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Critical Care Scenarios & Clinical Judgment Review
Emergency Nursing Q&A Review
1. During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next? A. Palpate extremities for bilateral pulses. B. Observe the patient’s respiratory effort. C. Check the patient’s level of consciousness. D. Examine the patient for any external bleeding. ✅ ANS: B. Observe the patient’s respiratory effort.
Rationale:
Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient’s breathing. The other actions are also part of the initial survey but assessment of breathing should be done immediately after assessing for airway patency.
Critical Care Scenarios & Clinical Judgment Review
2. During the primary survey of a patient with severe leg trauma, the nurse observes that the patient’s left pedal pulse is absent and the leg is swollen. Which action will the nurse take next? A. Send blood to the lab for a complete blood count. B. Assess further for a cause of the decreased circulation. C. Finish the airway, breathing, circulation, disability survey. D. Start normal saline fluid infusion with a large-bore IV line. ✅ ANS: D. Start normal saline fluid infusion with a large-bore IV line.
Rationale:
The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a possibly life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey.
Critical Care Scenarios & Clinical Judgment Review
4. A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should: A. Obtain a complete set of vital signs. B. Obtain a Glasgow Coma Scale score. C. Ask about chronic medical conditions. D. Attach a cardiac electrocardiogram monitor. ✅ ANS: B. Obtain a Glasgow Coma Scale score.
Rationale:
The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey.
Critical Care Scenarios & Clinical Judgment Review
5. A 19-year-old is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate giving: A. Tetanus immunoglobulin (TIG) only. B. TIG and tetanus-diphtheria toxoid (Td). C. Tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only. D. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap). ✅ ANS: D. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).
Rationale:
For an adult with no previous tetanus immunizations, TIG and Tdap are recommended. The other immunizations are not sufficient for this patient.
Critical Care Scenarios & Clinical Judgment Review
7. A patient with hypotension and an elevated temperature after
working outside on a hot day is treated in the emergency
department (ED). The nurse determines that discharge teaching
has been effective when the patient makes which statement?
A. "I will take salt tablets when I work outdoors in the summer." B. "I should take acetaminophen (Tylenol) if I start to feel too warm." C. "I should drink sports drinks when working outside in hot weather." D. "I will move to a cool environment if I notice that I am feeling confused." ✅ ANS: C. "I should drink sports drinks when working outside in hot weather."
Rationale:
Electrolyte solutions such as sports drinks help replace fluid and electrolytes lost when exercising in hot weather. Salt tablets are not recommended due to risks of gastric irritation and hypernatremia. Antipyretics are ineffective for heat-induced hyperthermia, and confusion indicates severe heat illness requiring immediate intervention.
Critical Care Scenarios & Clinical Judgment Review
8. A 22-year-old patient who experienced a near-drowning accident
in a local pool, but now is awake and breathing spontaneously, is
admitted for observation. Which assessment will be most
important for the nurse to take during the observation period?
A. Auscultate heart sounds. B. Palpate peripheral pulses. C. Auscultate breath sounds. D. Check pupil reaction to light. ✅ ANS: C. Auscultate breath sounds.
Rationale:
Pulmonary edema is a common complication after near-drowning. Frequent assessment of breath sounds is critical to detect respiratory compromise. Other assessments are secondary to airway/breathing concerns.
Critical Care Scenarios & Clinical Judgment Review
10. When rewarming a patient who arrived in the emergency
department (ED) with a temperature of 87°F (30.6°C), which
assessment indicates that the nurse should discontinue active
rewarming?
A. The patient begins to shiver. B. The BP decreases to 86/42 mmHg. C. The patient develops atrial fibrillation. D. The core temperature is 94°F (34.4°C). ✅ ANS: D. The core temperature is 94°F (34.4°C).
Rationale:
Active rewarming stops when core temperature reaches 93.2°F (34°C). Shivering, hypotension, and dysrhythmias are expected during rewarming and require treatment but do not indicate cessation. Here's your formatted list following the exact same structure and style:
Critical Care Scenarios & Clinical Judgment Review
11. When assessing an older patient admitted to the emergency
department (ED) with a broken arm and facial bruises, the nurse
observes several additional bruises in various stages of healing.
Which statement or question by the nurse is most appropriate?
A. "Do you feel safe in your home?" B. "You should not return to your home." C. "Would you like to see a social worker?" D. "I need to report my concerns to the police." ✅ ANS: A. "Do you feel safe in your home?"
Rationale:
The nurse's initial response should be to assess the patient's situation non- judgmentally. Direct questions about safety allow the patient to disclose potential abuse while maintaining autonomy. Other interventions may follow after further assessment.
Critical Care Scenarios & Clinical Judgment Review
13. A triage nurse in a busy emergency department (ED) assesses a
patient who complains of 7/10 abdominal pain and states, "I had a
temperature of 103.9°F (39.9°C) at home." The nurse's first action
should be to:
A. Assess the patient's current vital signs. B. Give acetaminophen (Tylenol) per agency protocol. C. Ask the patient to provide a clean-catch urine for urinalysis. D. Tell the patient that it will be 1 to 2 hours before being seen by the doctor. ✅ ANS: A. Assess the patient's current vital signs.
Rationale:
Vital signs are critical for triage decisions in patients reporting fever and severe pain. This objective data helps determine urgency of care before implementing other interventions.
Critical Care Scenarios & Clinical Judgment Review
14. The emergency department (ED) triage nurse is assessing four
victims involved in a motor vehicle collision. Which patient has the
highest priority for treatment?
A. A patient with no pedal pulses. B. A patient with an open femur fracture. C. A patient with bleeding facial lacerations. D. A patient with paradoxic chest movements. ✅ ANS: D. A patient with paradoxic chest movements.
Rationale:
Paradoxic chest movement indicates flail chest and potential life-threatening respiratory compromise, which takes priority in the ABC (Airway-Breathing- Circulation) protocol over circulatory or musculoskeletal injuries.
Critical Care Scenarios & Clinical Judgment Review
16. Gastric lavage and administration of activated charcoal are
ordered for an unconscious patient admitted after ingesting 30
lorazepam (Ativan) tablets. Which action should the nurse plan to
do first?
A. Insert a large-bore orogastric tube. B. Assist with intubation of the patient. C. Prepare a 60-mL syringe with saline. D. Give first dose of activated charcoal. ✅ ANS: B. Assist with intubation of the patient.
Rationale:
For an unconscious patient, airway protection via intubation must precede gastric decontamination to prevent aspiration. Other interventions follow once the airway is secured.
Critical Care Scenarios & Clinical Judgment Review
17. A 54-year-old patient arrives in the ED after powdered lime
exposure at work. Which action should the nurse take first?
A. Obtain the patient's vital signs. B. Obtain a baseline CBC. C. Decontaminate by showering with water. D. Brush off visible powder from skin/clothing. ✅ ANS: D. Brush off visible powder from skin/clothing.
Rationale:
Dry decontamination (brushing off powder) is priority for lime exposure to protect staff and prevent chemical reactions with water. Other assessments follow after decontamination.
Critical Care Scenarios & Clinical Judgment Review
19. A patient admitted after falling through ice requires priority
assessment of:
A. Heart rate. B. Breath sounds. C. Body temperature. D. Level of consciousness. ✅ ANS: B. Breath sounds.
Rationale:
Breath sounds assess for pulmonary edema/aspiration (primary drowning complications) per ABC (Airway-Breathing-Circulation) protocol. Other assessments are secondary.
Critical Care Scenarios & Clinical Judgment Review
20. After an earthquake, which triage patient should be assessed
first?
A. Red tag. B. Blue tag. C. Black tag. D. Yellow tag. ✅ ANS: A. Red tag.
Rationale:
Red-tagged patients have life-threatening, treatable injuries requiring immediate intervention. Black tags indicate expectant care, while yellow/blue tags are lower priority.
