Name: ____________________________ Date: _______________

EMERGENCY, GERONTOLOGY & CRITICAL CARE NURING

1. A pain scale is used to assess the degree of pain. The client rates the pain as an 8 on a scale of 10 before medication and a 7
on a scale of 10 after being medicated. Nurse Glenda determines that the: 
a. Client needs more education about the use of the pain scale
b. Medication is not adequately effective
c. Client has a low pain tolerance
d. Medication has sufficiently decreased the pain level

2. Before an amniocentesis, nurse Alexandra should: 

a. Assure that informed consent has been obtained from the client
b. Initiate the intravenous therapy as ordered by the physician
c. Perform a vaginal examination on the client to assess cervical dilation
d. Inform the client that the procedure could precipitate an infection

3. A client's sputum smears for acid fast bacilli (AFB) are positive, and transmission-based airborne precautions are ordered.
Nurse Kyle should instruct visitors to: 
a. Avoid contact with any objects present in the client’s room
b. Put on a gown and gloves before going into the client’s room
c. Limit contact with non-exposed family members
d. Wear an Ultra-Filter mask when they are in the client’s room

4. A male client has suffered a motor accident and is now suffering from hypovolemic shock. Nurse Helen should frequency
assess the client's vital signs during the compensatory stage of shock, because: 
a. The cardiac workload decreases
b. The parasympathetic nervous system is triggered
c. Decreased contractility of the heart occurs
d. Arteriolar constriction occurs

5. As a very anxious female client is talking to the nurse May, she starts crying. She appears to be upset that she cannot control
her crying. The most appropriate response by the nurse would be: 
a. “It is Ok to cry; I’ll just stay with you for now”
b. “You look upset; lets talk about why you are crying.”
c. “Sometimes it helps to get it out of your system.”
d. “Is talking about your problem upsetting you?

6. Nurse Sandy observes that there is blood coming from the client's ear after head injury. Nurse Sandy should: 
a. Place sterile cotton loosely in the external ear of the client
b. Test the drainage from the client’s ear with Dextrostix
c. Cleanse the client’s ear with sterile gauze
d. Turn the client to the unaffected side

7. Michael works as a triage nurse, and four clients arrive at the emergency department at the same time. List the order in which
he will assess these clients from first to last.

 1. A 50-year-old female with moderate abdominal pain and occasional vomiting.

 2. A 35-year-old jogger with a twisted ankle, having a pedal pulse and no deformity.
 3. An ambulatory dazed 25-year-old male with a bandaged head wound.
 4. An irritable infant with a fever, petechiae, and nuchal rigidity.
a. 1, 2, 3, 4
b. 2, 1, 3, 4
c. 4, 3, 1, 2
d. 3, 4, 2, 1

8. In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the
primary survey?
a. Initiation of pulse oximetry.
b. Complete set of vital signs.
c. Client's allergy history.
d. Brief neurologic assessment.

9. A 65-year-old patient arrived at the triage area with complaints of diaphoresis, dizziness, and left-sided chest pain. This
patient should be prioritized into which category?
a. Non-urgent.
b. Urgent.
c. Emergent.
d. High urgent.

10. You respond to a call for help from the ED waiting room. There is an elderly patient lying on the floor. List the order for the
actions that you must perform.

 1. Call for help and activate the code team.

 2. Instruct a nursing assistant to get the emergency cart.
 3. Initiate cardiopulmonary resuscitation (CPR).
 4. Perform the chin lift or jaw thrust maneuver.
 5. Establish unresponsiveness.

a. 5, 2, 4, 3, 1
b. 1, 5, 2, 4, 3
c. 1, 2, 5, 4, 3
d. 5, 1, 4, 3, 2
Prepared by: Aznida Alauya-DIca, RN, MAN
Name: ____________________________ Date: _______________

11. You are caring for a client with a frostbite on the feet. Place the following interventions in the correct order.

 1. Immerse the feet in warm water 100° F to 105° F (40.6º C to 46.1° C).
 2. Remove the victim from the cold environment.
 3. Monitor for signs of compartment syndrome.
 4. Apply a loose, sterile, bulky dressing.
 5. Administer a pain medication.

a. 5, 2, 1, 3, 4
b. 2, 5, 1, 4, 3
c. 2, 1, 5, 3, 4
d. 3, 2, 1, 4, 5

12. Following an emergency endotracheal intubation, nurses must verify tube placement and secure the tube. List in order the
steps that are required to perform this function?

 1. Obtain an order for a chest x-ray to document tube placement.

 2. Confirm that the breath sounds are equal and bilateral.
 3. Auscultate the chest during assisted ventilation.
 4. Secure the tube in place.

a. 1, 2, 3, 4
b. 4, 3, 2, 1
c. 3, 2, 4, 1
d. 4, 1, 2, 3

13. A 15-year-old male client arrives at the emergency department. He is conscious, coherent and ambulatory, but his shirt and
pants are covered with blood. He and his hysterical friends are yelling and trying to explain that they were goofing around and he
got poked in the abdomen with a stick. Which of the following comments should be given first consideration? 
a. “He’s a diabetic, so he needs attention right away.”
b. “There was a lot of blood and we used three bandages.”
c. “The stick was really dirty and covered with mud.”
d. “He pulled the stick out, just now, because it was hurting him.”

14. You are assessing a patient who has sustained a cat bite to the left hand. The cat is up-to-date immunizations. The date of
the patient’s last tetanus shot is unknown. Which of the following is the priority nursing diagnosis? 
a. Risk for Impaired Mobility related to potential tendon damage
b. Risk for Infection related to organisms specific to cat bites.
c. Ineffective Health Maintenance related to immunization status
d. Impaired Skin Integrity related to puncture wounds

15. A client in a one-car rollover presents with multiple injuries. Prioritize the interventions that must be initiated for this patient.

 1. Assess for spontaneous respirations.

 2. Give supplemental oxygen per mask.
 3. Insert a Foley catheter if not contraindicated.
 4. Obtain a full set of vital signs.
 5. Remove patient’s clothing.
 6. Secure/start two large-bore IVs with normal saline.
 7. Use the chin lift or jaw thrust method to open the airway.

a. 1, 7, 2, 6, 4, 5, 3
b. 7, 1, 4, 2, 3, 5, 6
c. 4, 1, 5, 7, 6, 3, 2
d. 5, 4, 1, 7, 2, 6, 3

16. A 36-year-old patient with a history of seizures and medication compliance of phenytoin (Dilantin) and carbamazepine
(Tegretol) is brought to the ED by the MS personnel for repetitive seizure activity that started 45 minutes prior to arrival. You
anticipate that the physician will order which drug for status epilepticus? 
a. Lorazepam (Ativan) IV
b. Magnesium sulfate IV.
c. Carbamazepine (Tegretol) IV.
d. Phenytoin and Carbamazepine PO

17. A client arrived at the emergency department after suffering multiple physical injuries including a fractured pelvis from a
vehicular accident. Upon assessment, the client is incoherent, pale, and diaphoretic. With vital signs as follows: temperature of
97°F (36.11° C), blood pressure of 60/40 mm Hg, heart rate of 143 beats/minute, and a respiratory rate of 30 breaths/minute.
The client is mostly suffering from which of the following shock? 
a. Cardiogenic
b. Distributive
c. Hypovolemic
d. Obstructive

18. A 15-year-old male client was sent to the emergency unit following a small laceration on the forehead. The client says that
he can’t move his legs. Upon assessment, respiratory rate of 20, strong pulses, and capillary refill time of less than 2 seconds.
Which triage category would this client be assigned to? 
a. Black
b. Green
Prepared by: Aznida Alauya-DIca, RN, MAN
Name: ____________________________ Date: _______________

c. Red
d. Yellow

19. An ER nurse is handling a 50-year-old woman complaining of dizziness and palpitations that occur from time to time. ECG
confirms the diagnosis of paroxysmal supraventricular tachycardia. The client seems worried about it. Which of the following is
an appropriate response of the nurse? 
a. “You can be discharged now; this is a probable sign of anxiety.”
b. "You have to stay here for a few hours to undergo blood tests to rule out myocardial infarction.”
c. “We’ll need to keep you for further assessment; you may develop blood clots.”
d. “The physician will prescribe you blood-thinning medications to lessen the episodes of palpitations.”

20. A client was brought to the ED due to an abdominal trauma caused by a motorcycle accident. During the assessment, the
client complains of epigastric pain and back pain. Which of the following is true regarding the diagnosis of pancreatic injury? 
a. Redness and bruising may indicate the site of the injury in blunt trauma.
b. The client is symptom-free during the early post-injury period.
c. Signs of peritoneal irritation may indicate pancreatic injury.
d. All of the above

21. A 20-year-old male client was brought to the emergency department with a gunshot wound to the chest. In obtaining a
history of the incident to determine possible injuries, the nurse should ask which of the following? 
a. "What was the initial first aid done?"
b. "Where did the incident happen?"
c. "What direction did the bullet enter into the body?"
d. "How long ago did the incident occur?"

22. When attending a client with a head and neck trauma following a vehicular accident, the nurse's initial action is to? 
a. Do oral and nasal suctioning
b. Provide oxygen therapy
c. Initiate intravenous access
d. Immobilize the cervical area

23. Nurse Ejay is assigned to a telephone triage. A client called who was stung by a honeybee and is asking for help. The client
reports of pain and localized swelling but has no respiratory distress or other symptoms of anaphylactic shock. What is the
appropriate initial action that the nurse should direct the client to perform?
a. Removing the stinger by scraping it.
b. Applying a cold compress
c. Taking an oral antihistamine
d. Calling the 911

24. Nurse Anna is an experienced travel nurse who was recently employed and is assigned in the emergency unit. In her first
week of the job, which of the following area is the most appropriate assignment for her?
a. Triage
b. Ambulatory section
c. Trauma team
d. Psychiatric care

25. A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. Which of the
following assessment should take the highest priority to take?
a. Irregular pulse
b. Ecchymosis in the flank area
c. A deviated trachea
d. Unequal pupils

26. Nurse Kelly, a triage nurse encountered a client who complaints of mid-sternal chest pain, dizziness, and diaphoresis. Which
of the following nursing action should take priority?
a. Complete history taking
b. Put the client on ECG monitoring
c. Notify the physician.
d. Administer oxygen therapy via nasal cannula

27. A group of people arrived at the emergency unit by a private car with complaints of periorbital swelling, cough, and tightness
in the throat. There is a strong odor emanating from their clothes. They report exposure to a "gas bomb" that was set off in the
house. What is the priority action?
a. Direct the clients to the decontamination area
b. Direct the clients to the cold or clean zone for immediate treatment
c. Measure vital signs and auscultate lung sounds
d. Immediately remove other clients and visitors from the area
e. Instruct personnel to don personal protective equipment

28. When an unexpected death occurs in the emergency department, which task is the most appropriate to delegate to a nursing
assistant?
a. Help the family to collect belongings
b. Assisting with postmortem care
c. Facilitate meeting between the family and the organ donor specialist
d. Escorting the family to a place of privacy

29. The physician has ordered cooling measures for a child with a fever who is likely to be discharged when the temperature
comes down. Which task would be appropriate to delegate to a nursing assistant?
a. Prepare and administer a tepid sponge bath
b. Explain the need for giving cool fluids
c. Assist the child in removing outer clothing
d. Advise the parent to use acetaminophen (Tylenol) instead of aspirin

Prepared by: Aznida Alauya-DIca, RN, MAN

Name: ____________________________ Date: _______________

30. You are preparing a child for IV conscious sedation before the repair of a facial laceration. What information should you
report immediately to the physician?
a. The parent wants information about the IV conscious sedation
b. The parent is not sure regarding the child's tetanus immunization status
c. The child suddenly pulls out the IV
d. The parent's refusal of the administration of the IV sedation

31. The emergency medical service has transported a client with severe chest pain. As the client is being transferred to the
emergency stretcher, you note unresponsiveness, cessation of breathing, and unpalpable pulse. Which of the following task is
appropriate to delegate to the nursing assistant?
a. Assisting with the intubation
b. Placing the defibrillator pads
c. Doing chest compressions
d. Initiating bag valve mask ventilation

32. The nursing manager decides to form a committee to address the issue of violence against ED personnel. Which
combination of employees would be best suited to fulfill this assignment?
a. RNs, LPNs, and nursing assistants
b. At least one representative from each group of ED personnel
c. Experienced RNs and experienced paramedics
d. ED physicians and charge nurses

33. A client arrives in the emergency unit and reports that a concentrated household cleaner was splashed in both eyes. Which
of the following nursing actions is a priority?
a. Use Restasis (Allergan) drops in the eye
b. Flush the eye repeatedly using sterile normal saline
c. Examine the client's visual acuity
d. Patch the eye

34. A client was brought to the emergency department after suffering a closed head injury and lacerations around the face due
to a hit-run accident. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessment
findings if observed after few hours, should be reported to the physician immediately?
a. Bleeding around the lacerations
b. Withdrawal of the client in response to painful stimuli
c. Bruises and minimal edema of the eyelids
d. Drainage of a clear fluid from the client's nose

35. A 5-year-old client was admitted to the emergency unit due to ingestion of unknown amount of chewable vitamins for
children at an unknown time. Upon assessment, the child is alert and with no symptoms. Which of the following information
should be reported to the physician immediately?
a. The child has been treated multiple times for injuries caused by accidents
b. The vitamin that was ingested contains iron
c. The child was nauseated and vomited once at home
d. The child has been treated several times for toxic substance ingestion

36. The following clients come at the emergency department complaining of acute abdominal pain. Prioritize them for care in
order of the severity of the conditions.

 1. A 27-year-old woman complaining of lightheadedness and severe sharp left lower quadrant pain who reports she
is possibly pregnant.
 2. A 43-year-old woman with moderate right upper quadrant pain who has vomited small amounts of yellow bile and
whose symptoms have worsened over the week.
 3. A 15-year-old boy with a low-grade fever, right lower quadrant pain, vomiting, nausea, and loss of appetite for the
past few days.
 4. A 57-year-old woman who complains of a sore throat and gnawing midepigastric pain that is worse between
meals and during the night.
 5. A 59-year-old man with a pulsating abdominal mass and sudden onset of persistent abdominal or back pain,
which can be described as a tearing sensation within the past hour.

a. 2,5,3,4,1
b. 3,1,4,5,2
c. 5,1,3,2,4
d. 2,5,1,4,3

37. The following clients are presented with signs and symptoms of heat-related illness. Which of them needs to be attended
first?
a. A relatively healthy homemaker who reports that the air conditioner has been broken for days and who manifest fatigue,
hypotension, tachypnea, and profuse sweating
b. An elderly person who complains of dizziness and syncope after standing in the sun for several hours to view a parade
c. A homeless person who is a poor historian; has altered mental status, poor muscle coordination, and hot, dry ashen skin; and
whose duration of heat exposure is unknown
d. A marathon runner who complains of severe leg cramps and nausea, and manifests weakness, pallor, diaphoresis, and
tachycardia
38. An anxious female client complains of chest tightness, tingling sensations, and palpitations. Deep, rapid breathing, and
carpal spasms are noted. Which of the following priority action should the nurse do first?
a. Provide oxygen therapy
b. Notify the physician immediately
c. Administer anxiolytic medication as ordered
d. Have the client breathe into a brown paper bag

Prepared by: Aznida Alauya-DIca, RN, MAN

Name: ____________________________ Date: _______________

39. A nurse is providing discharge instruction to a woman who has been treated for contusions and bruises due to a domestic
violence. What is the priority intervention for this client?
a. Making a referral to a counselor
b. Making an appointment to follow up on the injuries
c. Advising the client about contacting the police
d. Arranging transportation to a safe house

40. In the work setting, what is the primary responsibility of the nurse in preparation for disaster management, that includes
natural disasters and bioterrorism incidents?
a. Being aware of the signs and symptoms of potential agents of bioterrorism
b. Making ethical decisions regarding exposing self to potentially lethal substances
c. Being aware of the agency's emergency response plan
d. Being aware of what and how to report to the Centers for Disease Control and Prevention

41. The ambulance has transported a man with severe chest pain. As the man is being transferred to the emergency stretcher,
the nurse note unresponsiveness, cessation of breathing, and absence of palpable pulse. Which of the following tasks is proper
to assign to the nursing assistant?
a. Aiding with oral intubation
b. Performing chest compressions
c. Placing the defibrillator pads
d. Starting bag valve mask ventilation

42. A high school student comes in the triage area alert and ambulatory, and his uniform is soaked with blood. He and his
classmates are sounding, "We were running around outside the school and he got hit in the abdomen with a stick!" Which
statement should be a priority?
a. "The stick was absolutely filthy and muddy."
b. "He has a family history of diabetes, so he requires attention right now."
c. "He pulled the stick out because it was too painful for him."
d. “There was plenty of blood so we used three gauzes."

43. A client with multiple injuries is rushed to the ED after a head-on car collision. Which assessment finding takes priority?
a. Irregular apical pulse
b. Ecchymosis in the flank area
c. A deviated trachea
d. Unequal pupils

44. What is regarded as one of the priority actions that must be accomplished when a primary
assessment of a trauma client is conveyed?
a. Taking a full set of vital sign measurements
b. Completing a brief neurologic assessment
c. Monitoring pulse oximetry reading
d. Palpating and auscultating the abdomen

45. Prior to oral defense, a 21-year-old nursing student goes straight to the clinic due to tingling
sensations, palpitations, and chest tightness. Deep, rapid breathing and carpal spasms are also
observed. What is the nursing priority action for this situation?
a. Give supplemental oxygen
b. Allow the student to breathe into a paper bag
c. Report to the physician immediately
d. Get an order for an anxiolytic medication

46. Identify the five most important elements in conducting disaster triage for multiple victims.

 1. Assess level of consciousness

 2. Check airway, breathing, and circulation
 3. Monitor vital signs, including pulse and respirations
 4. Inquire about last tetanus shot
 5. Determine a history of allergies to food or medicine
 6. Know the list of current medications
 7. Identify past medical and surgical history
 8. Note color, presence of moisture and temperature of the skin
 9. Visually examine for gross deformities, bleeding, and obvious injuries

a. 1, 2, 3, 8, and 9
b. 4, 5, 6, and 7
c. 1, 2, 3, and 4
d. 1, 2, and 3

47. A drunk driver has been in the police station for 48 hours. During the first hours, he had
tremors and was feeling anxious and sweaty. Currently, he is experiencing disorientation,
hallucination, and hyperactivity. It was noted that the client has a history of alcohol abuse. What
is the priority nursing diagnosis?
a. Risk for Nutritional Deficit related to chronic alcohol abuse
b. Risk for Injury related to seizures
c. Risk for Situational Low Self-Esteem related to police custody
d. Risk for Other-Directed Violence related to hallucinations

48. Several people were killed and injured in a recent industrial explosion. The victims are being
interviewed and assessed by the nurses for possible psychiatric crises. Which client has the
greatest risk for posttraumatic distress disorder?
a. An individual who was injured and trapped for 8 hours before rescue
Prepared by: Aznida Alauya-DIca, RN, MAN
Name: ____________________________ Date: _______________

b. A person who saw the death of a co-worker during the blast

c. An individual who recently discovered that her daughter was killed in the incident
d. A person who repeatedly watched television coverage of the event

49. During a class discussion, the 50-year-old professor suddenly feels left-sided chest pain, dizziness, and diaphoresis. What is
the priority action when he arrives in the ED triage area?
a. Supply oxygen via nasal cannula
b. Place intravenous (IV) access
c. Notify the ED physician
d. Set the client on continuous electrocardiographic monitoring

50. Which task is most appropriate to assign to the nursing assistant when an instantaneous death transpires in the ED? (Select
all that apply.)

 1. Assisting with postmortem care

 2. Escorting the family to a place of privacy
 3. Going with the organ donor specialist to talk to the family
 4. Helping the family to collect belongings

a. 1
b. 1 and 2
c. 2, 3, and 4
d. 1, 2, 3, and 4

51. Which ethical principle underlies nursing actions respecting each patient's values and beliefs?
a. Autonomy.
b. Beneficence.
c. Justice.
d. Responsibility.

52. The most common symptoms of benign prostatic hypertrophy are:

a. chills, fever, and nausea.

b. dysuria, abdominal pain, and urinary retention.
c. intermittency, hesitancy, and dribbling.
d. nocturia, bladder spasms, and hematuria.

53. The gerontological nurse is monitoring signs of suspected abuse in an 89-year-old patient who was admitted from home.
When planning for the patient's discharge, the nurse's first action is to:
a. delay discharge by informing the provider of the suspected abuse.
b. enlist the help of family members with transitioning the patient home.
c. notify Adult Protective Services of the patient's discharge.
d. restrict the family members' access to the patient prior to discharge.

54. A resident in a nursing home requests a new room because he or she does not like the view from the current room. While
the resident is away from the home on a provider visit, the staff moves the resident's belongings to another room with a better
view. The resident and the resident's family later file a formal complaint regarding the move. Which statement gives the best
justification for the resident's complaint?
a. The change was made without a provider's order.
b. The resident was not included in the decision making.
c. The resident's belongings were moved without his or her assistance.
d. The resident's family was not included in the decision making.

55. A recently admitted nursing home resident and the resident's family only speak Spanish. One evening during a visit, the
resident and the family begin to wail and sob loudly. The gerontological nurse is unable to determine what is wrong. The nurse's
most appropriate action is to:
a. ask the supervisor to get an interpreter.
b. attempt to make the resident and the family comfortable.
c. contact the provider for orders.
d. find an escort to take the resident and the family to the chapel for privacy.

56. The gerontological nurse manager involves the nursing staff in the utilization of trend data and analysis for quality
improvement by:

a. encouraging staff to volunteer for The Joint Commission's onsite surveys.

b. highlighting the quality improvement work of experts in the specialty area.
c. informing how data and outcomes are directly related to the staff's daily work.
d. using scatter diagrams to identify the root cause of unresolved concerns

57. An effective way to adequately provide nourishment to a patient with moderate dementia is:

a. allowing the patient to choose foods from a varied menu.

b. hand feeding the patient's favorite foods.
c. routinely reminding the patient about the need for adequate nutrition.
d. serving soup in a mug, and offering finger foods.

58. An 82-year-old patient has a painful, vesicular rash that burns over the left abdomen. The patient indicates that he or she
has tried multiple creams that have not helped. Which question does the gerontological nurse first ask?
Prepared by: Aznida Alauya-DIca, RN, MAN
Name: ____________________________ Date: _______________

a. "Did you have the pain before the rash appeared?"

b. "Do you have any food or drug allergies?"
c. "Have you been around anyone with a rash?"
d. "Have your grandchildren visited recently?"

59. Which question does the gerontological nurse prioritize for an 86-year-old patient with abdominal pain, muscle weakness,
and leg cramps?
a. "Do you eat a lot of meat?"
b. "Do you have heart problems?"
c. "Do you take a diuretic?"
d. "Do you walk every day?"

60. When teaching an independent older adult patient how to self-administer insulin, the most productive approach is to:
a. facilitate involvement in a small group where the skill is being taught.
b. gather information about the patient's family health history.
c. provide frequent, competitive skills testing to enhance learning.
d. use repeated return demonstrations to promote the patient's retention of the involved tasks.

61. Signs and symptoms of age-related macular degeneration include:

a. decreases in depth perception.
b. deficits in peripheral vision.
c. distortion of lines and print.
d. reports of flashes of light.

62. A frail 80-year-old patient, who cares for a spouse at home without assistance, requires minor surgery. Lacking any family
members residing in the area, the patient expresses concern about the spouse's care while the patient is recovering. The
gerontological nurse's recommendation is:
a. arranging inpatient respite care for the spouse.
b. having the patient remain in the hospital during the post operative period.
c. hiring around-the-clock help for two weeks.
d. hospitalizing the spouse.

63. An older adult patient currently takes phenytoin (Dilantin) and tolterodine (Detrol). The gerontological nurse reinforces the
need for routine dental visits because these two medications decrease:
a. calcium levels in the blood.
b. innervations of the trigeminal nerve.
c. the muscle strength of the tongue.
d. the production of saliva.

64. A 90-year-old patient comes to the clinic with a family member. During the health history, the patient is unable to respond to
questions in a logical manner. The gerontological nurse's action is to:
a. ask the family member to answer the questions.
b. ask the same questions in a louder and lower voice.
c. determine if the patient knows the name of the current president.
d. rephrase the questions slightly, and slowly repeat them in a lower voice.

65. Which patient is at greatest risk for developing arteriosclerotic heart disease?
a. A 60-year-old female patient with a triglyceride level of 135 mg/dL, and a high-density lipoprotein level of 68 mg/dL.
b. A 70-year old male patient with a total cholesterol level of 181 mg/dL, and a low-density lipoprotein level of 90 mg/dL.
c. A 75-year old female patient with a triglyceride level of 189 mg/dL, and a low-density lipoprotein level of 149 mg/dL.
d. An 86-year-old male patient with a low-density lipoprotein level of 100 mg/dL, and a high-density lipoprotein level of 50 mg/dL.

66. A 65-year-old patient exhibits symptoms of hemianopsia. The most appropriate nursing intervention is to:
a. arrange the patient's meal tray so that all the food is in the patient's field of vision.
b. explain all tasks thoroughly to help allay the patient's fears.
c. look directly at the patient when speaking to maximize comprehension.
d. minimize the operating stimuli to reduce distractions to the patient.

67. An 80-year-old patient, who lives at home with a spouse, is instructed to follow a 2 g sodium diet. The patient states, "I've
always eaten the same way all my life, and I'm not going to change now." To promote optimal dietary adherence, the
gerontological nurse's initial approach is to:
a. inform the patient about the need to follow the diet.
b. inquire about the patient's current food preferences and eating habits.
c. list the variety of foods that are allowed on the diet.
d. provide dietary instruction to the patient's spouse, who prepares the meals.

68. For older adult patients who are taking neuroleptic medication, the primary concern is the development of:
a. lethargy.
b. nausea.
c. poor appetite.
d. tardive dyskinesia.

69. The gerontological nurse works with patients with non-insulin dependent diabetes at a senior center in a predominantly
Hispanic neighborhood. The nurse demonstrates competency in collaboration by:

Prepared by: Aznida Alauya-DIca, RN, MAN

Name: ____________________________ Date: _______________

a. assisting and educating patients on diet restrictions.

b. delivering care by preserving and protecting patient autonomy.
c. providing written education materials in Spanish.
d. working with Hispanic groups in the community.

70. An older adult patient, who has end-stage multiple myeloma, is receiving hospice care. Which situation illustrates that the
principles of hospice care are being met?
a. The caregiver asks if hospice includes weekend care.
b. The caregiver has been calling the provider on his or her own.
c. The patient reports enjoying daily excursions.
d. The patient reports no breakthrough pain medications are needed.

71. A 79-year-old retired actor, who continues to pursue lifelong interests in swimming and singing, exemplifies which theory of
aging?
a. Continuity.
b. Developmental.
c. Disengagement.
d. Physical.

72. A 75-year-old patient, whose marriage ended in divorce after two years, has lived alone for the past 50 years. Feeling as if
life has had little meaning, the patient is terrified of living out the remaining years and of dying. The age-related issue to be
resolved is:
a. disengagement vs. activity.
b. ego integrity vs. despair.
c. self-determination vs. resignation.
d. self-esteem vs. self-actualization.

73. Three months ago, an older adult patient, who lives in an apartment in a housing complex for senior citizens, began residing
with an older adult patient from the same complex. Upon learning of the situation, the patient's adult child expresses concern to
the housing administrator, who reports that both residents have reported satisfaction with the arrangement. When the child
requests advice, the gerontological nurse's initial response is:
a. I can understand why you are upset. Has he or she ever done something like this before?"
b. "Why don't we all talk to your parent to get his or her side of the story?"
c. "Your parent has the right to do what he or she wants because he or she is mentally competent."
d. "Your parent seems to be happy with the arrangement. Have you discussed this situation with him or her?”

74. Which situation would warrant the nurse obtaining information from a material safety data sheet (MSDS)?
a. The custodian spilled a chemical solvent in the hallway.
b. A visitor slipped and fell on the floor that had just been mopped.
c. A bottle of antineoplastic agent broke on the client’s floor.
d. The nurse was stuck with a contaminated needle in the client’s room.

75. Which statement best describes the role of the medical-surgical nurse during a disaster?
a. The nurse may be assigned to ride in the ambulance.
b. The nurse may be assigned as a first assistant in the operating room.
c. The nurse may be assigned to crowd control.
d. The nurse may be assigned to the emergency department.

76. The nurse is teaching CPR to a class. Which statement best explains the definition of sudden cardiac death?
a. Cardiac death occurs after being removed from a mechanical ventilator.
b. Cardiac death is the time that the physician officially declares the client dead.
c. Cardiac death occurs within one (1) hour of the onset of cardiovascular symptoms.
d. The death is caused by myocardial ischemia resulting from coronary artery disease.

77. Which statement explains the scientific rationale for having emergency suction equipment available during resuscitation
efforts?
a. Gastric distention can occur as a result of ventilation.
b. It is needed to assist when intubating the client.
c. This equipment will ensure a patent airway.
d. It keeps the vomitus away from the health-care provider.

78. Which equipment must be immediately brought to the client¶s bedside when a code is called for a client who has
experienced a cardiac arrest?
a. A ventilator.
b. A crash cart.
c. A gurney.
d. Portable oxygen.

79. The nursing administrator responds to a code situation. When assessing the situation, which role must the administrator
ensure is performed for legal purposes and continuity of care of the client?
a. A person is ventilating with an ambu bag.
b. A person is performing chest compressions correctly.
c. A person is administering medications as ordered.
d. A person is keeping an accurate record of the code.

80. A client with multiple injury following a vehicular accident is transferred to the critical care unit. He begins to complain of
increased abdominal pain in the left upper quadrant. A ruptured spleen is diagnosed and he is scheduled for emergency
splenectomy. In preparing the client for surgery, the nurse should emphasize in his teaching plan the:
a. Complete safety of the procedure
b. Expectation of postoperative bleeding
c. Risk of the procedure with his other injuries
Prepared by: Aznida Alauya-DIca, RN, MAN
Name: ____________________________ Date: _______________

d. Presence of abdominal drains for several days after surgery

81. After you managed to stabilize the respiratory function of your burn patient, your next goal is to prevent this you have to
replace the lost fluid and electrolytes. In starting fluid replacement therapy, the total volume and rate of IV fluid replacement are
gauged by the patient¶s response and by the patient’s response and by the resuscitation formula. In determining the adequacy
of fluid resuscitation, it is essential for you to monitor the:
a. urine output
b. blood pressure
c. intracranial pressure
d. cardiac output
82. You are a nurse in the emergency department and it is during the shift that Mr. CT is admitted in the area due to a fractured
skull from a motor accident. You scheduled him for surgery under which classification?
a. Urgent
b. Emergent
c. Required
d. Elective

83. Lucky was in a vehicular accident where he sustained injury to his left ankle. In the Emergency room, you noticed anxious he
looks. You establish rapport with him and to reduce his anxiety, you initially:
a. Identify yourself and state your purpose in being with the client
b. Take him to the radiology section for x-ray of affected extremity
c. Talk to the physician for an order of valium
d. Do inspection and palpation to check extent of his injuries

84. The nurse caring for a client diagnosed with cancer of the pancreas writes the nursing diagnosis of risk for altered skin
integrity related to pruritus. Which interventions should the nurse implement?
a. Assess tissue turgor.
b. Apply antifungal creams.
c. Monitor bony prominences for breakdown.
d. Have the client keep the fingernails short.

85. Intervention for a pt. who has swallowed a Muriatic Acid includes all of the following except: a. administering an irritant that
will stimulate vomiting
b. aspirating secretions from the pharynx if respirations are affected
c. neutralizing the chemical
d. washing the esophagus with large volumes of water via gastric lavage

86. John, 16 years old, is brought to the ER after a vehicular accident. He is pronounced dead on arrival. When his parents
arrive at the hospital, the nurse should:
a. ask them to stay in the waiting area until she can spend time alone with them
b. speak to both parents together and encourage them to support each other and express their emotions freely
c. Speak to one parent at a time so that each can ventilate feelings of loss without upsetting the other
d. ask the MD to medicate the parents so they can stay calm to deal with their son¶s death.

87. A nurse is eating in the hospital cafeteria when a toddler at a nearby table chokes on a piece of food and appears slightly
blue. The appropriate initial action should be to
a. Begin mouth to mouth resuscitation
b. Give the child water to help in swallowing
c. Perform 5 abdominal thrusts
d. Call for the emergency response team

88. The Heimlich maneuver (abdominal thrust), for acute airway obstruction, attempts to:
a. Force air out of the lungs
b. Increase systemic circulation
c. Induce emptying of the stomach
d. Put pressure on the apex of the heart

89. The nurse is triaging four clients injured in a train derailment. Which client should receive priority treatment?
A. A 42-year-old with dyspnea and chest asymmetry
B. A 17-year-old with a fractured arm
C. A 4-year-old with facial lacerations
D. A 30-year-old with blunt abdominal trauma

90. Direct pressure to a deep laceration on the client’s lower leg has failed to stop the bleeding. The nurse’s next action should
be to:
A. Place a tourniquet proximal to the laceration.
B. Elevate the leg above the level of the heart.
C. Cover the laceration and apply an ice compress.
D. Apply pressure to the femoral artery.

91. A pediatric client is admitted after ingesting a bottle of vitamins with iron. Emergency care would include treatment with:
A. Acetylcysteine
B. Deferoxamine
C. Calcium disodium acetate
D. British antilewisite

92. The nurse is preparing to administer Ringer’s Lactate to a client with hypovolemic shock. Which intervention is important in
helping to stabilize the client’s condition?
A. Warming the intravenous fluids
B. Determining whether the client can take oral fluids
C. Checking for the strength of pedal pulses
D. Obtaining the specific gravity of the urine

Prepared by: Aznida Alauya-DIca, RN, MAN

Name: ____________________________ Date: _______________

93. The emergency room staff is practicing for its annual disaster drill. According to disaster triage, which of the following four
clients would be cared for last?
A. A client with a pneumothorax
B. A client with 70% TBSA full thickness burns
C. A client with fractures of the tibia and fibula
D. A client with smoke inhalation injuries

94. An unresponsive client is admitted to the emergency room with a history of diabetes mellitus. The client’s skin is cold and
clammy, and the blood pressure reading is 82/56. The first step in emergency treatment of the client’s symptoms would be:
A. Checking the client’s blood sugar
B. Administering intravenous dextrose
C. Intubation and ventilator support
D. Administering regular insulin

95. A patient arrives in the emergency department and reports splashing concentrated household cleaner in his eye. Which of
the following nursing actions is a priority?
A. Irrigate the eye repeatedly with normal saline solution.
B. Place fluorescein drops in the eye.
C. Patch the eye.
D. Test visual acuity.

96. A nurse is caring for a patient who has had hip replacement. The nurse should be most concerned about which of the
following findings?
A. Complaints of pain during repositioning.
B. Scant bloody discharge on the surgical dressing.
C. Complaints of pain following physical therapy.
D. Temperature of 101.8 F (38.7 C).

97. A child is admitted to the hospital with an uncontrolled seizure disorder. The admitting physician writ orders for actions to be
taken in the event of a seizure. Which of the following actions would NOT be included?
A. Notify the physician.
B. Restrain the patient's limbs.
C. Position the patient on his/her side with the head flexed forward.
D. Administer rectal diazepam.

98. Emergency department triage is an important nursing function. A nurse working the evening shift is presented with four
patients at the same time. Which of the following patients should be assigned the highest priority?
A. A patient with low-grade fever, headache, and myalgias for the past 72 hours.
B. A patient who is unable to bear weight on the left foot, with swelling and bruising following a running accident.
C. A patient with abdominal and chest pain following a large, spicy meal.
D. A child with a one-inch bleeding laceration on the chin but otherwise well after falling while jumping on his bed.

99. A nurse is performing routine assessment of an IV site in a patient receiving both IV fluids and medications through the line.
Which of the following would indicate the need for discontinuation of the IV line as the next nursing action?
A. The patient complains of pain on movement.
B. The area proximal to the insertion site is reddened, warm, and painful.
C. The IV solution is infusing too slowly, particularly when the limb is elevated.
D. A hematoma is visible in the area of the IV insertion site.

100. A hospitalized patient has received transfusions of 2 units of blood over the past few hours. A nurse enters the room to find
the patient sitting up in bed, dyspneic and uncomfortable. On assessment, crackles are heard in the bases of both lungs,
probably indicating that the patient is experiencing a complication of transfusion. Which of the following complications is most
likely the cause of the patient's symptoms?
A. Febrile non-hemolytic reaction.
B. Allergic transfusion reaction.
C. Acute hemolytic reaction.
D. Fluid overload.

Prepared by: Aznida Alauya-DIca, RN, MAN