NCLEX-PN
Emergency Nursing NCLEX Questions Questions
Extract:
Question 1 of 5
The elderly female client with vertebral fractures who has been self-medicating with ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), presents to the ED complaining of abdominal pain, is pale and clammy, and has a P of 110 and a BP of 92/60. Which type of shock should the nurse suspect?
Correct Answer: B
Rationale: NSAID-induced gastrointestinal bleeding can cause hypovolemic shock, indicated by tachycardia, hypotension, and pale, clammy skin. Cardiogenic involves cardiac failure, neurogenic involves bradycardia, and septic involves fever.
Question 2 of 5
The ED nurse is working triage. Which client should be triaged first?
Correct Answer: A
Rationale: Multiple trauma from an MVA suggests life-threatening injuries, requiring immediate triage. Epigastric pain, fractures, and migraines are less urgent.
Question 3 of 5
The nurse in the emergency department administered an intramuscular antibiotic in the left gluteal muscle to the client with pneumonia who is being discharged home. Which intervention should the nurse implement?
Correct Answer: C
Rationale: Waiting 30 minutes post-antibiotic monitors for allergic reactions, critical for safety. Allergies should be checked pre-administration, sputum is diagnostic, and warm washcloths are not standard.
Question 4 of 5
The nurse is caring for a client diagnosed with septic shock who has hypotension, decreased urine output, and cool, pale skin. Which phase of septic shock is the client experiencing?
Correct Answer: A
Rationale: The hypodynamic (cold) phase of septic shock involves hypotension, low urine output, and cool, pale skin due to vasoconstriction. Compensatory is early, hyperdynamic is warm, and progressive involves organ failure.
Question 5 of 5
The adolescent female comes to the school nurse of an intermediate school and tells the nurse she thinks she is pregnant. During the interview, the client states her father is the baby’s father. Which intervention should the nurse implement first?
Correct Answer: B
Rationale: Alleged paternal incest requires immediate Child Protective Services notification as a mandatory reporter. Rape kit, parental contact, or clinic referral follow after ensuring safety.