale (GCS), pupil response, limb strength, and speech.
- Minimizing Aspiration Risk: For patients with difficulty swallowing, the nurse should implement aspiration precautions to prevent choking or aspiration pneumonia. The patient may require a swallowing evaluation and adjustments to their diet, such as soft or thickened liquids.
- Positioning: The nurse should position the patient to optimize cerebral perfusion. Typically, the head of the bed is elevated to about 30 degrees to reduce intracranial pressure and promote better circulation to the brain.
- Emotional Support and Education: A stroke can be a life-altering event for patients and their families. The nurse should provide emotional support and educate the patient and family members about stroke, recovery options, rehabilitation, and prevention of future strokes.
Explain the role of the nurse in managing a patient with sepsis in the emergency department.
Answer:
Sepsis is a life-threatening condition resulting from infection that can lead to organ failure and death if not promptly recognized and treated. The nurse plays a critical role in the early identification, management, and monitoring of the patient with sepsis.
Key nursing interventions for managing a patient with sepsis include:
- Early Identification and Assessment: The nurse should perform a thorough assessment of the patient, noting signs of infection (e.g., fever, chills, redness, or swelling) and signs of sepsis, such as altered mental status, hypotension, tachycardia, and tachypnea. The nurse should use screening tools, such as the qSOFA (quick Sequential Organ Failure Assessment) to identify patients at risk for sepsis.
- Administering IV Fluids: Fluid resuscitation is a key intervention for patients with sepsis. The nurse should administer intravenous fluids (e.g., crystalloids) as ordered to restore circulatory volume and improve tissue perfusion.
- Antibiotic Administration: Early administration of broad-spectrum antibiotics is essential to treat the underlying infection. The nurse should ensure that antibiotics are given within the first hour of sepsis recognition and as ordered, after obtaining blood cultures if possible.
- Oxygen Therapy: Sepsis often causes decreased oxygenation due to systemic vasodilation and impaired perfusion. The nurse should administer supplemental oxygen and monitor oxygen saturation to ensure adequate tissue oxygenation.
- Monitoring Vital Signs and Organ Function: The nurse should continuously monitor vital signs, including blood pressure, heart rate, respiratory rate, and temperature. Organ function, including renal, hepatic, and cardiac function, should be closely monitored through laboratory results and clinical assessment.
- Vasoactive Medications: If the patient remains hypotensive despite fluid resuscitation, vasoactive medications, such as norepinephrine, may be required to support blood pressure and perfusion.
- Preventing Complications: The nurse should closely monitor for complications of sepsis, such as acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation (DIC), and multi-organ failure. Early detection and intervention are crucial for improving outcomes.
- Patient and Family Education: Once the patient is stabilized, the nurse should educate both the patient and family about the nature of sepsis, prevention strategies, and the importance of follow-up care to reduce the risk of recurrent infections.
Discuss the management of a patient with acute myocardial infarction (MI) in the emergency department.
Answer:
Acute myocardial infarction (MI) is a medical emergency that requires immediate and coordinated care to minimize myocardial damage and prevent complications. The role of the nurse in managing a patient with MI is vital in ensuring the patient’s stability and providing life-saving interventions.
Key nursing interventions for managing acute MI include:
- Initial Assessment: The nurse should perform a quick but thorough assessment of the patient’s symptoms. Key symptoms of MI include chest pain (often described as crushing or squeezing), shortness of breath, diaphoresis, nausea, and lightheadedness. An initial 12-lead electrocardiogram (ECG) should be obtained to assess for ST-segment elevation or other signs of ischemia.
- Pain Management: Pain relief is a priority in the management of MI. The nurse should administer nitroglycerin (if blood pressure permits) and morphine for pain relief. These medications reduce myocardial oxygen demand and control pain. It’s important to monitor the patient’s blood pressure and response to medications carefully.
- Oxygen Therapy: Administering oxygen is essential to ensure adequate oxygenation to the heart muscle, particularly in patients with ST-segment elevation MI (STEMI) or non-ST-segment elevation MI (NSTEMI). The goal is to maintain an oxygen saturation level above 94%.
- Antiplatelet Therapy and Anticoagulants: Administer aspirin as soon as MI is suspected to inhibit platelet aggregation and reduce clot formation. In addition, other medications, such as clopidogrel or heparin, may be prescribed to further reduce clot formation. The nurse should ensure that these medications are administered promptly and monitor for adverse reactions.
- Thrombolytic Therapy or Percutaneous Coronary Intervention (PCI): Depending on the type of MI (STEMI vs. NSTEMI), the nurse may be involved in preparing the patient for thrombolytic therapy (if administered within the first 12 hours) or PCI (angioplasty and stent placement). Time is critical, and therapy should be initiated as soon as possible.
- Monitoring and Cardiac Rhythm: Continuous ECG monitoring is required to detect any arrhythmias, which are common in MI patients. The nurse should closely monitor the heart rate, rhythm, and blood pressure. Any signs of arrhythmias, such as ventricular tachycardia or fibrillation, must be addressed immediately.
- Patient Education: Once the patient’s condition stabilizes, the nurse should provide education on lifestyle modifications, including smoking cessation, dietary changes, exercise, and medications. The nurse should also provide information on recognizing symptoms of future heart attacks and the importance of follow-up care.
- Emotional Support: MI can be a frightening experience, so providing emotional support to the patient and their family is important. The nurse should provide reassurance and explain the treatment plan to help alleviate anxiety and build trust.
Explain the management of a patient presenting with a respiratory emergency, such as acute asthma exacerbation, in the emergency department.
Answer:
Acute asthma exacerbation is a common respiratory emergency where the patient experiences increased airway inflammation, bronchoconstriction, and mucous production. Rapid intervention is essential to restore airway patency and improve oxygenation. The nurse plays a key role in the initial assessment, medication administration, and ongoing monitoring of the patient’s condition.
Key nursing interventions for managing acute asthma exacerbation include:
- Initial Assessment: The nurse should assess the patient’s airway, breathing, and circulation. Signs of acute asthma exacerbation include wheezing, tachypnea, use of accessory muscles for breathing, and decreased oxygen saturation. The nurse should also assess the severity of symptoms using a peak flow meter, if available.
- Oxygen Therapy: Oxygen should be administered to patients with hypoxemia. The nurse should aim to keep oxygen saturation levels above 94%. Oxygen may be administered via nasal cannula or mask, depending on the severity of the exacerbation.
- Bronchodilator Administration: Short-acting beta-agonists (SABA), such as albuterol, are first-line treatments for acute asthma exacerbation. The nurse should administer inhaled bronchodilators as ordered, typically via a nebulizer or metered-dose inhaler. These medications help to relax the smooth muscles around the airways, improving airflow.
- Corticosteroids: Systemic corticosteroids (e.g., prednisone or methylprednisolone) are often prescribed to reduce airway inflammation and prevent recurrence of symptoms. The nurse should administer these medications as prescribed and monitor for side effects such as hyperglycemia or gastrointestinal upset.
- Monitoring Response to Treatment: The nurse should closely monitor the patient’s response to treatment, noting improvements in wheezing, oxygen saturation, respiratory rate, and use of accessory muscles. If the patient does not respond to initial treatment, additional doses of bronchodilators or other interventions may be necessary.
- Assessing for Complications: Severe asthma exacerbations may lead to respiratory failure or status asthmaticus, a life-threatening condition that does not respond to usual treatments. The nurse should monitor for signs of worsening respiratory distress, such as increased wheezing, inability to speak in full sentences, or changes in mental status.
- Patient Education: Once the patient is stable, the nurse should provide education on asthma management, including the proper use of inhalers, recognition of early warning signs of an exacerbation, and the importance of adherence to prescribed medications. The nurse should also educate the patient on avoiding triggers that can lead to asthma attacks.
- Follow-up Care: The nurse should ensure that the patient has a follow-up appointment with their healthcare provider and is provided with resources on asthma management, such as an asthma action plan.
Discuss the nursing interventions for a patient with hypovolemic shock in the emergency department.
Answer:
Hypovolemic shock is a life-threatening condition characterized by a decrease in circulating blood volume, resulting in inadequate tissue perfusion and oxygenation. The nurse plays a crucial role in identifying the signs of hypovolemic shock and initiating prompt interventions to restore circulatory volume and stabilize the patient.
Key nursing interventions for managing hypovolemic shock include:
- Initial Assessment: The nurse should assess the patient’s vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation. Early signs of hypovolemic shock include tachycardia, hypotension, weak or thready pulses, and pale, cool skin. The nurse should also assess for the source of blood loss (e.g., trauma, gastrointestinal bleeding).
- IV Fluid Resuscitation: Immediate fluid resuscitation is essential to restore circulating volume. The nurse should initiate an IV line and administer isotonic fluids, such as normal saline or lactated Ringer’s solution, as ordered. In cases of severe blood loss, blood products (e.g., packed red blood cells) may be needed.
- Monitoring for Response to Fluids: The nurse should monitor the patient’s response to fluid resuscitation, assessing for improvements in vital signs, urine output, and overall perfusion. If the patient does not respond to initial fluid administration, further interventions, such as blood transfusions or vasopressors, may be needed.
- Oxygen Therapy: Oxygen should be administered to support tissue oxygenation. The nurse should monitor oxygen saturation levels and ensure the patient is receiving adequate oxygenation to maintain organ function.
- Assessing for Complications: The nurse should monitor for signs of organ dysfunction, such as decreased urine output, altered mental status, or changes in skin color. These may indicate inadequate tissue perfusion and the need for more aggressive treatment.
- Monitoring Laboratory Values: The nurse should monitor laboratory values, such as hemoglobin and hematocrit levels, to assess the severity of blood loss. Coagulation studies may also be ordered to evaluate clotting function in patients with significant hemorrhage.
- Patient Education: Once the patient is stabilized, the nurse should provide education on the underlying cause of the shock, the importance of follow-up care, and strategies to prevent future episodes of blood loss or fluid imbalance.
- Emotional Support: Hypovolemic shock is often caused by trauma or significant blood loss, which can be distressing for patients. The nurse should provide emotional support to the patient and their family, offering reassurance and explaining the treatment plan.
Discuss the nursing management of a patient with a suspected stroke in the emergency department.
Answer:
A suspected stroke is a neurological emergency that requires immediate assessment and treatment to minimize brain damage and improve outcomes. The nurse’s role in the emergency department is critical for rapid identification, intervention, and coordination with other healthcare providers.
Key nursing interventions for managing a suspected stroke include:
- Initial Assessment: The nurse should quickly assess the patient’s level of consciousness, speech, and motor function. The use of screening tools such as the National Institutes of Health Stroke Scale (NIHSS) is essential to assess the severity of the stroke. The nurse should also assess the time of symptom onset, as this determines eligibility for thrombolytic therapy (tPA).
- Rapid Imaging: CT or MRI scans should be ordered as soon as possible to differentiate between ischemic and hemorrhagic stroke. This helps guide the treatment plan, as ischemic strokes may be treated with thrombolytics, whereas hemorrhagic strokes require different management.
- Oxygen and Vital Signs: The nurse should ensure the patient is receiving adequate oxygenation (target oxygen saturation of ≥94%) to prevent further ischemia. Monitoring vital signs, especially blood pressure, is essential, as uncontrolled hypertension can exacerbate brain injury in both ischemic and hemorrhagic strokes.
- Thrombolytic Therapy: If the patient is diagnosed with an ischemic stroke and meets eligibility criteria, the nurse may be involved in preparing and administering thrombolytic agents (e.g., alteplase or tPA) within the critical 3-4.5 hour window. The nurse should closely monitor for any signs of bleeding or complications during the infusion.
- Antiplatelet Therapy: For ischemic stroke patients who are not candidates for thrombolytic therapy, the nurse should administer antiplatelet agents (e.g., aspirin or clopidogrel) as ordered to prevent further clot formation.
- Management of Intracranial Pressure (ICP): For patients with hemorrhagic stroke, managing ICP is a priority. The nurse should monitor for signs of increased ICP, such as altered mental status, pupillary changes, and motor deficits. Positioning the patient with the head of the bed elevated at 30 degrees can help reduce ICP.
- Neurological Monitoring: The nurse should conduct frequent neurological assessments to monitor for any changes in the patient’s condition. This includes checking the Glasgow Coma Scale (GCS) score, assessing pupil response, and monitoring motor function.
- Patient Education: Once the patient is stabilized, the nurse should provide education on stroke prevention, including lifestyle changes such as smoking cessation, controlling blood pressure, and managing diabetes. The nurse should also discuss the importance of follow-up care, rehabilitation, and recognizing signs of a future stroke.
Explain the nursing management of a patient with an anaphylactic reaction in the emergency department.
Answer:
Anaphylaxis is a severe, life-threatening allergic reaction that requires immediate intervention to prevent airway compromise, circulatory collapse, and death. The nurse plays a crucial role in quickly recognizing the signs of anaphylaxis and implementing treatments to reverse the reaction.
Key nursing interventions for managing anaphylaxis include:
- Initial Assessment: The nurse should rapidly assess the patient for symptoms of anaphylaxis, including difficulty breathing, swelling of the face or throat, urticaria (hives), and hypotension. A thorough history should be obtained to identify the trigger (e.g., food allergies, insect stings, medication reactions).
- Administer Epinephrine: Epinephrine is the first-line treatment for anaphylaxis. The nurse should administer intramuscular epinephrine as soon as anaphylaxis is suspected, typically in the mid-outer thigh. This medication helps to reverse airway constriction, reduce swelling, and stabilize blood pressure.
- Positioning: The nurse should position the patient in a supine position with the legs elevated if hypotension is present. This helps improve circulation to vital organs and prevent shock. In severe cases, the patient may require endotracheal intubation or a tracheostomy if airway obstruction is imminent.
- Oxygen Therapy: Oxygen should be administered to maintain oxygen saturation levels above 94%. The nurse should assess respiratory status frequently, as severe anaphylaxis can cause respiratory failure due to airway constriction.
- IV Fluid Administration: Intravenous (IV) fluids, such as normal saline or lactated Ringer’s solution, should be administered to combat hypotension and prevent shock. The nurse should monitor for fluid overload, especially in patients with compromised cardiac function.
- Administer Antihistamines and Corticosteroids: After administering epinephrine, the nurse may also need to administer antihistamines (e.g., diphenhydramine) and corticosteroids (e.g., methylprednisolone) as ordered to reduce inflammation and prevent recurrence of symptoms.
- Monitor Vital Signs and Cardiac Status: The nurse should continuously monitor vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation. The patient may need additional doses of epinephrine if symptoms persist.
- Patient Education: After the acute episode, the nurse should provide education on preventing future anaphylactic reactions, including avoiding known allergens and carrying an epinephrine autoinjector (e.g., EpiPen). The nurse should also educate the patient about the importance of seeking medical care immediately if an allergic reaction occurs.
Describe the nursing interventions for a patient with a suspected spinal cord injury in the emergency department.
Answer:
Spinal cord injury (SCI) is a traumatic event that can lead to partial or complete loss of sensation and motor function below the level of injury. Prompt, evidence-based interventions are essential to minimize further neurological damage and prevent complications.
Key nursing interventions for suspected SCI include:
- Initial Assessment: The nurse should perform a thorough primary survey, following the ABCDE approach (Airway, Breathing, Circulation, Disability, and Exposure). It is crucial to maintain spinal immobilization at all times to prevent further damage. The nurse should assess the patient’s level of consciousness, respiratory function, and circulatory status.
- Spinal Immobilization: The patient should be kept on a spinal board or immobilized using a cervical collar until SCI is ruled out. The nurse should assist with proper positioning and ensure that spinal precautions are maintained during transport or while the patient is being moved.
- Airway Management: Patients with high cervical injuries are at risk for respiratory compromise due to diaphragmatic paralysis. The nurse should assess respiratory function and administer supplemental oxygen as needed. If necessary, the nurse should be prepared to assist with intubation or ventilation.
- IV Access and Fluid Resuscitation: The nurse should establish two large-bore IV lines and administer fluids to maintain blood pressure and perfusion to vital organs. Isotonic fluids, such as normal saline, are typically used. Hypotension is common in SCI, especially with injuries above T6, due to autonomic dysreflexia.
- Monitoring for Neurological Changes: The nurse should monitor the patient’s neurological status closely, including checking for motor and sensory deficits. Serial assessments of muscle strength, sensation, and reflexes are important to determine the extent of the injury.
- Preventing Complications: Patients with SCI are at increased risk for pressure ulcers, deep vein thrombosis (DVT), and autonomic dysreflexia. The nurse should ensure proper positioning, implement DVT prophylaxis, and monitor for signs of pressure injuries or abnormal blood pressure changes.
- Pain Management: Pain management is essential, as SCI can cause severe pain due to muscle spasms, fractures, and soft tissue injury. The nurse should administer pain medications, including opioids or muscle relaxants, as prescribed, and monitor the patient for side effects.
- Patient Education and Family Support: Once the patient is stable, the nurse should provide education on the long-term management of SCI, including rehabilitation, mobility aids, bowel and bladder care, and prevention of complications. Support for the patient and family is also crucial, as coping with SCI can be challenging.