Question 1

Which phone message should the nurse in the outpatient clinic return first to ensure client safety?

Accepted Answer

Answer reason: A client with a cervical spinal cord injury who suddenly develops a severe headache is likely experiencing autonomic dysreflexia, a critical emergency that can quickly cause dangerously high blood pressure. Immediate nursing intervention is required to remove the trigger (e.g., bladder distension).

Question 2

The nurse has just received the shift report and is preparing to make initial rounds. Which client should be assessed first to prevent deterioration?

Accepted Answer

Answer reason: The newly admitted client with shortness of breath may be unstable or developing respiratory failure. This finding demands immediate assessment and oxygen support to prevent rapid decline.

Question 3

A client experiences a traumatic amputation of a leg in a motor vehicle accident. Which nursing intervention should initially receive the lowest priority?

Accepted Answer

Answer reason: In the immediate post-trauma phase, priorities are circulation and hemorrhage control: maintain the compression dressing and monitor hemoglobin levels. Supportive communication may help, but formal teaching is not appropriate until the client is stabilized. Therefore, education on residual limb care is the lowest initial priority.

Question 4

Which client in the intensive care unit is the most stable for transfer to the step-down neurological unit?

Accepted Answer

Answer reason: The stroke patient, 4 days post-event and confused, is relatively stable for step-down care. The others are high acuity: a GCS of 7 indicates severe coma; a suspected postoperative CSF leak risks meningitis and requires close monitoring; and active seizures after head injury require ICU-level management.

Question 5

The nurse is working in the emergency room when a client arrives with severe burns to the left arm, hands, face, and neck. Which action should receive priority?

Accepted Answer

Answer reason: Burns to the face and neck suggest a possible inhalation injury and airway edema. Following the ABCs, the airway and breathing take priority—apply oxygen immediately.

Question 6

The nurse in the emergency department is responsible for the triage of four recently admitted clients. Which client should the nurse send directly to the treatment room?

Accepted Answer

Answer reason: A recent sexual assault requires immediate placement in a private treatment room for safety, privacy, timely forensic evidence collection, and urgent prophylaxis. The other complaints are non-emergent or stable.

Question 7

A pregnant patient arrives at the community health center with a moderate bloody discharge; what should the nurse do first?

Accepted Answer

Answer reason: Moderate vaginal bleeding in pregnancy may indicate placenta previa or abruptio placentae. Vaginal or speculum exams should be avoided until placental location is known. This is a potential obstetric emergency; the priority is to notify the provider immediately for further evaluation and management.

Question 8

The nurse is caring for a newborn with a tracheoesophageal fistula. Which of the following nursing diagnoses is a priority?

Accepted Answer

Answer reason: The airway is the immediate priority (ABCs). In TEF, the esophagus connects to the trachea, causing a high risk of aspiration and obstruction; maintaining a patent airway is paramount before addressing dehydration, nutrition, or general injury risk.

Question 9

The home health nurse is planning for the day's visits. Which client should be seen first?

Accepted Answer

Answer reason: See the client most susceptible to infection first, and infectious clients last. High-dose corticosteroids and a central venous catheter make this client markedly immunosuppressed and at high risk for severe infection. The MRSA client should be scheduled last.

Question 10

The nurse is caring for clients on the postpartum unit. Which of the following should the nurse assess first?

Accepted Answer

Answer reason: The client whose placenta was delivered 10 minutes ago is in the immediate postpartum period, which is the highest-risk time for postpartum hemorrhage. Uterine atony and bleeding can occur rapidly and without warning, requiring immediate fundal and bleeding assessment. Although precipitous labor increases the risk of hemorrhage, it represents a potential risk rather than an immediate condition. Therefore, the client in the immediate postpartum period takes priority.

Question 11

The nurse is working on a neurological unit. If the following events occur simultaneously, which would receive the RN's priority?

Accepted Answer

Answer reason: Sudden focal neurological deficit in a client with a cerebral aneurysm suggests an acute hemorrhage or stroke and threatens the airway, breathing, and cerebral perfusion. This requires immediate RN assessment and intervention. The other findings are nonemergent in comparison.

Question 12

Which of the following needs is given a higher priority among others?

Accepted Answer

Answer reason: Use Maslow and the ABCs: physiologic needs take priority. Dehydration threatens circulation and perfusion and must be addressed before safety and psychosocial concerns.

Question 13

The nurse has just received the change-of-shift report. The nurse should give priority to assessing the client with?

Accepted Answer

Answer reason: Chest tube drainage >100 mL/hr after thoracotomy suggests active hemorrhage and requires immediate assessment. The other findings are expected or less urgent: low-grade fever post-cholecystectomy, urinary urgency after TURP, and diminished hearing after stapedectomy due to packing.

Question 14

Triage means?

Accepted Answer

Answer reason: Triage means sorting or prioritizing patients by urgency; none of the given choices state this, so 'None above' is correct.

Question 15

Which victim should be transported by helicopter to the nearest hospital after a car accident involving four vehicles?

Accepted Answer

Answer reason: Unconsciousness with signs of shock (cold, clammy skin and tachycardia) indicates circulatory collapse and a life-threatening condition requiring immediate advanced care. This patient’s critical status warrants helicopter evacuation for rapid stabilization and definitive treatment.

Question 16

What is the priority nursing diagnosis in the case of neonatal jaundice?

Accepted Answer

Answer reason: Physiologic needs take priority. Elevated bilirubin in neonatal jaundice can cause lethargy and poor feeding (fatigue), which is a direct physiologic problem. Hyperthermia is not inherent to jaundice, and knowledge/anxiety are psychosocial and lower priority.

Question 17

After a storm, the rescue team is searching for injured people. A nurse on the team discovers a victim lying next to a broken natural gas line. The victim is not breathing and is bleeding heavily from a leg wound. How should the nurse proceed? Place care in order of its priority?

Accepted Answer

Answer reason: Scene safety is the highest priority. With a broken natural gas line, the nurse must first remove the victim from danger before initiating airway or bleeding interventions.

Question 18

An apartment fire spreads to seven apartment units. Victims suffer burns, minor injuries, and broken bones from jumping out of windows. Which client should be transported first?

Accepted Answer

Answer reason: In mass-casualty triage, airway compromise or inhalation injury takes priority. Rapid respirations and cough suggest possible airway burns requiring urgent care.

Question 19

Which of the following nursing diagnosis is a priority for a patient diagnosed with pneumonia?

Accepted Answer

Answer reason: Use ABCs: pneumonia impairs alveolar ventilation and oxygenation, making impaired gas exchange the immediate life-threatening priority. The others are secondary; risk for infection is not priority when infection already exists.

Question 20

A six year old child is admitted to the hospital with pneumonia. An immediate priority in this child's nursing care would include all of the following EXCEPT?

Accepted Answer

Answer reason: Immediate priorities for pneumonia follow the ABCs: assess breathing, position to ease ventilation, and provide oxygen. Nutrition is important but not an immediate priority.

Question 21

In triage, yellow color indicates..?

Accepted Answer

Answer reason: In disaster triage, yellow tags denote delayed/urgent care needs; red is emergent, green is nonurgent, and black is deceased/expectant.

Question 22

A 10-year-old child with asthma is admitted to the ward. Which of the following observations needs immediate action by the nurse?

Accepted Answer

Answer reason: Upright posture and refusal to lie down indicate significant respiratory distress/orthopnea in an asthmatic child and require immediate intervention. SpO2 of 96% and RR 20/min are within normal limits for age; refusal to eat is not emergent.

Question 23

As soon as the enters the post anesthesia care unit , first priority assessment by the nurse?

Accepted Answer

Answer reason: In the PACU, the immediate priority follows ABCs. Post-anesthesia patients are at highest risk for airway obstruction and hypoventilation, so airway patency and respiratory status must be assessed first.

Question 24

Priority intervention in patient of head injury is?

Accepted Answer

Answer reason: Use ABCs for trauma: ensure airway patency first in a head-injured patient to prevent hypoxia and aspiration.

Question 25

Thirty people are injured in a train derailment. Which client should be transported to the hospital first?

Accepted Answer

Answer reason: In mass casualty triage, clients with life-threatening but potentially survivable injuries are treated first. A sucking chest wound impairs ventilation and oxygenation, requiring immediate attention to prevent respiratory failure. Others have less urgent or nonsurvivable conditions.

Question 26

In what order should the nurse prioritize assessment of four clients: an 85-year-old with bacterial pneumonia and high fever, a 60-year-old postoperative thoracotomy client with chest tubes requesting pain medication, a 35-year-old with suspected tuberculosis and cough, and a 56-year-old with emphysema due for bronchodilator with no respiratory distress?

Accepted Answer

Answer reason: Prioritize by ABCs and acuity: the elderly client with bacterial pneumonia and high fever is at highest risk for respiratory compromise; next is the postoperative thoracotomy client with chest tubes needing pain control to support ventilation; the suspected TB client is stable and seen after isolation measures are initiated; the emphysema client without distress and only due for a bronchodilator is last.

Question 27

Which client should the triage nurse see first when four clients present at the same time in the emergency department?

Accepted Answer

Answer reason: An infant with petechial rash, fever, and nuchal rigidity suggests meningococcal meningitis/sepsis, a rapidly life-threatening and contagious emergency that requires immediate assessment and intervention.

Question 28

After receiving handoff shift report, which patient should the nurse assess first?

Accepted Answer

Answer reason: Increased difficulty breathing after inhaler use in a patient with asthma indicates worsening bronchospasm or poor response to treatment and may signal impending respiratory failure. This represents an acute change in respiratory status requiring immediate assessment. Although an SpO2 of 89% is low, it may be an expected baseline in clients with chronic bronchitis. Acute respiratory deterioration takes priority over chronic findings.

Question 29

The nurse is constructing a nursing care plan for a client post-operative open cholecystectomy. Which nursing diagnosis would be the priority for this client?

Accepted Answer

Answer reason: Use ABCs for prioritization. After an open cholecystectomy (upper abdominal surgery), pain and splinting can impair deep breathing and coughing, increasing risk for atelectasis and secretions. Airway clearance takes precedence over pain or urinary issues.

Question 30

The nurse has just received a report from the previous shift. Which of the following clients should the nurse visit first?

Accepted Answer

Answer reason: Use ABCs and unstable vs. stable. A trauma patient with shortness of breath may have airway/breathing compromise (e.g., pneumothorax) and requires immediate assessment. The COPD client with PCO2 of 50 may be baseline, cancer pain is important but not emergent, and a low-grade post-op fever (100°F) is expected.

Question 31

The nurse caring for a client after a suspected CVA recognizes which nursing diagnosis as the priority?

Accepted Answer

Answer reason: After a suspected stroke, the top priority is maintaining adequate cerebral perfusion to prevent further brain ischemia. Other diagnoses are important but not immediately life‑threatening.

Question 32

The nurse in the ER has received report of four clients en route to the emergency department. Which client should the nurse see first? A client with?

Accepted Answer

Answer reason: Facial and neck burns with singed nasal hairs indicate possible inhalation injury and impending airway compromise, which takes highest priority in triage.

Question 33

A client is post-operative laryngectomy for cancer of the larynx. Which nursing diagnosis would be the priority for this client?

Accepted Answer

Answer reason: Use ABCs: after laryngectomy the immediate priority is maintaining a patent airway; excess secretions can obstruct the airway. Body image, nutrition, and communication are important but not as urgent as airway clearance.

Question 34

The nurse is caring for clients on a respiratory unit. Upon receiving the following client reports, which client should be seen first?

Accepted Answer

Answer reason: The presence of edema and jugular vein distention in a bronchitis client indicates right-sided heart failure secondary to chronic pulmonary disease (cor pulmonale). This is a sign of worsening cardiopulmonary compromise and requires immediate assessment. The other clients are stable or expected findings for their conditions.

Question 35

A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive the highest priority at this time?

Accepted Answer

Answer reason: DVT causes venous obstruction with congestion and reduced tissue perfusion in the affected limb, making impaired peripheral tissue perfusion the immediate priority. Option A is incorrect pathophysiology and not current unless PE occurs; B is not expected; C is a risk rather than the actual primary problem.

Question 36

Which current client is best for immediate discharge when a major disaster is expected and a large influx of clients is anticipated within an hour?

Accepted Answer

Answer reason: During disaster discharge planning, the safest clients to discharge are stable patients with chronic, non–acute needs. A stage 3 pressure injury after 4 days is stable and manageable at home, whereas the others have acute infections or are in the early postoperative period requiring monitoring.

Question 37

Which telephone message should the nurse in the pediatric clinic return first?

Accepted Answer

Answer reason: Moist, reddened umbilical stump suggests possible infection (omphalitis) and requires prompt assessment. The Moro/startle reflex (A) and yellow exudate on a healing circumcision (B) are normal findings, and one stool daily in a formula-fed newborn (C) can be normal.

Question 38

Which patient condition requires more immediate attention: a person who is septic and developing petechiae, a COPD patient with symptoms and 90% oxygen saturation, or a patient with DVT who missed one dose of anticoagulant?

Accepted Answer

Answer reason: Petechiae in a septic patient suggests disseminated intravascular coagulation and impending hemodynamic instability, a life‑threatening emergency requiring immediate intervention. COPD with 90% SpO2 may be near baseline and less acute, and missing one anticoagulant dose for DVT is lower priority.

Question 39

Which client with diabetes mellitus should the nurse see first based on the report?

Accepted Answer

Answer reason: Hypotension with hot, dry skin indicates severe hyperglycemia with dehydration (DKA/HHS) and potential hypovolemia/shock, requiring immediate assessment and intervention. The other clients have non-urgent or stable symptoms.

Question 40

Which client with diabetes mellitus should the nurse see first based on the report received?

Accepted Answer

Answer reason: Hypotension with hot, dry skin suggests severe hyperglycemia with dehydration (DKA/HHS) and potential shock. This is the most unstable patient and requires immediate assessment and intervention.

Question 41

When planning care for a male client admitted with a cervical spine injury sustained during a diving accident, which nursing diagnosis should the nurse assign the highest priority?

Accepted Answer

Answer reason: Cervical spine injury can compromise diaphragmatic function (phrenic nerve C3–C5) and airway protection. Using ABCs, airway/breathing take priority; thus the highest-priority diagnosis is Ineffective breathing pattern.

Question 42

Which telephone message should the nurse return first in the pediatric clinic?

Accepted Answer

Answer reason: Moist, reddened umbilical stump suggests possible infection (omphalitis) and requires prompt assessment. The Moro reflex (A) is normal, yellow exudate on a healing circumcision (B) is expected, and one stool daily in a formula-fed newborn (C) can be normal.

Question 43

After receiving a report from the night nurse, which client should the nurse see first?

Accepted Answer

Answer reason: Newly postoperative clients (within 24 hours) are highest priority due to risk for complications and need for immediate assessment, including NG tube patency, bleeding, and bowel function. The other clients are stable or issues can be delegated/handled later.

Question 44

Which client should the nurse prioritize on a med-surg unit?

Accepted Answer

Answer reason: Petechiae in a septic client suggests DIC and impending hemodynamic instability—an immediate life-threatening complication. The ostomy leak is non-urgent, COPD with SpO2 90% may be baseline (target 88–92%), and a missed warfarin dose for DVT is not as emergent.

Question 45

Which current client is best for immediate discharge during a major disaster with a large influx of clients expected in less than 1 hour?

Accepted Answer

Answer reason: During disaster triage, stable clients who can safely continue recovery at home or in long-term care facilities are discharged first to free beds. A client hospitalized for a pressure injury is stable, chronic, and does not require acute care, whereas postoperative or acutely infected clients still need monitoring.

Question 46

Which client should the nurse see first in the emergency department after a weather disaster?

Accepted Answer

Answer reason: The client with diaphoresis and chest pain suggests myocardial ischemia, a life-threatening priority requiring immediate care. Musculoskeletal injuries are stable and can safely wait.

Question 47

Which client message should the nurse return first in the outpatient clinic?

Accepted Answer

Answer reason: Headache in a client with a cervical (C6) spinal cord injury suggests autonomic dysreflexia, a life-threatening emergency seen with injuries at or above T6. It requires immediate assessment and intervention. The other issues are expected or less urgent.

Question 48

Which adult client should the triage nurse assess first in the emergency department?

Accepted Answer

Answer reason: A persistent nosebleed (epistaxis) may indicate arterial bleeding or a coagulopathy, posing a higher risk for significant blood loss or airway compromise. According to triage principles, clients with active bleeding are prioritized for immediate assessment.

Question 49

An unconscious client with multiple injuries arrives in the emergency department; which nursing intervention receives the highest priority?

Accepted Answer

Answer reason: Follow ABCs in trauma; airway is the first priority for an unconscious patient to prevent hypoxia and death.

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