Question 1

The Somali parents bring their 1-year-old child to the ER of a large urban hospital. The child is lethargic and has bloody urine and blood seeping through a diaper. The child’s parents do not speak English. Which intervention should the nurse implement first?

Accepted Answer

Answer reason: Immediate nursing priority follows ABCs and perfusion assessment; a lethargic infant with visible bleeding is at risk for shock or severe illness and needs rapid physiologic stabilization assessment. Blood pressure is a critical indicator of hemodynamic status in pediatric triage and guides urgent interventions (e.g., IV access, fluids, escalation of care). Obtaining an interpreter is important but should not delay urgent assessment of potentially life-threatening instability. Genital inspection and cultures are secondary steps after initial vital signs and stabilization are addressed.

Question 2

The nurse has received the morning shift report. Which client should the nurse assess first?

Accepted Answer

Answer reason: This is an immediate physiologic threat requiring rapid assessment because severe hypertension can precipitate acute end-organ injury (e.g., stroke, myocardial ischemia, aortic catastrophe) and needs prompt confirmation and intervention. The concurrent bradycardia increases concern for possible increased intracranial pressure or conduction disturbance, making this patient potentially unstable compared with the others. A mild headache rated 3/10 is not an urgent red-flag presentation by itself without other neuro changes. Constipation and dissatisfaction about delayed call light response require attention, but they do not supersede unstable vital signs.

Question 3

A nurse arrives at a motor vehicle collision involving a school bus and a large truck. The school bus is lying on its side. The nurse observes that several children have been thrown from the windows of the school bus. Which child should the nurse assess first?

Accepted Answer

Answer reason: Unconsciousness suggests potential airway obstruction, apnea, severe head injury, or shock, any of which can rapidly become fatal without immediate evaluation. External bleeding from a scalp laceration and an open leg fracture can look dramatic but are typically secondary to ensuring a patent airway and adequate ventilation/perfusion. A hysterically crying child is demonstrating an intact airway and ventilation and can be addressed after life-threatening conditions are ruled out in others.

Question 4

Four parents call a clinic to have their children seen for unusual lumps or swelling. The nurse is trying to work the children into the HCP’s over-booked schedule. Which child should the nurse schedule to be seen first?

Accepted Answer

Answer reason: Triage in an overbooked clinic prioritizes the child with the greatest likelihood of a serious condition requiring prompt assessment. Living near power lines is not a reliable, actionable cancer-risk indicator for urgent scheduling, and chronic ear infections more commonly reflect recurrent otitis/ENT issues than malignancy. A sibling history of osteosarcoma alone is less predictive than a known chromosomal condition strongly linked to hematologic malignancy.

Question 5

The charge nurse in the medical/surgical department is making rounds at 0700. Which client should the nurse see first?

Accepted Answer

Answer reason: New, acute visual changes are treated as a potential emergency because they can signal retinal detachment, vitreous hemorrhage, acute glaucoma, or severe hyperglycemia-related complications that threaten permanent vision loss. This finding represents a possible rapid deterioration requiring immediate assessment of vision, glucose status, and urgent provider notification. By contrast, headache with a known brain tumor and stiff neck with known meningitis are expected symptoms of those diagnoses and are not, by themselves, the most time-critical change in status. Radicular pain from low back pain suggests sciatica, which is typically non-urgent unless red-flag neurologic deficits are present (not described).

Question 6

The nurse is caring for a client diagnosed with septic meningitis. The UAP reports T 101.6°F, P 128, R 32, B/P 96/46. Which action should the nurse implement first?

Accepted Answer

Answer reason: These vital signs indicate possible sepsis with evolving shock (hypotension, tachycardia, tachypnea) in a high-risk infection, which requires rapid nurse assessment to determine airway/breathing/circulation status and immediate needs. The nurse must first verify the client’s condition, assess perfusion and mental status, and identify signs of deterioration to guide urgent interventions. Provider notification and antipyretic preparation may follow, but they are unsafe to do before confirming stability and identifying time-critical problems. Looking up culture data is not a priority when the client may be hemodynamically unstable.

Question 7

A nurse working in the triage area of an emergency department sees that several pediatric clients arrive simultaneously. Which client should be treated first?

Accepted Answer

Answer reason: Stridor with drooling and tripod/upright positioning suggests severe upper-airway obstruction (e.g., epiglottitis or foreign body) requiring immediate airway management and minimal agitation. The scalp laceration is painful but not immediately life-threatening if bleeding is controlled. A barking cough with flushing is more consistent with croup, which is urgent but typically less immediately obstructive than stridor with drooling.

Question 8

The ED nurse is triaging a group of pediatric clients. Which child should the nurse attend to first?

Accepted Answer

Answer reason: Recent renal transplant with oliguria and hypertension suggests possible acute rejection, vascular compromise, or acute kidney injury, all of which can quickly progress to graft loss and severe fluid/electrolyte complications. This presentation requires immediate assessment, vital signs, strict I&O, and urgent provider notification for labs and potential imaging/intervention. By contrast, UTI symptoms and edema/weight gain are concerning but typically allow for rapid evaluation without the same immediate threat to a newly transplanted organ.

Question 9

Five families of clients injured in an apartment fire have arrived at an ED to inquire about the health status of their family members. Which is the nurse’s best action?

Accepted Answer

Answer reason: In a mass-casualty/emergency department surge, the priority is maintaining patient flow, safety, and confidentiality while providing structured family support. Moving families to a designated family-assistance area separates them from clinical care zones, reduces interference with triage/treatment, and supports crisis needs with trained personnel. Social work or clergy are appropriate resources for psychological first aid, grief support, and coordinating communication in a controlled manner. Allowing families into triage risks disrupting prioritization of care and can expose protected health information; simply waiting in the main waiting room does not provide adequate crisis support or organized updates.

Question 10

The nurse is triaging four clients who enter the ED at the same time. Which client should be assigned as the highest priority?

Accepted Answer

Answer reason: This presentation suggests myocardial ischemia with possible hemodynamic instability and risk of lethal dysrhythmias, making it an immediate/emergent priority. The other clients have problems that are painful or concerning but are less immediately life-threatening (e.g., superficial burn blistering or a laceration needing sutures). Neurologic symptoms with fever are serious and need prompt workup, but in triage the unstable cardiopulmonary complaint supersedes when compared side-by-side with stable vital function complaints.

Question 11

The triage nurse in an ED is caring for injured clients of a mass casualty disaster. Which client should the nurse establish as the priority client?

Accepted Answer

Answer reason: In mass-casualty triage, the priority is the client with an immediately correctable, life-threatening problem affecting airway/breathing. An open pneumothorax causes rapid ventilation failure and can be stabilized quickly with an occlusive dressing and subsequent chest decompression, making this client both high acuity and high salvageability. By contrast, an unresponsive client with a penetrating head injury is more likely to be expectant if resources are limited due to very poor prognosis. Extensive third-degree burns over a large BSA and facial fractures without airway compromise are serious but are not as immediately reversible as an open chest wound threatening oxygenation.

Question 12

The primary nurse in the neurological critical care unit is very busy. Which nursing task must be implemented first?

Accepted Answer

Answer reason: Airway and breathing threats are the highest triage priority because hypoventilation can rapidly progress to respiratory arrest. A high cervical spinal cord injury (C4) can impair diaphragmatic/intercostal function, and “air hunger” signals impending ventilatory failure requiring immediate preparation for advanced airway support. Having a tracheostomy tray at the bedside supports rapid intervention if intubation fails or prolonged ventilatory support is needed. Antibiotics for meningitis are urgent but do not supersede an active, evolving airway compromise; dressing changes and transcribing orders are non-urgent compared with respiratory failure risk.

Question 13

The nurse has been assigned to care for four clients. Which client should the nurse plan to assess first?

Accepted Answer

Answer reason: Sustained coughing can sharply increase intra-abdominal and intrathoracic pressure and can precipitate rupture of esophageal varices, leading to sudden massive upper GI hemorrhage and shock. This client also has an acute respiratory infection, adding risk for hypoxia and further coughing episodes, so prompt assessment and interventions to reduce cough/strain and monitor for bleeding are urgent. By comparison, moderate chronic pain, postoperative stability, and pruritus from jaundice are important but are not as time-critical as preventing or detecting catastrophic variceal bleeding.

Question 14

The NA is providing information to the nurse about clients receiving care from the NA. After receiving this report, which client should the nurse attend to first?

Accepted Answer

Answer reason: A postoperative thoracoscopy client with saturation in the high 80s to low 90s despite supplemental oxygen may be developing atelectasis, pneumothorax, hypoventilation from pain/sedation, or other respiratory compromise. The nurse must promptly assess respiratory status, verify pulse oximetry accuracy, evaluate breath sounds and work of breathing, and escalate oxygen/notify the provider as needed. The other reports (constipation, borderline but acceptable BP post-resection, and delayed voiding after catheter removal) are important but are not as immediately life-threatening as impaired oxygenation.

Question 15

A nurse is charting at the nurses’ station when a client uses the call light to ask for assistance to the bathroom. As the nurse answers the call light, a second client uses the call system to say, “I think I need some help! My IV site is bleeding a lot!” What criteria should the nurse use to prioritize these two client calls for assistance?

Accepted Answer

Answer reason: The client who reported the bleeding IV should be seen first. There is no way to know without examining the IV site if it is a central or peripheral IV, how much blood was lost, or what medications might be infusing through the IV Prioritization is based on acuity and the potential for rapid deterioration or serious harm. Active bleeding at an IV site can represent dislodgement or infiltration and could be significant if the line is central or if anticoagulants/vesicants are infusing, creating immediate risk of hemorrhage or tissue injury. The nurse must assess and intervene quickly (apply pressure, stop/secure infusion, evaluate circulation and dressing) to prevent ongoing blood loss and complications. Needing help to the bathroom is a safety issue (fall risk) but is typically less immediately life-threatening and can often be addressed by promptly sending assistive help while the nurse assesses the bleeding IV.

Question 16

The nurse is caring for assigned clients. Based on the pulse (P), respiratory rate (R), and blood pressure (BP) provided, it would be essential to follow up with which of the following clients?

Accepted Answer

Answer reason: A widened pulse pressure (very high systolic with low diastolic) is a potentially concerning hemodynamic pattern that can indicate significant cardiovascular pathology and higher immediate risk than isolated mild abnormalities. This set of vitals shows severe systolic hypertension with a markedly low diastolic, creating an unusually wide pulse pressure that warrants prompt assessment for causes and end-organ effects (e.g., neurologic changes, chest pain, acute heart failure signs). In contrast, mild tachycardia with tachypnea can occur with pain/anxiety/fever and the BP is normal, making it less urgent as a stand-alone vital-sign finding. Following up first on the most potentially unstable or high-risk vital-sign pattern reflects appropriate triage and prioritization.

Question 17

The nursery nurse received shift report on four newborns. The nurse first assess the?

Accepted Answer

Answer reason: This can progress to cardiovascular compromise as the ductus arteriosus closes, making prompt assessment of pulses, perfusion, oxygenation, and signs of shock the priority. A murmur in the first hours of life is often transitional and many benign flow murmurs are not immediately unstable without other symptoms. Delayed breastfeeding for 4.5 hours and a scheduled bilirubin recheck require follow-up, but they are typically less immediately life-threatening than potential critical congenital heart disease.

Question 18

A nurse is working in a busy medical-surgical unit and has received report on the following four clients. The nurse should first see the client?

Accepted Answer

Answer reason: New-onset atrial fibrillation can rapidly compromise cardiac output and precipitate ischemia; concurrent chest pain suggests acute coronary syndrome until proven otherwise and requires immediate assessment (vitals, ECG, oxygenation, and rapid provider notification). Post-op incisional pain rated 8/10 is significant but is not typically an immediate life threat if airway/breathing/circulation are stable. A mild fever with an infected diabetic foot wound and a recent fall in a confused patient both warrant prompt evaluation, but neither is as time-critical as possible cardiac ischemia with a new dysrhythmia.

Question 19

A cardiac alarm rings out that a patient is experiencing ventricular tachycardia. The nurse’s first course of action should be?

Accepted Answer

Answer reason: Checking responsiveness and signs of perfusion (e.g., capillary refill as a quick bedside indicator alongside overall assessment) helps distinguish pulseless VT (cardiac arrest) from VT with a pulse. If pulseless, immediate CPR and defibrillation are indicated; if a pulse is present but unstable, synchronized cardioversion is typically required. Silencing the alarm delays recognition and treatment, and defibrillation/chest compressions without confirming pulselessness risks inappropriate intervention.

Question 20

There are four patients in Labor and Delivery who all need attention. Which of the following should you see first?

Accepted Answer

Answer reason: A fetal heart rate of 80 bpm is marked fetal bradycardia and signals possible acute fetal hypoxia requiring immediate evaluation and intrauterine resuscitation, with rapid escalation for possible emergent delivery. This is an immediate threat to life, so it outranks symptoms that are concerning but not yet confirmed as unstable (e.g., preterm cramping without documented fetal distress). Requesting an epidural is a comfort need and is non-urgent when no instability is described. A standing order for dexamethasone is time-sensitive for fetal lung maturity but does not supersede an active abnormal fetal heart rate tracing suggestive of compromised perfusion/oxygenation.

Question 21

A nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign highest priority to which of the following clients?

Accepted Answer

Answer reason: Chest pain must be treated as potentially cardiac until proven otherwise, because myocardial ischemia can rapidly deteriorate and requires immediate assessment (vitals, ECG, oxygen as indicated) and time-sensitive intervention. Even if symptoms sound like reflux after spicy food, the risk of missing an MI outweighs the convenience of assuming a benign cause. The other presentations (viral-like symptoms, ankle sprain, minor laceration) are typically non–life-threatening and can safely wait compared with possible cardiac chest pain.

Question 22

The nurse is working triage in the ED when four clients present at the same time. Which client should be seen first?

Accepted Answer

Answer reason: An irritable 4-month-old with a petechial rash, nuchal rigidity, and temperature of 103.4°F This presentation suggests a time-critical, life-threatening infection such as meningitis with possible meningococcemia, where rapid deterioration and shock can occur. Petechiae with high fever indicates potential bacteremia/DIC risk, and nuchal rigidity supports CNS involvement requiring immediate evaluation, isolation precautions as indicated, and prompt antibiotics after cultures per protocol. In ED triage, unstable or potentially unstable patients with high-risk red flags are prioritized over non-urgent injuries. The other clients have conditions that are typically non-immediate (stable ankle sprain, dog bite from immunized dog, heavy menses without stated hemodynamic compromise).

Question 23

You are a nurse in a surgical unit caring for various post-operative patients. Which of the following patients should be assessed first?

Accepted Answer

Answer reason: A 65-year-old male who underwent a transurethral resection of the prostate (TURP) 6 hours ago, now reporting a feeling of bladder fullness, inability to urinate, and a temperature of 100.6 Acute urinary retention shortly after TURP can rapidly lead to painful bladder overdistention and may signal catheter obstruction or clot retention requiring urgent assessment and intervention. The additional fever raises concern for an evolving postoperative complication such as infection or inflammatory response and increases the priority for immediate evaluation of vital signs, urine output, and catheter patency. In contrast, moderate pain after knee replacement, mild incisional discomfort, and nausea without vomiting are expected postoperative symptoms that are important but typically less time-sensitive when airway/breathing/circulation and organ function are not threatened. Addressing the TURP patient first supports prevention of escalating complications and preserves urinary system function.

Question 24

The nurse is caring for assigned clients. The nurse should initially assess the client who was admitted for?

Accepted Answer

Answer reason:  Acute change in mental status signals potential life-threatening neurologic compromise and demands immediate assessment. In SIADH, excess free-water retention can rapidly produce hyponatremia, leading to cerebral edema with confusion, seizures, and decreased consciousness. New disorientation within hours suggests worsening sodium imbalance requiring prompt neuro assessment and urgent labs/therapy to prevent deterioration. By comparison, the post-op shoulder pain after lap chole is commonly referred pain from insufflation gas, and the chest pain episode with negative serial troponin is less emergent than evolving neurologic symptoms.

Question 25

The nurse has been made aware of the following client situations. The nurse should first assess the client who?

Accepted Answer

Answer reason: This presentation indicates a potentially emergent threat to a vital sense function and requires immediate assessment and rapid ophthalmology referral. In contrast, a localized leg wound with purulent drainage suggests infection that needs prompt care but is less immediately vision- or life-threatening in the moment. Migraine-like pain and early pregnancy GI symptoms are typically non-emergent unless accompanied by severe neurologic deficits, hemodynamic instability, or heavy bleeding.

Question 26

The nurse is working triage in the emergency department. The nurse manager informs the nurse that one treatment room has just opened. Which of the following clients should the nurse bring in for care first?

Accepted Answer

Answer reason: Triage prioritizes immediate threats to life or neurologic function, especially time-sensitive conditions where rapid intervention prevents irreversible injury. Sudden diplopia, dizziness, gait unsteadiness, and abnormal speech within 30 minutes are concerning for an acute cerebrovascular event (e.g., posterior circulation stroke) requiring emergent evaluation and possible reperfusion therapy. The abdominal pain with RLQ tenderness suggests appendicitis and is urgent but typically not as time-critical as suspected stroke. The HIV patient with odynophagia and the pregnant patient with vomiting/dehydration require prompt care, but neither presents the same immediate risk of rapid neurologic deterioration.

Question 27

The nurse is planning client care. It would be a priority for the nurse to intervene if the client with?

Accepted Answer

Answer reason: A MAP below 65 mm Hg indicates inadequate organ perfusion and is an immediate life threat, especially in septic shock. Persistent hypotension after initial fluid resuscitation suggests ongoing distributive shock requiring urgent escalation (e.g., rapid provider notification, vasopressor support per protocol, and reassessment of perfusion markers). This problem is prioritized over uncontrolled fever, pain, or nausea because it reflects potential progression to multi-organ failure. Fever with osteomyelitis and pain with diverticulitis are important but typically less immediately life-threatening than refractory shock.

Question 28

The nurse is triaging a group of pediatric clients. The nurse should first see the client who is?

Accepted Answer

Answer reason: Airway takes priority in triage, and drooling with dysphagia is a red flag for potential upper-airway obstruction (e.g., epiglottitis, deep neck infection, foreign body). This presentation can rapidly progress to stridor and respiratory failure, so the child needs immediate assessment and airway-ready intervention. By comparison, a localized forearm burn with moderate pain and a low-grade fever with headache are typically stable and can wait after emergent threats are addressed. Excessive thirst with a thready pulse suggests possible hypovolemia/shock and is serious, but imminent airway compromise is the most time-critical, life-threatening risk among the choices.

Question 29

A client with septic shock has a central venous pressure (CVP) of 3 mm Hg and a blood pressure of 86/40 mm Hg. Which intervention takes priority?

Accepted Answer

Answer reason: A CVP of 3 mm Hg indicates low preload, so rapid isotonic crystalloid boluses are the immediate priority to restore circulating volume and improve MAP/organ perfusion. Vasopressors are typically initiated after adequate fluid resuscitation (or concurrently if profound hypotension persists) because they are less effective and can worsen ischemia when preload is inadequate. Broad-spectrum antibiotics are essential early, but immediate stabilization of circulation with fluids is the first action when signs point to severe hypoperfusion from low intravascular volume. Elevating the head of the bed does not address the life-threatening hemodynamic instability.

Question 30

The hospital has just received word that a major disaster has occurred and a large influx of clients is expected in less than 1 hour. The nurse considers which current client is best for immediate discharge?

Accepted Answer

Answer reason: During disaster planning, stable clients with the lowest immediate risk for deterioration and minimal ongoing inpatient needs are prioritized for early discharge to free beds. By postoperative day 3 after a total hip replacement, many patients are hemodynamically stable, tolerating oral intake, mobilizing with therapy, and can often continue recovery with home health/rehab follow-up. In contrast, acute pyelonephritis at 12 hours typically still requires IV antibiotics, monitoring for sepsis, and hydration, making discharge unsafe. The immediate 24-hour post-hysterectomy period still carries higher risks of hemorrhage, urinary retention, and acute postoperative complications requiring close assessment, making it less appropriate for immediate discharge.

Question 31

The nurse has been made aware of the following client situations. The nurse should first assess the client?

Accepted Answer

Answer reason: Acute breathing difficulty signals a potential immediate threat to airway/breathing and requires the highest triage priority. New dyspnea in a client with a chest tube can indicate an urgent complication such as tube occlusion/kinking, disconnection with loss of negative pressure, or recurrent pneumothorax/tension physiology, all of which can rapidly compromise ventilation and oxygenation. The other findings are less emergent: an SpO2 of 90% may be baseline/acceptable for some clients with COPD, and BP 151/95 is elevated but not typically an immediate crisis without symptoms or end-organ findings. Fever and chills with an indwelling urinary catheter suggests infection and needs prompt evaluation, but it generally does not supersede a new respiratory complaint that can deteriorate within minutes.

Question 32

The nurse is notified of the following client situations. The nurse should first assess the client?

Accepted Answer

Answer reason: with appendicitis who is awaiting surgery and has abdominal rigidity and T 101.2 (38.4 C) Abdominal rigidity with fever in a client with appendicitis signals peritoneal irritation and possible perforation with evolving sepsis, which is a time-sensitive, potentially life-threatening complication. This presentation requires immediate assessment for worsening peritonitis (increasing pain, guarding, rebound), hemodynamic instability, and need for urgent surgical escalation and IV antibiotics/fluids. In contrast, pain from sickle cell crisis is significant but not as immediately suggestive of imminent deterioration without respiratory or neuro findings. Atrial fibrillation on a diltiazem drip with a heart rate of 98 is rate-controlled rather than unstable, and decreased hearing with otitis media is non-urgent.

Question 33

The nurse has been made aware of the following client situations. The nurse should first assess the client?

Accepted Answer

Answer reason: This presentation suggests fluid in the alveoli and potential rapid decompensation, so the nurse should quickly evaluate respiratory status, lung sounds, work of breathing, and vital signs. By comparison, an SpO2 of 88% in COPD may be near that client’s baseline target range (often 88–92%), so it is not automatically the most urgent without other distress signs. The sleep apnea client supine and the pneumonia positioning issue are important but are less likely to represent imminent, rapidly progressive respiratory failure than acute CHF symptoms.

Question 34

The nurse has been made aware of the following client situations. The nurse should first assess the client?

Accepted Answer

Answer reason: Restlessness suggests early hypoxemia/altered mentation, and a petechial rash on the neck/upper chest is a classic, high-priority sign supporting this diagnosis. ABCs and rapid identification of a potentially life-threatening embolic event take priority over stable chronic findings or non-immediate complications. The other situations warrant assessment, but they are not as immediately life-threatening as suspected embolism with evolving hypoxia.

Question 35

The nurse has become aware of the following client situations. It would be a priority for the nurse to follow up with the?

Accepted Answer

Answer reason: This requires prompt assessment of circulation, sensation, and movement and initiation of warming measures to prevent irreversible damage. In contrast, a localized bee sting with crying, a superficial burn that blanches, and poison ivy dermatitis are typically non-urgent if there are no systemic symptoms or airway involvement. Prioritization in triage focuses on threats to circulation and potential for rapid deterioration.

Question 36

A Patient has a dissection aortic aneurysm. The patient’s surgery would be categorized as?

Accepted Answer

Answer reason: Surgery is categorized based on immediacy needed to preserve life and prevent irreversible harm, and dissection generally requires immediate operative or endovascular intervention (especially ascending/Type A). This makes it an emergency rather than urgent or elective, which imply the patient can safely wait. “Diagnostic” is not a surgery prioritization category and does not address the need for immediate life-saving treatment.

Question 37

The nurse has received report on the assigned night-shift clients. Which client should the nurse see first?

Accepted Answer

Answer reason: Sudden warmth and pain at 48 hours is a change from expected recovery that may precede erythema, drainage, fever, and dehiscence, so the nurse should evaluate immediately and escalate as needed. The other situations are stable or expected/low acuity: a completed antibiotic infusion is routine to discontinue/flush per protocol, and a stable post-MRI return mainly needs routine checks. A scheduled diabetic ulcer dressing change is important but is not as time-sensitive as an acute postoperative change suggesting infection.

Question 38

The nurse is caring for an obese client who had a diagnostic laparotomy with midline incision one week ago. The client just called the nurse to report a "popping" sensation in the abdomen. Upon assessment, the nurse notes loops of bowel protruding through the incision. Place the nursing actions in order of priority. 1. Monitor vital signs 2. Stay with the client 3. Call for help and have surgeon notified 4. Place the client in low fowler's with the knees bent?

Accepted Answer

Answer reason: Remaining with the client maintains safety, reduces anxiety, and allows rapid response while not leaving exposed viscera unattended. Positioning in low Fowler’s with knees flexed decreases abdominal tension and strain on the incision, helping limit further evisceration until definitive management. After stabilizing the situation locally, the nurse should urgently summon help/notify the surgeon, then monitor vital signs to detect evolving hypovolemia, pain response, or hemodynamic instability.

Question 39

The nurse is caring for four postpartum clients. Which of the following clients should the nurse see first?

Accepted Answer

Answer reason: The other scenarios describe expected or explainable bleeding patterns early postpartum: oxytocin is being given to manage uterine atony risk, breastfeeding can transiently increase bleeding due to oxytocin-mediated uterine contractions, and a one-time “gush” on first ambulation often reflects pooled lochia being released. Prioritization in postpartum triage focuses on identifying infection or hemorrhage threats; among these, purulent lochia is the clearest sign of a pathologic process needing immediate evaluation. Rapid intervention reduces maternal morbidity from ascending uterine infection and systemic inflammatory response.

Question 40

The nurse receives a report on a group of postoperative clients. The nurse assesses which client first?

Accepted Answer

Answer reason: Using ABCs and postoperative risk prioritization, a sudden change in mental status is treated as an urgent assessment need until life-threatening causes are ruled out. Scant dressing drainage is commonly expected early after surgery and is less immediately concerning unless increasing or accompanied by instability. A respiratory rate of 14/min is within normal range, and moderate joint pain requires management but does not supersede evaluation for possible airway/breathing/circulation compromise.

Question 41

The charge nurse has received a change of shift report on the following laboring clients. The nurse should give priority for treatment to a?

Accepted Answer

Answer reason: Malpresentation with the presenting part being the face increases the risk of obstructed labor, fetal trauma, and acute fetal compromise, especially once the client is actively pushing. This situation often requires immediate intrapartum evaluation and rapid escalation (continuous fetal monitoring, preparation for operative delivery/cesarean if labor is not safely progressing). Meconium-stained fluid needs assessment but thin green fluid at term is less emergent than a likely obstructed delivery in the second stage. Failure to progress on oxytocin and preterm labor at 28 weeks are important but typically allow brief prioritization behind an actively pushing client with a high-risk presentation.

Question 42

Clients from a motor vehicle accident arrive in the emergency department. Which client does the nurse see first?

Accepted Answer

Answer reason: In emergency triage, immediate threats to airway and breathing are prioritized (ABCs) because they can rapidly become fatal. Shortness of breath with chest pressure after a motor vehicle accident can indicate life-threatening conditions such as pneumothorax/hemothorax, pulmonary contusion, or blunt cardiac injury requiring rapid assessment and intervention. While hypotension with tachycardia suggests possible shock, the breathing complaint signals an active respiratory compromise that must be addressed first to prevent hypoxia and arrest. Facial lacerations and anxiety/dizziness are typically lower acuity unless accompanied by airway obstruction or neurologic deterioration.

Question 43

The nurse has received a report on the following clients arriving at the emergency department following an explosion at a concert. Which client should the nurse treat first?

Accepted Answer

Answer reason: Shortness of breath with tracheal deviation strongly suggests a tension pneumothorax, a rapidly fatal obstructive process that requires emergent decompression to restore ventilation and venous return. Although pulsatile thigh bleeding is life-threatening and needs rapid hemorrhage control, the respiratory compromise described indicates an airway/breathing emergency with imminent collapse. The forearm deformity and superficial head/neck abrasions are lower priority in a mass-casualty context because they are less likely to cause immediate death.

Question 44

A nurse in the emergency department of a children's hospital is triaging patients. Which patient should the nurse arrange for the doctor to see first?

Accepted Answer

Answer reason: Drooling in a child with epiglottitis signals potential impending upper-airway obstruction, making airway the immediate priority in triage. This presentation can rapidly progress to respiratory failure and requires urgent medical evaluation and airway-ready management. The urinary symptoms with fever and the otitis media with fever suggest infection but are typically stable and not immediately life-threatening. Petechiae in leukemia can indicate thrombocytopenia/bleeding risk, but without active bleeding or hemodynamic/respiratory compromise it is less emergent than an airway-threatening condition.

Question 45

A nurse is caring for multiple patients on a medical-surgical unit. Which patient should the nurse assess first?

Accepted Answer

Answer reason: Lack of response to nitroglycerin increases concern for evolving MI or another critical cause (e.g., unstable angina), requiring rapid assessment, vital signs, ECG, and escalation of care. The pneumonia client with SpO2 92% is concerning but not as immediately unstable and may be acceptable depending on baseline/COPD and overall work of breathing. Post-op mild pain and a request for a snack are lower-acuity needs that can be addressed after stabilizing potential cardiac ischemia.

Question 46

The nurse working on an inpatient hospital unit is notified of the following client situations. The nurse should first assess?

Accepted Answer

Answer reason: g., intracranial hemorrhage or thromboembolic stroke), and atrial fibrillation increases embolic risk; if the patient is anticoagulated, bleeding risk is also higher. This presentation requires immediate assessment to identify time-sensitive, life-threatening complications and activate rapid response/urgent diagnostics as indicated. Hypoactive bowel sounds with small bowel obstruction and peripheral edema in heart failure are expected or non-immediate findings unless paired with instability (e.g., peritonitis, respiratory distress). Intermittent bubbling in the water-seal chamber can be an expected finding early with an air leak resolving and is typically less urgent than a new severe neurologic symptom.

Question 47

The nurse receives report on four assigned clients. Which client should the nurse assess first?

Accepted Answer

Answer reason: Airway/breathing/circulation and sudden neurologic changes take priority over stable upper-airway symptoms or routine postoperative pain. This presentation represents a time-sensitive complication where delays can lead to permanent deficits. By comparison, a barking cough from croup can sound dramatic yet may be stable if no stridor at rest or increased work of breathing is reported, and mild fever with RSV requires assessment but is less immediately suggestive of a catastrophic event than possible stroke.

Question 48

The nurse has been made aware of the following client situations. The nurse should first assess the client who is?

Accepted Answer

Answer reason: 11-months-old who has been vomiting for 24 hours with nasal congestion and a temperature of 102.3 F (39.1 C) Infants have limited physiologic reserve, and prolonged vomiting places them at high risk for rapid dehydration, hypoglycemia, and electrolyte imbalance, making this the highest-acuity assessment need. A fever of 39.1 C in an 11-month-old also raises concern for significant infection and potential deterioration, so airway/breathing/circulation and hydration status must be assessed promptly. In contrast, SSRI discontinuation symptoms and chronic hypothyroid symptoms are typically uncomfortable but not immediately life-threatening. The pregnant client’s pain pattern while standing is more consistent with round-ligament pain and is generally less urgent unless accompanied by bleeding, contractions, or severe persistent pain.

Question 49

The nurse arrives to assist victims following an earthquake. Which victim would the nurse recognize as the highest priority for immediate treatment?

Accepted Answer

Answer reason: In mass-casualty triage, immediate care goes to victims with threatened airway or breathing who can be stabilized quickly. Use of accessory (neck) muscles with fatigue signals significant respiratory distress and impending respiratory failure, which is an ABC priority. Uncontrolled hemorrhage is also critical, but this presentation most directly indicates an airway/breathing emergency requiring immediate intervention (positioning, oxygen, airway support). Severe pain or isolated limb injury and symptoms suggestive of concussion/closed head injury without clear airway compromise are typically treated after immediate life-threatening breathing problems are addressed.

Question 50

The nurse receives a shift hand-off report. Which client reporting pain should the nurse see first?

Accepted Answer

Answer reason: Atypical ischemic cardiac pain can present as epigastric discomfort and should be treated as possible acute coronary syndrome until proven otherwise. In a client with known CAD, severe epigastric pain may represent myocardial ischemia/infarction with immediate risk of dysrhythmias and sudden deterioration, making this the highest priority. The other scenarios (diverticulitis pain, sickle cell pain crisis, anxiety-related headache) can be severe but are less immediately life-threatening in the absence of airway/breathing/circulation compromise. Rapid assessment, monitoring, and escalation for possible ACS are time-sensitive to prevent myocardial damage and death.

Train with a large NCLEX question bank and jump into a full exam-style simulator

Triage NCLEX Practice Test

Continue Learning

The Somali parents bring their 1-year-old child to the ER of a large urban hospital. The child is lethargic and has bloody urine and blood seeping through a diaper. The child’s parents do not speak English. Which intervention should the nurse implement first?

The nurse has received the morning shift report. Which client should the nurse assess first?

A nurse arrives at a motor vehicle collision involving a school bus and a large truck. The school bus is lying on its side. The nurse observes that several children have been thrown from the windows of the school bus. Which child should the nurse assess first?

Four parents call a clinic to have their children seen for unusual lumps or swelling. The nurse is trying to work the children into the HCP’s over-booked schedule. Which child should the nurse schedule to be seen first?

The charge nurse in the medical/surgical department is making rounds at 0700. Which client should the nurse see first?

The nurse is caring for a client diagnosed with septic meningitis. The UAP reports T 101.6°F, P 128, R 32, B/P 96/46. Which action should the nurse implement first?

A nurse working in the triage area of an emergency department sees that several pediatric clients arrive simultaneously. Which client should be treated first?

The ED nurse is triaging a group of pediatric clients. Which child should the nurse attend to first?

Five families of clients injured in an apartment fire have arrived at an ED to inquire about the health status of their family members. Which is the nurse’s best action?

The nurse is triaging four clients who enter the ED at the same time. Which client should be assigned as the highest priority?

The triage nurse in an ED is caring for injured clients of a mass casualty disaster. Which client should the nurse establish as the priority client?

The primary nurse in the neurological critical care unit is very busy. Which nursing task must be implemented first?

The nurse has been assigned to care for four clients. Which client should the nurse plan to assess first?

The NA is providing information to the nurse about clients receiving care from the NA. After receiving this report, which client should the nurse attend to first?

The nurse is caring for assigned clients. Based on the pulse (P), respiratory rate (R), and blood pressure (BP) provided, it would be essential to follow up with which of the following clients?

The nursery nurse received shift report on four newborns. The nurse first assess the?

A nurse is working in a busy medical-surgical unit and has received report on the following four clients. The nurse should first see the client?

A cardiac alarm rings out that a patient is experiencing ventricular tachycardia. The nurse’s first course of action should be?

There are four patients in Labor and Delivery who all need attention. Which of the following should you see first?

A nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign highest priority to which of the following clients?

The nurse is working triage in the ED when four clients present at the same time. Which client should be seen first?

You are a nurse in a surgical unit caring for various post-operative patients. Which of the following patients should be assessed first?

The nurse is caring for assigned clients. The nurse should initially assess the client who was admitted for?

The nurse has been made aware of the following client situations. The nurse should first assess the client who?

The nurse is working triage in the emergency department. The nurse manager informs the nurse that one treatment room has just opened. Which of the following clients should the nurse bring in for care first?

The nurse is planning client care. It would be a priority for the nurse to intervene if the client with?

The nurse is triaging a group of pediatric clients. The nurse should first see the client who is?

A client with septic shock has a central venous pressure (CVP) of 3 mm Hg and a blood pressure of 86/40 mm Hg. Which intervention takes priority?

The hospital has just received word that a major disaster has occurred and a large influx of clients is expected in less than 1 hour. The nurse considers which current client is best for immediate discharge?

The nurse has been made aware of the following client situations. The nurse should first assess the client?

The nurse is notified of the following client situations. The nurse should first assess the client?

The nurse has been made aware of the following client situations. The nurse should first assess the client?

The nurse has been made aware of the following client situations. The nurse should first assess the client?

The nurse has become aware of the following client situations. It would be a priority for the nurse to follow up with the?

A Patient has a dissection aortic aneurysm. The patient’s surgery would be categorized as?

The nurse has received report on the assigned night-shift clients. Which client should the nurse see first?

The nurse is caring for four postpartum clients. Which of the following clients should the nurse see first?

The nurse receives a report on a group of postoperative clients. The nurse assesses which client first?

The charge nurse has received a change of shift report on the following laboring clients. The nurse should give priority for treatment to a?

Clients from a motor vehicle accident arrive in the emergency department. Which client does the nurse see first?

The nurse has received a report on the following clients arriving at the emergency department following an explosion at a concert. Which client should the nurse treat first?

A nurse in the emergency department of a children's hospital is triaging patients. Which patient should the nurse arrange for the doctor to see first?

A nurse is caring for multiple patients on a medical-surgical unit. Which patient should the nurse assess first?

The nurse working on an inpatient hospital unit is notified of the following client situations. The nurse should first assess?

The nurse receives report on four assigned clients. Which client should the nurse assess first?

The nurse has been made aware of the following client situations. The nurse should first assess the client who is?

The nurse arrives to assist victims following an earthquake. Which victim would the nurse recognize as the highest priority for immediate treatment?

The nurse receives a shift hand-off report. Which client reporting pain should the nurse see first?

Think you’re ready for the NCLEX?

Leave a Reply Cancel reply