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Relias ED RN A
- A 58-year-old male presents to the ED with chest pain radiating to the left arm. What is the nurse's priority action? A. Obtain a complete medical history B. Administer morphine for pain C. Apply oxygen and obtain vital signs D. Perform a 12-lead ECG and alert the provider ✅ Correct Answer: D. Perform a 12-lead ECG and alert the provider Rationale: The priority in suspected myocardial infarction is early ECG to detect ST elevation and initiate treatment quickly.
- Which of the following patients should be prioritized for treatment using the Emergency Severity Index (ESI) triage system? A. A 45-year-old with mild abdominal pain B. A 19-year-old with a twisted ankle C. A 67-year-old with shortness of breath and low oxygen saturation D. A 5-year-old with a low-grade fever ✅ Correct Answer: C. A 67-year-old with shortness of breath and low oxygen saturation Rationale: Airway and breathing issues are high-priority and may indicate life- threatening conditions needing immediate intervention.
- A patient presents with signs of stroke. Which assessment is the most critical during triage? A. Blood glucose level B. Full medication history C. Pain rating D. Respiratory rate ✅ Correct Answer: A. Blood glucose level Rationale: Hypoglycemia can mimic stroke symptoms and must be ruled out immediately before stroke protocols are initiated.
- What is the first intervention for a trauma patient with a GCS score of 6? A. Start an IV line B. Provide pain medication C. Secure the airway D. Assess pupil response ✅ Correct Answer: C. Secure the airway Rationale: A GCS score ≤ 8 indicates a need for airway protection to prevent aspiration or hypoxia.
breath and chest tightness. She has a history of asthma. What is the nurse’s priority intervention? A. Administer albuterol via nebulizer B. Place patient on continuous cardiac monitoring C. Obtain a peak flow measurement D. Start an IV for potential medication administration ✅ Correct Answer: A. Administer albuterol via nebulizer Rationale: The immediate treatment for an acute asthma exacerbation is bronchodilator therapy to open the airways.
- A patient is brought to the ED after being found unresponsive. The glucose level is 34 mg/dL. What is the appropriate initial action? A. Administer glucagon IM B. Administer IV D C. Start a 0.9% NS infusion D. Notify the provider and await orders ✅ Correct Answer: B. Administer IV D Rationale: IV dextrose is the fastest and most effective treatment for critically low blood glucose in an unresponsive patient.
- What is the correct nursing response if a patient suddenly becomes unresponsive and pulseless while in the ED? A. Call a code and start chest compressions B. Administer atropine immediately C. Notify the physician and wait for orders D. Check blood pressure manually ✅ Correct Answer: A. Call a code and start chest compressions Rationale: Immediate CPR is the standard of care for pulseless, unresponsive patients to restore circulation.
- A patient is receiving IV potassium chloride. What is the most important assessment during administration? A. Bowel sounds B. Respiratory rate C. ECG monitoring D. Skin turgor ✅ Correct Answer: C. ECG monitoring Rationale: Potassium affects cardiac conduction, and continuous ECG monitoring is essential during IV administration to detect dysrhythmias.
- A toddler presents with barking cough and stridor. What is the likely diagnosis and first-line treatment? A. Epiglottitis; administer antibiotics B. Croup; administer racemic epinephrine C. Asthma; give albuterol D. Foreign body aspiration; perform back blows ✅ Correct Answer: B. Croup; administer racemic epinephrine Rationale: The hallmark signs of croup are stridor and barking cough. Racemic epinephrine reduces airway swelling.
- A trauma patient arrives hypotensive and tachycardic with visible abdominal bruising. What should the nurse anticipate? A. Immediate discharge with pain medications B. Transfer to radiology for an MRI C. Emergent surgery for internal bleeding D. Administration of oral contrast for CT scan ✅ Correct Answer: C. Emergent surgery for internal bleeding
Rationale: Penetrating chest trauma can lead to pericardial effusion and tamponade, resulting in hypotension and muffled heart sounds.
- Which patient in the ED should the triage nurse prioritize? A. 65-year-old with stable vital signs and ankle pain B. 22-year-old with nosebleed controlled by pressure C. 45-year-old with jaw pain and diaphoresis D. 38-year-old with sore throat and mild fever ✅ Correct Answer: C. 45-year-old with jaw pain and diaphoresis Rationale: These are atypical symptoms of myocardial infarction, which must be evaluated immediately.
- A patient with a known seizure disorder presents postictal and confused. What is the nurse’s next step? A. Administer lorazepam B. Maintain a safe environment and monitor C. Start CPR D. Insert a nasogastric tube ✅ Correct Answer: B. Maintain a safe environment and monitor Rationale: During the postictal phase, patients are confused but usually stable. The focus is on safety and observation.
- Which of the following is a sign of increased intracranial pressure? A. Rapid, shallow breathing B. Pinpoint pupils C. Widening pulse pressure and bradycardia D. Hypotension and tachycardia ✅ Correct Answer: C. Widening pulse pressure and bradycardia
Rationale: These are part of Cushing’s triad, classic for increased intracranial pressure (ICP).
- Which ED patient should be placed in airborne isolation? A. Patient with bacterial meningitis B. Patient with influenza C. Patient with suspected tuberculosis D. Patient with norovirus ✅ Correct Answer: C. Patient with suspected tuberculosis Rationale: TB is transmitted via airborne droplets and requires a negative pressure room and N95 mask.
- A nurse is caring for a patient who overdosed on opioids. Which clinical sign requires the most immediate intervention? A. Sedation B. Constricted pupils C. Respiratory rate of 6 D. Hypoactive bowel sounds ✅ Correct Answer: C. Respiratory rate of 6 Rationale: Respiratory depression is life-threatening and requires naloxone administration.
- A nurse notes absent breath sounds on the left side after blunt chest trauma. What is the priority intervention? A. Order a chest x-ray B. Position the patient upright C. Notify the provider and prepare for chest tube insertion D. Start a 12-lead ECG ✅ Correct Answer: C. Notify the provider and prepare for chest tube insertion
Rationale: These are classic signs of DTs, a life-threatening alcohol withdrawal condition.26. A 70-year-old patient presents with slurred speech, right-sided weakness, and facial droop. The symptoms started 90 minutes ago. What is the immediate nursing action? A. Administer aspirin B. Notify the stroke team and prepare for CT scan C. Start IV heparin D. Administer labetalol for high blood pressure ✅ Correct Answer: B. Notify the stroke team and prepare for CT scan Rationale: Time is brain—rapid imaging is critical to determine eligibility for thrombolytic therapy.
- What is the first intervention for a patient with suspected anaphylaxis who is hypotensive and short of breath? A. Administer IV diphenhydramine B. Begin CPR C. Administer IM epinephrine D. Provide high-flow oxygen via nasal cannula ✅ Correct Answer: C. Administer IM epinephrine Rationale: Epinephrine is the first-line treatment for anaphylaxis and should be administered immediately.
- Which of the following is a red flag symptom in a patient presenting with headache? A. History of migraines B. Pain relief with rest C. Sudden onset "worst headache of life" D. Headache after missing a meal ✅ Correct Answer: C. Sudden onset "worst headache of life"
Rationale: This suggests subarachnoid hemorrhage and is a neurological emergency.
- A trauma patient with a pelvic fracture is showing signs of hypovolemic shock. What is the most appropriate intervention? A. Insert a Foley catheter B. Log-roll to assess for bleeding C. Apply a pelvic binder D. Administer oral fluids ✅ Correct Answer: C. Apply a pelvic binder Rationale: Pelvic fractures can cause massive internal bleeding; a binder stabilizes the pelvis and reduces bleeding.
- A child presents with high fever, drooling, and sits in the tripod position. What is the nurse's priority action? A. Administer ibuprofen B. Assess for dehydration C. Avoid throat examination and notify provider D. Obtain a throat culture ✅ Correct Answer: C. Avoid throat examination and notify provider Rationale: These signs suggest epiglottitis. Manipulating the airway can cause obstruction—airway support is urgent.
- Which lab value is most concerning in a patient presenting with chest pain? A. Troponin I of 0.7 ng/mL B. Hemoglobin of 14.2 g/dL C. Potassium of 4.3 mEq/L D. Sodium of 138 mEq/L ✅ Correct Answer: A. Troponin I of 0.7 ng/mL Rationale: Elevated troponin indicates myocardial injury and is consistent with ACS.
- Which symptom would the nurse expect in a patient with heat stroke? A. Cool, clammy skin B. Profuse sweating C. Altered mental status and hot, dry skin D. Bradycardia and hypotension ✅ Correct Answer: C. Altered mental status and hot, dry skin Rationale: Heat stroke presents with CNS dysfunction and inability to sweat. It’s a medical emergency.36. A patient presents to the ED with crushing chest pain, nausea, and diaphoresis. Vital signs are stable. What is the first nursing intervention? A. Administer nitroglycerin B. Establish IV access C. Place on cardiac monitor and obtain 12-lead ECG D. Administer aspirin ✅ Correct Answer: C. Place on cardiac monitor and obtain 12-lead ECG Rationale: An ECG within 10 minutes is essential for early diagnosis and management of myocardial infarction.
- What is the best indicator of fluid resuscitation effectiveness in a patient with hypovolemic shock? A. Decreased heart rate B. Increased blood pressure C. Improved capillary refill D. Urine output >0.5 mL/kg/hr ✅ Correct Answer: D. Urine output >0.5 mL/kg/hr Rationale: Adequate urine output is a reliable sign of perfusion and effective fluid resuscitation.
- A patient with end-stage renal disease presents with generalized weakness and ECG shows peaked T-waves. What is the priority intervention?
A. Administer sodium bicarbonate B. Administer IV insulin with dextrose C. Prepare for dialysis D. Provide a high-protein meal ✅ Correct Answer: B. Administer IV insulin with dextrose Rationale: This shifts potassium into cells and treats hyperkalemia, which is likely causing the ECG changes.
- What is the most appropriate initial intervention for a patient with an acute upper GI bleed and hematemesis? A. Administer proton pump inhibitor B. Start two large-bore IV lines C. Provide antiemetics D. Place in left lateral position ✅ Correct Answer: B. Start two large-bore IV lines Rationale: These patients are at high risk for hemorrhagic shock—establishing access for fluids/blood is critical.
- Which lab result is most concerning in a patient with sepsis? A. Hematocrit 38% B. Platelets 50,000/mm³ C. Potassium 4.0 mEq/L D. White blood cells 10,500/mm³ ✅ Correct Answer: B. Platelets 50,000/mm³ Rationale: Thrombocytopenia can indicate progression to disseminated intravascular coagulation (DIC), a life-threatening complication of sepsis.
- A patient has sustained a chemical burn to the eyes. What is the first nursing action?
A. Start IV fluids B. Administer antipyretics C. Obtain blood cultures D. Notify the provider immediately ✅ Correct Answer: D. Notify the provider immediately Rationale: Petechiae and lethargy may indicate meningococcemia—a life- threatening emergency requiring rapid intervention.
- What is the primary goal in the management of a patient with carbon monoxide poisoning? A. Induce vomiting B. Administer high-flow oxygen C. Begin corticosteroid therapy D. Place in Trendelenburg position ✅ Correct Answer: B. Administer high-flow oxygen Rationale: 100% oxygen decreases the half-life of carboxyhemoglobin and is the cornerstone of treatment.46. A patient with a history of diabetes presents with cold, clammy skin, confusion, and slurred speech. What is the priority nursing action? A. Start an insulin drip B. Administer IV dextrose C. Obtain a stat hemoglobin A1C D. Call a code stroke ✅ Correct Answer: B. Administer IV dextrose Rationale: These are signs of hypoglycemia. Immediate treatment with IV dextrose is required to prevent seizure or coma.
- A trauma patient has jugular venous distention, hypotension, and muffled heart sounds. What condition is most likely? A. Pulmonary embolism
B. Cardiac tamponade C. Tension pneumothorax D. Myocardial infarction ✅ Correct Answer: B. Cardiac tamponade Rationale: These are Beck’s triad—classic for cardiac tamponade. It’s a life- threatening condition needing urgent pericardiocentesis.
- A nurse is caring for a patient with suspected neurogenic shock. Which finding supports this diagnosis? A. Hypertension and tachycardia B. Bradycardia and hypotension C. Warm, flushed skin with fever D. Bounding pulses and chest pain ✅ Correct Answer: B. Bradycardia and hypotension Rationale: Neurogenic shock disrupts sympathetic tone, resulting in low blood pressure and heart rate.
- A 50-year-old male arrives with sudden, severe abdominal pain radiating to the back. He is hypotensive and diaphoretic. What condition is suspected? A. Renal colic B. Bowel obstruction C. Pancreatitis D. Abdominal aortic aneurysm rupture ✅ Correct Answer: D. Abdominal aortic aneurysm rupture Rationale: Sudden severe pain, hypotension, and back radiation strongly suggest AAA rupture—an immediate surgical emergency.
- Which patient should the nurse see first during triage? A. 30-year-old with fever and ear pain
