Question 1

A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to?

Accepted Answer

Answer reason: Apply ABCs in trauma; airway is the immediate priority before pain control or other interventions.

Question 2

A pregnant client reports severe abdominal pain and vaginal bleeding. The nurse suspects ectopic pregnancy. What should the nurse prioritize?

Accepted Answer

Answer reason: Severe abdominal pain with bleeding suggests a rupturing ectopic pregnancy and life‑threatening hemorrhage. Priority is rapid surgical intervention and preparation for the OR, not comfort measures.

Question 3

Four clients are to receive medication. Which client should receive medication first?

Accepted Answer

Answer reason: The client with labored respirations likely has pulmonary edema, requiring immediate administration of IV Lasix to reduce fluid overload and improve breathing. “Stat” indicates urgency.

Question 4

The charge nurse in the cardiac critical care unit is making rounds. Which client should the nurse see first?

Accepted Answer

Answer reason: An elevated CK-MB in a client with acute MI indicates ongoing myocardial injury and potential instability, requiring immediate assessment. The CAD client has a non-urgent psychosocial complaint, and an INR of 2.8 is therapeutic for atrial fibrillation.

Question 5

The nurse is assessing a client following a coronary artery bypass graft (CABG). The nurse should give priority to reporting?

Accepted Answer

Answer reason: Post-CABG chest tube drainage exceeding ~150 mL/hr indicates possible hemorrhage/tamponade and requires immediate reporting. Confusion and pallor are concerning but less emergent; urine output 40 mL/hr is adequate.

Question 6

Which is more life threatening?

Accepted Answer

Answer reason: Severe hypotension (80/50) indicates inadequate perfusion and potential shock, posing an immediate life-threatening risk. The hypertensive values are dangerous but generally less acutely life-threatening than profound hypotension.

Question 7

Among the following statements, which should be given the HIGHEST priority?

Accepted Answer

Answer reason: Apply ABCs: cyanosis indicates inadequate oxygenation (airway/breathing compromise) requiring immediate intervention. Hypotension, fever, and pain are serious but secondary to oxygenation.

Question 8

Which adult client should the emergency nurse assess first during triage?

Accepted Answer

Answer reason: A persistent nosebleed (epistaxis) can indicate potential hemodynamic instability, risk of airway compromise, or uncontrolled bleeding, making it higher priority than mild fever, minor trauma, or several hours of vomiting. Triage prioritizes clients based on the threat to life or airway, and active bleeding takes precedence.

Question 9

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

Accepted Answer

Answer reason: A suspected subdural hematoma is an acute, potentially life-threatening intracranial bleed that can rapidly worsen and requires immediate neurological assessment. The other clients are more stable or non-urgent.

Question 10

The nurse is formulating a plan of care for a client with a goiter. The priority nursing diagnosis for the client with a goiter is?

Accepted Answer

Answer reason: Use ABCs for prioritization. A large goiter can compress the trachea, threatening airway patency, so risk for ineffective airway clearance is the priority diagnosis over psychosocial or nutrition issues.

Question 11

A newly admitted client has sickle cell crisis. He is complaining of pain in his feet and hands. The nurse's assessment findings include a pulse oximetry of 92. Assuming that all the following interventions are ordered, which should be done first?

Accepted Answer

Answer reason: Use ABCs: the SpO2 is low (92%), so oxygenation is the immediate priority in sickle cell crisis to reduce hypoxia and further sickling before fluids, analgesia, or environmental measures.

Question 12

The nurse should visit which of the following clients first?

Accepted Answer

Answer reason: Chest pain can indicate unstable angina or MI and represents an immediate ABCs/circulation risk. The other clients are stable (normal glucose, controlled hypertension, and chronic Raynaud’s).

Question 13

The nurse is caring for an obstetrical client in early labor. After the rupture of membranes, the nurse should give priority to?

Accepted Answer

Answer reason: After rupture of membranes, the priority is to assess fetal heart rate to detect cord prolapse or compression and identify fetal distress promptly.

Question 14

A client is admitted to the emergency room with multiple injuries. What is the proper sequence for managing the client?

Accepted Answer

Answer reason: Follow ABC priorities in trauma: secure airway first, then address circulation by controlling bleeding and preventing shock; secondary assessments like head injury evaluation follow stabilization.

Question 15

The home health nurse is scheduled to visit four clients. Which client should she visit first?

Accepted Answer

Answer reason: Visit the most vulnerable, high-acuity client first. A recent burn autograft has critical risk for infection and graft failure and requires prompt, sterile assessment. The client with fever and cough should be scheduled last to prevent cross‑infection; the other two are stable/routine.

Question 16

The nurse is developing a plan of care for a client with acromegaly. Which nursing diagnosis should receive priority?

Accepted Answer

Answer reason: Airway has the highest priority. In acromegaly, soft-tissue overgrowth and enlarged tongue can obstruct the airway, making risk for ineffective airway clearance the most critical diagnosis over body image, mobility, or sexual concerns.

Question 17

The nurse is caring for a client with amyotrophic lateral sclerosis (ALS, Lou Gehrig’s disease). The nurse should give priority to?

Accepted Answer

Answer reason: ALS causes progressive motor neuron degeneration with risk of respiratory muscle weakness and failure. Airway and breathing take priority, so assessing respiratory status is the most urgent action.

Question 18

A home health nurse has four clients assigned for morning visits. The nurse should give priority to visiting the client with?

Accepted Answer

Answer reason: Frothy sputum in a client with CHF indicates acute pulmonary edema and impending respiratory compromise, requiring immediate assessment/intervention. The other conditions are urgent but not as imminently life‑threatening.

Question 19

The nurse is planning care for a client with adrenal insufficiency. Which nursing diagnosis should receive priority?

Accepted Answer

Answer reason: Adrenal insufficiency (low cortisol and aldosterone) causes sodium and water losses leading to hypotension and dehydration. Preventing and treating fluid volume deficit is the immediate, life‑threatening priority over sleep, nutrition, or body image concerns.

Question 20

The nurse on the cardiac unit has received the shift report from the outgoing nurse. Which client should the nurse assess first?

Accepted Answer

Answer reason: Chest pain—especially recently treated—can indicate evolving myocardial ischemia. A patient with active or recently treated chest pain remains the highest-priority assessment due to risk of deterioration.

Question 21

Which client should the telemetry nurse assess first after receiving the a.m. shift report?

Accepted Answer

Answer reason: Pink frothy sputum indicates acute pulmonary edema, a life-threatening condition requiring immediate assessment and intervention.

Question 22

In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnosis as a priority?

Accepted Answer

Answer reason: Ulcerative colitis often causes frequent bloody diarrhea, leading to dehydration and electrolyte loss; addressing fluid volume deficit is the immediate, life-threatening priority over anxiety, skin integrity, or nutrition.

Question 23

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

Accepted Answer

Answer reason: Immediate postoperative thoracic surgery poses the greatest risk to airway and hemorrhage; a client 2 hours post-lobectomy requires first assessment. The other clients are more stable (post-op day 2, fever with pneumonia, traction).

Question 24

A home health nurse is making preparations for morning visits. Which one of the following clients should the nurse visit first?

Accepted Answer

Answer reason: Nocturnal dyspnea in a client with CHF suggests worsening fluid overload and potential pulmonary edema, requiring urgent assessment. The other clients are stable chronic cases appropriate for later visits.

Question 25

The graduate nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority?

Accepted Answer

Answer reason: For organ donor maintenance, the priority is ensuring adequate perfusion; thus maintaining sufficient blood pressure comes first. Other targets are inappropriate (300 mL/hr urine is excessive, 33°F is impossible/typo for C°, and Hct

Question 26

A home health nurse is planning for her daily visits. Which client should the home health nurse visit first?

Accepted Answer

Answer reason: Airway takes priority. A client with a laryngectomy is at highest risk for airway obstruction and requires immediate assessment and potential suctioning. The others are more stable/chronic issues.

Question 27

The nurse employed in the emergency room is responsible for triage of four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care?

Accepted Answer

Answer reason: Sternal bruising signals potential blunt cardiac injury or internal trauma, making this client the highest priority.

Question 28

The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 68/34, pulse rate 130, and respirations 18. Which is the client's most appropriate priority nursing diagnosis?

Accepted Answer

Answer reason: Severe hypotension and tachycardia indicate hypovolemic shock, making fluid volume restoration the immediate priority.

Question 29

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

Accepted Answer

Answer reason: Diabetic clients with pressure ulcers deteriorate quickly and are at high risk for infection and sepsis; they require immediate evaluation.

Question 30

The nurse is providing home care for a client with heart failure and pulmonary edema. Which of the following nursing diagnoses should have PRIORITY in planning care?

Accepted Answer

Answer reason: In heart failure with pulmonary edema, decreased cardiac output and impaired oxygenation make activity intolerance an immediate priority over risks like skin breakdown, constipation, or infection.

Question 31

The nurse is caring for a client with congestive heart failure. Which of the following assessments requires the nurse's IMMEDIATE attention?

Accepted Answer

Answer reason: An SpO2 of 85% indicates significant hypoxemia and threatens airway/oxygenation, requiring immediate intervention. Nocturia, crackles, and diaphoresis can occur with CHF but are less emergent than severe desaturation.

Question 32

The nurse is caring for an acutely ill 10 year-old client. Which of the following assessments would require the nurses IMMEDIATE attention?

Accepted Answer

Answer reason: Airway and breathing take priority. Slow, irregular respirations indicate impending respiratory failure in a child and require immediate intervention; the other findings are concerning but less immediately life-threatening.

Question 33

When caring for a client with advanced cirrhosis of the liver, which of the following nursing diagnosis should take PRIORITY?

Accepted Answer

Answer reason: Advanced cirrhosis causes decreased synthesis of clotting factors and portal hypertension, creating a high risk for life-threatening hemorrhage (e.g., variceal bleeding). This takes priority over nutrition or fluid issues.

Question 34

A client has just been admitted with portal hypertension. Which one of the following nursing diagnosis would be a PRIORITY in planning care?

Accepted Answer

Answer reason: Portal hypertension greatly increases the risk of life-threatening variceal bleeding; preventing and monitoring for hemorrhage is the immediate priority over other needs.

Question 35

The nurse is assigned to care for four clients. Which of the following should be assessed immediately after hearing the report?

Accepted Answer

Answer reason: Active vomiting in a client with a peptic ulcer signals possible perforation or GI bleeding and acute fluid-electrolyte imbalance, which is potentially life-threatening and requires immediate assessment.

Question 36

The nurse is caring for a client who had a total hip replacement four days ago. Which of the following symptoms requires the nurse's IMMEDIATE attention?

Accepted Answer

Answer reason: Post–total hip replacement patients are at high risk for postoperative pulmonary embolism; chest pain with palpitations is a life‑threatening sign requiring immediate intervention. The other findings are expected or less urgent.

Question 37

The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs two hours ago. The nurse should?

Accepted Answer

Answer reason: Acute lethargy and confusion after a recent fall indicate possible head injury and require immediate emergency evaluation rather than calling the physician, reassuring, or waiting for worsening.

Question 38

An 80 year-old nursing home resident has a temperature of 101.6 rectally. This is a sudden change in an otherwise healthy client. Which should the nurse assess FIRST?

Accepted Answer

Answer reason: With an acute fever in an older adult, the priority is to assess level of consciousness to determine severity and potential neurologic compromise or sepsis; if alert, other assessments can follow.

Question 39

A home care nurse is planning activities for the day. Which of the following clients should the nurse see FIRST?

Accepted Answer

Answer reason: Pink-tinged (frothy) sputum suggests acute pulmonary edema/heart failure, a potential airway-breathing emergency requiring immediate assessment. The other clients are stable follow-ups without signs of acute deterioration.

Question 40

A three year-old child is treated in the emergency room after ingesting an ounce of a liquid narcotic. What FIRST action should the nurse take?

Accepted Answer

Answer reason: Use ABCs for toxic ingestion: first assess and stabilize airway and circulation before other interventions like oxygen, suction, or IV fluids.

Question 41

Which triage color is used for patients needing urgent, but not immediate, intervention during a mass-casualty event?

Accepted Answer

Answer reason: In disaster triage, Yellow indicates delayed/urgent care needed but not immediate. Red is immediate, Green minor, Black expectant/deceased.

Question 42

A client has been admitted to the Coronary Care Unit with a Myocardial Infarction. Which of the following nursing diagnosis should have PRIORITY?

Accepted Answer

Answer reason: In acute MI, untreated pain increases sympathetic stimulation, raising heart rate, blood pressure, and myocardial oxygen demand. Prompt pain control reduces ischemia and prevents further cardiac stress, making it the immediate priority.

Question 43

A child is injured on the school playground and appears to have a fractured leg. The FIRST action the school nurse should take is?

Accepted Answer

Answer reason: Follow the nursing process: assessment is the first step. Evaluate the child and injury (e.g., neurovascular status) before initiating interventions like immobilization or transport.

Question 44

A nurse in the emergency department receives four clients. Which client should be assessed first?

Accepted Answer

Answer reason: Sudden chest pressure suggests possible myocardial ischemia or infarction, which is an immediately life-threatening condition requiring rapid assessment and intervention. Compared to infection, dehydration, or musculoskeletal injury, cardiac compromise carries the highest risk of rapid deterioration.

Question 45

A nurse is caring for four post-operative clients. Which finding requires priority assessment?

Accepted Answer

Answer reason: Acute postoperative restlessness and confusion may indicate early hypoxia, hemorrhage, or neurologic compromise. These conditions pose immediate threats to airway, breathing, or circulation, making this finding higher priority than pain, ambulation needs, or appetite changes.

Question 46

A nurse is providing care in a medical-surgical unit. Which client should the nurse see first?

Accepted Answer

Answer reason: Hypoglycemia at this level can rapidly progress to seizures, loss of consciousness, or death. Although other clients require attention, critically low blood glucose presents the most immediate physiologic threat.

Question 47

Four clients have called the nurse using the call light. Who should the nurse assist first?

Accepted Answer

Answer reason: Sensation of throat closing suggests airway compromise, potentially due to anaphylaxis or edema. Airway issues take absolute priority in all emergencies following the ABC framework.

Question 48

A nurse cares for four patients on a cardiac floor. Which patient needs immediate attention?

Accepted Answer

Answer reason: These new neurologic deficits strongly indicate an acute ischemic stroke, where every minute of delay increases neuronal death. This client has the highest threat to life and long-term function.

Question 49

A nurse receives handoff for four clients. Which client should be evaluated first?

Accepted Answer

Answer reason: A sudden increase in bright red drainage suggests active hemorrhage, a potentially life-threatening complication that requires immediate assessment and intervention. The other issues are non-emergent.

Question 50

A nurse is caring for four clients during a busy morning round. Which client requires immediate assessment?

Accepted Answer

Answer reason: Severe hyperkalemia with ECG changes indicates impending lethal dysrhythmias such as ventricular fibrillation or asystole. This presentation represents an immediate life threat and requires rapid stabilization. The other clients have non-emergent or chronic issues.

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A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to?

A pregnant client reports severe abdominal pain and vaginal bleeding. The nurse suspects ectopic pregnancy. What should the nurse prioritize?

Four clients are to receive medication. Which client should receive medication first?

The charge nurse in the cardiac critical care unit is making rounds. Which client should the nurse see first?

The nurse is assessing a client following a coronary artery bypass graft (CABG). The nurse should give priority to reporting?

Which is more life threatening?

Among the following statements, which should be given the HIGHEST priority?

Which adult client should the emergency nurse assess first during triage?

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

The nurse is formulating a plan of care for a client with a goiter. The priority nursing diagnosis for the client with a goiter is?

A newly admitted client has sickle cell crisis. He is complaining of pain in his feet and hands. The nurse's assessment findings include a pulse oximetry of 92. Assuming that all the following interventions are ordered, which should be done first?

The nurse should visit which of the following clients first?

The nurse is caring for an obstetrical client in early labor. After the rupture of membranes, the nurse should give priority to?

A client is admitted to the emergency room with multiple injuries. What is the proper sequence for managing the client?

The home health nurse is scheduled to visit four clients. Which client should she visit first?

The nurse is developing a plan of care for a client with acromegaly. Which nursing diagnosis should receive priority?

The nurse is caring for a client with amyotrophic lateral sclerosis (ALS, Lou Gehrig’s disease). The nurse should give priority to?

A home health nurse has four clients assigned for morning visits. The nurse should give priority to visiting the client with?

The nurse is planning care for a client with adrenal insufficiency. Which nursing diagnosis should receive priority?

The nurse on the cardiac unit has received the shift report from the outgoing nurse. Which client should the nurse assess first?

Which client should the telemetry nurse assess first after receiving the a.m. shift report?

In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnosis as a priority?

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

A home health nurse is making preparations for morning visits. Which one of the following clients should the nurse visit first?

The graduate nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority?

A home health nurse is planning for her daily visits. Which client should the home health nurse visit first?

The nurse employed in the emergency room is responsible for triage of four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care?

The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 68/34, pulse rate 130, and respirations 18. Which is the client's most appropriate priority nursing diagnosis?

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

The nurse is providing home care for a client with heart failure and pulmonary edema. Which of the following nursing diagnoses should have PRIORITY in planning care?

The nurse is caring for a client with congestive heart failure. Which of the following assessments requires the nurse's IMMEDIATE attention?

The nurse is caring for an acutely ill 10 year-old client. Which of the following assessments would require the nurses IMMEDIATE attention?

When caring for a client with advanced cirrhosis of the liver, which of the following nursing diagnosis should take PRIORITY?

A client has just been admitted with portal hypertension. Which one of the following nursing diagnosis would be a PRIORITY in planning care?

The nurse is assigned to care for four clients. Which of the following should be assessed immediately after hearing the report?

The nurse is caring for a client who had a total hip replacement four days ago. Which of the following symptoms requires the nurse's IMMEDIATE attention?

The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs two hours ago. The nurse should?

An 80 year-old nursing home resident has a temperature of 101.6 rectally. This is a sudden change in an otherwise healthy client. Which should the nurse assess FIRST?

A home care nurse is planning activities for the day. Which of the following clients should the nurse see FIRST?

A three year-old child is treated in the emergency room after ingesting an ounce of a liquid narcotic. What FIRST action should the nurse take?

Which triage color is used for patients needing urgent, but not immediate, intervention during a mass-casualty event?

A client has been admitted to the Coronary Care Unit with a Myocardial Infarction. Which of the following nursing diagnosis should have PRIORITY?

A child is injured on the school playground and appears to have a fractured leg. The FIRST action the school nurse should take is?

A nurse in the emergency department receives four clients. Which client should be assessed first?

A nurse is caring for four post-operative clients. Which finding requires priority assessment?

A nurse is providing care in a medical-surgical unit. Which client should the nurse see first?

Four clients have called the nurse using the call light. Who should the nurse assist first?

A nurse cares for four patients on a cardiac floor. Which patient needs immediate attention?

A nurse receives handoff for four clients. Which client should be evaluated first?

A nurse is caring for four clients during a busy morning round. Which client requires immediate assessment?

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