Question 1

The intensive care unit (ICU) nurse receives a phone call stating a client diagnosed with a head trauma must undergo admission. There are no empty beds. Which client is most stable and eligible for a transfer to the step-down neurological unit?

Accepted Answer

Answer reason: Triage and bed management prioritize keeping ICU-level care for clients at highest risk of rapid neurologic or airway deterioration. A client 3 days post–cervical spinal injury in halo traction is typically hemodynamically and neurologically more stable once acute swelling and immediate post-injury instability have passed, and ongoing care is focused on immobilization and monitoring that can be managed in a neuro step-down setting. In contrast, increased ICP with a GCS of 8 signals severe brain injury with high risk for herniation and need for intensive neurologic monitoring/airway support. A CVA with a subdural hematoma just 1 day ago is also early and unstable, with significant risk for expanding bleed and worsening mental status requiring ICU resources.

Question 2

Several patients are taking antipsychotic medications and are having medication side effects. Place the following patients in priority order for additional assessment and appropriate interventions, with 1 being the most critical and 4 being the least?

Accepted Answer

Answer reason: A patient who is taking trifluoperazine and has a temperature of 103.6°F (39.8°C) with tachycardia, muscular rigidity, and dysphagia These findings are classic for neuroleptic malignant syndrome, a life-threatening antipsychotic reaction requiring immediate emergency assessment, medication discontinuation, and rapid supportive care (airway/ventilation, cooling, IV fluids) to prevent rhabdomyolysis, renal failure, and cardiovascular collapse. The combination of high fever, severe “lead-pipe” rigidity, autonomic instability (tachycardia), and dysphagia signals imminent airway and systemic risk. By comparison, clozapine-associated agranulocytosis is also dangerous but typically allows rapid protective isolation and urgent provider notification rather than the same immediate physiologic instability. Anticholinergic effects and tardive dyskinesia are important but are generally less immediately life-threatening than NMS.

Question 3

The nurse in the pediatric clinic is triaging telephone messages. The nurse should call the parent of which child first?

Accepted Answer

Answer reason: Ear pain after adenotonsillectomy can reflect referred throat pain but also can accompany edema, infection, or evolving bleeding risk, so the nurse should screen for airway symptoms, hydration status, and any signs of hemorrhage. A foreign body in the outer ear without respiratory distress is typically nonurgent and can usually wait for a scheduled evaluation. The request for a school note after 24 hours of antibiotics and the question about returning to sports at day 5 are administrative/activity guidance issues and are lower priority than a potential post-op complication.

Question 4

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

Accepted Answer

Answer reason: Acute pyelonephritis often requires prompt parenteral therapy, and loss of a functioning line can quickly delay treatment. The other situations are important but are not immediately threatening: a leaking ostomy appliance is a comfort/skin-integrity issue, questions before surgery can be addressed after immediate physiologic needs are stabilized, and no bowel movement for 2 days post-op is common constipation without signs of obstruction. Restoring reliable IV access and assessing the infiltration site should be prioritized first.

Question 5

A nurse on a cardiovascular unit has received a morning report stating that all clients were stable overnight with stable vital signs. Which client does the nurse assess first?

Accepted Answer

Answer reason: At 8 hours after admission, this client is still in a high-risk window for recurrent chest pain, evolving ECG changes, and complications from anticoagulants/antiplatelets, so early reassessment is the safest triage choice. Pre-op CABG within an hour is important but typically follows a structured preoperative checklist and monitoring while awaiting transport, and sudden deterioration is less likely than with an active MI. A client 24 hours post-stent is farther from the highest-risk immediate post-procedure period, and dialysis/holding a beta-blocker can be addressed after the highest-acuity cardiac assessment.

Question 6

The nurse is receiving handoff of care report on 4 clients. Which client should the nurse assess first?

Accepted Answer

Answer reason: New shivering and chills shortly after thyroid surgery can signal acute hypermetabolic decompensation and/or early systemic infection, both of which can quickly destabilize vital signs and oxygenation. This client needs immediate assessment of temperature, heart rate, blood pressure, mental status, and airway/neck for swelling or bleeding to determine if emergency interventions are needed. In contrast, expected incisional pain and mild sore throat 1 hour after parathyroidectomy are common postoperative findings without immediate red-flag features.

Question 7

The nurse has been made aware that the following 4 clients require assistance. The nurse should first assist the client who had?

Accepted Answer

Answer reason: This condition can rapidly progress to severe hypertension, stroke, seizures, or dysrhythmias unless the trigger is removed and blood pressure is treated promptly. The other situations are important but more stable: postoperative pain after hysterectomy is expected, numb feet 2 days post-laminectomy is concerning but typically not as immediately life-threatening, and a disconnected TURP catheter requires correction to maintain irrigation/drainage but is less urgent than a potential autonomic crisis. Therefore, this client must be assessed and managed first with immediate vital signs/BP evaluation and rapid intervention.

Question 8

The nurse in the emergency department (ED) is assessing a client with multiple injuries that occurred as a result of a motor vehicle collision. Which of the following nursing observations should receive highest priority?

Accepted Answer

Answer reason: A neck hematoma can rapidly expand and compress the airway or indicate major vascular injury (eg, carotid or jugular), making sudden deterioration possible. The other findings represent significant extremity injuries or superficial bleeding but are less likely to cause abrupt airway obstruction in the first moments of assessment. Therefore this observation requires the most urgent evaluation and airway preparedness.

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Triage Practice Test 8

Triage NCLEX Practice Test

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The intensive care unit (ICU) nurse receives a phone call stating a client diagnosed with a head trauma must undergo admission. There are no empty beds. Which client is most stable and eligible for a transfer to the step-down neurological unit?

Several patients are taking antipsychotic medications and are having medication side effects. Place the following patients in priority order for additional assessment and appropriate interventions, with 1 being the most critical and 4 being the least?

The nurse in the pediatric clinic is triaging telephone messages. The nurse should call the parent of which child first?

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

A nurse on a cardiovascular unit has received a morning report stating that all clients were stable overnight with stable vital signs. Which client does the nurse assess first?

The nurse is receiving handoff of care report on 4 clients. Which client should the nurse assess first?

The nurse has been made aware that the following 4 clients require assistance. The nurse should first assist the client who had?

The nurse in the emergency department (ED) is assessing a client with multiple injuries that occurred as a result of a motor vehicle collision. Which of the following nursing observations should receive highest priority?

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