NR 341/ NR341 COMPLEX ADULT HEALTH EXAM 1
LATEST REAL EXAM QUESTIONS AND CORRECT
ANSWERS | A GRADE
SECTION 1: EMERGENCY & TRAUMA NURSING
Question 1
An emergency room nurse assesses a client who has been raped. With which
health care team member should the nurse collaborate when planning this client's
care?
• A. Emergency medicine physician
• B. Case manager
• C. Forensic nurse examiner
• D. Psychiatric crisis nurse
Answer: C
Rationale: The forensic nurse examiner is specifically educated to obtain client
histories and collect evidence dealing with sexual assault, and can offer the
counseling and follow-up needed when dealing with the victim of an assault.
While other team members may be involved, the forensic nurse has specialized
training for this situation .
Question 2
The emergency department team is performing cardiopulmonary resuscitation on
a client when the client's spouse arrives. Which action should the nurse take first?
• A. Request that the client's spouse sit in the waiting room
, • B. Ask the spouse if he wishes to be present during the resuscitation
• C. Suggest that the spouse begin to pray for the client
• D. Refer the client's spouse to the hospital's crisis team
Answer: B
Rationale: If resuscitation efforts are still under way when family arrives, one or
two family members may be given the opportunity to be present during lifesaving
procedures. This allows the spouse to begin the closure process .
Question 3
An emergency room nurse is triaging victims of a multi-casualty event. Which
client should receive care first?
• A. A 30-year-old distraught mother holding her crying child
• B. A 65-year-old conscious male with a head laceration
• C. A 26-year-old male who has pale, cool, clammy skin
• D. A 48-year-old with a simple fracture of the lower leg
Answer: C
Rationale: The client with pale, cool, clammy skin is in shock and needs immediate
medical attention. This represents an emergent (life-threatening) condition. The
mother has no injuries (lowest priority), and the others need attention but not at
the expense of a person in shock .
Question 4
While triaging clients in a crowded emergency department, a nurse assesses a
client who presents with symptoms of tuberculosis. Which action should the
nurse take first?
• A. Apply oxygen via nasal cannula
, • B. Administer intravenous 0.9% saline solution
• C. Transfer the client to a negative-pressure room
• D. Obtain a sputum culture and sensitivity
Answer: C
Rationale: A client with signs and symptoms of tuberculosis or other airborne
pathogens should be placed in a negative-pressure room first to prevent
contamination of staff, clients, and family members in the crowded emergency
department. Infection control is the priority .
Question 5
A nurse is triaging clients in the emergency department (ED). Which client should
the nurse prioritize to receive care first?
• A. A 22-year-old with a painful and swollen right wrist
• B. A 45-year-old reporting chest pain and diaphoresis
• C. A 60-year-old reporting difficulty swallowing and nausea
• D. An 81-year-old with a respiratory rate of 28 breaths/min and
temperature of 101°F
Answer: B
Rationale: A client experiencing chest pain and diaphoresis would be classified as
emergent (potential myocardial infarction) and would be triaged immediately. The
other clients are more stable .
Question 6
A nurse is evaluating levels and functions of trauma centers. Which function is
appropriately paired with the level of the trauma center?
, • A. Level I: Located within remote areas and provides advanced life support
within resource capabilities
• B. Level II: Located within community hospitals and provides care to most
injured clients
• C. Level III: Located in rural communities and provides only basic care to
clients
• D. Level IV: Located in large teaching hospitals and provides a full
continuum of trauma care
Answer: B
Rationale: Level I trauma centers are in large teaching hospitals providing full
continuum of care. Level II and III are in community hospitals. Level IV are in
rural/remote areas providing basic care and stabilization .
Question 7
Emergency medical technicians arrive with an unresponsive client who has an
oxygen mask in place. Which action should the nurse take first?
• A. Assess that the client is breathing adequately
• B. Insert a large-bore intravenous line
• C. Place the client on a cardiac monitor
• D. Assess for the best neurologic response
Answer: A
Rationale: The highest-priority intervention in the primary survey is to establish
that the client is breathing adequately. Even with an oxygen mask in place, the
client may not be breathing adequately .
Question 8
LATEST REAL EXAM QUESTIONS AND CORRECT
ANSWERS | A GRADE
SECTION 1: EMERGENCY & TRAUMA NURSING
Question 1
An emergency room nurse assesses a client who has been raped. With which
health care team member should the nurse collaborate when planning this client's
care?
• A. Emergency medicine physician
• B. Case manager
• C. Forensic nurse examiner
• D. Psychiatric crisis nurse
Answer: C
Rationale: The forensic nurse examiner is specifically educated to obtain client
histories and collect evidence dealing with sexual assault, and can offer the
counseling and follow-up needed when dealing with the victim of an assault.
While other team members may be involved, the forensic nurse has specialized
training for this situation .
Question 2
The emergency department team is performing cardiopulmonary resuscitation on
a client when the client's spouse arrives. Which action should the nurse take first?
• A. Request that the client's spouse sit in the waiting room
, • B. Ask the spouse if he wishes to be present during the resuscitation
• C. Suggest that the spouse begin to pray for the client
• D. Refer the client's spouse to the hospital's crisis team
Answer: B
Rationale: If resuscitation efforts are still under way when family arrives, one or
two family members may be given the opportunity to be present during lifesaving
procedures. This allows the spouse to begin the closure process .
Question 3
An emergency room nurse is triaging victims of a multi-casualty event. Which
client should receive care first?
• A. A 30-year-old distraught mother holding her crying child
• B. A 65-year-old conscious male with a head laceration
• C. A 26-year-old male who has pale, cool, clammy skin
• D. A 48-year-old with a simple fracture of the lower leg
Answer: C
Rationale: The client with pale, cool, clammy skin is in shock and needs immediate
medical attention. This represents an emergent (life-threatening) condition. The
mother has no injuries (lowest priority), and the others need attention but not at
the expense of a person in shock .
Question 4
While triaging clients in a crowded emergency department, a nurse assesses a
client who presents with symptoms of tuberculosis. Which action should the
nurse take first?
• A. Apply oxygen via nasal cannula
, • B. Administer intravenous 0.9% saline solution
• C. Transfer the client to a negative-pressure room
• D. Obtain a sputum culture and sensitivity
Answer: C
Rationale: A client with signs and symptoms of tuberculosis or other airborne
pathogens should be placed in a negative-pressure room first to prevent
contamination of staff, clients, and family members in the crowded emergency
department. Infection control is the priority .
Question 5
A nurse is triaging clients in the emergency department (ED). Which client should
the nurse prioritize to receive care first?
• A. A 22-year-old with a painful and swollen right wrist
• B. A 45-year-old reporting chest pain and diaphoresis
• C. A 60-year-old reporting difficulty swallowing and nausea
• D. An 81-year-old with a respiratory rate of 28 breaths/min and
temperature of 101°F
Answer: B
Rationale: A client experiencing chest pain and diaphoresis would be classified as
emergent (potential myocardial infarction) and would be triaged immediately. The
other clients are more stable .
Question 6
A nurse is evaluating levels and functions of trauma centers. Which function is
appropriately paired with the level of the trauma center?
, • A. Level I: Located within remote areas and provides advanced life support
within resource capabilities
• B. Level II: Located within community hospitals and provides care to most
injured clients
• C. Level III: Located in rural communities and provides only basic care to
clients
• D. Level IV: Located in large teaching hospitals and provides a full
continuum of trauma care
Answer: B
Rationale: Level I trauma centers are in large teaching hospitals providing full
continuum of care. Level II and III are in community hospitals. Level IV are in
rural/remote areas providing basic care and stabilization .
Question 7
Emergency medical technicians arrive with an unresponsive client who has an
oxygen mask in place. Which action should the nurse take first?
• A. Assess that the client is breathing adequately
• B. Insert a large-bore intravenous line
• C. Place the client on a cardiac monitor
• D. Assess for the best neurologic response
Answer: A
Rationale: The highest-priority intervention in the primary survey is to establish
that the client is breathing adequately. Even with an oxygen mask in place, the
client may not be breathing adequately .
Question 8
