Emergency Nursing Response Assessment
Questions And Answers With Verified Rationales
2026/27 Qs & Ans | Digital Pdf Download
1. A client arrives in the emergency department with airway obstruction.
What is the nurse’s priority action?
A. Obtain vital signs
B. Start IV fluids
C. Establish a patent airway immediately
D. Perform a full physical assessment
Rationale: Airway is always the first priority in emergency care (ABCs).
2. Which finding indicates respiratory distress?
A. Normal speech
B. Calm breathing
C. Use of accessory muscles
D. Bradycardia
Rationale: Accessory muscle use indicates increased work of breathing.
3. A client is unresponsive and not breathing. What should the nurse do
first?
,A. Call family
B. Check blood pressure
C. Initiate CPR
D. Obtain oxygen saturation
Rationale: Immediate cardiopulmonary resuscitation is required.
4. Which is the priority assessment in emergency triage?
A. Past medical history
B. Insurance status
C. Airway, breathing, circulation (ABC)
D. Dietary habits
Rationale: ABCs determine life-threatening conditions.
5. A client with chest pain should be assessed first for:
A. Headache
B. Myocardial infarction
C. Urinary infection
D. Anxiety only
Rationale: Chest pain may indicate a life-threatening cardiac event.
6. Which symptom suggests shock?
,A. Increased urine output
B. Warm skin
C. Hypotension and tachycardia
D. Increased appetite
Rationale: Shock causes decreased perfusion and compensatory
tachycardia.
7. What is the priority intervention for hemorrhagic shock?
A. Administer diuretics
B. Restrict fluids
C. Control bleeding and restore volume
D. Encourage oral intake
Rationale: Stop bleeding and restore circulating volume.
8. A client with anaphylaxis requires immediate:
A. Oral fluids
B. Antihistamines only
C. Epinephrine administration
D. Bed rest
Rationale: Epinephrine is first-line treatment for anaphylaxis.
9. Which sign indicates airway compromise?
, A. Clear speech
B. Normal oxygen saturation
C. Stridor
D. Normal breathing
Rationale: Stridor indicates upper airway obstruction.
10. A client with suspected stroke should be transported for imaging
within:
A. 12 hours
B. 6 hours
C. Minutes (rapid CT scan immediately)
D. 24 hours
Rationale: Early imaging is critical for thrombolytic therapy.
11. Which tool is used for rapid stroke assessment?
A. APGAR score
B. Glasgow coma scale
C. FAST assessment
D. Braden scale
Rationale: FAST identifies stroke signs quickly.
12. Which symptom is most consistent with hypovolemic shock?
Questions And Answers With Verified Rationales
2026/27 Qs & Ans | Digital Pdf Download
1. A client arrives in the emergency department with airway obstruction.
What is the nurse’s priority action?
A. Obtain vital signs
B. Start IV fluids
C. Establish a patent airway immediately
D. Perform a full physical assessment
Rationale: Airway is always the first priority in emergency care (ABCs).
2. Which finding indicates respiratory distress?
A. Normal speech
B. Calm breathing
C. Use of accessory muscles
D. Bradycardia
Rationale: Accessory muscle use indicates increased work of breathing.
3. A client is unresponsive and not breathing. What should the nurse do
first?
,A. Call family
B. Check blood pressure
C. Initiate CPR
D. Obtain oxygen saturation
Rationale: Immediate cardiopulmonary resuscitation is required.
4. Which is the priority assessment in emergency triage?
A. Past medical history
B. Insurance status
C. Airway, breathing, circulation (ABC)
D. Dietary habits
Rationale: ABCs determine life-threatening conditions.
5. A client with chest pain should be assessed first for:
A. Headache
B. Myocardial infarction
C. Urinary infection
D. Anxiety only
Rationale: Chest pain may indicate a life-threatening cardiac event.
6. Which symptom suggests shock?
,A. Increased urine output
B. Warm skin
C. Hypotension and tachycardia
D. Increased appetite
Rationale: Shock causes decreased perfusion and compensatory
tachycardia.
7. What is the priority intervention for hemorrhagic shock?
A. Administer diuretics
B. Restrict fluids
C. Control bleeding and restore volume
D. Encourage oral intake
Rationale: Stop bleeding and restore circulating volume.
8. A client with anaphylaxis requires immediate:
A. Oral fluids
B. Antihistamines only
C. Epinephrine administration
D. Bed rest
Rationale: Epinephrine is first-line treatment for anaphylaxis.
9. Which sign indicates airway compromise?
, A. Clear speech
B. Normal oxygen saturation
C. Stridor
D. Normal breathing
Rationale: Stridor indicates upper airway obstruction.
10. A client with suspected stroke should be transported for imaging
within:
A. 12 hours
B. 6 hours
C. Minutes (rapid CT scan immediately)
D. 24 hours
Rationale: Early imaging is critical for thrombolytic therapy.
11. Which tool is used for rapid stroke assessment?
A. APGAR score
B. Glasgow coma scale
C. FAST assessment
D. Braden scale
Rationale: FAST identifies stroke signs quickly.
12. Which symptom is most consistent with hypovolemic shock?
