NCLEX Practice Test: Prioritization, Delegation, and Assignment on Medical-Surgical Emergencies

Below are NCLEX Practice Test: Prioritization, Delegation, and Assignment on Medical-Surgical Emergencies
nclex practice test


1. You are the charge nurse in an emergency department (ED) and must
assign two staff members to cover the triage area. Which team is the
most appropriate for this assignment?
a. An advanced practice nurse and an experienced LPN/LVN
b. An experienced LPN/LVN and an inexperienced RN
c. An experienced RN and an inexperienced RN
d. An experienced RN and a nursing assistant
Check answer
2. You are working in the triage area of an ED, and four patients
approach the triage desk at the same time. List the order in which
you will assess these patients.
a. An ambulatory, dazed 25-year-old male with a bandaged head wound
b. An irritable infant with a fever, petechiae, and nuchal rigidity
c. A 35-year-old jogger with a twisted ankle, having pedal pulse and no
d. A 50-year-old female with moderate abdominal pain and occasional
_____, _____, _____, _____
Check answer
3. In conducting a primary survey on a trauma patient, which of the
following is considered one of the priority elements of the primary
a. Complete set of vital signs
b. Palpation and auscultation of the abdomen
c. Brief neurologic assessment
d. Initiation of pulse oximetry
Check answer
4. A 56-year-old patient presents in triage with left-sided chest pain,
diaphoresis, and dizziness. This patient should be prioritized into
which category?
a. High urgent
b. Urgent
c. Non-urgent
d. Emergent
Check answer
5. The physician has ordered cooling measures for a child with fever
who is likely to be discharged when the temperature comes down.
Which of the following would be appropriate to delegate to the
nursing assistant?
a. Assist the child to remove outer clothing.
b. Advise the parent to use acetaminophen instead of aspirin.
c. Explain the need for cool fluids.
d. Prepare and administer a tepid bath.
Check answer
6. It is the summer season, and patients with signs and symptoms of
heat-related illness present in the ED. Which patient needs attention
a. An elderly person complains of dizziness and syncope after standing in
the sun for several hours to view a parade
b. A marathon runner complains of severe leg cramps and nausea.
Tachycardia, diaphoresis, pallor, and weakness are observed.
c. A previously healthy homemaker reports broken air conditioner for days.
Tachypnea, hypotension, fatigue, and profuse diaphoresis are observed.
d. A homeless person, poor historian, presents with altered mental status,
poor muscle coordination, and hot, dry, ashen skin. Duration of
exposure is unknown.
Check answer
7. 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.
a. Perform the chin lift or jaw thrust maneuver.
b. Establish unresponsiveness.
c. Initiate cardiopulmonary resuscitation (CPR).
d. Call for help and activate the code team.
e. Instruct a nursing assistant to get the crash cart.
_____, _____, _____, _____, _____
Check answer
8. The emergency medical service (EMS) has transported a patient with
severe chest pain. As the patient is being transferred to the
emergency stretcher, you note unresponsiveness, cessation of
breathing, and no palpable pulse. Which task is appropriate to
delegate to the nursing assistant?
a. Chest compressions
b. Bag-valve mask ventilation
c. Assisting with oral intubation
d. Placing the defibrillator pads
Check answer
9. An anxious 24-year-old college student complains of tingling
sensations, palpitations, and chest tightness. Deep, rapid breathing
and carpal spasms are noted. What priority nursing action should you
a. Notify the physician immediately.
b. Administer supplemental oxygen.
c. Have the student breathe into a paper bag.
d. Obtain an order for an anxiolytic medication.
Check answer
10.An experienced traveling nurse has been assigned to work in the ED;
however, this is the nurse’s first week on the job. Which area of the
ED is the most appropriate assignment for the nurse?
a. Trauma team
b. Triage
c. Ambulatory or fats track clinic
d. Pediatric medicine team
Check answer
11. A tearful parent brings a child to the ED for taking an unknown
amount of children’s chewable vitamins at an unknown time. The
child is currently alert and asymptomatic. What information should be
immediately reported to the physician?
a. The ingested children’s chewable vitamins contain iron.
b. The child has been treated several times for ingestion of toxic
c. The child has been treated several times for accidental injuries.
d. The child was nauseated and vomited once at home.
Check answer
12.In caring for a victim of sexual assault, which task is most
appropriate for an LPN/LVN?
a. Assess immediate emotional state and physical injuries.
b. Collect hair samples, saliva swabs, and scrapings beneath fingernails.
c. Provide emotional support and supportive communication.
d. Ensure that the “chain of custody” is maintained.
Check answer
13.You are caring for a victim of frostbite to the feet. Place the following
interventions in the correct order.Check answer
14.A patient sustains an amputation of the first and second digits in a
chainsaw accident. Which task should be delegated to the LPN/LVN?
a. Gently cleanse the amputated digits with Betadine solution.
b. Place the amputated digits directly into ice slurry.
c. Wrap the amputated digits in sterile gauze moistened with saline.
d. Store the amputated digits in a solution of sterile normal saline.
Check answer
15.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. PO phenytoin and carbamazepine
b. IV lorazepam (Ativan)
c. IV carbamazepam
d. IV magnesium sulfate
Check answer
16.You are preparing a child for IV conscious sedation prior to repair of a
facial laceration. What information should you immediately report to
the physician?
a. The parent is unsure about the child’s tetanus immunization status.
b. The child is upset and pulls out the IV.
c. The parent declines the IV conscious sedation.
d. The parent wants information about the IV conscious sedation.
Check answer
17.An intoxicated patient presents with slurred speech, mild confusion,
and uncooperative behavior. The patient is a poor historian but
admits to “drinking a few on the weekend.” What is the priority
nursing action for this patient?
a. Obtain an order for a blood alcohol level.
b. Contact the family to obtain additional history and baseline information.
c. Administer naloxone (Narcan) 2 – 4 mg as ordered.
d. Administer IV fluid support with supplemental thiamine as ordered.
Check answer
18.When an unexpected death occurs in the ED, which of the following
tasks is most appropriate to delegate to the nursing assistant?
a. Escort the family to a place of privacy.
b. Go with the organ donor specialist to talk to the family.
c. Assist with postmortem care.
d. Assist the family to collect belongings.
Check answer
19.Following emergency endotracheal intubation, you must verify tube
placement and secure the tube. List in order the steps that are
required to perform this function?
a. Obtain an order for a chest x-ray to document tube placement.
b. Secure the tube in place.
c. Auscultate the chest during assisted ventilation.
d. Confirm that the breath sounds are equal and bilateral.
_____, _____, _____, _____
Check answer
20.A teenager arrives by private car. He is alert and ambulatory, but this
shirt and pants are covered with blood. He and his hysterical friends
are yelling and trying to explain that 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. “There was a lot of blood and we used three bandages.”
b. “He pulled the stick out, just now, because it was hurting him.”
c. “The stick was really dirty and covered with mud.”
d. “He’s a diabetic, so he needs attention right away.”
Check answer
21.A prisoner, with a known history of alcohol abuse, has been in police
custody for 48 hours. Initially, anxiety, sweating, and tremors were
noted. Now, disorientation, hallucination, and hyper-reactivity are
observed. The medical diagnosis is delirium tremens. What is the
priority nursing diagnosis?
a. Risk for Injury related to seizures
b. Risk for Other-Directed Violence related to hallucinations
c. Risk for Situational Low Self-esteem related to police custody
d. Risk for Nutritional Deficit related to chronic alcohol abuse
Check answer
22.You are assigned to telephone triage. A patient who was stung by a
common honey bee calls for advice, reports pain and localized
swelling, but denies any respiratory distress or other systemic signs
of anaphylaxis. What is the action that you should direct the caller to
a. Call 911.
b. Remove the stinger by scraping.
c. Apply a cool compress.
d. Take an oral antihistamine.
Check answer
23.In relation to submersion injuries, which task is most appropriate to
delegate to an LPN/LVN?
a. Talk to a community group about water safety issues.
b. Stabilize the cervical spine for an unconscious drowning victim.
c. Remove wet clothing and cover the victim with a warm blanket.
d. Monitor an asymptomatic near-drowning victim.
Check answer
24.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 Infection related to organisms specific to cat bites
b. Impaired Skin Integrity related to puncture wounds
c. Ineffective Health Maintenance related to immunization status
d. Risk for Impaired Mobility related to potential tendon damage
Check answer
25.These patients present to the ED complaining of acute abdominal
pain. Prioritize them in order of severity.
a. A 35-year-old male complaining of severe, intermittent cramps with
three episodes of watery diarrhea, 2 hours after eating
b. A 11-year-old boy with a low-grade fever, left lower quadrant
tenderness, nausea, and anorexia for the past 2 days
c. A 40-year-old female with moderate left upper quadrant pain, vomiting
small amounts of yellow bile, and worsening symptoms over the past
d. A 56-year-old male with a pulsating abdominal mass and sudden onset
of pressure-like pain in the abdomen and flank within the past hour
_____, _____, _____, _____
Check answer
26.The nursing manager decides to form a committee to address the
issue of violence against ED personnel. Which combination of
employees is best suited to fulfill this assignment?
a. ED physicians and charge nurses
b. Experienced RNs and experienced paramedics
c. RNs, LPN/LVNs, and nursing assistants
d. At least one representative from each group of ED personnel
Check answer
27.In a multiple-trauma victim, which assessment finding signals the
most serious and life-threatening condition?
a. A deviated trachea
b. Gross deformity in a lower extremity
c. Decreased bowel sounds
d. Hematuria
Check answer
28.A patient in a one-car rollover presents with multiple injuries.
Prioritize the interventions that must be initiated for this patient.
a. Secure/start two large-bore IVs with normal saline
b. Use the chin lift or jaw thrust method to open the airway.
c. Assess for spontaneous respirations
d. Give supplemental oxygen per mask.
e. Obtain a full set of vital signs.
f. Remove patient’s clothing.
g. Insert a Foley catheter if not contraindicated.
_____, _____, _____, _____, ____, ____, ____
Check answer
29.In the work setting, what is your primary responsibility in preparing
for disaster management that includes natural disasters or
bioterrorism incidents?
a. Knowledge of the agency’s emergency response plan
b. Awareness of the signs and symptoms for potential agnets of
c. Knowledge of how and what to report to the CDC
d. Ethical decision-making about exposing self to potentially lethal
Check answer
30.You are giving discharge instructions to a woman who has been
treated for contusions and bruises sustained during an episode of
domestic violence. What is your priority intervention for this patient?
a. Transportation arrangements to a safe house
b. Referral to a counselor
c. Advise about contacting the police
d. Follow-up appointment for injuries
Check answer
31.Emergency and ambulatory care nurses are among the first health
care workers to encounter victims from a bioterrorist attack.
Prioritize the actions for the ED staff in the event of a biochemical
a. Report to the public health department or CDC per protocol.
b. Decontaminate the victims in a separate area.
c. Protect the environment for the safety of personnel and non-affected
d. Don personal protective equipment.
e. Triage according to protocol.
_____, _____, _____, _____, _____
Check answer


1. ANSWER C – Triage requires at least one experienced RN. Pairing an
experienced RN with inexperienced RN provides opportunities for mentoring.
Advanced practice nurses are qualified to perform triage; however, their services
are usually required in other areas of the ED. An LPN/LVN is not qualified to
perform the initial patient assessment or decision making. Pairing an experienced
RN with a nursing assistant is the second best option, because the assistant can
obtain vital signs and assist in transporting. Go back to question
2. ANSWER B, A, D, C – An irritable infant with fever and petechiae should be
further assessed for other meningeal signs. The patient with the head wound
needs additional history and assessment for intracranial pressure. The patient
with moderate abdominal pain is uncomfortable, but not unstable at this point.
For the ankle injury, medical evaluation can be delayed 24 – 48 hours if
necessary. Go back to question
3. ANSWER C – A brief neurologic assessment to determine level of consciousness
and pupil reaction is part of the primary survey. Vital signs, assessment of the
abdomen, and initiation of pulse oximetry are considered part of the secondary survey. Go back to question
4. ANSWER D – Chest pain is considered an emergent priority, which is defined as
potentially life-threatening. Patients with urgent priority need treatment within 2
hours of triage (e.g. kidney stones). Non-urgent conditions can wait for hours or
even days. (High urgent is not commonly used; however, in 5-tier triage
systems, High urgent patients fall between emergent and urgent in terms of the
time lapsing prior to treatment). Go back to question
5. ANSWER A – The nursing assistant can assist with the removal of the outer
clothing, which allows the heat to dissipate from the child’s skin. Advising and
explaining are teaching functions that are the responsibility of the RN. Tepid
baths are not usually performed because of potential for rebound and shivering. Go back to question
6. ANSWER D – The homeless person has symptoms of heat stroke, a medical
emergency, which increases risk for brain damage. Elderly patients are at risk for
heat syncope and should be educated to rest in cool area and avoid future similar
situations. The runner is having heat crams, which can be managed with rest and
fluids. The housewife is experiencing heat exhaustion, and management includes
fluids (IV or parenteral) and cooling measures. The prognosis for recovery is
good. Go back to question
7. ANSWER B, D, A, C, E – Establish unresponsiveness first. (The patient may
have fallen and sustained a minor injury.) If the patient is unresponsive, get help
and have someone initiate the code. Performing the chin lift or jaw thrust
maneuver opens the airway. The nurse is then responsible for starting CPR. CPR
should not be interrupted until the patient recovers or it is determined that heroic
efforts have been exhausted. A crash cart should be at the site when the code
team arrives; however, basic CPR can be effectively performed until the team
arrives. Go back to question
8. ANSWER A – Nursing assistants are trained in basic cardiac life support and can
perform chest compressions. The use of the bag-valve mask requires practice
and usually a respiratory therapist will perform this function. The nurse or the
respiratory therapist should provide PRN assistance during intubation. The
defibrillator pads are clearly marked; however, placement should be done by the
RN or physician because of the potential for skin damage and electrical arcing. Go back to question
9. ANSWER C – The patient is hyperventilating secondary to anxiety, and
breathing into a paper bag will allow rebreathing of carbon dioxide. Also,
encouraging slow breathing will help. Other treatments such as oxygen and
medication may be needed if other causes are identified. Go back to question
10.ANSWER C – The fast track clinic will deal with relatively stable patients.
Triage, trauma, and pediatric medicine should be staffed with experienced nurses
who know the hospital routines and policies and can rapidly locate equipment. Go back to question
11.ANSWER A – Iron is a toxic substance that can lead to massive hemorrhage,
coma, shock, and hepatic failure. Deferoxame is an antidote that can be used for
severe cases of iron poisoning. Other information needs additional investigation,
but will not change the immediate diagnostic testing or treatment plan. Go back to question
12.ANSWER C – The LPN/LVN is able to listen and provide emotional support for
her patients. The other tasks are the responsibility of an RN or, if available, a
SANE (sexual assault nurse examiner) who has received training to assess,
collect and safeguard evidence, and care for these victims. Go back to question
13.ANSWER C, B, D, A – The victim should be removed from the cold environment
first, and then the rewarming process can be initiated. It will be painful, so give
pain medication prior to immersing the feet in warmed water. Go back to question
14.ANSWER C – The only correct intervention is C. the digits should be gently
cleansed with normal saline, wrapped in sterile gauze moistened with saline, and
placed in a plastic bag or container. The container is then placed on ice. Go back to question
15.ANSWER B – IV Lorazepam (Ativan) is the drug of choice for status epilepticus.
Tegretol is used in the management of generalized tonic-clonic, absence or mixed
type seizures, but it does not come in an IV form. PO (per os) medications are
inappropriate for this emergency situation. Magnesium sulfate is given to control
seizures in toxemia of pregnancy. Go back to question
16.ANSWER C – Parent refusal is an absolute contraindication; therefore, the
physician must be notified. Tetanus status can be addressed later. The RN can
restart the IV and provide information about conscious sedation; if the parent still
not satisfied, the physician can give more information. Go back to question
17.ANSWER D – The patient presents with symptoms of alcohol abuse and there is
a risk for Wernicke’s syndrome, which is caused by a thiamine deficiency.
Multiples drug abuse is not uncommon; however, there is nothing in the question
that suggests an opiate overdose that requires naloxone. Additional information
or the results of the blood alcohol level are part of the total treatment plan but
should not delay the immediate treatment. Go back to question
18.ANSWER C – Postmortem care requires some turning, cleaning, lifting, etc., and
the nursing assistant is able to assist with these duties. The RN should take
responsibility for the other tasks to help the family begin the grieving process. In
cases of questionable death, belongings may be retained for evidence, so the
chain of custody would have to be maintained. Go back to question
19.ANSWER C, D, B, A – Auscultating and confirming equal bilateral breath sounds
should be performed in rapid succession. If the sounds are not equal or if the
sounds are heard over the mid-epigastric area, tube placement must be
corrected immediately. Securing the tube is appropriate while waiting for the xray
study. Go back to question
20.ANSWER B – An impaled object may be providing a tamponade effect, and
removal can precipitate sudden hemodynamic decompensation. Additional history
including a more definitive description of the blood loss, depth of penetration,
and medical history should be obtained. Other information, such as the dirt on
the stick or history of diabetes, is important in the overall treatment plan, but
can be addressed later. Go back to question
21.ANSWER A – The patient demonstrates neurologic hyperactivity and is on the
verge of a seizure. Patient safety is the priority. The patient needs
chlordiazepoxide (Librium) to decrease neurologic irritability and phenytoin
(Dilantin) for seizures. Thiamine and haloperidol (Haldol) will also be ordered to
address the other problems. The other diagnoses are pertinent but not as
immediate. Go back to question
22.ANSWER B – The stinger will continue to release venom into the skin, so prompt
removal of the stinger is advised. Cool compresses and antihistamines can follow.
The caller should be further advised about symptoms that require 911 assistance. Go back to question
23.ANSWER D – The asymptomatic patient is currently stable but should be
observed for delayed pulmonary edema, cerebral edema, or pneumonia.
Teaching and care of critical patients is an RN responsibility. Removing clothing
can be delegated to a nursing assistant. Go back to question
24.ANSWER A – Cat’s mouths contain a virulent organism, Pasteurella multocida,
that can lead to septic arthritis or bacteremia. There is also a risk for tendon
damage due to deep puncture wounds. These wounds are usually not sutured. A
tetanus shot can be given before discharge. Go back to question
25.ANSWER D, B, C, A – The patient with a pulsating mass has an abdominal
aneurysm that may rupture and he may decompensate suddenly. The 11-yearold
boy needs evaluation to rule out appendicitis. The woman needs evaluation
for gallbladder problems that appear to be worsening. The 35-year-old man has
food poisoning, which is usually self-limiting. Go back to question
26.ANSWER D – At least one representative from each group should be included
because all employees are potential targets fro violence in the ED. Go back to question
27.ANSWER A – A deviated trachea is a symptoms of tension pneumothorax. All of
the other symptoms need to be addressed, but are of lesser priority. Go back to question
28.ANSWER C, B, D, A, E, F, G – For a multiple trauma victim, many interventions
will occur simultaneously as team members assist in the resuscitation. Methods
to open the airway such as the chin lift or jaw thrust can be used simultaneously
while assessing for spontaneous respirations. However, airway and oxygenation
are priority. Starting IVs for fluid resuscitation is part of supporting circulation.
(EMS will usually establish at least one IV in the field.) Nursing assistants can be
directed to take vitals and remove clothing. Foley catheter is necessary to closely
monitor output. Go back to question
29.ANSWER A – In preparing for disasters, the RN should be aware of the
emergency response plan. The plan gives guidance that includes roles of team
members, responsibilities, and mechanisms of reporting. Signs and symptoms of
many agents will mimic common complaints, such as flu-like symptoms.
Discussions with colleagues and supervisors may help the individual nurse to sort
through ethical dilemmas related to potential danger to self. Go back to question
30.ANSWER A – Safety is a priority for this patient, and she should not return to a
place where violence could reoccur. The other options are important for the long
term management of this care. Go back to question
31.ANSWER C, D, B, E, A – The first priority is to protect personnel, unaffected
patients, bystanders, and the facility. PPG should be donned prior to exposure to
victims. Decontamination of victims in a separate area is followed by triage and
treatment. The incident should be reported according to protocol as information
about the number of persons involved, history, signs and symptoms becomes available. Go back to question