ED/Triage & Neuro Assessment
A client arrives after a seizure and is postictal. Which assessment finding requires the nurse’s immediate intervention?
A. Fatigue and confusion
B. Drooling
C. Oxygen saturation 88%
D. No memory of event
Answer: C — Oxygen saturation 88%
(Airway and oxygenation are priority.)
Rationale:
Postictal confusion and fatigue are expected, but oxygen saturation below 90% indicates impaired gas exchange and risk of hypoxia — airway/breathing always take priority.
Which finding in diabetes insipidus requires urgent reporting?
A. Polyuria
B. Sodium 151 mEq/L
C. Thirst
D. Daily urine output 4 L
Answer: B — Sodium 151 mEq/L
(Hypernatremia can cause seizures.)
Rationale:
Hypernatremia can trigger brain cell dehydration → seizures → coma. Polyuria, thirst, and high urine output are expected — severe Na elevation is dangerous.
Which assessment signals DKA rather than HHS?
A. Severe dehydration
B. Fruity breath and Kussmauls
C. Confusion progressing to coma
D. Tachycardia
Answer: B — Fruity breath and Kussmauls
Rationale:
DKA produces ketones → acidosis → deep rapid breathing (Kussmauls) and acetone (fruity) odor. HHS lacks ketone production.
Which CVP reading indicates fluid overload?
A. 2 mmHg
B. 5 mmHg
C. 12 mmHg
D. 0 mmHg
Answer: C — 12 mmHg
Rationale:
Normal CVP = 0–8 mmHg. Higher values indicate excess preload/fluid overload.
After intubation, which assessment is priority?
A. End-tidal CO₂
B. Bilateral breath sounds
C. Tube marking
D. Pulse oximetry
Answer: B — Bilateral breath sounds
Rationale:
Must ensure tube is in the trachea — asymmetry may mean right-mainstem intubation or pneumothorax.
A trauma client is brought into the ED with unresponsive status. What is the nurse’s first priority?
A. Apply oxygen
B. Assess carotid pulse
C. Establish IV access
D. Perform Glasgow Coma Scale
Answer: B — Assess carotid pulse
(Circulation is first after establishing airway assessment.)
Rationale:
During the primary survey, after airway check you assess circulation — checking carotid pulse confirms perfusion and determines need for CPR.
A patient with SIADH is confused and weak. Which intervention is priority?
A. Encourage fluids
B. Restrict fluids
C. Give high salt diet
D. Administer insulin
Answer: B — Restrict fluids
Rationale:
SIADH causes water retention → dilutional hyponatremia → cerebral edema; restricting fluids prevents worsening edema and neurologic decline.
Which intervention is FIRST for a suspected DKA patient?
A. IV insulin bolus
B. IV 0.9% normal saline
C. Potassium infusion
D. Bicarbonate injection
Answer: B — IV 0.9% normal saline
Rationale:
Shock and dehydration are life-threatening; perfusion must be restored before insulin can work safely.
What complication is suspected when a client has sudden SOB after central line insertion?
A. Fluid overload
B. Pneumothorax
C. Hypoglycemia
D. Infection
Answer: B — Pneumothorax
Rationale:
The subclavian area sits near the lung apex — puncturing it can collapse a lung, causing respiratory distress.
Which suctioning rule helps prevent dysrhythmias?
A. Apply suction continuously during insertion
B. Limit suction time to <10 seconds
C. Increase sedation
D. Suction only after meals
Answer: B — Limit suction time to <10 seconds
Rationale:
Long suctioning causes hypoxia → vagal stimulation → arrhythmias. Short duration minimizes risk.
A patient’s LOC suddenly declines after head trauma. Which action is priority?
A. Call rapid response
B. Increase IV fluids
C. Elevate legs
D. Give acetaminophen
Answer: A — Call rapid response
(Neuro deterioration requires immediate escalation.)
Rationale:
Sudden neurological decline may indicate rising ICP or brain herniation — this is a clinical emergency requiring immediate escalation and intervention.
Which lab pattern confirms diabetes insipidus?
A. Low sodium, concentrated urine
B. Low sodium, dilute urine
C. High sodium, dilute urine
D. High sodium, concentrated urine
Answer: C — High sodium, dilute urine
Rationale:
In DI, the body cannot retain water → dehydration → hypernatremia and high serum osmolality, while urine remains dilute.
A DKA patient has potassium 2.9 mEq/L. What is the priority action?
A. Give insulin infusion
B. Start bicarbonate
C. Administer potassium
D. Restrict fluids
Answer: C — Administer potassium
(Insulin must be held until K+ normalizes.)
Rationale:
Insulin drives K+ into cells — giving insulin with low K+ can cause respiratory/cardiac arrest. Replace K+ first.
What is priority if an arterial line becomes dislodged?
A. Flush with saline
B. Call the provider
C. Apply direct pressure immediately
D. Remove tubing
Answer: C — Apply direct pressure immediately
Rationale:
Arterial lines bleed forcefully due to pressure — hemorrhage must be controlled immediately.
Which finding indicates possible ventilator-associated pneumonia?
A. High oxygen saturation
B. Sudden fever and increased secretions
C. Sinus bradycardia
D. Hyperactive bowel sounds
Answer: B — Sudden fever and increased secretions
Rationale:
Classic signs of infection in intubated patients — high risk due to colonization and aspiration.
Which finding indicates increasing intracranial pressure requiring urgent action?
A. Equal and reactive pupils
B. Widened pulse pressure
C. Alert and oriented behavior
D. Muscle stiffness in legs
Answer: B — Widened pulse pressure
Rationale:
Widened pulse pressure (↑SBP, ↓DBP) is a classic late sign of ICP and Cushing’s triad — requires urgent action to prevent herniation.
A patient with central DI is prescribed DDAVP. Which outcome indicates effectiveness?
A. Decreased urine output
B. Decreased blood pressure
C. Increased sodium
D. Weight loss
Answer: A — Decreased urine output
Rationale:
DDAVP replaces ADH → promotes water retention → decreases urine volume. Other options do not indicate treatment effectiveness.
Which finding differentiates HHS from DKA?
A. Glucose >250
B. Positive urine ketones
C. Neurological changes without ketones
D. Rapid Kussmaul respirations
Answer: C — Neurological changes without ketones
Rationale:
HHS is characterized by severe dehydration and neurologic decline without ketosis or acidosis.
Which finding suggests possible air embolism from central line misuse?
A. Hypertension
B. Chest pain and dyspnea
C. Decreased urine output
D. LOC alert
Answer: B — Chest pain and dyspnea
Rationale:
Air in circulation obstructs pulmonary flow → sudden chest pain, SOB, tachycardia — treat immediately.
A burn client with charred skin and no pain in the center likely has:
A. Superficial burn
B. Superficial partial thickness
C. Deep partial thickness
D. Full thickness burn
Answer: D — Full thickness burn
Rationale:
Deep nerve destruction causes loss of sensation; tissue is leathery and does not heal without grafting.
A triage nurse evaluates four clients. Which client is highest priority?
A. Dizziness with BP 150/90
B. Headache post-seizure but alert
C. Altered LOC and unequal pupils
D. Small scalp laceration, controlled bleeding
Answer: C — Altered LOC and unequal pupils
(Signs of possible brain herniation.)
Rationale:
This indicates possible brain herniation — airway protection and emergent neuro intervention are necessary.
Which assessment finding is most concerning in SIADH?
A. Weight gain
B. Crackles
C. Serum sodium 120
D. Low urine output
Answer: C — Sodium 120
(High seizure risk — priority action.)
Rationale:
Severe hyponatremia (<125) places the patient at risk for seizures and coma — this is a medical emergency.
When transitioning from IV to subQ insulin, what must be done?
A. Stop IV and start subQ at the same time
B. Give subQ insulin 1–2 hours before stopping IV
C. Give insulin only when glucose reaches 100
D. Switch immediately if the patient is eating
Answer: B — Give subQ insulin 1–2 hours before stopping IV
(Prevents rebound hyperglycemia.)
Rationale:
This prevents rebound hyperglycemia since IV insulin wears off rapidly.
A dampened arterial waveform indicates what complication?
A. Kink or clot in line
B. Blood loss improves
C. Equipment malfunction
D. Infection
Answer: A — Kink or clot in line
Rationale:
Dampened waves reflect poor pressure transmission — usually from occlusion or catheter malfunction.
A client with circumferential burns to both legs has weak pulses and increasing pain. Which action is priority?
A. Apply warming blankets
B. Administer opioid analgesics
C. Prepare for fasciotomy
D. Give oral fluids
Answer: C — Prepare for fasciotomy
(Signs of compartment syndrome.)
Rationale:
This suggests compartment syndrome — tissue perfusion must be restored surgically to prevent limb loss.