MOH Prometric · Clinical Practice & Patient Safety

Primary Nursing, Acute Patient Assessment and Triage

28 practice questions, each with the answer and an explanation.

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Random questions from this topic, one at a time. You see the answer and the explanation straight after each one.

All 28 questions

  1. During emergency triage in a UAE hospital emergency department utilizing the Emergency Severity Index (ESI), a 45-year-old male arrives pulseless and apneic following an electric shock. Under which ES…
  2. A nurse is assessing a postoperative patient's level of consciousness using the Glasgow Coma Scale (GCS). The patient opens eyes to verbal command (3), utters inappropriate words during conversation (…
  3. A nurse performs a neurological assessment on a patient with suspected bacterial meningitis. With the patient lying supine, the nurse flexes the patient's neck forward toward the chest, which elicits…
  4. A patient is admitted following a motor vehicle collision. On physical examination, the nurse notes bruising over the mastoid process behind the ear (Battle's sign) and periorbital ecchymosis ('raccoo…
  5. A nurse is assessing an elderly bedridden patient for pressure injury risk using the Braden Scale. Which six physiological and environmental subscales constitute the validated Braden Scale?
  6. A nurse performs an abdominal assessment on a patient presenting with abdominal pain. In what sequential order should the four physical examination techniques be conducted on the abdomen to avoid alte…
  7. A 58-year-old male is admitted with suspected acute stroke. The triage nurse performs an assessment using the Cincinnati Prehospital Stroke Scale (CPSS). Which three physical findings comprise this va…
  8. A patient who underwent a thyroidectomy 24 hours ago develops numbness and tingling around the lips and fingertips, muscle twitching, and positive Chvostek and Trousseau signs. What acute post-surgica…
  9. A nurse is caring for a patient who develops a suspected acute hemolytic transfusion reaction 10 minutes after starting a unit of packed red blood cells. What is the very first action the nurse must t…
  10. A triage nurse assesses a 22-year-old female presenting with severe acute lower abdominal pain. Which diagnostic test is mandatory in all female patients of reproductive age presenting with acute abdo…
  11. A nurse assesses an infant presenting with lethargy, sunken fontanelles, dry mucous membranes, absence of tears when crying, and delayed skin turgor recoil (> 3 seconds). According to WHO clinical deh…
  12. A nurse is performing a physical assessment on a patient with chronic liver disease. The nurse observes involuntary rhythmic, non-synchronous flapping movements of the hands when the patient extends t…
  13. A 65-year-old male with chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. The nurse notes central cyanosis, barrel chest, and clubbing of the fingers. Clubbing of th…
  14. A nurse in the post-anesthesia care unit (PACU) is evaluating a patient following general anesthesia using the Aldrete Score. Which five physical criteria are evaluated to determine readiness for disc…
  15. A nurse palpates the radial pulse of a patient with atrial fibrillation and simultaneously auscultates the apical pulse with a stethoscope for a full minute. The apical pulse rate is 108 bpm and the r…
  16. A nurse is caring for a patient who suddenly develops severe dyspnea and chest pain 3 days after an open reduction and internal fixation of a femur fracture. The nurse notes petechiae across the anter…
  17. A nurse enters the hospital room of a patient receiving intravenous fluids and notes that the patient's forearm at the peripheral catheter insertion site is cool, pale, swollen, and non-tender, with I…
  18. A nurse performs an admission intake on a patient. While measuring the patient's blood pressure, the nurse notices that the blood pressure cuff width covers only 20% of the patient's upper arm circumf…
  19. A 72-year-old male with severe benign prostatic hyperplasia has not voided for 14 hours and presents with acute agonizing suprapubic pain. Bedside bladder ultrasound scan demonstrates 1,200 mL of reta…
  20. A nurse is suctioning an adult patient with a tracheostomy who has thick, retained secretions. According to clinical practice guidelines, what is the maximum recommended duration for an individual tra…
  21. A nurse is reviewing a postoperative patient's arterial blood gas (ABG) results: pH 7.28, PaCO2 55 mmHg, PaO2 78 mmHg, and HCO3 24 mEq/L. What is the interpretation of this acid-base disturbance?
  22. A patient is admitted to the intensive care unit with a tracheostomy tube. While repositioning the patient, the nurse hears sudden gurgling sounds, and the patient displays respiratory distress. The n…
  23. A nurse is caring for a patient who has a closed chest drainage system (underwater seal) for a traumatic pneumothorax. While checking the system, the nurse observes continuous, vigorous bubbling in th…
  24. A 70-year-old male with chronic renal failure on hemodialysis presents to the triage desk with severe generalized weakness and peaked T waves on 12-lead ECG. Point-of-care serum potassium is 7.2 mmol/…
  25. Using the five-level Emergency Severity Index, which patient is assigned to level 2?
  26. A patient opens the eyes to a spoken command, speaks only inappropriate words, and localises pain by pushing at the examiner's hand. What is the Glasgow Coma Scale score?
  27. A patient with suspected infection has a respiratory rate of 24/min, a systolic blood pressure of 96 mmHg and is fully alert. What is the qSOFA score and what does it mean?
  28. A sacral pressure injury has full-thickness skin loss with visible subcutaneous fat and some slough that does not hide the depth. No muscle or bone is exposed. Which stage applies?

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