Question 1

The unit secretary notifies the nurse that 4 clients called the nurses' station reporting pain. Which client should the nurse assess first?

Accepted Answer

Answer reason: A recent postoperative patient is also at increased risk for myocardial ischemia and thromboembolic complications, increasing urgency. Pancreatitis pain and sickle cell vaso-occlusive pain are typically severe but are not as immediately suggestive of a time-critical cardiac event without additional instability signs. Deep pelvic pain with exertion in multiple myeloma suggests bone involvement/fracture risk but is generally less emergent than possible cardiac ischemia.

Question 2

Clinical Scenario: You are the nurse in a medical-surgical unit caring for four clients. Based on the information below, determine which client the nurse should assess first. Client Reports?

Accepted Answer

Answer reason: Symptomatic hypoglycemia is an immediate, high-risk problem because it can rapidly progress to neuroglycopenia, seizures, loss of consciousness, and cardiac dysrhythmias. This client already shows adrenergic symptoms (diaphoresis) with a low glucose, so prompt assessment and rapid carbohydrate treatment are time-critical. In contrast, the pneumonia client is tachypneic but has an SpO2 that is low yet not immediately failing on supplemental oxygen, while severe pain with stable vitals is important but less immediately life-threatening. Markedly elevated blood pressure without end-organ symptoms suggests hypertensive urgency rather than emergency, making it lower priority than active hypoglycemia.

Question 3

You are the nurse on a medical-surgical unit. You receive the following four patients during shift change. Which patient should you assess first?

Accepted Answer

Answer reason: Patient 4 A 68-year-old male admitted for congestive heart failure who suddenly reports new-onset confusion and restlessness. His oxygen saturation is 92% on room air. Acute change in mental status is a high-priority sign of potential hypoxia, hypercapnia, poor cerebral perfusion, or evolving cardiopulmonary instability and must be assessed immediately. In a patient with heart failure, sudden confusion/restlessness can indicate worsening pulmonary edema, low cardiac output, or impaired oxygen delivery even when the pulse oximeter reading appears only mildly reduced. Early assessment allows rapid escalation (focused respiratory/cardiac assessment, vital trends, lung sounds, neuro check) and timely interventions to prevent deterioration. By comparison, hyperglycemia with dehydration and post-op pain with tachycardia require prompt care but are typically less immediately life-threatening than new-onset confusion suggesting impending decompensation.

Question 4

Nurse Channing is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first?

Accepted Answer

Answer reason: Airway patency is the highest priority in triage (ABCs) because obstruction can rapidly lead to hypoxia and respiratory arrest. Copious secretions with a tracheostomy raise immediate concern for mucus plugging, impaired ventilation, and need for prompt assessment and suctioning. The other situations represent scheduled care or longer-term needs (discharge teaching, therapy timing, routine dressing change) and are less likely to be immediately life-threatening. Prioritizing the client with the most unstable, potentially compromised airway best aligns with emergency assessment principles.

Question 5

A 60-year-old male client comes into the emergency department with complaints of crushing chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infarction. Immediate admission orders include oxygen by NC at 4L/minute, blood work, chest X-ray, an ECG, and two (2) mg of morphine given intravenously. The nurse should first?

Accepted Answer

Answer reason: Rapid identification of STEMI/NSTEMI is time-critical because it determines immediate reperfusion and antithrombotic treatment. A 12-lead ECG is the fastest, highest-yield initial test to confirm ischemia/infarction patterns and guide emergent provider actions. Pain control with morphine can be appropriate but should not delay diagnostic confirmation and may obscure ongoing symptom assessment while risking hypotension/respiratory depression. Labs (e.g., troponin) and chest x-ray are important, but they do not provide the immediate actionable information needed to activate cath lab or thrombolysis pathways.

Question 6

A client with pneumonia develops dyspnea with a respiratory rate of 32 breaths/minute and difficulty expelling his secretions. The nurse auscultates his lung fields and hears bronchial sounds in the left lower lobe. The nurse determines that the client requires which of the following treatments first?

Accepted Answer

Answer reason: Tachypnea and dyspnea indicate impaired gas exchange and increased work of breathing, so immediate support to improve oxygenation is the safest first action. Antibiotics treat the infection but do not rapidly correct hypoxemia and can be initiated after stabilization. Bed rest and nutrition are supportive measures and are not priority over correcting compromised ventilation/oxygenation.

Question 7

The charge nurse has received a change-of-shift report on the following clients in labor. The charge nurse should ask a staff member to first see the client in?

Accepted Answer

Answer reason: This finding requires prompt bedside assessment of maternal-fetal status (pain, uterine tone, bleeding, fetal heart rate pattern) and rapid intervention if needed. The other findings are less immediately concerning: a low-grade temperature of 99.7°F is not fever, respirations of 26 can be mild anxiety/pain-related if oxygenation is adequate, and 60-second contractions in second stage can be normal. Therefore, the client with contractions every 30 seconds is the highest priority to see first.

Question 8

The next morning Maria said she did not feel well, you would say?

Accepted Answer

Answer reason: The priority in nursing care is assessment before intervention. The statement “I do not feel well” is nonspecific, so the nurse must first gather data rather than make assumptions or give premature advice. Options A and D involve actions without assessment, and C is inappropriate communication. Therefore, initiating an assessment is the correct priority.

Question 9

After receiving report on four clients the emergency room nurse should see the client with which of the following diagnosis first?

Accepted Answer

Answer reason: In the ER, triage prioritizes threats to life and rapidly evolving instability over stable, non–life-threatening complaints. This presentation warrants prompt assessment for bleeding, mental status changes, hemodynamics, and urgent labs (e.g., INR/PT, platelets) with potential need for reversal/support. In contrast, itchy cellulitis suggests a less urgent symptom change, chronic back pain is significant but typically not life-threatening, and an ovarian cyst is usually nonemergent unless signs of rupture/torsion are present.

Question 10

An adolescent client presents to the emergency department (ED) for an overdose of aspirin. Which action does the nurse perform first?

Accepted Answer

Answer reason: Early overdose management follows triage/assessment priorities to rapidly determine exposure severity and guide immediate interventions. Knowing the time and quantity ingested determines whether decontamination (e.g., activated charcoal within an appropriate window), serum salicylate trending, and anticipated acid–base changes are likely, which directly affects urgency and treatment planning. The other medication options are antidotes for different toxicities (protamine for heparin; vitamin K for warfarin) and do not address salicylate poisoning. ABG assessment is important in salicylate toxicity, but it follows the initial focused history that drives the rest of the emergency workup and management pathway.

Question 11

The nurse is caring for a client who reports sudden heartburn and shortness of breath. Which action should the nurse take first?

Accepted Answer

Answer reason: Sudden heartburn accompanied by shortness of breath can indicate myocardial ischemia or an acute coronary syndrome rather than simple gastrointestinal discomfort. This represents a potentially life-threatening condition requiring immediate escalation. Because no direct assessment option is provided, the most appropriate priority action is to notify the health care provider without delay. Other options either delay care, delegate inappropriately, or treat a non-priority cause.

Question 12

The nurse has just received shift report. Which client should be seen first?

Accepted Answer

Answer reason: This client needs prompt assessment of safety, reinforcement of activity restrictions as ordered, and evaluation for PE warning signs (new dyspnea, chest pain, tachycardia, hypoxia) before further ambulation. The other situations are either expected post-op findings or localized symptoms that are less likely to deteriorate rapidly into life-threatening compromise. Priority goes to preventing imminent embolic complications and ensuring safe care.

Question 13

Which client should the nurse assess first?

Accepted Answer

Answer reason: Airway and breathing threats take priority in triage, and new dyspnea signals potential impending respiratory compromise. Hypoparathyroidism can cause acute hypocalcemia leading to laryngospasm/bronchospasm and upper-airway obstruction, which can deteriorate rapidly and requires immediate assessment and intervention. By comparison, a glucose of 300 mg/dL in DKA is expected but not, by itself, the most immediate life threat without signs of shock or altered mental status. A heart rate of 60 in hypothyroidism is typically stable, and peripheral edema in SIADH is not the classic dangerous presentation and is less urgent than breathing difficulty.

Question 14

The nurse is managing an assigned team. The following clients have family members reporting a concern. Which client should the nurse see first?

Accepted Answer

Answer reason: A GCS of 9 already reflects significant impaired consciousness, and becoming newly unresponsive suggests worsening neurologic status with high risk for aspiration and need for immediate assessment and possible rapid response activation. Severe migraine pain with nausea is distressing but is not as time-critical as a change in level of consciousness. Postictal drowsiness/confusion and ALS-related dysarthria can be expected findings without evidence here of acute airway compromise, making them lower priority than abrupt unresponsiveness.

Question 15

The nurse provides care for several clients. Which client does the nurse assess first?

Accepted Answer

Answer reason: Atypical acute coronary syndrome in women can present with nausea, fatigue, and jaw pain, and represents a potential immediate threat to life requiring rapid assessment and escalation. This presentation suggests possible myocardial ischemia where delays increase risk of dysrhythmia, infarct extension, and death, so it outranks other complaints in triage priority. While shortness of breath can be serious, a productive cough more commonly reflects infection/bronchitis unless severe respiratory distress is described, making it less immediately time-critical than suspected cardiac ischemia. Gastroenteritis symptoms and chronic urinary hesitancy/weak stream are typically lower acuity unless there are red flags like dehydration with shock or urinary retention with severe pain, which are not stated.

Question 16

A 70-year-old female client with type 2 diabetes mellitus comes to the emergency department with diaphoresis, nausea, generalized weakness, and epigastric burning pain. Which intervention should the nurse implement first?

Accepted Answer

Answer reason: In the ED, rapid identification of ischemia or infarction is time-critical because it directly determines emergent therapies and reduces morbidity and mortality. A 12-lead ECG is a fast, noninvasive first step that can immediately reveal STEMI or other ischemic changes requiring urgent action. Fingerstick glucose is important but does not explain the epigastric pain pattern as urgently as ruling out a cardiac event, and labs/morphine should not delay definitive cardiac assessment.

Question 17

Which client should the nurse on a cardiac unit assess first after receiving the shift report?

Accepted Answer

Answer reason: Acute dyspnea with an S3 gallop is a classic sign of new or worsening heart failure and possible pulmonary edema, which is an immediate airway/breathing threat requiring rapid assessment and intervention. In a client with valvular disease, these findings suggest decompensation (fluid overload, reduced cardiac output) and can deteriorate quickly without prompt evaluation of oxygenation, lung sounds, vital signs, and hemodynamic status. Four unifocal PVCs per minute after MI can be monitored but are not as immediately life-threatening as respiratory compromise unless accompanied by instability. Ambulation request in stable coronary artery disease is routine, and a late antibiotic dose in pericarditis is important but generally less urgent than signs of acute cardiopulmonary decompensation.

Question 18

The nurse assistant reports vital signs on 4 clients. Which client should be a priority for the nurse to assess?

Accepted Answer

Answer reason: A liver biopsy carries risk of internal bleeding due to the organ’s vascularity, so this finding is time-sensitive and potentially life-threatening even if the heart rate is only moderately elevated. Sinus tachycardia with pancreatitis can reflect pain, dehydration, or systemic inflammation but is less specific for sudden catastrophic deterioration than post-procedure bleeding. Atrial fibrillation while on a diltiazem drip and mild tachycardia is expected to be under active management, and a heart rate of 105/min with endocarditis is comparatively less urgent without other instability cues.

Question 19

Which pediatric respiratory presentation in the emergency department is a priority for nursing care?

Accepted Answer

Answer reason: Wheezing with bronchiolitis and mild fever typically reflects moving air and is often managed supportively unless signs of severe distress or hypoxia are present. A barky cough suggests croup, which can be serious but is prioritized based on stridor at rest, retractions, and oxygenation; the stem only notes URI symptoms and barking cough without severe distress cues. Fever with yellow sputum in cystic fibrosis suggests pulmonary infection and needs treatment, but it is generally less immediately life-threatening than a potentially “silent” severe asthma exacerbation requiring rapid bronchodilation and possible escalation of respiratory support.

Question 20

An obviously pregnant woman comes to the emergency department. She says that her water just broke at home and she felt the cord. Which action would be a priority for the emergency nurse?

Accepted Answer

Answer reason: The knee-chest position uses gravity to shift the presenting part away from the cord and is a rapid bedside intervention the nurse can implement without delay. Checking fetal heart rate is important, but it does not treat the immediate cause of fetal compromise and should follow measures to reduce cord compression. McRoberts is used for shoulder dystocia, not cord prolapse, and prenatal history is non-urgent in this scenario.

Question 21

The nurse receives report for 4 clients in the emergency department. Which client should be seen first?

Accepted Answer

Answer reason: Headache with vomiting after a closed-head injury suggests rising intracranial pressure and possible intracranial hemorrhage, requiring rapid evaluation and intervention. Concurrent atrial fibrillation commonly implies anticoagulant use, which markedly increases the risk and severity of intracranial bleeding after trauma, further elevating urgency. By comparison, phenytoin toxicity symptoms are concerning but usually progress less abruptly than an evolving intracranial bleed, and urinary retention from an L3 injury is important but not typically the most time-critical in the absence of shock or high spinal cord compromise.

Question 22

The nurse at an outpatient care facility has received the following telephone messages from clients who were previously seen at the facility. The nurse should first telephone the client who is at?

Accepted Answer

Answer reason: At 35 weeks, confirming membrane rupture and assessing fetal status and presentation are time-sensitive safety priorities. Nausea/vomiting at 12 weeks is common and usually non-urgent unless severe dehydration is described. Yellow nipple leakage near term is consistent with colostrum and is expected. Dysuria at 22 weeks suggests a UTI and needs follow-up to prevent pyelonephritis, but it is typically less emergent than possible membrane rupture.

Question 23

Assessing a Group of Clients in Order of Priority The nurse is assigned to the following clients. The order of priority in assessing the clients is as follows?

Accepted Answer

Answer reason: Rapid weight gain with dyspnea in heart failure suggests acute fluid overload and possible pulmonary edema, which can quickly progress to impaired oxygenation and respiratory failure. The post-op thoracic client with a functioning closed chest tube system is high risk but is not described as having acute distress, making this less immediate than active shortness of breath. Absent bowel sounds and next-day preop planning are important but do not typically represent an immediate threat to airway/breathing compared with worsening cardiopulmonary status.

Question 24

Four clients give birth to their newborns vaginally within a 10-minute period. Which client does the nurse evaluate first?

Accepted Answer

Answer reason: A multipara who gives birth to a 5-lb, 8-oz neonate after 2.5 hours of labor. The immediate postpartum priority is to identify conditions with the highest risk for acute maternal or neonatal compromise, using risk factors that predict urgent complications. A multiparous client with a precipitous/very short labor is at increased risk for uterine atony and postpartum hemorrhage due to uterine overdistension and ineffective contraction following rapid delivery, making rapid assessment of fundal tone and bleeding time-sensitive. In contrast, crying after delivery and psychosocial histories (substance use or past abuse) warrant timely support and screening but are less likely to represent an imminent physiologic emergency in the first minutes after birth. The lower birth weight noted also raises concern for neonatal issues (e.g., temperature or glucose instability), further supporting prioritizing this dyad for early evaluation.

Question 25

There has been a major disaster with the collapse of a large building. Hundreds of victims are expected. The emergency department nurse is sent to triage victims. Which client should the nurse tag "red" and send to the hospital first?

Accepted Answer

Answer reason: See-saw (paradoxical) chest movement indicates severe respiratory compromise (e.g., flail chest or major airway obstruction) with a high risk of rapid decompensation but a chance of survival if treated urgently, so this is tagged red. The client with fixed, dilated pupils and absent spontaneous respirations is triaged as expectant/black in most disaster systems because survival is unlikely with limited resources. The pregnancy spotting and isolated open leg injury with stable pulses are more consistent with delayed/urgent but not immediate life-threatening problems.

Question 26

Which clients can be assigned to share a room in the emergency department during a disaster?

Accepted Answer

Answer reason: Disaster ED rooming uses triage to cohort clients who are stable enough to wait and who do not require continuous, high-acuity monitoring. These two presentations are potentially urgent but can often be managed without the immediate, intensive resources needed for life-threatening conditions, making shared rooming appropriate. In contrast, chest pain and penetrating abdominal trauma demand rapid evaluation and close monitoring for shock/MI and should not be paired. Likewise, severe neurologic findings (fixed, dilated pupils; head injury) indicate possible herniation/increased ICP and require high-priority care and monitoring rather than shared placement.

Question 27

The telemetry nurse reports the cardiac monitor rhythms of 4 clients to the medical unit nurse assigned to care for them. The nurse should assess the client with which rhythm first?

Accepted Answer

Answer reason: This is a potential immediate instability risk requiring prompt assessment of vital signs, perfusion, symptoms (syncope, chest pain), and pacer function, and may require urgent intervention. The atrial fibrillation option is rate-controlled and anticoagulated, making it less emergent. First-degree AV block and sinus tachycardia from dehydration are typically non-life-threatening rhythms and can be addressed after ruling out pacemaker malfunction.

Question 28

During a flood, two ambulances arrive at an emergency substation at the same time. One contains a toddler near-drowning victim on a ventilator. The other contains an older adult client diagnosed with a left-sided cerebrovascular accident (CVA), and who is conscious and has a blood pressure of 220/130 mm Hg. Which client does the nurse see first?

Accepted Answer

Answer reason: Triage prioritizes immediate threats to airway, breathing, and circulation and the likelihood of rapid deterioration. A near-drowning toddler requiring mechanical ventilation has an unstable airway/respiratory status and is at high risk for hypoxemia and sudden decompensation, making this the most time-critical assessment. The older adult with stroke who is conscious, despite severe hypertension, is not described as having airway compromise or altered mental status requiring immediate life-saving intervention. Severe blood pressure can be addressed promptly, but it is typically secondary to stabilizing ventilation and oxygenation in an actively supported pediatric drowning victim.

Question 29

You respond to a call for help from the ED waiting room. There is an elderly patient lying on the floor. List the order for the actions that you must perform. 1. Perform the chin lift or jaw thrust maneuver. 2. Establish unresponsiveness. 3. Initiate cardiopulmonary resuscitation (CPR). 4. Call for help and activate the code team. 5. Instruct a nursing assistant to get the crash cart?

Accepted Answer

Answer reason: First, confirm unresponsiveness to determine the need for resuscitation actions. Next, call for help/activate the code team and delegate retrieval of the crash cart so advanced equipment and personnel are mobilized while you remain with the patient. Then open the airway with a chin lift/jaw thrust and promptly begin CPR if the patient is not breathing normally and has no signs of circulation.

Question 30

A 9-month-old client is evaluated in the emergency department due to cyanosis precipitated by crying. The nurse provides what intervention first?

Accepted Answer

Answer reason: This presentation is classic for a hypercyanotic (“tet”) spell, where increased right-to-left shunting acutely worsens hypoxemia. The knee-chest position increases systemic vascular resistance, reducing the shunt and improving pulmonary blood flow and oxygenation quickly. Oxygen can be supportive but does not correct the underlying shunting as effectively as immediate positioning. Morphine may be used after initial stabilization to reduce agitation and hyperpnea, and resuscitation is reserved for deterioration despite first-line measures.

Question 31

The nurse receives report on 4 clients. Which client should the nurse see first?

Accepted Answer

Answer reason: This finding requires immediate assessment of respiratory status (work of breathing, SpO2, lung sounds) and rapid intervention because deterioration can occur quickly. The other situations are important but are either scheduled treatments or problems that are typically less immediately life-threatening than evolving respiratory compromise. A common trap is prioritizing tasks (e.g., medication due, NG placement) over an acute change in breathing that could represent decompensation.

Question 32

The healthcare provider has written these orders for a client with a diagnosis of pulmonary edema. The client's morning assessment reveals bounding peripheral pulses, weight gain of 2 lb, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time?

Accepted Answer

Answer reason: The immediate priority is to reduce intravascular volume and pulmonary congestion to improve oxygenation; an IV loop diuretic provides the fastest therapeutic effect among the listed orders. Fluid restriction and daily weights are important but are slower, supportive measures and do not address the current acute pulmonary congestion. Accurate intake and output is monitoring and does not treat the urgent problem.

Question 33

The nurse receives report on several postpartum clients who gave birth at term gestation. Which client should the nurse assess first?

Accepted Answer

Answer reason: Soaking a pad every hour for multiple hours shortly after delivery exceeds expected lochia and requires urgent assessment of uterine tone, fundal position, and vital signs, and rapid escalation for interventions (uterine massage/uterotonics, IV access, labs). Foul-smelling lochia suggests endometritis and fever with a red swollen breast suggests mastitis, but both are typically less immediately unstable than active hemorrhage. The DVT client is already identified and anticoagulated, making them lower priority than uncontrolled bleeding.

Question 34

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

Accepted Answer

Answer reason: This client requires immediate assessment of vital signs, puncture site and distal perfusion, abdominal/flank findings, and trending hemoglobin/hematocrit with prompt provider notification. The heparin infusion with aPTT of 60 seconds is generally within/near therapeutic range and is not an immediate instability cue. A GCS of 14 and postoperative incisional pain on day 2 are important but are less time-critical than suspected post-procedure internal bleeding.

Question 35

The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend to first?

Accepted Answer

Answer reason:  Disaster triage prioritizes immediate threats to life, especially uncontrolled hemorrhage because it can rapidly lead to hypovolemic shock and death. A child with severe leg bleeding suggests potentially major blood loss and requires rapid bleeding control (direct pressure, tourniquet as indicated) and urgent stabilization. The pregnant client reporting decreased fetal movement is concerning but is not an immediately fatal airway/breathing/circulation threat compared with active severe hemorrhage. The distressed toddler and the grieving older adult primarily need psychological support once life-threatening physiologic problems are addressed.

Question 36

The nurse is triaging victims at the site of a mass casualty incident. Which victim should be seen first?

Accepted Answer

Answer reason: An open femur fracture can cause life-threatening hemorrhage but the presence of palpable distal pulses suggests perfusion is currently maintained and rapid bleeding control/splinting can be lifesaving. Fixed, dilated pupils after head injury suggests severe brain herniation and is typically categorized as expectant in MCI conditions. Full-thickness burns over 85% TBSA also have very poor survival odds in an MCI and are generally not the first seen, while superficial lacerations are delayed/minor.

Question 37

A nurse cares for a group of clients on a nursing care unit. Which client does the nurse assess first?

Accepted Answer

Answer reason: New distal paresthesias (tingling) are an early neurovascular compromise sign requiring immediate assessment of pulses, capillary refill, color, temperature, and pain, with urgent escalation for possible escharotomy. A dull headache on nitroglycerin is a common expected adverse effect and is typically non-urgent if vital signs are stable. Tremor in hepatic encephalopathy and weakness/dark urine in rhabdomyolysis are concerning, but they are less immediately time-critical than threatened limb perfusion from a constricting burn.

Question 38

The charge nurse in an intensive care unit is rounding and reviewing hemodynamic data for clients in the unit. Which client requires immediate intervention?

Accepted Answer

Answer reason: Active GI bleeding with a MAP of 58 strongly suggests hemorrhagic shock with high risk of end-organ ischemia and rapid deterioration. This finding warrants immediate interventions such as securing IV access, fluid/blood product resuscitation per protocol, and urgent provider notification. In contrast, a cardiac output of 5 L/min is within normal range, and a CVP of 6 mm Hg is not an emergent abnormality by itself in a septic client without other instability.

Question 39

All of these events are occurring at the same time. Which one should the registered nurse deal with first?

Accepted Answer

Answer reason: A person found on the floor could be unconscious, not breathing, actively bleeding, or have sustained trauma, requiring immediate assessment and emergency response activation. In contrast, a beeping blood transfusion pump is important but often reflects a non-life-threatening issue (e.g., occlusion or completion) and the client can be quickly checked right after immediate collapse is addressed. Severe pain and an HCP request are urgent/important tasks but are not as time-critical as a potential cardiopulmonary emergency in the hallway.

Question 40

After assessing 4 clients in the pediatric emergency department, the nurse should alert the health care provider to see which client first?

Accepted Answer

Answer reason: Lethargy in a 4-month-old with fever and vomiting suggests a potentially serious systemic infection and possible dehydration, requiring rapid evaluation and likely urgent labs/IV fluids and antimicrobial decision-making. The child with an occasional barking cough who is calm and alert is more consistent with mild croup and is lower acuity if there is no stridor at rest or respiratory distress. Cola-colored urine with edema is concerning for glomerulonephritis but is typically not as immediately life-threatening as an infant with possible sepsis/AMS, while dysuria in a stable adolescent is generally non-emergent.

Question 41

A client calls the clinic and tells the nurse that her daughter has just been stung by a bee on the arm. She is worried that her daughter will have a severe reaction. What should the nurse do?

Accepted Answer

Answer reason: A history of previous bee stings and any past generalized symptoms (e.g., hives away from the site, wheeze, facial swelling, hypotension) strongly increases concern for a severe reaction and guides escalation to emergency care. Automatically directing to the emergency room without first clarifying risk can lead to unnecessary use of emergency resources when the likely scenario is a localized reaction. Elevation and “call back if worse” are incomplete because they do not first assess for red-flag history that would require immediate emergency response.

Question 42

A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the priority?

Accepted Answer

Answer reason: This finding indicates compromised circulation and can quickly progress to loss of function or amputation if not treated promptly. In comparison, preoperative anxiety/crying and a scheduled dressing change are important but not immediately life- or limb-threatening. A low-grade fever in a client with MRSA warrants monitoring and infection control, but it is less urgent than evidence of acute vascular compromise.

Question 43

All of these events are occurring at the same time. Which one should the registered nurse deal with first?

Accepted Answer

Answer reason: A blood transfusion problem signaled by an alarm can indicate occlusion, disconnection, incorrect rate, or other issues that could rapidly lead to hemodynamic instability or delay recognition of an acute transfusion reaction, so it requires immediate assessment of the patient and the transfusion setup. A visitor on the floor may represent an emergency, but the prompt provides no airway/breathing compromise and the RN can quickly call for assistance while first ensuring the highest-risk patient situation is addressed. Severe pain and an HCP request are important but are not typically as immediately life-threatening as a possible transfusion-related issue.

Question 44

The nurse receives report on 4 clients. Which client should be seen first?

Accepted Answer

Answer reason: Worsening dysarthria in ALS can reflect progressive bulbar weakness with impaired swallowing and inability to clear secretions, creating imminent risk for aspiration and airway compromise. This client needs immediate assessment of breathing, cough/gag effectiveness, and oxygenation with rapid escalation if needed. The other clients describe painful but typically non–life-threatening conditions (renal colic) or slower-developing issues (edema suggesting cor pulmonale/heart failure) or expected early course of infection treatment (fever after only 12 hours of antibiotics).

Question 45

A nurse in the cardiac intensive care unit receives report on 4 clients. Which client should the nurse assess first?

Accepted Answer

Answer reason: This complaint is an acute red-flag symptom requiring immediate assessment of hemodynamics, puncture site, distal perfusion, and signs of shock, with rapid escalation if instability is found. The fever with endocarditis is expected and typically managed with ongoing antibiotics unless accompanied by sepsis signs or hemodynamic compromise. Mild tachycardia post-transplant and donor-leg swelling post-CABG are more likely non-emergent compared with possible occult major bleeding.

Question 46

A nurse on a medical surgical unit receives a report on multiple clients. Based on this report, which client should the nurse assess first?

Accepted Answer

Answer reason: Smoke inhalation can cause upper-airway edema, bronchospasm, carbon monoxide poisoning, and impaired oxygen delivery, requiring immediate assessment of respiratory status and oxygenation. The other clients have serious problems, but they are primarily circulation/pain issues that are typically addressed after ensuring a patent airway and adequate ventilation. Active post-op bleeding is urgent, yet an unstable airway takes precedence in initial assessment and intervention.

Question 47

The nurse receives telephone messages from the following 4 clients. Which client should the nurse call back first?

Accepted Answer

Answer reason: This requires immediate evaluation, prompt discontinuation of the suspected medication, and supportive/emergent care due to risk of mucosal involvement, dehydration, infection, and organ dysfunction. In contrast, gingival hyperplasia/bleeding with cyclosporine, photosensitivity sunburn with doxycycline, and orthostatic dizziness with sildenafil are typically nonemergent and can be addressed with counseling and routine follow-up unless severe or associated with red-flag symptoms. Therefore, this client must be called back first based on urgency and potential for rapid deterioration.

Question 48

The psychiatric nurse receives report on a group of clients. The nurses assesses the clients in what order? (Place each client in order, from first to last.)?

Accepted Answer

Answer reason: This presentation suggests severe alcohol withdrawal with possible delirium tremens, which is an immediate physiologic emergency due to risk of seizures, dysrhythmias, and autonomic instability. This client needs rapid assessment of airway/breathing/circulation, vital signs, withdrawal severity scoring, and prompt benzodiazepine-based management per protocol. The restrained manic client has continuous observation already in place, lowering immediate unattended risk compared with unstable withdrawal. The diabetes refusal and the self-injury history while calmly eating are important but are typically less immediately life-threatening than suspected severe withdrawal.

Question 49

The nurse receives handoff of care report on four clients. Which client should the nurse see first?

Accepted Answer

Answer reason: The rapid drop over an hour represents an acute change requiring urgent assessment for obstructive shock (worsening perfusion, tachycardia, muffled heart sounds, JVD) and rapid escalation of care. By comparison, atrial fibrillation at 122/min with palpitations can be concerning but is often stable and not necessarily accompanied by hypotension or signs of shock. Bleeding at an IV site with thrombocytopenia and a rising WBC in pneumonia are important but typically do not outrank a potential tamponade with deteriorating blood pressure in immediate priority.

Question 50

The nurse receives report on 4 clients. Which client should the nurse assess first?

Accepted Answer

Answer reason: This patient has two high-risk respiratory conditions (pneumonia plus asthma) and requires immediate reassessment of work of breathing, breath sounds, oxygenation, and need for escalation (e.g., oxygen, steroids, rapid response). By contrast, moderate pain after analgesia, exertional dyspnea from anemia in CKD, and headache with mild hyponatremia are generally less immediately life-threatening than a potential rapid deterioration in ventilation. Prioritizing airway and breathing problems aligns with ABCs and emergency triage principles.

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The unit secretary notifies the nurse that 4 clients called the nurses' station reporting pain. Which client should the nurse assess first?

Clinical Scenario: You are the nurse in a medical-surgical unit caring for four clients. Based on the information below, determine which client the nurse should assess first. Client Reports?

You are the nurse on a medical-surgical unit. You receive the following four patients during shift change. Which patient should you assess first?

Nurse Channing is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first?

The charge nurse has received a change-of-shift report on the following clients in labor. The charge nurse should ask a staff member to first see the client in?

The next morning Maria said she did not feel well, you would say?

After receiving report on four clients the emergency room nurse should see the client with which of the following diagnosis first?

An adolescent client presents to the emergency department (ED) for an overdose of aspirin. Which action does the nurse perform first?

The nurse is caring for a client who reports sudden heartburn and shortness of breath. Which action should the nurse take first?

The nurse has just received shift report. Which client should be seen first?

Which client should the nurse assess first?

The nurse is managing an assigned team. The following clients have family members reporting a concern. Which client should the nurse see first?

The nurse provides care for several clients. Which client does the nurse assess first?

A 70-year-old female client with type 2 diabetes mellitus comes to the emergency department with diaphoresis, nausea, generalized weakness, and epigastric burning pain. Which intervention should the nurse implement first?

Which client should the nurse on a cardiac unit assess first after receiving the shift report?

The nurse assistant reports vital signs on 4 clients. Which client should be a priority for the nurse to assess?

Which pediatric respiratory presentation in the emergency department is a priority for nursing care?

An obviously pregnant woman comes to the emergency department. She says that her water just broke at home and she felt the cord. Which action would be a priority for the emergency nurse?

The nurse receives report for 4 clients in the emergency department. Which client should be seen first?

The nurse at an outpatient care facility has received the following telephone messages from clients who were previously seen at the facility. The nurse should first telephone the client who is at?

Assessing a Group of Clients in Order of Priority The nurse is assigned to the following clients. The order of priority in assessing the clients is as follows?

Four clients give birth to their newborns vaginally within a 10-minute period. Which client does the nurse evaluate first?

There has been a major disaster with the collapse of a large building. Hundreds of victims are expected. The emergency department nurse is sent to triage victims. Which client should the nurse tag "red" and send to the hospital first?

Which clients can be assigned to share a room in the emergency department during a disaster?

The telemetry nurse reports the cardiac monitor rhythms of 4 clients to the medical unit nurse assigned to care for them. The nurse should assess the client with which rhythm first?

A 9-month-old client is evaluated in the emergency department due to cyanosis precipitated by crying. The nurse provides what intervention first?

The nurse receives report on 4 clients. Which client should the nurse see first?

The healthcare provider has written these orders for a client with a diagnosis of pulmonary edema. The client's morning assessment reveals bounding peripheral pulses, weight gain of 2 lb, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time?

The nurse receives report on several postpartum clients who gave birth at term gestation. Which client should the nurse assess first?

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

The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend to first?

The nurse is triaging victims at the site of a mass casualty incident. Which victim should be seen first?

A nurse cares for a group of clients on a nursing care unit. Which client does the nurse assess first?

The charge nurse in an intensive care unit is rounding and reviewing hemodynamic data for clients in the unit. Which client requires immediate intervention?

All of these events are occurring at the same time. Which one should the registered nurse deal with first?

After assessing 4 clients in the pediatric emergency department, the nurse should alert the health care provider to see which client first?

A client calls the clinic and tells the nurse that her daughter has just been stung by a bee on the arm. She is worried that her daughter will have a severe reaction. What should the nurse do?

A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the priority?

All of these events are occurring at the same time. Which one should the registered nurse deal with first?

The nurse receives report on 4 clients. Which client should be seen first?

A nurse in the cardiac intensive care unit receives report on 4 clients. Which client should the nurse assess first?

A nurse on a medical surgical unit receives a report on multiple clients. Based on this report, which client should the nurse assess first?

The nurse receives telephone messages from the following 4 clients. Which client should the nurse call back first?

The psychiatric nurse receives report on a group of clients. The nurses assesses the clients in what order? (Place each client in order, from first to last.)?

The nurse receives handoff of care report on four clients. Which client should the nurse see first?

The nurse receives report on 4 clients. Which client should the nurse assess first?

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