NCLEX-PN
Emergency Nursing NCLEX Questions Questions
Extract:
Question 1 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 2 of 5
The client who was abused as a child is diagnosed with post-traumatic stress disorder (PTSD). Which intervention should the nurse implement when the client is resting?
Correct Answer: A
Rationale: Calling the name without touching avoids startling a PTSD client, preventing flashbacks.
Touching, quiet entry, or preventing awakening may trigger or disrupt.
Question 3 of 5
The nurse is discharging a client diagnosed with accidental carbon monoxide poisoning. Which statement made by the client indicates the need for further teaching?
Correct Answer: B
Rationale: Bright-red lips indicate CO poisoning, not health, requiring further teaching. Detectors, odorlessness, and furnace checks are correct preventive measures.
Question 4 of 5
The ED nurse is caring for the client who has taken an overdose of cocaine. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)?
Correct Answer: C
Rationale: Placing a cardiac monitor is a technical task delegable to UAPs. Airway evaluation, IV monitoring, and transfers require nursing judgment.
Question 5 of 5
The ED receives a client involved in a motor-vehicle accident. The nurse notes a large hematoma on the right flank. Which intervention should the nurse implement first?
Correct Answer: B
Rationale: Frequent vital signs assess for hypovolemia from potential internal bleeding (flank hematoma suggests renal or retroperitoneal injury). Catheter, skin turgor, and marking are secondary.