Nclexrn Quiz: Prioritization And First Action
20 questions · exam conditions
0:00
Prioritization And First ActionQuestion 1 of 20

A 24-year-old is brought to the emergency department after an opioid overdose. Assessment: RR 6, shallow respirations, SpO2 82% on room air, pinpoint pupils, HR 58, BP 102/60. What is the nurse's FIRST action?

Insert an indwelling urinary catheter to monitor output
Administer naloxone per protocol and prepare for repeat dosing as needed
Obtain a urine drug screen and blood alcohol level
Interview family members about substance use history and prior overdoses
← Back to quizzes

Nclexrn Quiz

Nclexrn Quiz: Prioritization And First Action

Practice Prioritization And First Action in Nclexrn with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.

What this quiz covers

This quiz focuses on Prioritization And First Action, giving you a quick way to practice the rules, question types, and explanations that matter most for Nclexrn.

How to use this quiz

Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.

All questions

Question 1

A 24-year-old is brought to the emergency department after an opioid overdose. Assessment: RR 6, shallow respirations, SpO2 82% on room air, pinpoint pupils, HR 58, BP 102/60. What is the nurse's FIRST action?

  1. Insert an indwelling urinary catheter to monitor output
  2. Administer naloxone per protocol and prepare for repeat dosing as needed (correct answer)
  3. Obtain a urine drug screen and blood alcohol level
  4. Interview family members about substance use history and prior overdoses
Explanation: This question assesses prioritization and clinical judgment skills in opioid overdose. The prioritization framework used is the ABCs, emphasizing breathing and reversal. Administering naloxone per protocol is the first action to antagonize opioids and restore respirations. Obtaining drug screens is diagnostic but delays; inserting a catheter monitors output secondarily; and interviewing family gathers history after stabilization. The underlying decision-making principle is to reverse respiratory depression immediately in overdoses. This restores airway patency. A generalizable prioritization strategy is to use antidotes first in toxin-induced respiratory failure, applying ABCs in emergency toxicology.

Question 2

A nurse is caring for four clients in the emergency department. Which client should the nurse assess FIRST? (1) 29-year-old with ankle sprain, pain 6/10, stable vital signs; (2) 61-year-old with sudden severe headache, BP 190/104, nausea, photophobia; (3) 46-year-old with kidney stone, pain 9/10, BP 152/88; (4) 52-year-old with influenza-like illness, temp 38.6°C (101.5°F), SpO2 96%.

  1. Assess the 61-year-old with sudden severe headache and BP 190/104 (correct answer)
  2. Assess the 29-year-old with ankle sprain and pain 6/10
  3. Assess the 52-year-old with influenza-like illness and fever
  4. Assess the 46-year-old with suspected kidney stone and pain 9/10
Explanation: This question assesses prioritization and clinical judgment skills in an emergency department. The prioritization framework used is the ABCs, prioritizing neurological stability. The 61-year-old with sudden severe headache and BP 190/104 should be assessed first due to potential hypertensive emergency or stroke, requiring urgent evaluation. The 46-year-old has pain but stable vitals; the 52-year-old has fever without distress; and the 29-year-old has minor injury. The underlying decision-making principle is to address acute neurological changes with hypertension before pain or infection. This prevents irreversible damage. A generalizable prioritization strategy is to evaluate sudden onset symptoms suggesting cerebrovascular events first, applying ABCs in ED triage.

Question 3

A nurse receives report on four clients in an acute care setting. Which client should the nurse assess FIRST? (1) 63-year-old with chronic kidney disease and potassium 6.2 mEq/L (reference 3.5–5.0), peaked T waves noted on telemetry; (2) 51-year-old with asthma requesting PRN inhaler, SpO2 94%; (3) 38-year-old with migraine, pain 9/10, photophobia; (4) 74-year-old with constipation, no bowel movement for 3 days, abdomen soft.

  1. Assess the 74-year-old with constipation for 3 days and soft abdomen
  2. Assess the 38-year-old with migraine pain 9/10 and photophobia
  3. Assess the 63-year-old with potassium 6.2 mEq/L and peaked T waves (correct answer)
  4. Assess the 51-year-old with asthma requesting a PRN inhaler and SpO2 94%
Explanation: This question assesses prioritization and clinical judgment skills in an acute care setting. The prioritization framework used is the ABCs, emphasizing circulation and cardiac stability. The 63-year-old with potassium 6.2 mEq/L and peaked T waves should be assessed first due to hyperkalemia risking arrhythmias. The 38-year-old has pain; the 51-year-old has mild hypoxia; and the 74-year-old has constipation. The underlying decision-making principle is to address electrolyte imbalances causing ECG changes immediately. This prevents cardiac events. A generalizable prioritization strategy is to evaluate abnormal labs with cardiac implications first, using ABCs in multi-client care.

Question 4

A 6-year-old is brought to the clinic after eating a cookie containing peanuts. Assessment: lip swelling, hives, hoarse voice, stridor, RR 32, SpO2 89% on room air, HR 148, BP 88/54. What is the nurse's FIRST action?

  1. Provide oral fluids to prevent dehydration and reassess in 30 minutes
  2. Obtain a throat culture and assess for infection
  3. Start an IV line and administer diphenhydramine as prescribed
  4. Administer intramuscular epinephrine per anaphylaxis protocol (correct answer)
Explanation: This question assesses prioritization and clinical judgment skills in pediatric anaphylaxis. The prioritization framework used is the ABCs, focusing on airway and circulation. Administering intramuscular epinephrine per protocol is the first action to reverse severe allergic reaction and stabilize breathing and blood pressure. Starting an IV with diphenhydramine is supportive but secondary; obtaining a throat culture assumes infection; and providing fluids delays critical treatment. The underlying decision-making principle is to use epinephrine immediately in anaphylaxis to counteract histamine effects. This ensures rapid symptom reversal. A generalizable prioritization strategy is to administer reversal agents first in allergic emergencies, using ABCs to guide pediatric acute care.

Question 5

A 79-year-old with dementia in a long-term care facility is found on the floor next to the bed. Assessment: grimacing with movement, right leg shortened and externally rotated, BP 168/94, HR 104, RR 22, SpO2 95%. What is the nurse's PRIORITY action?

  1. Apply heat to the hip and encourage range-of-motion exercises
  2. Offer oral fluids and reorient the client to place and time
  3. Assist the client back into bed to prevent further embarrassment
  4. Keep the client still, assess neurovascular status of the extremity, and notify the provider (correct answer)
Explanation: This question assesses prioritization and clinical judgment skills in a potential hip fracture. The prioritization framework used is the ABCs, focusing on circulation and neurovascular integrity. Keeping the client still, assessing neurovascular status, and notifying the provider is the priority to prevent further injury and complications like compartment syndrome. Assisting back to bed ignores assessment; applying heat could worsen swelling; and offering fluids addresses orientation but not injury. The underlying decision-making principle is to immobilize and evaluate suspected fractures immediately. This minimizes risks like displacement. A generalizable prioritization strategy is to stabilize and assess injuries before movement, using ABCs in fall-related scenarios for older adults.

Question 6

In the emergency department, a 34-year-old arrives with severe shortness of breath and audible wheezing after exposure to a cat. Assessment: RR 34, SpO2 86% on room air, HR 132, BP 148/92, speaking in 1–2 word sentences, use of accessory muscles. What is the nurse's PRIORITY action?

  1. Obtain a peak expiratory flow measurement and document the value
  2. Teach pursed-lip breathing and have the client lie flat to rest
  3. Start an intravenous line and draw blood for a complete blood count
  4. Apply oxygen and initiate a prescribed short-acting bronchodilator via nebulizer (correct answer)
Explanation: This question assesses prioritization and clinical judgment skills in an emergency asthma exacerbation. The prioritization framework used is the ABCs, emphasizing airway and breathing as immediate needs. Applying oxygen and initiating a short-acting bronchodilator via nebulizer is the priority action to rapidly relieve bronchospasm and improve oxygenation in this client with severe respiratory distress. Obtaining a peak flow is diagnostic but delays treatment; starting an IV and drawing blood addresses secondary needs; and teaching pursed-lip breathing while lying flat is inappropriate for acute distress and could worsen symptoms. The underlying decision-making principle is to intervene immediately on airway compromise to prevent respiratory failure. This approach stabilizes the client before further assessments or diagnostics. A generalizable prioritization strategy is to use the ABCs to address life-threatening breathing issues first in acute respiratory scenarios, ensuring rapid reversal of hypoxia.

Question 7

A nurse is caring for a single client with multiple competing needs: a 69-year-old with heart failure admitted for fluid overload who now reports dizziness when standing. Assessment: BP 88/52, HR 110, crackles at bases, SpO2 93% on 2 L/min nasal cannula, urine output 20 mL/hr after IV diuretics. What is the nurse's FIRST action?

  1. Assist the client to ambulate to evaluate functional tolerance and reassess blood pressure
  2. Provide low-sodium diet teaching to reduce future fluid overload
  3. Administer the next scheduled dose of IV diuretic to improve oxygenation
  4. Place the client supine with legs elevated and reassess blood pressure and symptoms (correct answer)
Explanation: This question assesses prioritization and clinical judgment skills for a single client with competing needs. The prioritization framework used is the ABCs, prioritizing circulation in orthostatic hypotension. Placing the client supine with legs elevated and reassessing is the first action to improve blood pressure and perfusion. Assisting to ambulate risks falls; administering diuretic could worsen; and diet teaching is long-term. The underlying decision-making principle is to treat hypotension positionally before further interventions. This stabilizes vitals. A generalizable prioritization strategy is to use positioning for acute BP drops first, applying ABCs in heart failure management.

Question 8

A nurse receives report on four clients on an oncology unit. Which client should the nurse assess FIRST? (1) 60-year-old receiving chemotherapy with temperature 38.5°C (101.3°F), ANC 400/mm³ (reference ~1500–8000), HR 110; (2) 48-year-old with nausea after chemotherapy, BP 126/78; (3) 72-year-old with chronic anemia, Hgb 9.2 g/dL, reports fatigue; (4) 55-year-old with mucositis, pain 7/10, able to swallow liquids.

  1. Assess the 60-year-old with fever and ANC 400/mm³ (correct answer)
  2. Assess the 72-year-old with chronic anemia and fatigue
  3. Assess the 55-year-old with mucositis and pain 7/10
  4. Assess the 48-year-old with nausea after chemotherapy
Explanation: This question assesses prioritization and clinical judgment skills on an oncology unit. The prioritization framework used is Maslow's hierarchy, prioritizing physiological needs like infection prevention. The 60-year-old with fever and ANC 400/mm³ should be assessed first due to neutropenic sepsis risk, requiring urgent intervention. The 48-year-old has nausea without instability; the 72-year-old has chronic fatigue; and the 55-year-old has pain but can swallow. The underlying decision-making principle is to address infection in immunocompromised clients before symptoms like pain. This prevents rapid deterioration. A generalizable prioritization strategy is to evaluate low ANC with fever first, applying Maslow's in oncology prioritization.

Question 9

A nurse in an acute care unit receives report on four clients. Which client should the nurse assess FIRST? (1) 50-year-old with pancreatitis reporting pain 8/10, BP 138/84, HR 98; (2) 67-year-old with GI bleed, black tarry stool, BP 104/62, HR 112, Hgb 7.4 g/dL (reference ~12–16 female, 13.5–17.5 male); (3) 73-year-old with UTI, temp 38.3°C (100.9°F), BP 128/76; (4) 45-year-old with cellulitis awaiting first dose of antibiotics, BP 122/74.

  1. Assess the 67-year-old with GI bleed, tachycardia, and hemoglobin 7.4 g/dL (correct answer)
  2. Assess the 45-year-old with cellulitis awaiting first dose of antibiotics and BP 122/74
  3. Assess the 73-year-old with UTI, temperature 38.3°C (100.9°F), and BP 128/76
  4. Assess the 50-year-old with pancreatitis reporting pain 8/10, BP 138/84, and HR 98
Explanation: The client with GI bleed, tachycardia, and hemoglobin 7.4 g/dL is the priority because they show signs of active bleeding and potential hypovolemia, risking hemodynamic instability. The client with cellulitis awaiting antibiotics has stable blood pressure and no signs of systemic compromise; although treatment is important, it is not immediately life-threatening. The client with UTI and temperature 38.3°C has a mild fever with no hypotension, indicating a less urgent infection. The client with pancreatitis reporting pain 8/10 has elevated but stable vital signs; pain management is needed but does not outweigh the risk of hypovolemic shock. Prioritize using ABCs—circulation first—and recognize abnormal labs indicating blood loss as the highest urgency.

Question 10

The nurse is assigned four clients on a pediatric unit. Which client should the nurse assess FIRST? (1) 4-year-old with croup receiving humidified air, mild stridor when crying, SpO2 95%; (2) 8-year-old with sickle cell disease, reports chest pain and shortness of breath, RR 30, SpO2 89%; (3) 2-year-old with gastroenteritis, dry mucous membranes, cap refill 3 seconds, HR 132; (4) 10-year-old with appendectomy yesterday, pain 6/10, afebrile.

  1. Assess the 2-year-old with gastroenteritis, dry mucous membranes, and delayed capillary refill
  2. Assess the 4-year-old with croup, mild stridor when crying, and SpO2 95%
  3. Assess the 10-year-old post-appendectomy with pain 6/10, afebrile, and normal heart rate
  4. Assess the 8-year-old with sickle cell disease, chest pain, and SpO2 89% (correct answer)
Explanation: The 8-year-old with sickle cell disease, chest pain, and SpO2 89% should be seen first because these findings suggest acute chest syndrome, a life-threatening oxygenation emergency. Use the ABCs: airway, breathing, circulation. This client has a low oxygen saturation and chest pain, indicating respiratory compromise that can rapidly worsen. The 2-year-old with gastroenteritis, dry mucous membranes, and delayed capillary refill is dehydrated, but this is a circulatory issue that is less immediately life-threatening than hypoxia. The 4-year-old with croup has mild stridor and an SpO2 of 95%, which shows adequate oxygenation and a stable airway. The 10-year-old post-appendectomy with pain 6/10, afebrile, and normal heart rate has no signs of acute instability or sepsis. Prioritize the client with the greatest risk of decompensation; the sickle cell client's hypoxia and chest pain put them at the highest risk.

Question 11

A nurse receives report on four clients on a step-down unit. Which client should the nurse assess FIRST? (1) 57-year-old with diabetic ketoacidosis on insulin infusion, blood glucose 210 mg/dL and trending down, potassium 4.2 mEq/L; (2) 66-year-old with sepsis receiving IV antibiotics, lactate 1.8 mmol/L, BP 118/70; (3) 74-year-old with a new tracheostomy who has copious secretions, audible gurgling, RR 26, SpO2 90%; (4) 39-year-old with pancreatitis, NPO, pain controlled with PCA, RR 16.

  1. Assess the 66-year-old with sepsis receiving IV antibiotics and stable blood pressure
  2. Assess the 39-year-old with pancreatitis and pain controlled with PCA
  3. Assess the 74-year-old with new tracheostomy, gurgling secretions, and SpO2 90% (correct answer)
  4. Assess the 57-year-old with diabetic ketoacidosis on insulin infusion and improving glucose
Explanation: When a stem asks who to see first, apply the ABCs and look for the client whose airway or breathing is actively threatened. The client with a new tracheostomy has copious secretions with audible gurgling, a respiratory rate of 26, and SpO2 of 90 percent — a partially obstructed artificial airway that will fail without prompt assessment and suctioning, and a new tracheostomy has no margin for delay. The septic client receiving antibiotics has a lactate of 1.8 and a blood pressure of 118 over 70, which reflects treatment that is working rather than deterioration, so this is a circulation concern already trending in the right direction. The client in diabetic ketoacidosis on an insulin infusion has a glucose of 210 trending down and a potassium of 4.2, both expected and reassuring on therapy; important to monitor, but stable. The client with pancreatitis has pain controlled on a PCA and a respiratory rate of 16, which is comfort and monitoring, not instability. Rank by physiologic threat, not by diagnosis severity or the number of interventions running: an airway or breathing problem in progress outranks a circulation issue that is improving and any stable client.

Question 12

A nurse is caring for a 59-year-old with a central venous catheter receiving total parenteral nutrition (TPN). Assessment: temperature 39.0°C (102.2°F), HR 122, BP 92/54, chills, and the insertion site is erythematous with drainage. What is the nurse's FIRST action?

  1. Change the central line dressing using sterile technique, obtain a culture of the drainage, and document the findings
  2. Apply a warm compress to the insertion site and reassess the erythema and drainage in 30 minutes
  3. Stop the TPN infusion, maintain IV access with normal saline, and notify the provider/rapid response per policy (correct answer)
  4. Administer acetaminophen as prescribed to reduce the fever and encourage oral fluids while monitoring vital signs
Explanation: The patient's fever, tachycardia, hypotension, chills, and purulent site suggest a central line-associated bloodstream infection progressing toward sepsis. The first priority is to stop the infusion that is delivering the infectious source into the bloodstream, and to keep a patent IV line with normal saline so resuscitation and antibiotics can be given; notifying the provider or rapid response per policy is part of that immediate action. Changing the dressing and culturing the drainage addresses only the local site, which does nothing to stop the infection from reaching the bloodstream and is not the first step when systemic signs are present. A warm compress treats the local erythema but ignores the fever, hypotension, and chills that signal sepsis, so it delays urgent care. Acetaminophen lowers the fever but does not treat the line infection, does not correct the hypotension, and does not stop the ongoing infusion. In any suspected line infection with systemic signs, stop the line first, then alert the team.

Question 13

A nurse on a medical unit is notified that a 71-year-old client with a nasogastric (NG) tube for decompression has new onset coughing and difficulty breathing. Assessment: RR 28, SpO2 87% on room air, coarse breath sounds, and the NG tube marking at the nare has shifted outward by 6 cm. What is the nurse's PRIORITY action?

  1. Stop the suction, apply oxygen, and assess tube placement per facility policy (correct answer)
  2. Document the external tube length change and recheck in 1 hour
  3. Administer PRN cough suppressant and encourage deep breathing
  4. Irrigate the NG tube with 30 mL of air to restore patency
Explanation: This question assesses prioritization and clinical judgment skills in NG tube complications. The prioritization framework used is the ABCs, focusing on airway and breathing. Stopping suction, applying oxygen, and assessing tube placement is the priority to address potential displacement causing aspiration risk. Irrigating with air could worsen; administering cough suppressant ignores cause; and documenting delays intervention. The underlying decision-making principle is to correct tube malposition immediately in respiratory distress. This restores safety. A generalizable prioritization strategy is to verify placement first in tube-related coughing, applying ABCs in enteral feeding issues.

Question 14

In an acute care medical-surgical unit, the nurse receives shift report on four clients. Which client should the nurse assess FIRST?

A. A 58-year-old with type 2 diabetes who is diaphoretic and confused; bedside glucose is 42 mg/dL (reference 70–110), vital signs: T 36.8°C (98.2°F), HR 104/min, RR 18/min, BP 148/86 mm Hg. B. A 76-year-old with heart failure reporting mild dyspnea on exertion; SpO2 93% on 2 L nasal cannula, lungs with bibasilar crackles, HR 88/min, RR 20/min, BP 154/78 mm Hg. C. A 44-year-old postoperative day 1 after appendectomy with pain 7/10; incision dry, HR 92/min, RR 16/min, BP 132/74 mm Hg, T 37.2°C (99.0°F). D. A 67-year-old with a urinary tract infection receiving IV antibiotics; temperature 38.1°C (100.6°F), HR 96/min, RR 18/min, BP 126/70 mm Hg, reports burning with urination.

  1. A 67-year-old with a urinary tract infection and fever 38.1°C (100.6°F) receiving IV antibiotics.
  2. A 76-year-old with heart failure reporting mild dyspnea on exertion; SpO2 93% on 2 L nasal cannula.
  3. A 44-year-old postoperative day 1 after appendectomy with pain 7/10 and stable vital signs.
  4. A 58-year-old with type 2 diabetes who is diaphoretic and confused; bedside glucose is 42 mg/dL. (correct answer)
Explanation: This question assesses prioritization and clinical judgment skills in determining which client requires immediate intervention. The nurse should use the ABCs (Airway, Breathing, Circulation) framework and recognize that severe hypoglycemia poses an immediate threat to brain function and consciousness. The client with a blood glucose of 42 mg/dL who is diaphoretic and confused is experiencing severe hypoglycemia, which can rapidly progress to seizures, loss of consciousness, and permanent neurological damage if not treated immediately. The other clients have stable conditions: the heart failure patient has mild symptoms with adequate oxygenation, the postoperative patient has expected pain with stable vitals, and the UTI patient has a low-grade fever while receiving appropriate treatment. The underlying principle is that acute metabolic emergencies affecting neurological function take precedence over chronic conditions or expected postoperative findings. When prioritizing care, always address life-threatening conditions that can cause rapid deterioration first, particularly those affecting brain function or consciousness.

Question 15

On a medical unit, a provider writes four PRN orders for a 64-year-old admitted with gastrointestinal bleeding and dizziness. Current assessment: BP 88/52 mm Hg, HR 122/min, RR 22/min, SpO2 95% on room air; hemoglobin 7.4 g/dL (reference 12–16). The nurse should QUESTION which order?

A. Insert two large-bore IV catheters and infuse 0.9% sodium chloride bolus. B. Administer morphine 4 mg IV every 4 hours PRN pain. C. Type and crossmatch for 2 units of packed red blood cells. D. Place the client supine with legs elevated and monitor vital signs every 5 minutes.

  1. Insert two large-bore IV catheters and infuse 0.9% sodium chloride bolus.
  2. Administer morphine 4 mg IV every 4 hours PRN pain. (correct answer)
  3. Type and crossmatch for 2 units of packed red blood cells.
  4. Place the client supine with legs elevated and monitor vital signs every 5 minutes.
Explanation: This question assesses prioritization and clinical judgment skills in recognizing potentially harmful orders in a hypotensive, bleeding patient. Using critical thinking and medication safety principles, the nurse should question the morphine order (option B) because opioids can cause vasodilation and worsen hypotension in a patient who is already hemodynamically unstable (BP 88/52, HR 122). The client is in hypovolemic shock from GI bleeding and needs volume resuscitation and blood products, not medications that could further compromise blood pressure. The other orders are appropriate: IV access and fluid bolus (option A) addresses hypovolemia, blood product preparation (option C) treats anemia and blood loss, and positioning with frequent monitoring (option D) optimizes perfusion and allows early detection of deterioration. The underlying principle is that nurses must critically evaluate all orders in the context of the patient's current condition and question those that could cause harm. When caring for patients in shock, recognize that any medication causing vasodilation or cardiac depression should be avoided until hemodynamic stability is achieved.

Question 16

On a telemetry unit, a 70-year-old with atrial fibrillation is receiving a heparin infusion. The nurse notes oozing from the IV site and new dark, tarry stool. Vital signs: BP 98/60 mm Hg (baseline 130/76), HR 112/min, RR 20/min. Labs: aPTT 118 seconds (reference 25–35), hemoglobin 8.2 g/dL (reference 12–16). What is the nurse's PRIORITY action?

A. Stop the heparin infusion and notify the provider. B. Recheck the aPTT in 1 hour to trend the result. C. Administer PRN acetaminophen for reported headache. D. Encourage oral fluids and reassess stool color in 4 hours.

  1. Stop the heparin infusion and notify the provider. (correct answer)
  2. Recheck the aPTT in 1 hour to trend the result.
  3. Administer PRN acetaminophen for reported headache.
  4. Encourage oral fluids and reassess stool color in 4 hours.
Explanation: This question assesses prioritization and clinical judgment skills in recognizing and managing a potentially life-threatening bleeding complication. Using the circulation component of the ABC framework, the nurse must recognize that this client is experiencing signs of significant bleeding: oozing from IV site, melena (dark, tarry stool indicating GI bleeding), hypotension, tachycardia, critically prolonged aPTT (118 seconds vs normal 25-35), and low hemoglobin. The priority action is to stop the heparin infusion immediately and notify the provider, as continuing the anticoagulation could lead to hemorrhagic shock and death. Rechecking the aPTT in an hour (option B) delays critical intervention, administering acetaminophen (option C) addresses a minor symptom while ignoring the emergency, and encouraging fluids (option D) is inappropriate for active bleeding. The underlying principle is that when a medication is causing life-threatening adverse effects, the first action is always to stop the medication and seek immediate medical intervention. In anticoagulation management, recognize that signs of bleeding with supratherapeutic levels require immediate cessation of the anticoagulant to prevent hemorrhagic complications.

Question 17

In a community health clinic, four clients arrive at the same time. Which client should the nurse assess FIRST?

A. A 52-year-old with a history of hypertension reporting a sudden, severe headache and blurred vision; BP 218/122 mm Hg, HR 96/min. B. A 19-year-old with sore throat for 2 days; T 38.0°C (100.4°F), HR 88/min, able to swallow. C. A 40-year-old requesting smoking cessation resources; vital signs stable. D. A 6-year-old with an itchy rash after playing outside; no respiratory symptoms; vital signs stable.

  1. A 6-year-old with an itchy rash after playing outside and no respiratory symptoms.
  2. A 19-year-old with sore throat for 2 days and T 38.0°C (100.4°F), able to swallow.
  3. A 40-year-old requesting smoking cessation resources with stable vital signs.
  4. A 52-year-old with sudden severe headache and blurred vision; BP 218/122 mm Hg. (correct answer)
Explanation: This question assesses prioritization and clinical judgment skills in recognizing a hypertensive emergency in a community setting. Using the circulation component of the ABC framework and recognizing neurological symptoms, the nurse must identify that severe hypertension (BP 218/122) with acute end-organ damage symptoms (sudden severe headache, blurred vision) constitutes a hypertensive emergency requiring immediate treatment. This client is at immediate risk for stroke, myocardial infarction, or other catastrophic cardiovascular events and needs emergency department referral for IV antihypertensive therapy. The other clients have non-urgent conditions: pharyngitis with mild fever can be treated with antibiotics if bacterial, smoking cessation counseling is preventive care, and a simple rash without systemic symptoms is minor. The underlying principle is that hypertensive emergency (severely elevated BP with symptoms of organ damage) differs from hypertensive urgency and requires immediate BP reduction to prevent permanent organ damage. In community settings, recognize that neurological symptoms with severe hypertension indicate a medical emergency requiring immediate hospital evaluation.

Question 18

In a long-term care facility, the nurse is called to evaluate four residents. Which resident should the nurse assess FIRST?

A. An 83-year-old with dementia who has new-onset wheezing and audible stridor after taking a bite of a sandwich; RR 30/min, SpO2 88% on room air, HR 118/min. B. A 79-year-old with osteoarthritis requesting PRN acetaminophen for knee pain rated 6/10; HR 78/min, BP 138/72 mm Hg. C. An 86-year-old with heart failure who gained 1.4 kg (3 lb) in 3 days; mild ankle edema; BP 146/84 mm Hg, SpO2 94% on room air. D. A 74-year-old with diabetes whose pre-lunch glucose is 64 mg/dL (reference 70–110) and is alert; HR 84/min, BP 132/70 mm Hg.

  1. An 83-year-old with new-onset wheezing and audible stridor after eating; SpO2 88% on room air. (correct answer)
  2. A 79-year-old requesting PRN acetaminophen for knee pain rated 6/10.
  3. An 86-year-old with heart failure and a 1.4 kg (3 lb) weight gain in 3 days and mild edema.
  4. A 74-year-old with diabetes and a pre-lunch glucose of 64 mg/dL who is alert.
Explanation: This question assesses prioritization and clinical judgment skills in identifying a life-threatening emergency in a long-term care setting. The nurse must apply the ABC (Airway, Breathing, Circulation) framework to recognize that the resident with stridor and wheezing after eating is experiencing acute airway obstruction, likely from aspiration or choking. The combination of stridor (indicating upper airway obstruction), wheezing, tachypnea (RR 30/min), hypoxemia (SpO2 88%), and tachycardia (HR 118/min) immediately after eating indicates a critical airway emergency requiring immediate intervention. The other residents have less urgent needs: mild hypoglycemia in an alert patient can be quickly treated with oral glucose, chronic pain and heart failure with weight gain are important but not immediately life-threatening. The principle guiding this decision is that airway emergencies always take highest priority because without a patent airway, death can occur within minutes. In any care setting, recognize that acute airway compromise supersedes all other concerns and requires immediate assessment and intervention.

Question 19

A 32-year-old is 1 hour post-vaginal delivery. Assessment: uterus firm at the umbilicus, lochia rubra moderate, BP 118/72, HR 92. The client reports sudden shortness of breath and chest pain. New vitals: RR 32, SpO2 88% on room air, HR 126. What is the nurse's PRIORITY action?

  1. Administer the prescribed ibuprofen to manage postpartum discomfort and continue to monitor her vital signs.
  2. Perform fundal massage, assess uterine tone and lochia, and prepare to administer a uterotonic if bleeding increases.
  3. Assist the client to ambulate to relieve gas pain and reassess oxygen saturation after walking.
  4. Apply oxygen, raise the head of the bed, and activate the rapid response team. (correct answer)
Explanation: The sudden onset of shortness of breath, chest pain, hypoxia, and tachycardia in a postpartum patient raises concern for pulmonary embolism or another acute respiratory emergency. The nurse's priority is to stabilize oxygenation and obtain expert help. Applying oxygen, raising the head of the bed, and activating the rapid response team directly addresses the ABC priority and brings a team able to diagnose and treat the cause. Administering ibuprofen treats postpartum discomfort but does nothing for hypoxia and delays definitive care; the clinical findings are not explained by ordinary pain. Fundal massage and uterine/lochia assessment with uterotonic preparation target postpartum hemorrhage, but the uterus is firm and the immediate abnormality is respiratory, not bleeding. Ambulating the client for gas pain could worsen oxygenation in a suspected pulmonary embolism and is unsafe until the cause is identified. Thus, applying oxygen, raising the head of the bed, and activating the rapid response team is the only option that matches the priority.

Question 20

A nurse is preparing to delegate tasks for four clients on a telemetry unit. Which task is most appropriate to delegate to an experienced unlicensed assistive personnel (UAP)? Client data: (1) 58-year-old with chest pain awaiting troponin results; (2) 76-year-old with heart failure receiving IV furosemide, strict intake and output; (3) 44-year-old with new-onset atrial fibrillation on a heparin infusion; (4) 65-year-old 2 days post-stroke with dysphagia precautions. What should the nurse delegate?

  1. Titrate the heparin infusion based on the activated partial thromboplastin time result
  2. Assess the chest pain client and obtain a focused cardiac history
  3. Perform a dysphagia screening before giving oral medications
  4. Obtain and document hourly urine output from the client receiving IV furosemide (correct answer)
Explanation: This question assesses prioritization and clinical judgment skills in delegation on a telemetry unit. The prioritization framework used is the nursing process, focusing on safe delegation within scope of practice. Obtaining and documenting hourly urine output from the client receiving IV furosemide is most appropriate to delegate to an experienced UAP, as it involves routine measurement without assessment. Performing dysphagia screening requires nursing judgment; titrating heparin involves evaluation; and assessing chest pain demands professional skills. The underlying decision-making principle is to delegate stable, non-invasive tasks to UAP while retaining complex assessments. This optimizes team efficiency safely. A generalizable prioritization strategy is to evaluate tasks for delegation based on stability and skill level, ensuring nurses handle judgments in similar unit settings.