1. A patient arrives in the emergency department with chest pain radiating to the left arm. What is the nurse's priority intervention?
a) Obtain a 12-lead ECG
b) Administer nitroglycerin
c) Start an IV line
d) Assess vital signs
Answer: a) Obtain a 12-lead ECG
Rationale: The priority in a pat...
1. A patient arrives in the emergency department with chest pain radiating to the
left arm. What is the nurse's priority intervention?
a) Obtain a 12-lead ECG
b) Administer nitroglycerin
c) Start an IV line
d) Assess vital signs
Answer: a) Obtain a 12-lead ECG
Rationale: The priority in a patient with chest pain is to assess the cardiac status by obtaining a
12-lead ECG to identify any acute cardiac issues, such as myocardial infarction.
2. A client is suspected of having an anaphylactic reaction. What is the most
appropriate nursing action?
a) Administer diphenhydramine
b) Start oxygen therapy
c) Administer epinephrine
d) Call the physician
Answer: c) Administer epinephrine
Rationale: Epinephrine is the first-line treatment for anaphylaxis as it works to reverse the
severe allergic reaction and improve airway patency and blood pressure.
3. The nurse is assessing a patient who fell from a height and has an open
fracture of the left femur. What should the nurse assess first?
a) Capillary refill
b) Neurovascular status of the affected limb
c) Pain level
d) Signs of shock
Answer: d) Signs of shock
Rationale: In trauma situations, it’s crucial to assess for signs of shock (e.g., hypotension,
tachycardia) to address life-threatening conditions before focusing on localized injuries.
4. A patient with a suspected stroke is brought to the emergency department.
Which assessment finding is most critical?
,a) Slurred speech
b) Facial drooping
c) Arm weakness
d) Sudden headache
Answer: d) Sudden headache
Rationale: A sudden, severe headache can indicate a hemorrhagic stroke, which requires
immediate intervention, making it the most critical assessment finding.
5. The nurse is caring for a patient experiencing a panic attack. Which nursing
intervention is appropriate?
a) Encourage the patient to express feelings
b) Provide a quiet and calm environment
c) Administer anti-anxiety medication
d) Ask the patient to take deep breaths
Answer: b) Provide a quiet and calm environment
Rationale: Creating a calm environment helps to reduce anxiety and allows the patient to regain
control during a panic attack.
6. A patient is admitted to the emergency department with symptoms of severe
dehydration. Which assessment finding would the nurse expect?
a) Bradycardia
b) Edema
c) Dry mucous membranes
d) Increased urine output
Answer: c) Dry mucous membranes
Rationale: Severe dehydration commonly leads to dry mucous membranes due to fluid loss,
making it a key assessment finding.
7. A patient with asthma is in respiratory distress. What is the priority nursing
action?
a) Administer a bronchodilator
b) Obtain a peak flow measurement
c) Assess the patient's respiratory rate
d) Provide reassurance to the patient
, Answer: a) Administer a bronchodilator
Rationale: Administering a bronchodilator is the priority action to alleviate acute respiratory
distress in a patient with asthma.
8. Which symptom would indicate to the nurse that a patient may be
experiencing a myocardial infarction?
a) Severe headache
b) Abdominal pain
c) Shortness of breath
d) Blurred vision
Answer: c) Shortness of breath
Rationale: Shortness of breath can indicate a myocardial infarction and should be evaluated
immediately.
9. The nurse is monitoring a patient with a head injury. What is the most critical
assessment to perform?
a) Pupillary response
b) Level of consciousness
c) Blood pressure
d) Temperature
Answer: b) Level of consciousness
Rationale: Monitoring the level of consciousness is crucial in patients with head injuries to
detect any deterioration in their neurological status.
10. A patient arrives at the emergency department with severe abdominal pain
and vomiting. What is the nurse's first action?
a) Start an IV
b) Perform a physical assessment
c) Administer antiemetics
d) Obtain a detailed history
Answer: b) Perform a physical assessment
Rationale: A physical assessment is essential to determine the cause of the abdominal pain
before any interventions are made.
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller njengamartin399. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $6.69. You're not tied to anything after your purchase.
