• 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.
• 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.
• 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
• 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
• 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
• 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
• 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
• 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
• 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.
• C. Red.
• D
• Yellow.