Emergency and trauma questions test one disciplined skill: work the ABCDE primary survey and fix each life threat before moving on. Work through these 10 practice questions on the primary survey, ESI triage, tension pneumothorax, impaled objects, overdose antidotes, and environmental emergencies, each with a full rationale.
Emergency & Trauma: The ABCDE Primary Survey & Triage
Emergency and trauma nursing on the NCLEX rewards a disciplined, priority-driven mindset. The organizing framework is the primary survey: A-B-C-D-E. Assess and treat life threats in that order; after any exsanguinating bleeding is controlled (current ATLS teaches x-ABCDE), airway comes first, and in any trauma patient with a possible spinal injury you protect the c-spine and open the airway with a jaw-thrust rather than a head-tilt/chin-lift. Breathing means looking for absent or asymmetric breath sounds that signal tension pneumothorax, open chest wounds, or flail chest. Circulation means controlling hemorrhage with direct pressure first, then a tourniquet for life-threatening extremity bleeding, plus large-bore IV access. Disability is a quick neuro check (pupils, Glasgow Coma Scale), and Exposure means fully undressing the patient to find hidden injuries, then immediately preventing hypothermia with warming. A head-to-toe secondary survey follows only after life threats are addressed.
Triage in the emergency department uses the Emergency Severity Index (ESI), a five-level scale. Level 1 is immediate resuscitation (cardiac arrest, apnea, unresponsive); level 2 is emergent/high-risk (cardiac chest pain, stroke symptoms, severe respiratory distress); levels 3-5 descend in acuity and resource needs. Triage sorts by acuity, not order of arrival. Recognize the classic life-threatening patterns: tension pneumothorax (tracheal deviation, absent breath sounds, JVD, hypotension) needs immediate needle decompression; cardiac tamponade (Beck triad—hypotension, JVD, muffled heart sounds) needs pericardiocentesis; and you never remove an impaled object—stabilize it in place.
Toxicology and environmental emergencies round out the topic. Memorize core antidotes: naloxone for opioids, flumazenil for benzodiazepines, acetylcysteine for acetaminophen, deferoxamine for iron, digoxin immune Fab for digoxin, vitamin K for warfarin, and atropine plus pralidoxime for organophosphates. Call Poison Control at 1-800-222-1222; ipecac is obsolete. Heat stroke (very high core temp plus altered mental status) is a true emergency requiring rapid active cooling, while hypothermia calls for controlled rewarming (passive external warming for mild cases, active core rewarming for moderate-to-severe hypothermia)—remember "not dead until warm and dead."
Emergency & Trauma Nursing NCLEX Practice Questions
Question 1 · Primary Survey (Airway/C-spine)
A client is brought to the emergency department after a high-speed motor vehicle collision. A cervical spine injury is suspected, and the client has snoring respirations with a partially obstructed airway. Which action should the nurse take FIRST to open the airway?
- A Perform a head-tilt/chin-lift maneuver
- B Insert a nasopharyngeal airway
- C Perform a jaw-thrust maneuver
- D Suction the oropharynx with a rigid catheter
Show answer & rationale
Correct answer: C
In trauma with a suspected cervical spine injury, airway is still the first priority, but it must be opened while protecting the spine. The jaw-thrust maneuver lifts the mandible forward to relieve obstruction from the tongue without extending the neck, so it is the correct first action. A head-tilt/chin-lift hyperextends the cervical spine and could convert an unstable fracture into spinal cord injury or paralysis, making it contraindicated whenever trauma is suspected. Inserting a nasopharyngeal airway may become useful, but it is not the first maneuver and is relatively contraindicated if facial or basilar skull trauma is present; you first reposition the jaw. Suctioning clears secretions or blood but does not address the tongue-based obstruction causing the snoring, and it is not the initial airway-opening maneuver. Clinical pearl: in any trauma client, think 'A with c-spine.' Manually stabilize the head in a neutral position and use jaw-thrust; reserve head-tilt/chin-lift for non-trauma airway management. Snoring or gurgling respirations are a red flag that the airway is not fully patent and demand immediate intervention before moving on to breathing and circulation. Current ATLS guidance (11th edition, 2025) uses x-ABCDE: any exsanguinating external hemorrhage is controlled first, then the airway is opened with c-spine protection, so with no catastrophic bleeding, as here, the airway is the first priority.
Question 2 · Primary Survey (ABCDE)
A nurse is performing the primary survey on a trauma client who arrives after a fall from a roof. Which actions are appropriate components of the primary survey? Select all that apply.
- A Obtain a detailed past medical and medication history
- B Auscultate for the presence of bilateral breath sounds
- C Apply direct pressure to an actively bleeding thigh wound
- D Assess pupil size, reactivity, and Glasgow Coma Scale
- E Remove all clothing and then cover the client with warm blankets
- F Clean and suture superficial facial lacerations
Show answer & rationale
Correct answer: B, C, D, E
The primary survey follows A-B-C-D-E and addresses only immediate life threats. Applying direct pressure to active bleeding is the Circulation (C) step—hemorrhage control begins with direct pressure before considering a tourniquet. Assessing pupils and Glasgow Coma Scale is Disability (D), a rapid neurologic check for evolving brain injury. Removing all clothing and then covering with warm blankets is Exposure (E): you must fully expose the client to find hidden injuries but immediately prevent hypothermia, which worsens coagulopathy and outcomes. Auscultating for bilateral breath sounds is Breathing (B), screening for tension pneumothorax, flail chest, or an open chest wound. Obtaining a detailed medication and medical history is valuable but belongs to the secondary survey (the AMPLE history), not the time-critical primary survey. Cleaning and suturing superficial lacerations is definitive wound care that is deferred until after life threats are managed—it is part of later treatment, not the primary survey. Clinical pearl: during the primary survey, if you find a problem you fix it before moving to the next letter—'find it, fix it, then advance.' A non-life-threatening laceration or a full history never takes precedence over airway, breathing, circulation, disability, and exposure. Remember that exposure and warming are a single linked step: undress to assess, then re-cover to protect body temperature.
Question 3 · Tension Pneumothorax
A client with blunt chest trauma suddenly develops severe dyspnea. The nurse notes tracheal deviation to the left, absent breath sounds on the right, distended neck veins, and a blood pressure of 78/44 mm Hg. Which intervention should the nurse anticipate as the immediate priority?
- A Prepare for needle decompression of the right chest
- B Administer high-flow oxygen and reassess in 15 minutes
- C Position the client supine with the legs elevated
- D Obtain a stat chest x-ray before any intervention
Show answer & rationale
Correct answer: A
This is a classic tension pneumothorax: tracheal deviation (away from the affected side), absent breath sounds on the affected side, jugular venous distention, and hypotension. Air trapped under pressure collapses the lung and shifts the mediastinum, compressing the great vessels and the opposite lung, producing obstructive shock. The immediate life-saving treatment is needle decompression (typically second intercostal space, midclavicular line, or the fifth intercostal space at the anterior axillary line), which releases the trapped air and is followed by chest tube placement. Giving oxygen and reassessing in 15 minutes is dangerously inadequate—oxygen alone does not relieve the trapped intrapleural pressure, and delay can be fatal within minutes. Positioning supine with legs elevated (a shock/Trendelenburg-type position) does not address the mechanical cause and can further embarrass ventilation; it will not restore perfusion when the problem is compression of the heart and vessels. Obtaining a chest x-ray first wastes critical time—tension pneumothorax is a clinical diagnosis treated on presentation, not a radiographic one. Clinical pearl: 'tension = decompress now.' Deviated trachea plus absent breath sounds plus JVD plus hypotension should trigger immediate action, not imaging. Distinguish it from cardiac tamponade, which shares hypotension and JVD but has muffled heart sounds and midline trachea and is treated with pericardiocentesis.
Question 4 · ED Triage (ESI)
Four clients arrive in the emergency department within minutes of each other. Using the Emergency Severity Index, which client should the triage nurse prioritize to be seen FIRST?
- A An ambulatory adult with a swollen ankle sprain who is requesting an x-ray
- B An adolescent with a sore throat and a temperature of 100.2 F (37.9 C)
- C An adult with 3 days of localized wrist pain and mild swelling after gardening
- D An adult with slurred speech and right-arm weakness that began 30 minutes ago
Show answer & rationale
Correct answer: D
Triage sorts clients by acuity and resource needs, not by order of arrival. Sudden slurred speech with right-arm weakness beginning 30 minutes ago is a classic acute stroke presentation—an ESI level 2 (emergent, high-risk) situation that is time-critical because thrombolytic and thrombectomy windows are narrow. This client must be seen first to begin the stroke protocol ('time is brain'). An ankle sprain in an ambulatory client is a lower-acuity complaint (roughly ESI level 4) requiring limited resources and no immediate threat to life. A sore throat with a low-grade fever in an otherwise stable adolescent is nonurgent (ESI level 4-5). Localized wrist pain with mild swelling present for three days is acute but stable and low-acuity (ESI level 4-5), carrying no life or limb threat. Clinical pearl: ESI level 1 = immediate resuscitation (cardiac arrest, apnea, unresponsive); level 2 = high-risk/emergent situations where deterioration is likely, including stroke symptoms, cardiac chest pain, and severe respiratory distress. When you spot a condition on the level-1 or level-2 list, it jumps the line regardless of how long lower-acuity clients have waited. Recognizing time-sensitive diagnoses—stroke, STEMI, sepsis—is the heart of safe triage.
Question 5 · Impaled Object
A client arrives in the emergency department with a large knife impaled in the abdomen after an assault. The client is alert with stable vital signs. Which action should the nurse take?
- A Carefully remove the knife and apply firm direct pressure
- B Gently rock the knife to determine the depth of penetration
- C Stabilize the knife in place with bulky dressings
- D Apply a tourniquet proximal to the wound to control bleeding
Show answer & rationale
Correct answer: C
An impaled object must never be removed in the field or at the bedside; it may be tamponading a lacerated vessel or organ, and removal can trigger catastrophic hemorrhage. The correct action is to stabilize the object in place with bulky dressings and secure it so it cannot move during transport or assessment, leaving definitive removal to the operating room where bleeding can be controlled surgically. Removing the knife and applying pressure is exactly the dangerous action to avoid—it can convert a contained injury into massive uncontrolled bleeding. Rocking or manipulating the object to gauge depth can extend the injury, dislodge a clot, and lacerate additional structures; it is never appropriate. Applying a tourniquet to the abdomen is anatomically impossible and clinically wrong—tourniquets are used only for life-threatening extremity hemorrhage, not truncal wounds, where direct pressure and surgical control are required. Clinical pearl: 'impaled = immobilize, don't remove.' Stabilize in place, control surrounding bleeding with pressure around (not on) the object, monitor for shock, and prepare the client for surgery. The only rare exception discussed in prehospital care is an object obstructing the airway or interfering with CPR, which does not apply to a stable abdominal injury.
Question 6 · Antidotes
A nurse is reviewing common toxicologic emergencies. Which poison-and-antidote pairings are correctly matched? Select all that apply.
- A Acetaminophen overdose — acetylcysteine
- B Warfarin toxicity — protamine sulfate
- C Iron overdose — deferoxamine
- D Benzodiazepine overdose — flumazenil
- E Organophosphate poisoning — activated charcoal as the sole treatment
- F Opioid overdose — naloxone
Show answer & rationale
Correct answer: A, C, D, F
Correctly matched pairs: naloxone reverses opioids by competitively blocking opioid receptors and rapidly restores respiratory drive; acetylcysteine (N-acetylcysteine) is the antidote for acetaminophen overdose, replenishing glutathione to prevent fatal hepatotoxicity and working best within 8-10 hours of ingestion; flumazenil reverses benzodiazepines by blocking the benzodiazepine site on the GABA-A receptor (used cautiously because it can precipitate seizures or withdrawal); and deferoxamine chelates iron in iron overdose to enhance elimination. Two pairings are wrong. Warfarin toxicity is reversed with vitamin K (phytonadione) and, for serious bleeding, prothrombin complex concentrate or fresh frozen plasma—protamine sulfate reverses heparin, not warfarin, a very common NCLEX distractor. Organophosphate poisoning is treated with atropine plus pralidoxime to counter the cholinergic crisis; activated charcoal may adsorb some agents if given early but is never the sole or definitive treatment, so this pairing is incorrect. Clinical pearl for antidote recall: opioids-naloxone, benzos-flumazenil, acetaminophen-acetylcysteine, iron-deferoxamine, digoxin-digoxin immune Fab, warfarin-vitamin K, heparin-protamine, organophosphates-atropine + pralidoxime. Always call Poison Control at 1-800-222-1222 for guidance, and remember that ipecac syrup is obsolete and no longer recommended for any ingestion.
Question 7 · Heat Stroke
A marathon runner is brought to the emergency department confused and combative. The core temperature is 41.1 C (106 F), and the skin is hot and dry. Which intervention is the priority?
- A Encourage oral electrolyte fluids and rest in a shaded area
- B Begin rapid active cooling measures immediately
- C Administer an oral acetaminophen antipyretic
- D Apply warm blankets to prevent shivering
Show answer & rationale
Correct answer: B
A very high core temperature combined with altered mental status (confusion, combativeness) and hot skin defines heat stroke, a life-threatening emergency in which thermoregulation has failed and organ damage is occurring. The priority is rapid active cooling—remove clothing and use cold-water immersion, evaporative cooling with misting and fans, ice packs to the groin, axillae, and neck, and cooled IV fluids—to bring the core temperature down quickly before neurologic and multiorgan injury become irreversible. Encouraging oral fluids and rest in the shade is treatment for heat exhaustion, the milder condition where mental status is intact; it is grossly insufficient here and an altered, combative patient also cannot safely drink. Acetaminophen does not work in heat stroke because the hyperthermia is not mediated by the hypothalamic set point (as in fever); antipyretics are ineffective and may add hepatic risk. Applying warm blankets is the opposite of what is needed and would worsen the hyperthermia. Clinical pearl: the key discriminator between heat exhaustion and heat stroke is the central nervous system—altered mental status means heat stroke until proven otherwise, and it demands aggressive cooling. Monitor for seizures, rhabdomyolysis, and cardiac arrhythmias, and stop active cooling around 38.3-38.9 C (about 101-102 F) to avoid overshoot hypothermia.
Question 8 · Hypothermia
A hiker is found unresponsive in the snow and brought to the emergency department with a core temperature of 29 C (84.2 F), a heart rate of 38 beats/min, and no palpable radial pulse. Which nursing consideration is most appropriate?
- A Rewarm rapidly by immersing the extremities in hot water
- B Withhold resuscitation because survival at this temperature is unlikely
- C Vigorously rub the skin to stimulate peripheral circulation
- D Initiate gradual, controlled rewarming and continue resuscitation efforts
Show answer & rationale
Correct answer: D
Severe hypothermia is managed with gradual, controlled rewarming while resuscitation continues. Core rewarming methods include warmed humidified oxygen, warmed IV fluids, and, in severe cases, warmed peritoneal or extracorporeal techniques, alongside gentle handling and continuous cardiac monitoring. The guiding principle is 'not dead until warm and dead'—cold profoundly depresses metabolism and can protect the brain, so patients have survived neurologically intact after prolonged arrest; resuscitation must not be stopped until the patient is rewarmed. Withholding resuscitation because of the low temperature is therefore wrong and potentially fatal. Immersing the extremities in hot water causes rapid peripheral rewarming that shunts cold, acidotic, hyperkalemic blood back to the core, precipitating 'afterdrop' and lethal arrhythmias such as ventricular fibrillation; peripheral rapid rewarming is avoided in systemic hypothermia. Vigorously rubbing the skin is contraindicated because rough handling and massage can trigger ventricular fibrillation in the irritable cold myocardium and worsen tissue injury. Clinical pearl: handle hypothermic patients gently, rewarm the core before the periphery, and keep resuscitating until core temperature is restored (generally at least 32-35 C) before making decisions about viability. Note this contrasts with frostbite, where rapid rewarming of the affected part in warm (not hot) water is correct and rubbing is still prohibited.
Question 9 · ED Triage (ESI)
Six clients are in the emergency department waiting room. Using the Emergency Severity Index, which clients require immediate (ESI level 1 or 2) evaluation? Select all that apply.
- A A child with a single episode of vomiting who is tolerating fluids
- B An adult with crushing substernal chest pain radiating to the jaw who is diaphoretic
- C An adult with a minor abrasion to the knee
- D An adult in cardiac arrest with CPR in progress
- E An adult with new facial droop and slurred speech that began 1 hour ago
- F An adult with severe respiratory distress and audible stridor
Show answer & rationale
Correct answer: B, D, E, F
ESI level 1 is immediate resuscitation, and level 2 is emergent/high-risk—both jump ahead of lower-acuity clients regardless of arrival order. The client in cardiac arrest with CPR in progress is ESI level 1, the highest acuity. Crushing substernal chest pain radiating to the jaw with diaphoresis is a suspected acute coronary syndrome, an ESI level 2 requiring immediate ECG and cardiac workup ('time is muscle'). Severe respiratory distress with stridor signals impending airway compromise—an ESI level 1-2 emergency demanding immediate airway assessment. New facial droop and slurred speech one hour ago is an acute stroke, ESI level 2 and time-critical for reperfusion therapy ('time is brain'). The two lower-acuity clients do not need immediate evaluation: a child with a single episode of vomiting who is tolerating fluids is stable and low-risk (roughly ESI level 4), and a minor knee abrasion is a level 4-5 complaint requiring minimal resources. Clinical pearl: memorize the high-acuity triggers—cardiac arrest and apnea/unresponsiveness are level 1; cardiac chest pain, stroke symptoms, and severe respiratory distress are level 2. Triage is about recognizing patterns that predict rapid deterioration, then acting on acuity rather than the clock of who arrived first.
Question 10 · Cardiac Tamponade
A client with blunt chest trauma from a steering-wheel injury develops hypotension, jugular venous distention, and muffled heart sounds. The trachea is midline. The nurse recognizes these findings and prepares to assist with which intervention?
- A Pericardiocentesis
- B Needle decompression of the pleural space
- C Immediate chest tube insertion for a hemothorax
- D Application of a pelvic binder
Show answer & rationale
Correct answer: A
Hypotension, jugular venous distention, and muffled heart sounds are Beck triad, the hallmark of cardiac tamponade. Blood accumulating in the pericardial sac compresses the heart, limiting ventricular filling and producing obstructive shock. The definitive emergency intervention is pericardiocentesis (or pericardial window/surgery), which removes the fluid and relieves the compression, so the nurse should prepare to assist with that procedure. Needle decompression treats tension pneumothorax; although tension pneumothorax also causes hypotension and JVD, it presents with tracheal deviation and absent unilateral breath sounds, not muffled heart sounds with a midline trachea—so decompressing the pleural space would not help this client. A chest tube for hemothorax addresses blood in the pleural cavity and does not relieve fluid inside the pericardium. A pelvic binder is used to stabilize a suspected pelvic fracture with hemorrhage, which is unrelated to these cardiac findings. Clinical pearl: differentiate the two great 'JVD plus hypotension' obstructive emergencies. Tension pneumothorax = deviated trachea, absent breath sounds on one side, needle decompression. Cardiac tamponade = muffled heart sounds, midline trachea, pericardiocentesis. Both are treated on clinical recognition without waiting for imaging, and both can arise from blunt chest trauma, so a focused breath-sound and heart-sound assessment guides the correct life-saving action.
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Emergency & Trauma Nursing FAQ
What is the ABCDE primary survey in trauma nursing?
ABCDE is the ordered sequence for finding and treating life threats (current ATLS adds an initial ‘x’ step to control exsanguinating hemorrhage): Airway with cervical spine protection (use a jaw-thrust, not a head-tilt, if spinal injury is suspected), Breathing (check for absent or asymmetric breath sounds), Circulation (control hemorrhage with direct pressure, then a tourniquet, and establish large-bore IV access), Disability (assess pupils and Glasgow Coma Scale), and Exposure (fully undress the patient to find injuries, then warm them to prevent hypothermia). You fix each problem before moving to the next letter, then complete a head-to-toe secondary survey once life threats are addressed.
How does ESI triage decide who is seen first in the ED?
The Emergency Severity Index is a five-level scale that sorts patients by acuity and resource needs, not by order of arrival. Level 1 is immediate resuscitation (cardiac arrest, apnea, unresponsiveness); level 2 is emergent/high-risk (cardiac chest pain, stroke symptoms, severe respiratory distress); levels 3 through 5 descend in urgency. On the NCLEX, identify time-critical, deteriorating conditions—stroke, STEMI, airway compromise, sepsis—and prioritize them ahead of stable, lower-acuity complaints regardless of how long those patients have waited.
What are the must-know antidotes for the NCLEX?
Memorize these pairs: opioids reversed by naloxone, benzodiazepines by flumazenil, acetaminophen by acetylcysteine (N-acetylcysteine), iron by deferoxamine, digoxin by digoxin immune Fab, warfarin by vitamin K, heparin by protamine sulfate, and organophosphates by atropine plus pralidoxime. Always call Poison Control at 1-800-222-1222, use activated charcoal only for select recent ingestions, and remember that syrup of ipecac is obsolete and no longer recommended.
How is heat stroke treated differently from heat exhaustion?
The key difference is mental status. Heat exhaustion is milder—the patient has a normal or mildly elevated temperature with an intact mental status—and is treated with rest, a cool environment, and oral electrolyte fluids. Heat stroke is a medical emergency marked by a very high core temperature plus altered mental status (confusion, combativeness, or unconsciousness). It requires immediate rapid active cooling with cold-water immersion, evaporative cooling, ice packs to the groin, axillae, and neck, and cooled IV fluids. Antipyretics like acetaminophen do not work in heat stroke because the hyperthermia is not fever-driven.