**Title:** **Emergency Nursing & Triage:
NCLEX-RN Critical Care Scenarios**
---
### Question 1 of 92
A nurse in the ED is triaging clients after a mass casualty event. Which client should receive immediate
(red tag) treatment?
A) Partial-thickness burns 30% TBSA, conscious, talking
B) Open femur fracture, palpable distal pulses
C) Unconscious with RR 8 breaths/min
D) Sucking chest wound, alert, SpO2 91%
💫RATIONALE✔️✔️: Unconscious with RR 8 (C) has airway/breathing compromise, life-threatening. Red
tag.
💫ANSWER✔️✔️: C) Unconscious with RR 8 breaths/min
---
### Question 2 of 92
A client with carbon monoxide poisoning. Which finding is most consistent?
A) Cherry-red skin color
,B) Cyanosis of lips/nail beds
C) Jaundice of sclera
D) Pallor and diaphoresis
💫RATIONALE✔️✔️: Carbon monoxide causes cherry-red skin color (A) due to carboxyhemoglobin.
💫ANSWER✔️✔️: A) Cherry-red skin color
---
### Question 3 of 92
**Select-All-That-Apply (SATA):** A nurse assesses tension pneumothorax after blunt chest trauma.
Which findings expected? (Select all that apply.)
A) Absent breath sounds affected side
B) Tracheal deviation toward affected side
C) Hypotension
D) Jugular vein distention
E) Hyperresonance on percussion
💫RATIONALE✔️✔️: Tension pneumothorax: absent breath sounds (A), hypotension (C), JVD (D),
hyperresonance (E). Tracheal deviation away from affected side.
💫ANSWER✔️✔️: A, C, D, E
---
### Question 4 of 92
ICU client with pulmonary artery catheter. PAWP 4 mmHg. Suspect?
,A) Hypervolemia
B) Left ventricular failure
C) Hypovolemia
D) Pulmonary hypertension
💫RATIONALE✔️✔️: Normal PAWP 4-12 mmHg. PAWP 4 low normal trending toward hypovolemia (C).
💫ANSWER✔️✔️: C) Hypovolemia
---
### Question 5 of 92
Client with new ARDS. Early phase finding?
A) Refractory hypoxemia
B) Hypercapnia
C) Normal CXR
D) Bradycardia
💫RATIONALE✔️✔️: Early ARDS causes refractory hypoxemia (A) from intrapulmonary shunting.
💫ANSWER✔️✔️: A) Refractory hypoxemia
---
### Question 6 of 92
Discharge teaching after hip replacement with new enoxaparin (Lovenox). Which statement indicates
understanding?
, A) "Inject into thigh muscle."
B) "Take ibuprofen for pain."
C) "Do not rub injection site."
D) "Stop if see bruising."
💫RATIONALE✔️✔️: Do not rub injection site (C) to prevent bleeding. Subcutaneous in abdomen. Avoid
NSAIDs.
💫ANSWER✔️✔️: C) "Do not rub injection site."
---
### Question 7 of 92
**Select-All-That-Apply (SATA):** A nurse cares for client with status epilepticus. First actions? (Select
all that apply.)
A) Administer lorazepam (Ativan)
B) Place client in lateral position
C) Insert padded tongue blade
D) Establish IV access
E) Apply oxygen
💫RATIONALE✔️✔️: Lateral position (B), establish IV (D), benzodiazepines (A), oxygen (E). Tongue blades
contraindicated.
💫ANSWER✔️✔️: A, B, D, E
---
### Question 8 of 92
NCLEX-RN Critical Care Scenarios**
---
### Question 1 of 92
A nurse in the ED is triaging clients after a mass casualty event. Which client should receive immediate
(red tag) treatment?
A) Partial-thickness burns 30% TBSA, conscious, talking
B) Open femur fracture, palpable distal pulses
C) Unconscious with RR 8 breaths/min
D) Sucking chest wound, alert, SpO2 91%
💫RATIONALE✔️✔️: Unconscious with RR 8 (C) has airway/breathing compromise, life-threatening. Red
tag.
💫ANSWER✔️✔️: C) Unconscious with RR 8 breaths/min
---
### Question 2 of 92
A client with carbon monoxide poisoning. Which finding is most consistent?
A) Cherry-red skin color
,B) Cyanosis of lips/nail beds
C) Jaundice of sclera
D) Pallor and diaphoresis
💫RATIONALE✔️✔️: Carbon monoxide causes cherry-red skin color (A) due to carboxyhemoglobin.
💫ANSWER✔️✔️: A) Cherry-red skin color
---
### Question 3 of 92
**Select-All-That-Apply (SATA):** A nurse assesses tension pneumothorax after blunt chest trauma.
Which findings expected? (Select all that apply.)
A) Absent breath sounds affected side
B) Tracheal deviation toward affected side
C) Hypotension
D) Jugular vein distention
E) Hyperresonance on percussion
💫RATIONALE✔️✔️: Tension pneumothorax: absent breath sounds (A), hypotension (C), JVD (D),
hyperresonance (E). Tracheal deviation away from affected side.
💫ANSWER✔️✔️: A, C, D, E
---
### Question 4 of 92
ICU client with pulmonary artery catheter. PAWP 4 mmHg. Suspect?
,A) Hypervolemia
B) Left ventricular failure
C) Hypovolemia
D) Pulmonary hypertension
💫RATIONALE✔️✔️: Normal PAWP 4-12 mmHg. PAWP 4 low normal trending toward hypovolemia (C).
💫ANSWER✔️✔️: C) Hypovolemia
---
### Question 5 of 92
Client with new ARDS. Early phase finding?
A) Refractory hypoxemia
B) Hypercapnia
C) Normal CXR
D) Bradycardia
💫RATIONALE✔️✔️: Early ARDS causes refractory hypoxemia (A) from intrapulmonary shunting.
💫ANSWER✔️✔️: A) Refractory hypoxemia
---
### Question 6 of 92
Discharge teaching after hip replacement with new enoxaparin (Lovenox). Which statement indicates
understanding?
, A) "Inject into thigh muscle."
B) "Take ibuprofen for pain."
C) "Do not rub injection site."
D) "Stop if see bruising."
💫RATIONALE✔️✔️: Do not rub injection site (C) to prevent bleeding. Subcutaneous in abdomen. Avoid
NSAIDs.
💫ANSWER✔️✔️: C) "Do not rub injection site."
---
### Question 7 of 92
**Select-All-That-Apply (SATA):** A nurse cares for client with status epilepticus. First actions? (Select
all that apply.)
A) Administer lorazepam (Ativan)
B) Place client in lateral position
C) Insert padded tongue blade
D) Establish IV access
E) Apply oxygen
💫RATIONALE✔️✔️: Lateral position (B), establish IV (D), benzodiazepines (A), oxygen (E). Tongue blades
contraindicated.
💫ANSWER✔️✔️: A, B, D, E
---
### Question 8 of 92
