Question 1

A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?

Accepted Answer

Answer reason: New tachypnea in a client with a hip fracture suggests an acute respiratory complication such as fat embolism syndrome, pulmonary embolism, or evolving hypoxia, which can rapidly become life-threatening. Airway and breathing concerns take priority in triage and require immediate assessment of oxygenation, respiratory effort, and vital signs. The other findings are either expected/benign (sinus arrhythmia on monitoring), indicate stable chronic control (A1C 6.8%), or can be an expected effect of neuraxial analgesia unless accompanied by red-flag signs like progressive motor block or hypotension.
Category reason: This item tests nursing prioritization of which patient to assess first during shift report using acute change and ABCs/triage principles, which aligns with Management of Care—Triage.

Question 2

A nurse cares for four patients. Which should be assessed first?

Accepted Answer

Answer reason: A. A patient with new confusion post-surgery New-onset confusion after surgery can indicate hypoxia, hemorrhage, sepsis, medication effects, or acute delirium, all of which may signal rapid deterioration and require immediate assessment. A client with stable vital signs after hip replacement is not as urgent without other red flags. A medication due in 30 minutes is a time-based task but does not outweigh assessing a potentially unstable patient. A resolved UTI suggests improvement and lowest priority for immediate assessment.
Category reason: This question tests nursing prioritization and triage—deciding which patient requires immediate assessment based on potential instability and risk of deterioration.

Question 3

A client with chest pain is admitted to the emergency department. What is the priority nursing assessment?

Accepted Answer

Answer reason: Chest pain can signal life-threatening conditions (e.g., acute coronary syndrome, pulmonary embolism, aortic dissection) where immediate stabilization is essential. Using the ABC approach ensures the nurse identifies and addresses hypoxia, inadequate ventilation, or hemodynamic instability before pursuing less urgent history-taking. Early recognition of compromise enables rapid interventions such as oxygen support, monitoring, IV access, and escalation of care. The other assessments are important but do not take precedence over immediate physiologic stability in the emergency setting.
Category reason: This is a priority-setting emergency nursing question requiring rapid initial assessment and prioritization using ABCs, which aligns with triage in the ED rather than foundational biomedical recall.

Question 4

A nurse is prioritizing care for four patients. Which patient should be assessed first?

Accepted Answer

Answer reason: Chest pain is a potential sign of acute coronary syndrome and represents an immediate threat to life, so it requires rapid assessment and escalation of care. Early identification enables time-sensitive interventions (e.g., vital signs, ECG, oxygen if indicated, and provider notification) that reduce morbidity and mortality. The other situations (insulin order clarification/administration, dressing change, discharge) are important but generally non-emergent compared with possible myocardial ischemia.
Category reason: This is a nursing prioritization question requiring triage based on threat to life and urgency of assessment, which falls under Management of Care—Triage.

Question 5

The nurse is caring for four clients. Which client should be assessed first?

Accepted Answer

Answer reason: B. A client with chest pain and a heart rate of 130 beats/min This presentation suggests potential acute coronary syndrome or another life-threatening cardiopulmonary event with hemodynamic instability (tachycardia). Airway/breathing/circulation threats and possible ischemia take priority over non-urgent issues such as mild postoperative nausea or routine medication timing. A glucose of 200 mg/dL is abnormal but typically not immediately life-threatening without severe symptoms (e.g., altered mental status, dehydration, ketones). Rapid assessment enables prompt ECG acquisition, oxygenation/IV access as indicated, and activation of emergency protocols.
Category reason: This is a nursing-prioritization question asking which patient requires first assessment based on urgency and physiologic threat, which aligns with triage decision-making in Management of Care.

Question 6

The nurse receives handoff report on four clients. Which client requires immediate attention?

Accepted Answer

Answer reason: B. A client with shortness of breath and oxygen saturation of 85% This indicates acute hypoxemia with respiratory compromise, which can rapidly progress to respiratory failure and cardiac dysrhythmias if not treated immediately. Airway and breathing take priority in triage, and an SpO2 of 85% typically requires prompt assessment, oxygen supplementation, and escalation of care. The other situations are non-emergent: low urine output over 8 hours is concerning but not as immediately life-threatening, a new antihypertensive order is routine, and ambulation assistance can be safely delayed.
Category reason: This is a priority-setting/triage question asking which patient needs immediate nursing attention based on acuity and ABCs, which fits NCLEX Management of Care—Triage.

Question 7

Nurse Lynette is working in the triage area of an emergency department. She sees that several pediatric clients arrive simultaneously. The client who needs to be treated first is?

Accepted Answer

Answer reason: Stridor with drooling and tripod/upright positioning signals impending upper-airway obstruction (e.g., epiglottitis or severe airway edema), which is an immediate ABC threat. This child is at high risk for rapid deterioration and complete airway occlusion, so they must be prioritized for urgent airway management while minimizing agitation. The scalp laceration is unlikely to be life-threatening, croup signs are concerning but typically less emergent than drooling/stridor at rest, and pallor/sleeping requires assessment but does not trump an unstable airway.
Category reason: This is a triage prioritization question requiring nursing judgment to identify the most life-threatening presentation and treat based on airway/breathing urgency, which fits Management of Care: Triage.

Question 8

A nurse in the emergency department is caring for clients in a disaster situation. Which of the following clients should the nurse attend to first?

Accepted Answer

Answer reason: Facial burns are treated as a potential airway emergency because edema can rapidly compromise the upper airway, making early assessment and intervention time-critical. A large TBSA burn also places the client at high risk for hypovolemic shock from massive fluid shifts, which requires prompt resuscitation and monitoring. In disaster triage, the client with the most immediate threat to life that is potentially reversible with rapid care is prioritized. The open fracture with borderline hypotension suggests possible shock and is serious, but the explicit facial involvement signals a higher likelihood of sudden loss of airway if delayed.

Question 9

Four mothers have delivered their infants vaginally within a 10-minute period. Which of the following mothers should the nurse evaluate first?

Accepted Answer

Answer reason: A multipara who delivered a 5-lb, 8-oz baby girl after 2.5 hours of labor and has a history of rapid labor. Postpartum priority is early recognition of life-threatening complications, especially hemorrhage from uterine atony and genital tract trauma. A precipitous/rapid labor (suggested by 2.5 hours and prior rapid labor) increases risk of uterine overdistension/fatigue and lacerations, making acute bleeding more likely and requiring immediate assessment of fundal tone and lochia. The other situations (crying, substance use history, remote abuse history) warrant support and follow-up but are less immediately likely to represent an unstable physiologic emergency in the minutes after delivery. Therefore, this client is the most urgent to evaluate first to prevent or detect postpartum hemorrhage.

Question 10

4 clients receiving blood transfusions. Which of the ff clients should the nurse see first?

Accepted Answer

Answer reason: This is a triage question prioritizing the most immediate life-threatening transfusion-related complication. Neck vein distention during a transfusion suggests circulatory overload (TACO) and possible evolving pulmonary edema/heart failure, which can rapidly compromise oxygenation and require urgent intervention (stop/slow transfusion, upright positioning, oxygen, diuretics per orders). Itching is more consistent with a mild allergic reaction and is typically less immediately dangerous unless accompanied by airway symptoms or hypotension. Headache and vomiting can occur with several reactions but are less specific for imminent cardiopulmonary decompensation than signs of volume overload.

Question 11

A nurse is assessing four clients. Which of the following clients should the nurse see first?

Accepted Answer

Answer reason: Gurgling with respirations signals pooled secretions/blood and an immediately threatened airway, requiring rapid suctioning and airway stabilization. In a neck-injury patient, airway obstruction can progress abruptly and is addressed first under ABCs because it is an imminent life threat. Accessory muscle use in asthma indicates increased work of breathing, but it does not inherently indicate a currently obstructed airway as clearly as gurgling does. An SpO2 of 87% in COPD can be near an acceptable target range for some COPD patients and is typically less emergent than signs of active airway compromise.

Question 12

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

Accepted Answer

Answer reason: Contractions every 30 seconds in the first stage suggest uterine tachysystole or precipitous labor, both of which can quickly compromise fetal status and maternal safety. By contrast, an oral temperature of 99.7°F is not a fever, and a respiratory rate of 26 can occur with pain/anxiety and is less immediately threatening without other signs. Contractions lasting 60 seconds in the second stage are commonly expected and, without other abnormal data, are lower priority than excessively frequent contractions.

Question 13

The newborn nursery is filled to capacity. Which of the following infants should the RN assess first?

Accepted Answer

Answer reason: Post-procedure infants have the highest near-term risk for acute complications, so they are prioritized for assessment over infants showing normal hunger/behavioral cues. At about 2 hours after circumcision, the nurse must evaluate for bleeding, urinary obstruction (failure to void), and escalating pain, any of which can become urgent if missed. The other findings describe common, expected newborn behaviors (hand-to-mouth self-soothing, vigorous crying, waking to feed) without an immediate safety threat. A key triage principle is to assess first the client most likely to deteriorate or have an unrecognized complication.

Question 14

The nurse receives the following report. Which client should be seen first?

Accepted Answer

Answer reason: Hematuria suggests excessive anticoagulation and possible progression to significant hemorrhage, so the nurse must promptly assess bleeding severity, check vital signs, review coagulation studies, and anticipate holding or reversing anticoagulation per orders. The COPD patient’s SpO2 of 90% can be expected for some COPD patients on low-flow oxygen and is less immediately dangerous without signs of acute distress. Post-op pain and a modest 24-hour weight gain in heart failure warrant attention but are not as immediately time-critical as suspected anticoagulant-related bleeding.

Question 15

Practice Questions Question 1: Diabetic Crisis You're the nurse on a busy med-surg unit. Who do you see first?

Accepted Answer

Answer reason:  Severe hypoglycemia is an immediate, life-threatening problem because the brain depends on glucose and can rapidly deteriorate to seizure, coma, or death. A glucose of 42 mg/dL with neurologic symptoms (slurred speech) indicates symptomatic hypoglycemia requiring urgent assessment and rapid carbohydrate/IV dextrose per protocol. The COPD patient’s SpO2 of 90% on 2 L is often an expected target range in COPD and is not as time-critical without signs of distress. Post-op pain and anxiety/spiritual support are important but do not supersede an unstable neurologic/metabolic emergency.

Question 16

In Integrated Management of Childhood Illness, severe conditions generally require urgent referral to a hospital, which of the following severe conditions DOES NOT always require urgent referral to a hospital?

Accepted Answer

Answer reason:  IMCI referral decisions are based on whether the child has general danger signs or a “very severe” classification requiring pre-referral treatment and urgent transfer. Severe dehydration, mastoiditis, and severe febrile disease are typically treated as emergencies because they imply high risk of shock, intracranial spread, sepsis, or malaria/meningitis and therefore need urgent hospital-level care. In contrast, pneumonia classified as severe may be managed with immediate antibiotics and supportive care, and referral urgency depends on the presence of danger signs and the child’s ability to tolerate oral intake and maintain oxygenation. This makes it the option that does not invariably mandate urgent referral in all cases under IMCI triage logic. A common pitfall is assuming every “severe” label is automatically equivalent to “urgent referral” regardless of stabilization and danger-sign assessment.

Question 17

The nurse is caring for four clients. Which client should the nurse assess first?

Accepted Answer

Answer reason: This requires rapid assessment and escalation because deterioration can be abrupt (hypoxemia, hemodynamic collapse). The COPD client’s SpO2 of 91% may be near baseline and is not necessarily an acute change. Abdominal cramping with obstruction and a low-grade post-op fever are important but generally less time-critical than suspected PE.

Question 18

With an alert of an internal disaster and the need for beds, the charge nurse is asked to list clients who are potential discharges within the next hour. Which client should the charge nurse select?

Accepted Answer

Answer reason: Disaster bed allocation relies on triage principles—discharge the most stable client with the lowest immediate risk for deterioration and minimal ongoing inpatient needs. A recent diabetic ketoacidosis admission remains at significant risk for recurrent acidosis, electrolyte shifts (especially potassium), and need for ongoing insulin/IV monitoring, making rapid discharge unsafe. Unexplained syncope in a client with an implanted defibrillator suggests potentially life-threatening dysrhythmias and requires continued evaluation and monitoring, so it is not appropriate for discharge. Compared with those high-risk conditions, a client hospitalized overnight for acetaminophen ingestion may be medically cleared for discharge if levels and liver function are stable and treatment/observation is complete, making this the best potential rapid discharge candidate.

Question 19

Which of these clients would the triage nurse request for the health care provider to examine immediately?

Accepted Answer

Answer reason: Airway and breathing problems are the highest triage priority because they can rapidly progress to respiratory failure, especially in infants with limited physiologic reserve. Audible wheezing and grunting signal significant respiratory distress and increased work of breathing, requiring immediate provider assessment and likely urgent interventions (e.g., bronchodilation, oxygen/ventilatory support). In contrast, soot on the face/shirt and singed hair raise concern for inhalation injury but are not, by themselves, as definitive for current respiratory compromise as active wheezing with grunting. A localized second-degree burn to the hand is painful and needs treatment, but it is typically not immediately life-threatening compared with impending airway compromise.

Question 20

The nurse is assigned to care for 4 clients. Which of the following should be assessed immediately after hearing the report?

Accepted Answer

Answer reason: Persistent vomiting raises concern for hypovolemia, electrolyte abnormalities (e.g., hypokalemia, metabolic alkalosis), aspiration risk, and possible upper GI bleeding in the setting of peptic ulcer disease. This client needs immediate assessment of vital signs, hydration status, emesis characteristics (including blood/coffee-ground), and mental status to determine urgency of interventions. By contrast, a client returning from dialysis is often stable with routine post-treatment monitoring, and the discharge-ready asthma client is the lowest priority. Pancreatitis admitted yesterday may have ongoing pain and fluid needs, but “vomiting all night” signals a more immediate instability risk.

Question 21

Which of these children at the site of a disaster at a child day care center would the triage nurse put in the "treat last" category?

Accepted Answer

Answer reason: An extremely extensive deep skin injury involving nearly the entire body implies massive fluid loss, shock risk, high infection risk, and a very low likelihood of survival without immediate, resource-intensive burn/critical care. In contrast, isolated fractures are typically survivable and can be stabilized and treated, and singed hair suggests possible inhalation injury that requires prompt airway assessment rather than delay. Bulging fontanelle can indicate increased intracranial pressure or serious illness and warrants evaluation, but it is not as immediately prognostically dire as near-total-body deep injury in a mass-casualty setting.

Question 22

A triage nurse has these 4 clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?

Accepted Answer

Answer reason: Singed facial hair suggests inhalation injury, which can rapidly progress to airway edema and obstruction even if the client initially appears stable. This requires prompt airway assessment (voice changes, stridor, soot in nares/oropharynx, oxygenation) and early intervention to prevent deterioration. By contrast, diarrhea, intermittent scapular pain, and a bulging fontanel described only with crying do not signal as imminent an airway-compromising emergency as suspected inhalation injury.

Question 23

Following change-of-shift report on an orthopedic unit, which client should the nurse see first?

Accepted Answer

Answer reason: At 2 hours post–hip arthroplasty, the client is at highest risk for acute airway/respiratory compromise, hemorrhage/hypovolemia, anesthetic effects, and early neurovascular compromise of the operative extremity, all of which can deteriorate quickly. The other clients are either later postoperative (10 hours), stable in long-term traction (2 weeks), or preoperative in skin traction, which are typically more predictable and lower acuity if no new findings are reported. Therefore, the most time-sensitive assessment is the immediate post-op hip replacement client, with focused monitoring of vital signs, oxygenation, bleeding, pain control, and neurovascular status.

Question 24

Which of these women in the labor and delivery unit would the nurse check first when the water breaks for all of them within a 2 minute period?

Accepted Answer

Answer reason: A higher, unengaged presenting part (negative station) leaves more room for the cord to slip past the fetus after rupture, making this situation most urgent to check first. This client is still early in labor (3 cm, minimal effacement) and the presenting part is not well applied to the cervix, increasing prolapse risk compared with clients at 0 or positive station. By contrast, a +2 station indicates a well-engaged head, which reduces the likelihood of cord prolapse and makes it a lower triage priority immediately after rupture.

Question 25

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: Antibiotic-associated diarrhea is often manageable with stopping/changing the offending agent, hydration, and monitoring, and is typically less resource-intensive than the other listed problems. In contrast, Stevens-Johnson syndrome is an acute, high-risk condition needing close monitoring and complex supportive care, and ventilator dependence with recent bacterial pneumonia suggests high acuity and likely ongoing respiratory support needs. Acute cellulitis in an HIV-positive adolescent may require continued IV antibiotics and monitoring for systemic spread, making it less suitable for immediate discharge than a stable client with uncomplicated diarrhea.

Question 26

Which of these clients, who all have the findings of a board-like abdomen, would the nurse suggest that the health care provider examine first?

Accepted Answer

Answer reason: " Sudden cessation of severe abdominal pain in the setting of a rigid, board-like abdomen is a red flag for perforation or ischemia with progression to peritonitis, where pain may briefly lessen as nerves become impaired or the process advances. This represents a time-critical, potentially rapidly decompensating surgical abdomen requiring immediate provider evaluation and likely urgent imaging and operative management. Older adults may deteriorate quickly and can present atypically, so triage should favor the client most likely to have life-threatening intra-abdominal catastrophe. By comparison, diverticulitis with poor intake suggests dehydration/nutrition risk but is typically less immediately life-threatening than an evolving perforation/peritonitis picture, and the other scenarios do not signal the same acute change indicating impending collapse.

Question 27

A triage nurse has these four (4) clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?

Accepted Answer

Answer reason: Age under 1 year and limited ability to localize symptoms further increase urgency, warranting rapid neurologic assessment and emergent imaging/airway preparedness as needed. By contrast, a singed beard suggests possible inhalation injury but without signs like stridor, hoarseness, facial burns, or respiratory distress it is less clearly emergent than suspected increased ICP. Diarrhea and intermittent scapular pain can be concerning (dehydration or referred pain from biliary/cardiac causes), but neither is as immediately time-critical as potential intracranial bleeding in a young infant.

Question 28

A client in the third trimester of pregnancy is rushed to the hospital for abrupt, painless, and bright red vaginal bleeding. The physician diagnoses placenta previa after an ultrasound. Which intervention does the nurse perform first?

Accepted Answer

Answer reason: Vital signs are the fastest way to detect early shock (tachycardia, hypotension) and guide urgent escalation (large-bore IV access, fluids/blood, OR readiness). Estimating blood loss and assessing fetal heart rate are important, but they follow initial maternal stabilization assessment because fetal status can deteriorate secondary to maternal hypovolemia. Oxygen may be appropriate if there are signs of hypoxia or nonreassuring fetal status, but it is not the first step without confirming maternal instability.

Question 29

While triaging pregnant clients in the obstetrics clinic, the nurse should alert the health care provider to see which client first?

Accepted Answer

Answer reason: This presentation requires immediate provider evaluation and likely urgent labs, blood pressure assessment, and potential expedited delivery depending on severity and gestational age. In contrast, frequent nausea/vomiting in the first trimester and vascular spiders in the second trimester are commonly benign physiologic changes unless accompanied by severe dehydration or other danger signs. Decreased fetal movement is concerning and needs prompt assessment, but the combination of pain plus liver involvement indicates a potentially life-threatening maternal emergency that takes priority in triage.

Question 30

Which patient should the nurse see first?

Accepted Answer

Answer reason: Airway and breathing threats take priority over pain, scheduled medications, or comfort requests because deterioration can be rapid and life-threatening. Pain rated 7/10 in a stable post-op patient is important but not typically immediately life-threatening unless accompanied by signs of complication. Routine antihypertensives and providing water can be safely delayed while the nurse evaluates and stabilizes breathing.

Question 31

Psych nurse assigned in the ED. Which client needs to be seen first?

Accepted Answer

Answer reason: In ED psychiatric triage, the highest priority is immediate risk of self-harm or harm to others with intent, plan, or inability to maintain safety. This statement is a classic indirect suicidal communication, suggesting hopelessness and potential imminent self-harm, requiring rapid suicide risk assessment, close observation, and safety precautions. Auditory hallucinations to harm others is also high risk, but the prompt does not establish command hallucinations with intent/plan or imminent action, so it is second to suspected active suicidality. Performance-related hyperventilation/palpitations and fear after witnessing a murder indicate anxiety/acute stress responses but are generally not immediately life-threatening when compared with possible suicide risk.

Question 32

A nurse receives report on a group of clients. Which client should the nurse assess first?

Accepted Answer

Answer reason: The combination of sudden distress while playing with small objects, inability to speak, and circumoral cyanosis strongly indicates a foreign-body airway obstruction with inadequate ventilation. This represents an immediate, life-threatening problem requiring rapid assessment and emergency intervention. The other children show respiratory illness signs (wheezing/stridor) but with less severe indicators of hypoxia and no inability to vocalize, making them lower priority than a probable complete or near-complete obstruction.

Question 33

Which patient should the nurse assess first?

Accepted Answer

Answer reason: Wheezing with accessory muscle use indicates increased work of breathing and impending fatigue, requiring immediate assessment and likely escalation (e.g., bronchodilator, oxygen, possible rapid response). Fever with pneumonia and postoperative pain are important but typically do not threaten ventilation as immediately as active bronchospasm. A glucose of 210 mg/dL is mild-to-moderate hyperglycemia and is not the most time-critical compared with signs of respiratory distress.

Question 34

The nurse has been made aware of the following situations. The nurse should first assess the client?

Accepted Answer

Answer reason: g., hemorrhage/hypovolemia, pain crisis, pulmonary embolism, dysrhythmia). A hip fracture places the client at elevated risk for bleeding and thromboembolic events, and tachycardia may be an early deterioration cue before hypotension develops. This presentation is the most time-sensitive because it directly suggests compromised cardiopulmonary or circulatory status. The other situations are important but are more consistent with safety/comfort issues that can generally be addressed after ruling out imminent instability.

Question 35

A nurse is assessing a patient who has just returned from surgery. The patient reports a pain level of 8 out of 10, has a heart rate of 120 beats per minute, and is diaphoretic. Which nursing hypothesis should the nurse prioritize?

Accepted Answer

Answer reason: Postoperative tachycardia and diaphoresis can be early compensatory signs of acute blood loss with impending circulatory compromise, which is a life-threatening priority over comfort and teaching. A pain score of 8/10 can contribute to sympathetic activation, but assuming pain alone risks missing occult hemorrhage or third-spacing that can rapidly progress to decompensation. Anxiety is less likely to explain the physiologic instability immediately after surgery and does not address potential perfusion failure. Prioritizing possible shock prompts urgent focused assessment (vitals trends, surgical site/drain output, mental status, urine output) and rapid escalation of care.

Question 36

The nursery nurse received shift report on four newborns. The nurse should first assess the?

Accepted Answer

Answer reason: This finding warrants immediate assessment of femoral pulses, perfusion, oxygenation, and signs of shock because delayed recognition can become life-threatening. By comparison, an early newborn murmur is often transitional, and the phototherapy infant is already receiving treatment with a lab draw that is time-sensitive but typically not an immediate airway/breathing/circulation threat. Therefore, the infant with the arm-leg blood pressure gradient is the highest priority for first assessment.

Question 37

The nurse is working in the emergency department during the holidays. The nurse should first assess the client who has?

Accepted Answer

Answer reason: In ED triage, conditions with potential for limb-threatening compromise and worsening perfusion take priority over minor injuries and self-limited symptoms. This presentation warrants immediate neurovascular assessment (color, temperature, cap refill, pulses, sensation) and rapid initiation of appropriate warming and protection measures. By contrast, a superficial blanchable fingertip burn, a splinter, and uncomplicated alcohol-related nausea/vomiting are typically lower acuity unless additional red flags are present.

Question 38

Four clients come to the emergency department. The nurse should first assess the client who?

Accepted Answer

Answer reason: Stress can precipitate myocardial ischemia or a dysrhythmia, so this symptom requires immediate assessment of airway/breathing/circulation, vital signs, and rapid ECG monitoring. Profuse diarrhea and a brief vasovagal syncopal episode are concerning but are typically less immediately life-threatening than potential cardiac ischemia unless signs of shock are present. The “hallucination” description suggests a perceptual misunderstanding and is not an immediate physiologic threat compared with possible cardiac compromise.

Question 39

The nurse is working in the emergency department on New Year’s Eve. The nurse should first assess the client with?

Accepted Answer

Answer reason: Palpitations in a client with known hypertension after heavy alcohol intake raises concern for acute tachyarrhythmia (e.g., alcohol-triggered atrial fibrillation) and requires prompt vital signs, rhythm assessment, and evaluation for hemodynamic instability. The seizure described has already resolved after 2 minutes and, while it warrants assessment, it is less immediately threatening than a potentially ongoing dysrhythmia. A periorbital hematoma and a superficial laceration are typically lower acuity unless there are red flags for head/eye injury or uncontrolled bleeding, which are not stated.

Question 40

The nurse provides care for four assigned clients. Using knowledge of pathophysiology, which client will the nurse decide to assess first?

Accepted Answer

Answer reason: Anaphylaxis can rapidly progress to life-threatening airway edema and bronchospasm, so any new respiratory symptom signals impending airway compromise. Sudden forceful coughing may indicate worsening bronchoconstriction, laryngeal swelling, or secretion/airway irritation that can quickly lead to hypoxia and complete obstruction. This client requires immediate assessment and intervention (airway support, oxygen, epinephrine per protocol) ahead of pain control, feeding assistance, or routine repositioning. While pain and pressure-injury prevention are important, they are not as time-critical as a potentially failing airway.

Question 41

The nurse is assigned to an urgent care clinic when 5 clients present at the same time. Prioritize the clients in order. 1. The client who is limping after spraining the right ankle. 2. The client who is experiencing heaviness in the chest after eating a big meal. 3. The client who is running a fever and reports muscle aches and malaise. 4. The client who is applying pressure to the hand after sustaining a minor cut. 5. The client who is having difficulty breathing after eating shellfish.?

Accepted Answer

Answer reason: Difficulty breathing after shellfish suggests anaphylaxis with impending airway compromise and requires immediate intervention. Chest heaviness after a big meal could still represent acute coronary syndrome and must be rapidly assessed next rather than assumed to be indigestion. Ongoing bleeding from a cut is an immediate circulation/hemorrhage concern but is lower priority than airway/breathing and suspected cardiac ischemia; influenza-like symptoms and a sprained ankle are stable and can safely wait.

Question 42

The triage nurse is prioritizing adult clients to be evaluated in the emergency department. Which client does the nurse assess first?

Accepted Answer

Answer reason: Triage prioritizes threats to airway, breathing, and circulation and conditions with potential for rapid deterioration. Ongoing epistaxis represents active bleeding and can quickly lead to hemodynamic instability, aspiration risk, and inability to maintain the airway if bleeding is heavy or posterior. The other presentations are more likely non-urgent or stable in the short term: a low-grade temperature, localized arm pain after a minor fall (without red flags provided), and several hours of vomiting typically allow for brief delay while monitoring for dehydration. Therefore the client with active, persistent bleeding requires the most immediate assessment and intervention.

Question 43

The nurse providing care for clients with diabetes mellitus receives report. Which client does the nurse see first?

Accepted Answer

Answer reason: This presentation suggests severe dehydration with possible hyperosmolar hyperglycemic state (or impending shock), which is an immediate threat to perfusion and requires rapid assessment and intervention. Hypotension plus hot, dry skin indicates significant volume depletion and impaired thermoregulation, prioritizing ABCs/circulation. The other findings (UTI symptoms, polyuria/polydipsia with stable BP, and polyphagia) are important but are less immediately life-threatening and can be addressed after stabilization. Early recognition and prompt fluid resuscitation and glucose evaluation reduce risk of rapid deterioration and end-organ injury.

Question 44

A pediatric nurse is receiving a report on four clients that were recently admitted. Which of the following clients should the nurse see first?

Accepted Answer

Answer reason: Airway and breathing problems take priority because deterioration can be rapid and life-threatening if bronchospasm progresses to respiratory failure. New wheezes in a child with asthma indicate active airflow obstruction that may require immediate assessment of work of breathing, oxygenation, and prompt bronchodilator therapy. The sore throat after surgery is commonly expected after intubation and is typically non-urgent in the absence of stridor or swelling. Severe extremity pain and a persistent low-grade fever need timely management, but they are generally less immediately life-threatening than compromised ventilation.

Question 45

The emergency department nurse is caring for a 10-year-old client with hemophilia who was in a motor vehicle collision. Which of the following findings should receive highest priority?

Accepted Answer

Answer reason: This finding suggests evolving neurologic compromise that can rapidly progress to loss of airway protection and herniation, requiring immediate assessment and intervention. In contrast, external facial cuts are typically controllable with local pressure and are less likely to be immediately fatal. Abdominal bruising and neck pain are concerning for internal injury, but a declining mental status is the most time-critical indicator of instability in a bleeding-prone child.

Question 46

The nurse on the medical-surgical unit has received two new client admissions simultaneously. Which assessment is essential to determine which client the nurse should see first?

Accepted Answer

Answer reason: The core prioritization principle is triage using ABCs and physiologic stability to identify immediate threats to life. Vital signs provide the fastest, most objective snapshot of airway/breathing/circulation adequacy and can reveal shock, sepsis, hypoxia, or hemodynamic instability that requires immediate nursing action. In contrast, medication count and medical history influence planning but do not rapidly identify who is currently unstable. Code status guides resuscitation decisions during an arrest, but it does not determine who is most acutely at risk right now; current physiologic status does.

Question 47

The nurse in the outpatient clinic has four phone messages. Which message does the nurse return first?

Accepted Answer

Answer reason: A sudden headache in a patient with a spinal cord injury at/above T6 is a red-flag for autonomic dysreflexia, a time-critical emergency driven by noxious stimuli below the lesion causing severe hypertension. Rapid assessment and intervention are needed to prevent stroke, seizure, myocardial ischemia, or retinal hemorrhage. The other calls describe expected or non-emergent issues (bowel prep diarrhea is anticipated, postpartum engorgement is common, and nausea 3 days post–cataract surgery is concerning but not as immediately life-threatening without other symptoms). Prioritization follows triage principles: address the highest risk of rapid deterioration first.

Question 48

The ED nurse is triaging four children. Which child should be the nurse’s priority?

Accepted Answer

Answer reason: Respiratory distress signals compromised ventilation/oxygenation, and an abdominal mass can further impair breathing via diaphragmatic elevation or reflect a serious underlying condition requiring urgent assessment. The other presentations are typically less immediately life-threatening: gastroenteritis for 24 hours needs dehydration evaluation, a facial laceration needs wound care, and a moderate fever can often be managed after ruling out instability. This presentation most strongly indicates an unstable child needing prompt evaluation and support.

Question 49

When prioritizing care, which client should the nurse assess first?

Accepted Answer

Answer reason: Guillain-Barré syndrome can ascend quickly to involve the diaphragm and bulbar muscles, causing impending respiratory failure and inability to protect the airway, so early assessment of respiratory status (vital capacity, breath sounds, ability to handle secretions) is critical. The other clients are more likely to be stable or have slower-developing complications (routine post-op at 24 hours, diverticulitis typically not immediately life-threatening without sepsis/perforation signs, and 3 days post-MI is important but not as immediately airway-threatening without acute symptoms provided). Therefore, the neuromuscular respiratory-risk client is assessed first.

Question 50

The nurse triages children involved in a school bus accident that resulted in the children being submerged in cold water. Which child has the greatest risk of a respiratory arrest and should be triaged as the priority?

Accepted Answer

Answer reason: In cold-water submersion, laryngospasm and airway blockage can rapidly prevent effective gas exchange, so this presentation demands immediate airway and breathing support. Hypoxia describes low oxygenation but does not by itself specify the mechanism or immediacy of complete ventilatory failure compared with asphyxia. Aspiration and hypothermia are serious concerns, but they more commonly lead to delayed respiratory compromise or systemic instability rather than the most immediate risk of respiratory arrest.

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