**Title:** **Emergency Nursing & Triage:
NCLEX-RN Critical Care Scenarios**
---
### Question 1 of 81
A nurse in the ED is triaging clients after a mass casualty event. Which client should receive immediate
(red tag) treatment?
A) Client with partial-thickness burns to 30% TBSA who is conscious and talking
B) Client with an open femur fracture and palpable distal pulses
C) Client who is unconscious with a respiratory rate of 8 breaths/min
D) Client with a sucking chest wound who is alert with SpO2 91%
💫RATIONALE✔️✔️: Unconscious with RR 8 (C) has airway/breathing compromise, life-threatening. Red
tag. Others are stable or can wait (yellow/green).
💫ANSWER✔️✔️: C) Client who is unconscious with a respiratory rate of 8 breaths/min
---
### Question 2 of 81
A nurse is caring for a client admitted with carbon monoxide poisoning. Which finding is most
consistent?
A) Cherry-red skin color
,B) Cyanosis of lips and nail beds
C) Jaundice of the sclera
D) Pallor and diaphoresis
💫RATIONALE✔️✔️: Carbon monoxide poisoning causes cherry-red skin color (A) due to
carboxyhemoglobin formation. Cyanosis indicates hypoxemia from other causes.
💫ANSWER✔️✔️: A) Cherry-red skin color
---
### Question 3 of 81
**Select-All-That-Apply (SATA):** A nurse is assessing a client with tension pneumothorax following
blunt chest trauma. Which findings should the nurse expect? (Select all that apply.)
A) Absent breath sounds on 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 (B wrong).
💫ANSWER✔️✔️: A, C, D, E
---
### Question 4 of 81
,A nurse in the ICU is caring for a client with a pulmonary artery catheter. PAWP is 4 mmHg. Which
condition should the nurse suspect?
A) Hypervolemia
B) Left ventricular failure
C) Hypovolemia
D) Pulmonary hypertension
💫RATIONALE✔️✔️: Normal PAWP 4-12 mmHg. PAWP 4 is low normal trending toward hypovolemia (C).
Hypervolemia and LV failure increase PAWP.
💫ANSWER✔️✔️: C) Hypovolemia
---
### Question 5 of 81
A nurse is caring for a client with new ARDS. Which finding is expected in the early phase?
A) Severe hypoxemia that does not improve with oxygen therapy
B) Hypercapnia and respiratory acidosis
C) Normal chest x-ray
D) Bradycardia and hypotension
💫RATIONALE✔️✔️: Early ARDS causes refractory hypoxemia (A) from intrapulmonary shunting.
Hypercapnia occurs late. X-ray shows bilateral infiltrates.
💫ANSWER✔️✔️: A) Severe hypoxemia that does not improve with oxygen therapy
---
### Question 6 of 81
, A nurse is providing discharge teaching to a client after hip replacement with new enoxaparin (Lovenox).
Which statement indicates understanding?
A) "I will inject this medication into my thigh muscle."
B) "I will take ibuprofen for pain because it is safe."
C) "I will not rub the injection site after giving the shot."
D) "I will stop this medication if I see bruising at the injection site."
💫RATIONALE✔️✔️: Do not rub injection site (C) to prevent bleeding. Subcutaneous in abdomen. Avoid
NSAIDs. Bruising expected.
💫ANSWER✔️✔️: C) "I will not rub the injection site after giving the shot."
---
### Question 7 of 81
**Select-All-That-Apply (SATA):** A nurse is caring for a client with status epilepticus. Which actions
should the nurse take first? (Select all that apply.)
A) Administer lorazepam (Ativan) as prescribed
B) Place the client in a lateral position
C) Insert a padded tongue blade to prevent injury
D) Establish IV access
E) Apply oxygen via nasal cannula
💫RATIONALE✔️✔️: Lateral position (B), establish IV (D), benzodiazepines (A), oxygen (E) correct. Tongue
blades (C) contraindicated (vomiting/airway obstruction).
💫ANSWER✔️✔️: A, B, D, E
NCLEX-RN Critical Care Scenarios**
---
### Question 1 of 81
A nurse in the ED is triaging clients after a mass casualty event. Which client should receive immediate
(red tag) treatment?
A) Client with partial-thickness burns to 30% TBSA who is conscious and talking
B) Client with an open femur fracture and palpable distal pulses
C) Client who is unconscious with a respiratory rate of 8 breaths/min
D) Client with a sucking chest wound who is alert with SpO2 91%
💫RATIONALE✔️✔️: Unconscious with RR 8 (C) has airway/breathing compromise, life-threatening. Red
tag. Others are stable or can wait (yellow/green).
💫ANSWER✔️✔️: C) Client who is unconscious with a respiratory rate of 8 breaths/min
---
### Question 2 of 81
A nurse is caring for a client admitted with carbon monoxide poisoning. Which finding is most
consistent?
A) Cherry-red skin color
,B) Cyanosis of lips and nail beds
C) Jaundice of the sclera
D) Pallor and diaphoresis
💫RATIONALE✔️✔️: Carbon monoxide poisoning causes cherry-red skin color (A) due to
carboxyhemoglobin formation. Cyanosis indicates hypoxemia from other causes.
💫ANSWER✔️✔️: A) Cherry-red skin color
---
### Question 3 of 81
**Select-All-That-Apply (SATA):** A nurse is assessing a client with tension pneumothorax following
blunt chest trauma. Which findings should the nurse expect? (Select all that apply.)
A) Absent breath sounds on 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 (B wrong).
💫ANSWER✔️✔️: A, C, D, E
---
### Question 4 of 81
,A nurse in the ICU is caring for a client with a pulmonary artery catheter. PAWP is 4 mmHg. Which
condition should the nurse suspect?
A) Hypervolemia
B) Left ventricular failure
C) Hypovolemia
D) Pulmonary hypertension
💫RATIONALE✔️✔️: Normal PAWP 4-12 mmHg. PAWP 4 is low normal trending toward hypovolemia (C).
Hypervolemia and LV failure increase PAWP.
💫ANSWER✔️✔️: C) Hypovolemia
---
### Question 5 of 81
A nurse is caring for a client with new ARDS. Which finding is expected in the early phase?
A) Severe hypoxemia that does not improve with oxygen therapy
B) Hypercapnia and respiratory acidosis
C) Normal chest x-ray
D) Bradycardia and hypotension
💫RATIONALE✔️✔️: Early ARDS causes refractory hypoxemia (A) from intrapulmonary shunting.
Hypercapnia occurs late. X-ray shows bilateral infiltrates.
💫ANSWER✔️✔️: A) Severe hypoxemia that does not improve with oxygen therapy
---
### Question 6 of 81
, A nurse is providing discharge teaching to a client after hip replacement with new enoxaparin (Lovenox).
Which statement indicates understanding?
A) "I will inject this medication into my thigh muscle."
B) "I will take ibuprofen for pain because it is safe."
C) "I will not rub the injection site after giving the shot."
D) "I will stop this medication if I see bruising at the injection site."
💫RATIONALE✔️✔️: Do not rub injection site (C) to prevent bleeding. Subcutaneous in abdomen. Avoid
NSAIDs. Bruising expected.
💫ANSWER✔️✔️: C) "I will not rub the injection site after giving the shot."
---
### Question 7 of 81
**Select-All-That-Apply (SATA):** A nurse is caring for a client with status epilepticus. Which actions
should the nurse take first? (Select all that apply.)
A) Administer lorazepam (Ativan) as prescribed
B) Place the client in a lateral position
C) Insert a padded tongue blade to prevent injury
D) Establish IV access
E) Apply oxygen via nasal cannula
💫RATIONALE✔️✔️: Lateral position (B), establish IV (D), benzodiazepines (A), oxygen (E) correct. Tongue
blades (C) contraindicated (vomiting/airway obstruction).
💫ANSWER✔️✔️: A, B, D, E
