Several adults arrive at the emergency department at the same time. Which patient does the triage nurse prioritize to be seen first?
A man with chest pain spreading to the left arm and heavy sweating
✓
A woman with a swollen, painful ankle after a fall
A man with a sore throat and a mild fever
A woman who needs a refill of her blood pressure medicine
Correct Answer
A man with chest pain spreading to the left arm and heavy sweating
Chest pain that spreads to the arm with heavy sweating can signal a myocardial infarction, an immediate threat to life, so this patient is seen first. A woman with a swollen, painful ankle after a fall may have a fracture, but it is not life-threatening. A man with a sore throat and a mild fever has a minor, stable complaint. A woman who needs a medication refill has a nonurgent need.
Category: Triage and Primary Survey
Question 2
A patient triaged as low priority for a minor hand laceration becomes pale, sweaty and short of breath while waiting. What does the nurse do?
Keep the patient's place in line, because triage is already complete
Reassess the patient and re-triage based on the new findings
✓
Ask the patient to describe the symptoms to the provider later
Recheck the vital signs at the next scheduled interval
Correct Answer
Reassess the patient and re-triage based on the new findings
Triage is not a single event: it is repeated whenever a patient's condition changes, and new pallor, sweating and shortness of breath may signal a serious problem. Keeping the patient's place in line ignores a change that could be life-threatening. Asking the patient to describe the symptoms to the provider later delays assessment of a possible emergency. Rechecking the vital signs at the next scheduled interval wastes time the patient may not have.
Category: Triage and Primary Survey
Question 3
An unresponsive patient arrives after a fall from a ladder. In the ABCDE survey, which assessment comes first?
The blood pressure and pulse
The level of consciousness
Whether the airway is open
✓
The skin for hidden injuries
Correct Answer
Whether the airway is open
In the ABCDE survey the airway is assessed first, with the cervical spine kept stable after a fall, because without an open airway no oxygen can reach the lungs and the rest of the body. Trauma teams also stop any catastrophic external bleeding at once, but among these options the airway comes first. The blood pressure and pulse belong to the circulation step, which follows airway and breathing. The level of consciousness is the disability step. Checking the skin for hidden injuries is part of the exposure step at the end of the survey.
Category: Triage and Primary Survey
Question 4
To check airway patency in an alert patient arriving at triage, which action gives the nurse the quickest information?
Applying a pulse oximeter to a finger
Counting the respiratory rate
Checking capillary refill in the nail beds
Asking a question and listening to the voice
✓
Correct Answer
Asking a question and listening to the voice
A patient who answers in a normal, clear voice has an open airway at that moment, while a muffled or crackling voice can signal obstruction. Applying a pulse oximeter to a finger measures oxygen saturation, not whether the airway is open. Counting the respiratory rate is part of the breathing assessment. Checking capillary refill in the nail beds assesses circulation.
Category: Triage and Primary Survey
Question 5
A patient arrives after a suspected drug overdose. Alongside the ABCDE survey, which history does the nurse obtain right away?
The substance taken and the time of last use
✓
The patient's childhood immunization record
The family history of heart disease
The patient's usual diet and exercise habits
Correct Answer
The substance taken and the time of last use
Knowing what was taken and when guides the choice of antidote or reversal agent, the tests ordered and how long the patient must be watched for delayed effects, so this history is gathered as early as possible, from the patient, family, emergency crews or pill bottles. The childhood immunization record does not affect overdose treatment. The family history of heart disease is not urgent information during a poisoning. The patient's usual diet and exercise habits can wait until the patient is stable.
Category: Poisoning Care
Question 6
During the exposure step of the ABCDE survey for a trauma patient, which action does the nurse take?
Asking whether the patient was around anyone who was sick
Inspecting the whole body, including the back and groin
✓
Examining only the area the patient says is painful
Testing how the pupils respond to light
Correct Answer
Inspecting the whole body, including the back and groin
The exposure step means removing clothing and inspecting the entire body, front and back, for bleeding, wounds and rashes, while also checking temperature. Asking whether the patient was around anyone who was sick is part of the history, not this step. Examining only the area the patient says is painful can miss injuries the patient cannot feel or report. Testing how the pupils respond to light is part of a neurological check.
Category: Triage and Primary Survey
Question 7
A patient with long-standing COPD is in the emergency department. Applying the acute-before-chronic principle, which finding does the nurse address first?
A barrel-shaped chest
Clubbing of the fingertips
Confusion that began this morning
✓
Breathlessness on exertion that is unchanged for years
Correct Answer
Confusion that began this morning
New confusion is an acute change that can signal worsening gas exchange or another emergency, so it takes priority over long-standing findings. A barrel-shaped chest is an expected, chronic change in COPD. Clubbing of the fingertips develops slowly over time. Breathlessness on exertion that is unchanged for years is the patient's baseline rather than a new problem.
Category: Priorities and Consent
Question 8
An unconscious adult arrives after a car crash with life-threatening bleeding, and no family can be reached. How does the team proceed?
It waits for a family member to sign a consent form
It obtains a court order before giving any treatment
It provides comfort measures until the patient wakes
It gives lifesaving treatment under implied consent
✓
Correct Answer
It gives lifesaving treatment under implied consent
When a patient cannot consent and the situation is life-threatening, consent is presumed, so the team gives lifesaving care right away. Waiting for a family member to sign a consent form could let the patient die. Obtaining a court order before giving any treatment is not required in an emergency and would cause a dangerous delay. Providing comfort measures until the patient wakes withholds treatment the patient needs to survive.
Category: Priorities and Consent
Question 9
A teenager with severe abdominal pain is brought to the emergency department by a family friend, and the parents cannot be reached yet. What is required?
A medical screening exam to find out whether an emergency exists
✓
Sending the teenager home until a parent arrives
Treatment only after the friend signs consent for all care
Waiting for a court to appoint a guardian
Correct Answer
A medical screening exam to find out whether an emergency exists
Federal law requires that anyone who comes to an emergency department, including a minor brought by someone other than a parent, receive a medical screening exam to determine whether an emergency condition exists. Sending the teenager home until a parent arrives could leave a dangerous condition untreated. Treatment only after the friend signs consent for all care is wrong because a family friend cannot give legal consent for a minor. Waiting for a court to appoint a guardian is unnecessary and would delay the screening.
Category: Priorities and Consent
Question 10
A worker is freed after being pinned for a long time under a collapsed wall and has a crushed leg. Which intervention is a priority?
Restricting oral and IV fluids
Rapid IV fluid resuscitation
✓
Wrapping the leg in a tight compression bandage
Having the worker walk to test the leg
Correct Answer
Rapid IV fluid resuscitation
Rapid fluid resuscitation is key after a crush injury because it restores circulating volume and helps flush myoglobin and potassium released from damaged muscle, protecting the kidneys and heart. Restricting oral and IV fluids would worsen hypovolemia and kidney injury. Wrapping the leg in a tight compression bandage adds pressure to tissue that is already at risk for compartment syndrome. Having the worker walk to test the leg could worsen the injury and delays treatment.
Category: Trauma Care
Question 11
Which urine finding in a patient with a crush injury suggests that damaged muscle is releasing its contents into the blood?
Pale, dilute urine
Cloudy urine with a foul odor
Tea-colored or dark red urine
✓
Urine with a sweet, fruity odor
Correct Answer
Tea-colored or dark red urine
Tea-colored or dark red urine reflects myoglobin from broken-down skeletal muscle and is an early sign of rhabdomyolysis that the nurse reports right away. Pale, dilute urine reflects a large volume of urine with few solutes. Cloudy urine with a foul odor suggests a urinary tract infection. Urine with a sweet, fruity odor is linked with ketones rather than muscle injury.
Category: Trauma Care
Question 12
A family arrives with headache, dizziness and confusion after running a gasoline generator inside a closed garage. Which treatment does the nurse anticipate first?
Activated charcoal given by mouth
Rewarming with heated blankets
An IV antiemetic for the headache
High-flow oxygen through a nonrebreather mask
✓
Correct Answer
High-flow oxygen through a nonrebreather mask
These findings point to carbon monoxide poisoning, and high-flow oxygen speeds the removal of carbon monoxide from hemoglobin so oxygen delivery can recover. Activated charcoal given by mouth binds swallowed toxins and does nothing for an inhaled gas. Rewarming with heated blankets treats hypothermia, which is not the problem here. An IV antiemetic for the headache treats a symptom without addressing the poisoning.
Category: Poisoning Care
Question 13
A patient arrives with clothing soaked in a liquid pesticide. What is the nurse's first action?
Putting on appropriate protective equipment
✓
Removing the soaked clothing with bare hands
Starting an IV line before anything else
Giving activated charcoal by mouth
Correct Answer
Putting on appropriate protective equipment
Personal protective equipment keeps the chemical from contaminating the nurse and spreading to others, so the nurse protects themself before touching the patient. Removing the soaked clothing with bare hands would expose the nurse to the pesticide. Starting an IV line before anything else skips the safety step that protects staff. Giving activated charcoal by mouth does not address chemical on the skin and is not a first action.
Category: Poisoning Care
Question 14
How does the nurse screen a patient for intimate partner violence?
By asking in front of the partner to watch the reactions
By asking direct questions in private, away from the partner
✓
By asking only when visible injuries are present
By letting the partner answer for the patient
Correct Answer
By asking direct questions in private, away from the partner
Screening is done privately and directly, with the suspected abuser out of the room, so the patient can answer honestly and safely. Asking in front of the partner to watch the reactions can put the patient in danger and discourages honest answers. Asking only when visible injuries are present misses abuse that leaves no marks or that the patient has covered. Letting the partner answer for the patient silences the person who may be at risk.
Category: Abuse and Forensic Care
Question 15
A child's account of how an arm was injured differs from the parent's, and the child seems withdrawn and afraid. What is the nurse's responsibility?
Confronting the parent about the inconsistency
Waiting for proof of abuse before telling anyone
Reporting the suspicion through the required channels
✓
Documenting the injury as an accident
Correct Answer
Reporting the suspicion through the required channels
Nurses are mandatory reporters, and an injury that does not match the history, along with a fearful, withdrawn child, is enough to report through state and facility channels. Confronting the parent about the inconsistency can escalate risk to the child and is not the nurse's role. Waiting for proof of abuse before telling anyone is wrong because the law requires reporting a reasonable suspicion. Documenting the injury as an accident records a conclusion the evidence does not support.
Category: Abuse and Forensic Care
Question 16
How should the nurse package swabs collected as forensic evidence?
Sealed while still wet in a plastic bag
Combined in a single labeled container
Rinsed with saline before packaging
Air-dried, then sealed in separate paper envelopes
✓
Correct Answer
Air-dried, then sealed in separate paper envelopes
Swabs are allowed to dry completely and each one is sealed in its own envelope, because moisture trapped in plastic can degrade biological evidence. Sealing them while still wet in a plastic bag traps moisture and can ruin the specimen. Combining them in a single labeled container risks cross-contamination between samples. Rinsing them with saline before packaging would wash away the evidence.
Category: Abuse and Forensic Care
Question 17
Which patient behavior is a warning sign of possible violence?
Pacing, staring and a rising tone of voice
✓
Asking questions about discharge medicines
Resting quietly with the eyes closed
Requesting a blanket and some water
Correct Answer
Pacing, staring and a rising tone of voice
Pacing, staring and a louder or sharper tone of voice are behavioral cues that a patient may be about to become violent, so the nurse begins de-escalation and calls for help early. Asking questions about discharge medicines is ordinary engagement in care. Resting quietly with the eyes closed suggests calm. Requesting a blanket and some water is a routine comfort request.
Category: Safety and Behavioral Emergencies
Question 18
A medically stable patient in a mental health crisis arrives saying they want to harm themself. Which action makes the care area safe?
Leave the patient alone to calm down
Remove items that could be used to cause harm
✓
Send the patient to the main waiting room
Apply restraints right away as a precaution
Correct Answer
Remove items that could be used to cause harm
Safety is the priority in a psychiatric emergency, so the nurse removes unnecessary objects and has the patient change into a gown before continuing the assessment. Leaving the patient alone to calm down removes the supervision a person at risk of self-harm needs. Sending the patient to the main waiting room leaves the patient unsupervised among other people. Applying restraints right away as a precaution is wrong because restraints are a last resort that requires a provider order.
Category: Safety and Behavioral Emergencies
Question 19
Before an emergency department patient is transferred to another facility, what does federal law require?
That the patient have insurance coverage
That the receiving hospital be the nearest one
That the receiving hospital agree to accept the patient and be able to provide the needed care
✓
That the patient sign a waiver of liability
Correct Answer
That the receiving hospital agree to accept the patient and be able to provide the needed care
Under the Emergency Medical Treatment and Active Labor Act, a transfer must be appropriate: the sending hospital treats the patient within its capability to reduce the risks of transfer, and the receiving hospital must have agreed to accept the patient and have the space and staff to provide the care needed. Stabilizing the patient first is the usual goal, but an unstable patient may still be transferred when the patient asks in writing or a physician certifies that the benefits outweigh the risks. Requiring insurance coverage is not allowed, since screening and stabilization cannot depend on ability to pay. Requiring that the receiving hospital be the nearest one is not the rule. Requiring the patient to sign a waiver of liability is not part of the law.
Category: Transfer and Discharge
Question 20
When does the nurse begin the secondary survey of a trauma patient?
Before the airway is assessed
Only after the patient reaches an inpatient unit
In place of the ABCDE survey when the provider is delayed
After life-threatening problems found in the primary survey are managed
✓
Correct Answer
After life-threatening problems found in the primary survey are managed
The secondary survey is a comprehensive head-to-toe assessment, with history and diagnostics, that follows the primary ABCDE survey once immediate threats have been stabilized. Starting before the airway is assessed would delay care of the most critical problem. Waiting until the patient reaches an inpatient unit leaves injuries undiscovered in the emergency department. Using it in place of the ABCDE survey skips the priority check for life threats.
Category: Triage and Primary Survey