Question 1

A nurse in a mass-casualty event assesses four clients. Which client should be tagged with the **highest priority (immediate)** category?

Accepted Answer

Answer reason: A sucking chest wound causes rapid loss of negative intrathoracic pressure and impending respiratory failure. This client has a life-threatening but potentially survivable condition that requires immediate airway support and occlusive dressing. The others are either expectant (severe full-thickness burn with unresponsiveness) or delayed (fracture, dislocation) because their injuries do not cause imminent airway or perfusion collapse.

Question 2

During a multi-vehicle collision response, the nurse evaluates four victims. Which client should be assigned a **delayed (yellow)** tag?

Accepted Answer

Answer reason: A closed femur fracture with stable hemodynamics is serious but not immediately life-threatening and can tolerate delay. Immediate (red) clients include airway or shock states. Expectant (black) clients include those with signs of non-survivable injury such as fixed, dilated pupils or agonal breathing. Thus, the stable femur fracture appropriately fits delayed classification.

Question 3

In an emergency department surge event, four clients arrive simultaneously. Which client should the nurse evaluate **first** according to triage priority?

Accepted Answer

Answer reason: Chest pain accompanied by diaphoresis and nausea suggests an acute coronary syndrome requiring immediate evaluation to prevent myocardial damage or death. This makes the client highest priority in triage. The others have non-emergent, non-life-threatening conditions appropriate for lower categories.

Question 4

The nurse in the emergency department is caring for a client who sustained multiple rib fractures and a nasal fracture from a motor vehicle crash. Which assessment finding requires immediate follow-up?

Accepted Answer

Answer reason: In chest and facial trauma, airway and breathing are the highest priorities. Shallow respirations indicate inadequate ventilation and may signal complications such as pneumothorax, flail chest, or painful splinting that can rapidly lead to hypoxemia. Chest pain with repositioning and chest bruising are expected findings, and vomiting is concerning but less emergent than respiratory compromise. Therefore, shallow respirations require immediate follow-up.

Question 5

A newly admitted client is suspected to have avian influenza ('bird flu') due to increasing dyspnea and dehydration. Which of these prescribed actions will the nurse implement first?

Accepted Answer

Answer reason: With increasing dyspnea, the immediate life-threatening issue is impaired oxygenation. Following ABCs, the nurse should first provide high-concentration oxygen via a nonrebreather mask to rapidly correct hypoxemia. Antivirals (oseltamivir) and IV fluids address etiology and dehydration but do not treat acute respiratory compromise. Specimen collection can wait until the airway and breathing are stabilized.

Question 6

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

Accepted Answer

Answer reason: After reduction of a dislocated shoulder, new numbness and tingling in the fingers is an abnormal neurovascular finding suggesting possible nerve injury or compromised circulation that can progress to permanent deficit if not treated promptly. This requires immediate assessment of distal pulses, capillary refill, color/temperature, movement, and sensation and potential urgent provider notification. The thoracotomy pain is expected postoperatively and important to manage, but it is not as immediately limb-threatening as a possible post-reduction neurovascular compromise. Shoulder pain after laparoscopic cholecystectomy is commonly referred pain from diaphragmatic irritation by CO2, and nausea/constipation after glaucoma surgery is typically less urgent unless severe vomiting/straining threatens increased intraocular pressure.

Question 7

In a triage area, a patient has respiratory rate 35/min, capillary refill >2 seconds, and is conscious. What color tag should be given?

Accepted Answer

Answer reason: Using START triage, a respiratory rate >30/min meets criteria for Immediate (red) because it indicates significant respiratory distress and potential impending failure. Additionally, capillary refill >2 seconds suggests poor perfusion/shock, which also supports Immediate classification. The patient being conscious does not downgrade acuity when airway/breathing or circulation criteria are abnormal; they need rapid intervention and transport.

Question 8

During a mental health assessment, a patient says " I hear voices telling me I am worthless". What is the most appropriate initial nursing response?

Accepted Answer

Answer reason: With reported auditory hallucinations, the priority initial nursing action is to assess safety by determining whether the voices include command content to harm self or others. This directly evaluates immediate risk and guides urgent interventions (e.g., increased observation, removal of hazards, notifying the provider). Option A offers reassurance but does not assess risk; option C suggests coping before safety is established; option D is premature because medication changes are not the nurse’s initial/independent action and require assessment first.

Question 9

A nurse is caring for four patients. Which patient should be seen first?

Accepted Answer

Answer reason: New-onset confusion and restlessness in an older adult is an acute change in mental status that can signal hypoxia, stroke, sepsis, or other rapidly life-threatening problems, making it the highest-priority assessment. The patient with chest pain relieved by rest suggests stable angina and is less immediately critical than acute delirium until proven otherwise. Post-op pain medication requests and fever with chills generally allow for brief delay while the potentially unstable neurologic/oxygenation status is assessed. Therefore, the safest triage decision is to see the 78-year-old with new confusion first.

Question 10

Which of the following client should the nurse assess first when preparing to do initial rounds?

Accepted Answer

Answer reason: Airway always takes priority. A client with a tracheostomy and copious secretions is at high risk for airway obstruction and impaired gas exchange, which can rapidly become life-threatening. Discharge planning, scheduled therapy, and routine dressing changes are non-urgent compared to an immediate airway concern.

Question 11

The nurse is caring for four clients, which client should the nurse assess first?

Accepted Answer

Answer reason: Shortness of breath in a client with heart failure can indicate acute decompensation (pulmonary edema, hypoxemia) and represents a potential airway/breathing problem requiring immediate assessment. The pneumonia client with fever and productive cough is likely expected and more stable if no respiratory distress is described. Serosanguineous drainage can be normal post-op unless excessive or accompanied by signs of hemorrhage/infection, which are not stated. A newly diagnosed diabetes client asking about insulin is important education but not urgent compared with possible cardiopulmonary compromise.

Question 12

Which triage color indicates life-threatening but treatable?

Accepted Answer

Answer reason: In disaster triage systems (e.g., START), red indicates immediate priority: the client has life-threatening injuries that are potentially survivable with rapid intervention (e.g., airway compromise, severe bleeding, shock). Yellow indicates delayed care for serious but not immediately life-threatening conditions. Green indicates minor injuries (“walking wounded”), and black indicates deceased/expectant with injuries not compatible with survival given available resources.

Question 13

Four clients arrive in the emergency department simultaneously with chest pain. The client with which type of chest pain requires immediate attention by the nurse?

Accepted Answer

Answer reason: Chest pain radiating to the shoulder is a classic concerning feature for acute coronary syndrome/myocardial ischemia and should be prioritized for immediate assessment and intervention. This presentation can indicate evolving myocardial infarction, where time-sensitive actions (vital signs, ECG, oxygen if indicated, IV access, and provider notification) reduce morbidity and mortality. In contrast, pain with palpation is more consistent with musculoskeletal chest wall pain, and pleuritic pain with deep inspiration more often suggests pleurisy or pulmonary causes. A “rubbing” quality can suggest pericarditis, which is important but is generally less immediately life-threatening than suspected ACS without additional instability indicators.

Question 14

A client with multiple injuries is rushed to the ED after a head-on car collision. Which assessment finding takes priority?

Accepted Answer

Answer reason: In a multi-trauma patient, priority follows ABCs, and a deviated trachea is a classic sign of tension pneumothorax with impending airway/breathing failure. This is immediately life-threatening due to rapid compromise of ventilation and venous return, requiring emergent intervention (e.g., needle decompression/chest tube). The other findings may be serious (possible dysrhythmia, retroperitoneal bleeding, increased ICP) but are not as immediately correctable threats to airway/breathing as a deviated trachea.

Question 15

Nurse Jenna is caring for a post-operative client who has returned to the unit with a blood pressure of 90/50, pulse of 132, and respirations of 30. What should be Nurse Jenna's priority action?

Accepted Answer

Answer reason: The combination of hypotension (90/50), marked tachycardia (132), and tachypnea (30) in a post-op client suggests acute instability such as hemorrhage or shock and requires immediate escalation. The priority is to notify the provider/rapid response per facility protocol to initiate urgent evaluation and treatment (e.g., fluids, labs, assessment for bleeding). Simply continuing to monitor or asking how the client feels delays life-saving interventions. Delegation is inappropriate because the RN must manage and escalate this potentially emergent situation.

Question 16

Which patient should the RN see first?

Accepted Answer

Answer reason: New slurred speech is an acute neurologic change that can indicate stroke/TIA and is time-sensitive because rapid assessment and treatment (e.g., stroke alert, imaging, thrombolysis eligibility) can prevent permanent disability. While a glucose of 65 mg/dL is mild hypoglycemia and needs prompt treatment, it is typically less immediately life-threatening than suspected stroke unless accompanied by severe symptoms. An SpO2 of 88% in a COPD patient may be close to their baseline (often targeted 88–92%) and is not automatically the most urgent without distress. A routine request for post-op pain medication is important but not prioritized over potential stroke.

Question 17

The nurse has received the following information. The nurse should initially assess the client who is at?

Accepted Answer

Answer reason: Late decelerations indicate uteroplacental insufficiency and are a nonreassuring fetal heart rate pattern that can signal fetal hypoxia, requiring immediate assessment and intervention (e.g., repositioning, oxygen per protocol, evaluation for expedited delivery). Irregular contractions at 36 weeks can be Braxton Hicks and are typically not emergent if there are no other warning signs. Dependent edema at 28 weeks is common in pregnancy and is less urgent unless accompanied by hypertension, headache, or visual changes suggesting preeclampsia. At 15 weeks, fetal movement is often not reliably perceived yet, especially in a first pregnancy, making it less urgent than nonreassuring FHR findings.

Question 18

A nurse cares for a group of clients on a busy medical-surgical unit. Which client does the nurse identify as the priority when deciding the order of care?

Accepted Answer

Answer reason: A new rash while receiving IV levofloxacin suggests a potential hypersensitivity reaction, which can rapidly progress to anaphylaxis with airway compromise and hemodynamic instability. This is a time-sensitive, potentially life-threatening problem requiring immediate assessment, stopping the infusion, and preparing emergency interventions. The COPD client’s SpO2 of 89% can be an expected baseline for some COPD patients and is not necessarily an acute change without additional distress signs. The potassium infusion discomfort suggests possible phlebitis/infiltration and post-op moderate pain is expected and typically less urgent than a possible allergic reaction.

Question 19

Which client is the highest priority for the nurse?

Accepted Answer

Answer reason: Absent pedal pulses in a post-op client suggests acute arterial occlusion/compromised perfusion to the limb, which is an immediate limb-threatening emergency (possible compartment syndrome or vascular compromise). This requires rapid assessment and urgent escalation to the surgical team to prevent ischemia and potential tissue necrosis. The asthma client with SpO2 94% is relatively stable, urinary retention is urgent but not immediately life/limb threatening, and BG 16 mmol/L is hyperglycemia that typically allows time for evaluation and treatment unless DKA/HHS features are present.

Question 20

Which client should the nurse see first?

Accepted Answer

Answer reason: A respiratory rate of 32/min indicates potential respiratory distress and is an airway/breathing priority requiring immediate assessment and intervention. A mild headache, a request for pain medication, and discharge paperwork can be addressed after stabilizing clients with compromised breathing.

Question 21

Which client should the nurse see first?

Accepted Answer

Answer reason: Sudden shortness of breath suggests an acute airway/breathing problem and is potentially life-threatening, requiring immediate assessment and intervention. Chronic pain rated 4/10 is not an emergency priority compared with breathing compromise. Discharge instructions and routine comfort requests (water) can be addressed after stabilization of urgent physiologic needs.

Question 22

Which client should the nurse see first?

Accepted Answer

Answer reason: An oxygen saturation of 85% indicates significant hypoxemia and impaired oxygenation, which is potentially life-threatening. According to ABC priorities, breathing problems require immediate nursing assessment and intervention before nonurgent needs.

Question 23

The nurse is caring for four clients in the emergency department. Which client should the nurse see first?

Accepted Answer

Answer reason: Diaphoresis and trembling in a diabetic client strongly indicate hypoglycemia, an immediate life-threatening condition requiring rapid intervention. Although hypoxia and impaired perfusion are serious, hypoglycemia poses the most immediate risk of loss of consciousness or seizure.

Question 24

A patient is choking. Who do you see first?

Accepted Answer

Answer reason: In triage, address airway and breathing threats first. A toddler “turning blue” indicates severe hypoxia from airway obstruction and impending respiratory arrest, requiring immediate intervention (e.g., age-appropriate choking relief/activation of emergency response). Low O2 in an elderly patient and asthma in a teen can be serious, but cyanosis from choking signals the most time-critical, reversible cause of death. An adult crying in pain is lower priority when compared with an actively hypoxic child.

Question 25

Four clients call at once. Who do you see first?

Accepted Answer

Answer reason:  Audible inspiratory stridor signals potential upper-airway obstruction and impending respiratory failure, making this an immediate ABC priority. Airway compromise can deteriorate rapidly and requires urgent assessment and intervention (e.g., oxygen, bronchodilator therapy if appropriate, and preparation for advanced airway management). While chest pain with diaphoresis suggests possible ACS and is also urgent, an unstable airway takes precedence over circulation issues when both present. Severe abdominal pain and sliding-scale insulin requests are not as immediately life-threatening as a compromised airway.

Question 26

A 6-month-old infant is brought to the emergency department with a high-pitched cry, poor feeding, and a bulging fontanel. The nurse suspects meningitis. Which of the following is the priority nursing action?

Accepted Answer

Answer reason:  Notify the healthcare provider and prepare for lumbar puncture Bulging fontanel, high-pitched cry, and poor feeding in an infant suggest increased intracranial pressure and possible meningitis, which is a medical emergency requiring rapid diagnostic confirmation and treatment. Preparing for a lumbar puncture (and prompt provider notification) facilitates timely diagnosis and initiation of appropriate antibiotics. Acetaminophen may improve comfort but does not address the urgent need to diagnose and treat a potentially life-threatening infection. Prone positioning is not a standard intervention for suspected meningitis/increased ICP, and teaching is not the immediate priority in the ED.

Question 27

Which client should the nurse see first?

Accepted Answer

Answer reason:  Post-op with HR 128 and cool clammy skin This presentation suggests possible shock (e.g., hemorrhage or other acute complication) with tachycardia and signs of poor perfusion, which is immediately life-threatening and requires rapid assessment and intervention. Post-op patients are at risk for internal bleeding, hypovolemia, and rapid deterioration, so this client has the highest priority. The other clients are stable: BG 180 mg/dL while eating is not emergent, PRN pain medication is important but not life-threatening, and discharge education can be delayed.

Question 28

Which client requires immediate intervention by the nurse?

Accepted Answer

Answer reason: Sudden onset of a severe headache accompanied by acute confusion is a red flag for a potential life-threatening neurologic emergency such as intracranial hemorrhage, stroke, or increased intracranial pressure. These conditions can rapidly compromise airway protection, cerebral perfusion, and consciousness, requiring immediate assessment and intervention. The other clients are stable or present with urgent but not immediately life-threatening conditions.

Question 29

A nurse is caring for four clients. Which one should the nurse assess first?

Accepted Answer

Answer reason: An oxygen saturation of 88% indicates hypoxemia and an immediate threat to airway and breathing. According to ABC priorities, impaired oxygenation must be assessed and addressed first to prevent respiratory failure and tissue hypoxia. The other clients are stable: a GCS of 15 reflects intact neurologic status, severe pain is important but not life-threatening, and a potassium level of 4.9 mEq/L is within high-normal range.

Question 30

Which patient should the nurse assess first after receiving the shift report?

Accepted Answer

Answer reason: A post-op patient with a blood pressure of 80/50 mm Hg Post-op hypotension (80/50) can indicate hemorrhage, hypovolemia, or developing shock and is immediately life-threatening, requiring rapid assessment and intervention. The other findings are comparatively stable: glucose 210 mg/dL is mild-moderate hyperglycemia, SpO2 91% on 2 L in COPD can be acceptable depending on baseline, and chronic pain medication requests are important but not emergent. Prioritization follows ABCs/circulation and potential for rapid deterioration.

Question 31

A nurse receives four clients at shift change. Who should be assessed first?

Accepted Answer

Answer reason: 72-year-old who became acutely confused; respirations 8/min after IV morphine Respiratory rate 8/min after opioid administration indicates significant respiratory depression, an immediate life-threatening airway/breathing problem requiring rapid assessment and intervention (e.g., stimulation, oxygen, possible naloxone, provider notification/rapid response). Acute confusion in this context may be a sign of hypoxia or opioid toxicity. The asthma client has hypoxemia but is breathing and already received a bronchodilator; pain and cellulitis antibiotics are important but not as immediately life-threatening as opioid-induced hypoventilation.

Question 32

A nurse receives four clients at shift change. Who should be assessed first?

Accepted Answer

Answer reason: 72-year-old who became acutely confused; respirations 8/min after IV morphine Respirations of 8/min after IV morphine indicates opioid-induced respiratory depression, an immediate life-threatening airway/breathing problem requiring rapid assessment and intervention (e.g., stimulation, airway support, naloxone per protocol). Acute confusion in this context can be a sign of hypoxia/hypercapnia. The asthma client has hypoxemia (SpO2 89%) but is not as immediately unstable as bradypnea after an opioid. Pain and timing of antibiotics for cellulitis are important but are lower priority than compromised ventilation.

Question 33

A nurse is assigned four patients. Who should the nurse assess first?

Accepted Answer

Answer reason: Continuous bubbling in the water seal chamber suggests an air leak in the chest drainage system, which can prevent effective lung re-expansion and compromise ventilation. This finding requires immediate assessment of the tubing connections, drainage system, and insertion site, and rapid intervention to prevent respiratory deterioration. The other findings are less immediately life-threatening: 200 mL/4 hr post-op may be expected depending on surgery, fever with pneumonia is common but not emergent, and K+ 5.2 mEq/L is mild hyperkalemia without additional instability provided.

Question 34

A nurse is working in a hospital that has been affected by a landslide. The hospital is being evacuated due to the risk of further landslides and damage. The nurse has to prioritize which patient to move first. Which patient should the nurse prioritize for evacuation?

Accepted Answer

Answer reason: During an evacuation, the highest priority is the client with the greatest risk for rapid deterioration or death if care is interrupted. A patient requiring continuous oxygen is dependent on ongoing respiratory support and may quickly decompensate with hypoxemia if oxygen delivery is disrupted. The other patients are stable (fractured leg), not physiologically unstable despite confusion (dementia), or are in labor without complications and can typically be moved safely after higher-risk respiratory patients.

Question 35

Which client should the nurse assess first at the start of shift report?

Accepted Answer

Answer reason: 25-year-old with asthma who reports sudden absence of wheezing and increasing drowsiness Sudden absence of wheezing in an asthmatic can indicate “silent chest” from critically decreased airflow, which is an impending respiratory failure sign. Increasing drowsiness suggests rising CO2 retention/hypoxemia and deteriorating ventilation, requiring immediate assessment and rapid intervention (e.g., oxygen, bronchodilators, possible escalation to advanced airway support). The other clients are currently more stable: fever requesting acetaminophen, postoperative pain, and DKA already managed on an insulin infusion without a stated acute deterioration.

Question 36

The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission?

Accepted Answer

Answer reason: In a disaster situation, the nurse prioritizes discharging the most stable client with the lowest risk of rapid deterioration and least complex ongoing inpatient needs. Antibiotic-induced diarrhea is often manageable with medication adjustment, hydration, and outpatient follow-up if the client is stable and not severely dehydrated or suspected to have severe C. difficile. The ventilator-dependent client with pneumonia, the newly admitted Stevens-Johnson syndrome client, and the cellulitis client with HIV all have higher acuity and/or greater risk for complications requiring continued inpatient monitoring and treatment.

Question 37

The labor and delivery room nurse has just received reports on 4 clients. After reviewing the client data, the nurse should assess which client first?

Accepted Answer

Answer reason:  Magnesium sulfate can rapidly cause maternal toxicity, including respiratory depression, hypotension, decreased deep tendon reflexes, and decreased urine output. Immediately after a loading dose, the nurse must assess vital signs, respiratory status, level of consciousness, reflexes, and fetal status to detect early complications. The other clients are more stable or less immediately life-threatening compared with potential magnesium toxicity.

Question 38

A nurse is triaging four clients who have arrived at the emergency department following a multi-vehicle collision. Which client should the nurse prioritize for treatment first?

Accepted Answer

Answer reason: Altered mental status, tachycardia, and signs of poor perfusion suggest shock and possible internal bleeding, which takes priority over visible but stable injuries.

Question 39

Which patient requires immediate action?

Accepted Answer

Answer reason: Chest pain patient with potassium 5.8 mEq/L This combination suggests a time-sensitive, potentially life-threatening cardiac risk: hyperkalemia can precipitate malignant dysrhythmias and cardiac arrest, and concurrent chest pain increases concern for acute coronary syndrome or unstable cardiac status. A potassium of 5.8 mEq/L is clinically significant and warrants prompt assessment (telemetry/ECG) and rapid treatment per protocol. By comparison, an elevated creatinine in chronic kidney disease may be expected, WBC 2,000/mm³ indicates neutropenia requiring protective precautions and evaluation but is not typically an “immediate crash” lab by itself, and Hgb 7.2 g/dL post-op is serious but is generally managed urgently with assessment and possible transfusion rather than being the highest immediate dysrhythmia threat.

Question 40

The nurse is reviewing the vital signs of a client admitted with atrial fibrillation. The client's vital signs are: T 37.5°C (99.6°F), P 92 and irregular, RR 18, BP 90/56, pulse oximetry reading 96% on room air. The nurse should immediately address which vital sign?

Accepted Answer

Answer reason:  The priority is hemodynamic stability; a BP of 90/56 suggests hypotension and possible decreased cardiac output, which can rapidly compromise perfusion. In atrial fibrillation, loss of atrial kick and irregular ventricular response can reduce stroke volume, making hypotension an urgent finding. The other values are not immediately threatening (afebrile/slightly elevated temp, RR normal, SpO2 adequate, pulse rate not tachycardic despite irregularity). Immediate nursing actions would include reassessment, monitoring for shock/altered mental status, notifying the provider, and preparing for interventions such as fluids or rate/rhythm management per orders.

Question 41

True or False The nurse should prioritize a patient with active bleeding over one with stable vital signs?

Accepted Answer

Answer reason: Active bleeding represents an immediate threat to circulation and life, whereas stable vital signs indicate lower urgency. NCLEX prioritization frameworks favor addressing life-threatening conditions first.

Question 42

A 6-week pregnant client presents with unilateral lower abdominal pain, dizziness, and mild vaginal spotting. What is the priority action?

Accepted Answer

Answer reason: The presentation is concerning for ectopic pregnancy with possible intra-abdominal bleeding, and dizziness suggests early hypovolemia. The immediate nursing priority is to support circulation and prevent shock while urgent evaluation and provider notification occur. Establishing or supporting IV access with isotonic fluids improves perfusion and buys time for definitive diagnosis and treatment. Diagnostic steps (e.g., ultrasound) are important but should not delay stabilization when hemodynamic compromise is suspected.

Question 43

Which patient should the nurse see first?

Accepted Answer

Answer reason: This represents an acute change in mental status, which can be an early sign of hypoxia, sepsis, stroke, or other rapidly deteriorating conditions and requires immediate assessment. Restlessness and confusion can precede respiratory failure or shock, so airway/breathing/circulation and neurologic status must be evaluated promptly. Post-op pain at 8/10 is important but is not usually immediately life-threatening if vital signs are stable. COPD with SpO2 90% may be acceptable for some patients depending on baseline and symptoms, and discharge planning is lowest priority.

Question 44

What is the key question asked in the first step of ESI triage?

Accepted Answer

Answer reason: ESI triage begins by identifying whether the patient is unstable and needs immediate intervention to prevent death (e.g., airway compromise, respiratory failure, shock, unresponsiveness). If yes, the patient is categorized as ESI level 1 and resuscitation resources are mobilized immediately. Questions about ambulation, trauma status, or consciousness may inform assessment, but they do not replace the primary ESI step-1 decision about immediate life-saving needs.

Question 45

A post-operative patient suddenly develops shortness of breath and chest pain. The nurse notices a drop in oxygen saturation. What is the priority action?

Accepted Answer

Answer reason: This presentation suggests acute respiratory compromise (e.g., pulmonary embolism, atelectasis, pneumothorax), so the immediate priority is to support airway/breathing and improve oxygenation. High Fowler’s maximizes lung expansion and reduces work of breathing, while supplemental oxygen treats hypoxemia promptly. Notifying the provider is important but follows initiating immediate stabilizing nursing interventions. Increasing IV fluids or checking glucose does not address the life-threatening problem of impaired gas exchange.

Question 46

A nurse is caring for four children on a pediatric surgical unit. Who should the nurse assess first?

Accepted Answer

Answer reason: Frequent swallowing after tonsillectomy can indicate occult oropharyngeal bleeding, and pallor suggests possible significant blood loss and impending shock. This is an airway and circulation risk that requires immediate assessment and rapid intervention (vital signs, inspection for bleeding, readiness to manage hemorrhage). The other children’s needs (moderate postoperative pain, toileting assistance, and a snack request) are lower acuity and can be addressed after stabilizing potential hemorrhage.
Category reason: This item tests nursing prioritization/triage on a surgical unit, requiring recognition of a high-risk postoperative complication and deciding which patient to assess first.

Question 47

A patient’s blood pressure is 88/56 mmHg, pulse 120 bpm, and respirations 26/min. What’s your priority action?

Accepted Answer

Answer reason: The vitals indicate hemodynamic instability consistent with shock (hypotension with tachycardia and tachypnea), requiring immediate nursing intervention and rapid assessment for a reversible cause. Elevating the legs can temporarily improve venous return and perfusion while the nurse evaluates for active bleeding as a common cause of hypovolemic shock. Waiting to recheck delays care, and administering antihypertensives would worsen hypotension. The provider should be notified after initiating immediate stabilizing measures and assessment findings are obtained.

Question 48

The nurse is caring for a group of patients on a medical-surgical unit. Which patient should the licensed practical nurse/vocational nurse (LPN/LVN) assess first?

Accepted Answer

Answer reason: Severe hypoglycemia is an immediate, life-threatening condition that can rapidly progress to seizures, loss of consciousness, and neurologic injury if not promptly addressed. This finding represents an airway/breathing/circulation–threatening instability (altered neurologic function risk) and requires urgent assessment and intervention. The other patients are either stable (mild pain, mildly elevated respiratory rate) or primarily require psychosocial support rather than emergent physiologic management.

Question 49

A nurse is caring for four post-operative clients. Who should be seen first?

Accepted Answer

Answer reason: This indicates significant oliguria (~10 mL/hr), which can be an early sign of hypovolemia, poor renal perfusion, or evolving shock in the post-operative period and requires prompt assessment and intervention. Prioritization follows ABCs/circulation and detection of life-threatening complications over expected post-anesthesia drowsiness or comfort needs. Mild incisional pain and needing restroom assistance are lower acuity concerns compared with possible compromised perfusion/renal function.

Question 50

The nurse is caring for four clients on a telemetry unit. After receiving shift report, which client should the nurse assess first?

Accepted Answer

Answer reason:  This presentation suggests opioid-induced respiratory depression with decreased level of consciousness, which is an immediate airway/breathing threat. A low respiratory rate plus difficult arousal indicates impending ventilatory failure and requires rapid assessment and likely urgent interventions (stimulate, stop opioid, support ventilation, consider naloxone per protocol). The other clients have concerning findings (possible hypoxemia in pneumonia, chest discomfort with tachyarrhythmia, severe asymptomatic hypertension), but none are as immediately life-threatening as compromised breathing and altered mental status after opioid administration.

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A nurse in a mass-casualty event assesses four clients. Which client should be tagged with the **highest priority (immediate)** category?

During a multi-vehicle collision response, the nurse evaluates four victims. Which client should be assigned a **delayed (yellow)** tag?

In an emergency department surge event, four clients arrive simultaneously. Which client should the nurse evaluate **first** according to triage priority?

The nurse in the emergency department is caring for a client who sustained multiple rib fractures and a nasal fracture from a motor vehicle crash. Which assessment finding requires immediate follow-up?

A newly admitted client is suspected to have avian influenza ('bird flu') due to increasing dyspnea and dehydration. Which of these prescribed actions will the nurse implement first?

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

In a triage area, a patient has respiratory rate 35/min, capillary refill >2 seconds, and is conscious. What color tag should be given?

During a mental health assessment, a patient says " I hear voices telling me I am worthless". What is the most appropriate initial nursing response?

A nurse is caring for four patients. Which patient should be seen first?

Which of the following client should the nurse assess first when preparing to do initial rounds?

The nurse is caring for four clients, which client should the nurse assess first?

Which triage color indicates life-threatening but treatable?

Four clients arrive in the emergency department simultaneously with chest pain. The client with which type of chest pain requires immediate attention by the nurse?

A client with multiple injuries is rushed to the ED after a head-on car collision. Which assessment finding takes priority?

Nurse Jenna is caring for a post-operative client who has returned to the unit with a blood pressure of 90/50, pulse of 132, and respirations of 30. What should be Nurse Jenna's priority action?

Which patient should the RN see first?

The nurse has received the following information. The nurse should initially assess the client who is at?

A nurse cares for a group of clients on a busy medical-surgical unit. Which client does the nurse identify as the priority when deciding the order of care?

Which client is the highest priority for the nurse?

Which client should the nurse see first?

Which client should the nurse see first?

Which client should the nurse see first?

The nurse is caring for four clients in the emergency department. Which client should the nurse see first?

A patient is choking. Who do you see first?

Four clients call at once. Who do you see first?

A 6-month-old infant is brought to the emergency department with a high-pitched cry, poor feeding, and a bulging fontanel. The nurse suspects meningitis. Which of the following is the priority nursing action?

Which client should the nurse see first?

Which client requires immediate intervention by the nurse?

A nurse is caring for four clients. Which one should the nurse assess first?

Which patient should the nurse assess first after receiving the shift report?

A nurse receives four clients at shift change. Who should be assessed first?

A nurse receives four clients at shift change. Who should be assessed first?

A nurse is assigned four patients. Who should the nurse assess first?

A nurse is working in a hospital that has been affected by a landslide. The hospital is being evacuated due to the risk of further landslides and damage. The nurse has to prioritize which patient to move first. Which patient should the nurse prioritize for evacuation?

Which client should the nurse assess first at the start of shift report?

The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission?

The labor and delivery room nurse has just received reports on 4 clients. After reviewing the client data, the nurse should assess which client first?

A nurse is triaging four clients who have arrived at the emergency department following a multi-vehicle collision. Which client should the nurse prioritize for treatment first?

Which patient requires immediate action?

The nurse is reviewing the vital signs of a client admitted with atrial fibrillation. The client's vital signs are: T 37.5°C (99.6°F), P 92 and irregular, RR 18, BP 90/56, pulse oximetry reading 96% on room air. The nurse should immediately address which vital sign?

True or False The nurse should prioritize a patient with active bleeding over one with stable vital signs?

A 6-week pregnant client presents with unilateral lower abdominal pain, dizziness, and mild vaginal spotting. What is the priority action?

Which patient should the nurse see first?

What is the key question asked in the first step of ESI triage?

A post-operative patient suddenly develops shortness of breath and chest pain. The nurse notices a drop in oxygen saturation. What is the priority action?

A nurse is caring for four children on a pediatric surgical unit. Who should the nurse assess first?

A patient’s blood pressure is 88/56 mmHg, pulse 120 bpm, and respirations 26/min. What’s your priority action?

The nurse is caring for a group of patients on a medical-surgical unit. Which patient should the licensed practical nurse/vocational nurse (LPN/LVN) assess first?

A nurse is caring for four post-operative clients. Who should be seen first?

The nurse is caring for four clients on a telemetry unit. After receiving shift report, which client should the nurse assess first?

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A nurse in a mass-casualty event assesses four clients. Which client should be tagged with the highest priority (immediate) category?

During a multi-vehicle collision response, the nurse evaluates four victims. Which client should be assigned a delayed (yellow) tag?

In an emergency department surge event, four clients arrive simultaneously. Which client should the nurse evaluate first according to triage priority?