Leigh
NUR445 Exam 4 Emergency Nursing – 40+ NCLEX-Style Questions with Answers
& Full Rationales (Disaster Triage, Burns, Trauma, PPE, Bioterrorism)
1. A nurse is triaging victims after an explosion. Which client should be assigned
highest priority?
A. A conscious adult with second-degree burns on both legs, RR 22/min
B. A child with minor abrasions and crying loudly
C. A conscious adult with second-degree burns on both legs, RR > 30/min
D. An unconscious adult with a faint pulse and agonal breathing
Answer: C
Rationale:
RR > 30/min = red tag (immediate) under START triage.
Airway + breathing abnormalities override burn severity.
Option D = black tag (non-salvageable).
Option A = yellow tag.
2. During the heroic phase of disaster response, which statement indicates
understanding?
A. “People are angry and feeling abandoned.”
B. “The community is ready to return to normal life.”
C. “Personnel are willing to work in dangerous conditions to provide help.”
D. “Long-term rebuilding begins during this stage.”
Answer: C
Rationale:
Heroic phase = adrenaline, rescue efforts, risk-taking.
Honeymoon phase = community bonding.
,Leigh
Disillusionment = anger/fatigue.
3. An adolescent with blunt abdominal trauma presents with the following: BP
92/50. What is the nurse’s priority?
A. Check bowel sounds
B. Assess cap refill
C. Treat hypotension immediately
D. Administer oral fluids
Answer: C
Rationale:
Hypotension after blunt trauma = internal hemorrhage until proven
otherwise.
This is the earliest and most dangerous sign.
Oral fluids contraindicated.
4. A client with an open right-femur fracture is most at risk for which
complication?
A. Fat embolism
B. Osteomyelitis
C. Compartment syndrome
D. DVT
Answer: C
Rationale:
Open long-bone fractures = high edema + pressure → compartment
syndrome.
The 5 Ps: pain, pallor, pulselessness, paresthesia, paralysis.
,Leigh
Requires immediate intervention.
5. After exposure to which bioterrorism agent is vaccination recommended?
A. Tularemia
B. Plague
C. Anthrax
D. Smallpox
Answer: D
Rationale:
Smallpox vaccine can be given post-exposure to reduce severity.
6. A client with a brown recluse bite may show which sign of internal bleeding?
A. Muscle rigidity
B. Fever and chills
C. Black/tarry stools and dark urine
D. Reddish rash
Answer: C
Rationale:
Brown recluse venom can cause hemolysis and internal bleeding → melena,
hematuria.
7. Which statements about botulism are correct? (Select all)
A. Paralysis can develop within 12–72 hours
B. Report only when >3 cases occur
C. Vomiting and diarrhea may occur
D. Spread by direct person-to-person contact
E. Found in castor beans
, Leigh
Answer: A, C
Rationale:
A = true
C = true
B = false (report 1 case)
D = false (foodborne)
E = false (ricin is from castor beans)
8. A burn client with facial burns. Which finding is priority?
A. Cherry-red lips
B. Hoarse voice
C. Difficulty swallowing
D. Anxiety
Answer: C
Rationale:
Difficulty swallowing = sign of airway edema → immediate threat.
9. A client with a sucking chest wound: BP 100/60, HR 118, RR 40. What should
the nurse do first?
A. Apply a tight chest seal
B. Insert a chest tube
C. Administer oxygen immediately
D. Give IV morphine
Answer: C
Rationale:
Airway + oxygenation always first. Chest seal is next intervention.
NUR445 Exam 4 Emergency Nursing – 40+ NCLEX-Style Questions with Answers
& Full Rationales (Disaster Triage, Burns, Trauma, PPE, Bioterrorism)
1. A nurse is triaging victims after an explosion. Which client should be assigned
highest priority?
A. A conscious adult with second-degree burns on both legs, RR 22/min
B. A child with minor abrasions and crying loudly
C. A conscious adult with second-degree burns on both legs, RR > 30/min
D. An unconscious adult with a faint pulse and agonal breathing
Answer: C
Rationale:
RR > 30/min = red tag (immediate) under START triage.
Airway + breathing abnormalities override burn severity.
Option D = black tag (non-salvageable).
Option A = yellow tag.
2. During the heroic phase of disaster response, which statement indicates
understanding?
A. “People are angry and feeling abandoned.”
B. “The community is ready to return to normal life.”
C. “Personnel are willing to work in dangerous conditions to provide help.”
D. “Long-term rebuilding begins during this stage.”
Answer: C
Rationale:
Heroic phase = adrenaline, rescue efforts, risk-taking.
Honeymoon phase = community bonding.
,Leigh
Disillusionment = anger/fatigue.
3. An adolescent with blunt abdominal trauma presents with the following: BP
92/50. What is the nurse’s priority?
A. Check bowel sounds
B. Assess cap refill
C. Treat hypotension immediately
D. Administer oral fluids
Answer: C
Rationale:
Hypotension after blunt trauma = internal hemorrhage until proven
otherwise.
This is the earliest and most dangerous sign.
Oral fluids contraindicated.
4. A client with an open right-femur fracture is most at risk for which
complication?
A. Fat embolism
B. Osteomyelitis
C. Compartment syndrome
D. DVT
Answer: C
Rationale:
Open long-bone fractures = high edema + pressure → compartment
syndrome.
The 5 Ps: pain, pallor, pulselessness, paresthesia, paralysis.
,Leigh
Requires immediate intervention.
5. After exposure to which bioterrorism agent is vaccination recommended?
A. Tularemia
B. Plague
C. Anthrax
D. Smallpox
Answer: D
Rationale:
Smallpox vaccine can be given post-exposure to reduce severity.
6. A client with a brown recluse bite may show which sign of internal bleeding?
A. Muscle rigidity
B. Fever and chills
C. Black/tarry stools and dark urine
D. Reddish rash
Answer: C
Rationale:
Brown recluse venom can cause hemolysis and internal bleeding → melena,
hematuria.
7. Which statements about botulism are correct? (Select all)
A. Paralysis can develop within 12–72 hours
B. Report only when >3 cases occur
C. Vomiting and diarrhea may occur
D. Spread by direct person-to-person contact
E. Found in castor beans
, Leigh
Answer: A, C
Rationale:
A = true
C = true
B = false (report 1 case)
D = false (foodborne)
E = false (ricin is from castor beans)
8. A burn client with facial burns. Which finding is priority?
A. Cherry-red lips
B. Hoarse voice
C. Difficulty swallowing
D. Anxiety
Answer: C
Rationale:
Difficulty swallowing = sign of airway edema → immediate threat.
9. A client with a sucking chest wound: BP 100/60, HR 118, RR 40. What should
the nurse do first?
A. Apply a tight chest seal
B. Insert a chest tube
C. Administer oxygen immediately
D. Give IV morphine
Answer: C
Rationale:
Airway + oxygenation always first. Chest seal is next intervention.
