Question 1

A client arrives in the emergency department after being rescued from a house fire. Pulse oximetry is 95% and the client is alert. Which intervention does the nurse do first?

Accepted Answer

Answer reason: Airway assessment and early recognition of inhalation injury are the immediate priority after smoke exposure because airway edema can progress rapidly and lead to sudden obstruction. A normal pulse oximetry reading can be misleading in carbon monoxide exposure and does not rule out impending upper-airway compromise. Assessing for facial/airway burns and symptoms of obstruction identifies the need for urgent airway protection and escalation (e.g., early intubation) before deterioration. Starting fluids or cardiac monitoring is important but comes after confirming airway patency and breathing are stable.

Question 2

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

Accepted Answer

Answer reason: In a client with a hip fracture, new tachycardia can signal acute blood loss, pain-related sympathetic surge, pulmonary embolism, or dysrhythmia, any of which may require urgent intervention. The other situations are important but are lower acuity: sliding in traction risks loss of alignment/skin breakdown, ambulating after a bone scan requires radiation-safety education, and scratching inside a cast raises skin injury/infection risk. Prioritizing the telemetry change prevents missing rapid deterioration and allows timely escalation of care.

Question 3

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

Accepted Answer

Answer reason: A soft abdomen despite painful contractions suggests loss of normal uterine tone or another emergent intra-abdominal process, both of which can precede maternal hemorrhage and fetal compromise. This presentation requires immediate assessment of vital signs, fetal heart rate, uterine tone, and bleeding, with rapid escalation if instability is found. By comparison, irregular tightening at 28 weeks is more consistent with Braxton Hicks/false labor unless accompanied by cervical change or other warning signs, and the newborn scalp lump that does not cross sutures is typically a cephalohematoma that is usually nonemergent. Mildly elevated postpartum blood pressures and edema warrant follow-up for postpartum preeclampsia, but they are less immediately life-threatening than a sudden pain change during active term labor.

Question 4

The nurse is caring for assigned clients. The nurse should initially assess the client who has?

Accepted Answer

Answer reason: The core priority principle is ABCs—impaired oxygenation is assessed and addressed before non–life-threatening findings. An SpO2 of 90% despite supplemental oxygen suggests significant gas-exchange impairment and risk for rapid respiratory decompensation, requiring immediate assessment (work of breathing, lung sounds, mental status) and escalation of oxygen/therapy. Gentle intermittent bubbling in a water-seal chamber with exhalation is an expected finding indicating air evacuation, not an emergency. Fever/tachycardia with empyema and decreased fremitus with pleural effusion are clinically important but are typically less immediately threatening than refractory hypoxemia.

Question 5

The nurse on a telemetry unit has received a shift report on 4 assigned clients. Which action should the nurse prioritize first?

Accepted Answer

Answer reason: Using prioritization principles (ABCs), a newly admitted COPD patient may have unstable airway or breathing status and requires immediate assessment. This takes priority over delayed medications and routine tasks.

Question 6

The client with DM is admitted with possible osteomyelitis secondary to an ankle wound. The client's ankle is painful, red, swollen, and the wound is persistently draining. The client's temperature is 102.2°F (39°C). Based on the client's status, which HCP order should the nurse plan to defer until later?

Accepted Answer

Answer reason: The client shows clear signs of an acute, severe infection (suspected osteomyelitis) with systemic involvement (fever 39°C). Immediate priorities are infection control and stabilization. Obtaining a wound culture should be done promptly (preferably before antibiotics), IV antibiotics must be initiated quickly, and immobilization can help reduce pain and limit spread of infection. Teaching is not a priority during the acute phase of illness. Education should be deferred until the client is stabilized and able to participate effectively in learning.

Question 7

The nurse coming on duty receives the report from the nurse going off duty. Which client should the on-duty nurse assess first?

Accepted Answer

Answer reason: Priority is given to the client with the highest risk for rapid deterioration. A newly admitted client with new-onset atrial fibrillation on an IV rate-controlling medication (diltiazem) requires close monitoring for hemodynamic instability, bradycardia, or hypotension. This is an acute, unstable situation requiring immediate assessment. Option A is stable. Option B has hypotension but is end-stage with a DNR order, indicating a palliative focus rather than aggressive intervention. Option C is stable on anticoagulation and does not indicate immediate instability.

Question 8

At 0730 an oncoming shift nurse is planning care for four clients. Which client should the nurse plan to assess first?

Accepted Answer

Answer reason: This client shows signs of acute respiratory compromise following a recent chest tube removal, raising concern for complications such as pneumothorax or respiratory distress. Airway and breathing take priority, and this situation represents a potential life-threatening condition requiring immediate assessment.
Option A involves a scheduled test and is stable. Option B shows a mild fever in a known infection. Option D involves routine medication administration. None are as urgent as new-onset dyspnea after chest tube removal.

Question 9

The nurse is caring for clients on a medical surgical floor. Which client should be assessed first?

Accepted Answer

Answer reason: Shortness of breath indicates a potential airway or breathing problem, which takes highest priority (ABCs). Even though L1 injuries typically spare diaphragm function, dyspnea during activity may signal a serious complication and requires immediate assessment.

Question 10

The client with infective endocarditis is admitted to the medical department. Which HCP's order should be implemented first?

Accepted Answer

Answer reason: Priority follows implementation sequencing. Intravenous access must be established before administering IV antibiotics, which are critical in treating infective endocarditis. Therefore, inserting the IV catheter is the first action that enables timely treatment.

Question 11

The telemetry nurse is unable to read the telemetry monitor at the nurse's station. Which intervention should the telemetry nurse implement?

Accepted Answer

Answer reason: When monitoring data is unclear or unavailable, the priority is direct assessment of the client to determine actual clinical status. Immediate bedside evaluation ensures timely recognition of any deterioration. Delegating or escalating without first verifying the client’s condition can delay appropriate intervention, and requesting emergency equipment without assessment is premature.

Question 12

The nurse learns of the following client situations. Which client should the nurse see first?

Accepted Answer

Answer reason: Children with Down syndrome have an increased risk of leukemia, making this constellation especially concerning for bleeding/infection from bone marrow failure. The Kawasaki findings described are consistent with the expected inflammatory presentation and, while urgent for IVIG/ASA, are typically less immediately unstable than a potentially septic, bleeding child. Enuresis during therapy and chronic movement abnormalities in cerebral palsy are lower-acuity concerns unless accompanied by acute airway/breathing compromise.

Question 13

The nurse is providing care on a medical-surgical unit. Which patient requires immediate intervention?

Accepted Answer

Answer reason: Chills and acute back/flank pain during a transfusion are classic warning signs of an acute hemolytic transfusion reaction, which can rapidly progress to shock, hemoglobinuria, DIC, and acute kidney injury. This is an immediate life-threatening complication requiring the nurse to stop the transfusion, maintain IV access with normal saline, and initiate the facility’s transfusion-reaction protocol while assessing airway, breathing, circulation, and vital signs. The other findings are non-urgent in comparison: creatinine 2.0 mg/dL can be expected in CKD, pre-lunch glucose 180 mg/dL is mild hyperglycemia, and postoperative incisional pain 6/10 is common and treatable but not typically emergent. Prioritization follows ABCs and recognition of acute deterioration.

Question 14

The nurse is assessing a patient with a cardiac condition. Which patient is showing the most concerning symptom?

Accepted Answer

Answer reason: Atrial fibrillation can cause loss of atrial kick and fast ventricular rates, reducing ventricular filling and precipitating acute decompensation, especially in patients with underlying heart disease. This symptom warrants immediate assessment of airway/breathing, vital signs, lung sounds, oxygen saturation, and hemodynamic stability. By contrast, headache with hypertension and leg edema with heart failure are often less immediately life-threatening unless accompanied by severe BP, neuro deficits, or acute respiratory symptoms.

Question 15

Multiple clients from a motor vehicle accident arrive in the ED. Which client does the nurse see first?

Accepted Answer

Answer reason: Hypotension with tachycardia is a classic sign of shock, indicating inadequate tissue perfusion and a potentially life-threatening condition requiring immediate intervention. Although shortness of breath and chest pressure are concerning, unstable vital signs take priority in triage. The other clients present with less urgent findings that can safely wait.

Question 16

A nurse employed in the emergency department is assigned to triage clients arriving to the emergency room for treatment on the evening shift. The nurse should assign highest priority to which of the following clients?

Accepted Answer

Answer reason: Chest pain is treated as a potential cardiac emergency regardless of suspected cause. Even if the client attributes the pain to food or indigestion, conditions such as myocardial infarction must be ruled out first. In triage, any symptom suggestive of impaired circulation or cardiac compromise takes priority over minor injuries or non-urgent complaints.

Question 17

An emergency department nurse must determine which adult client requires immediate evaluation. Which of the following clients should be seen first?

Accepted Answer

Answer reason: Continuous bleeding indicates an active and unresolved problem that can lead to significant blood loss and potential airway compromise. In triage, conditions involving active bleeding are prioritized over stable symptoms such as low-grade fever, minor injury, or vomiting without signs of instability.

Question 18

The nurse in the emergency department is prioritizing clients for assessment. Which client should be seen first?

Accepted Answer

Answer reason: Vaginal bleeding in early pregnancy can indicate serious complications such as ectopic pregnancy or impending miscarriage, both of which may rapidly become life-threatening. This makes it a higher priority than stable gastrointestinal symptoms or low-grade fever in pediatric clients.

Question 19

A triage nurse in a pediatric emergency department must determine which client requires immediate assessment. Which of the following clients should be seen first?

Accepted Answer

Answer reason: Abnormal vital signs such as tachycardia and tachypnea indicate possible physiological instability and require immediate evaluation. These findings may reflect pain, infection, or an acute abdominal emergency. The other clients present with conditions that are concerning but do not show signs of immediate systemic compromise.

Question 20

The nurse is the first responder to the site of a disaster in which several people were injured in a train crash. Which victim of the crash would the nurse attend to first?

Accepted Answer

Answer reason: Profuse bleeding from an upper leg injury suggests major vascular injury and can cause rapid hypovolemic shock, making immediate hemorrhage control (direct pressure/tourniquet) time-critical. A nonbreathing victim with a severe head injury is typically categorized as expectant/black in many disaster triage systems when resources are limited, because survival is unlikely without advanced resuscitation. Isolated fractures and bruising are delayed/minor injuries and are treated after immediate threats are managed.

Question 21

A nurse working on an inpatient detoxification unit receives hand-off on the following clients. Which client should the nurse prioritize?

Accepted Answer

Answer reason: The combination of agitation, diaphoresis, and disorientation on day 3 strongly suggests worsening withdrawal delirium requiring immediate assessment and escalation of treatment (e.g., CIWA-driven benzodiazepines and close monitoring). In contrast, opioid withdrawal symptoms like nausea, vomiting, and myalgias are typically distressing but not usually life-threatening. Benzodiazepine withdrawal can be dangerous, but mild hypertension and insomnia without acute neurologic changes is less urgent than active delirium.

Question 22

The nurse receives report on 4 assigned postoperative pediatric clients. Which client should the nurse assess first?

Accepted Answer

Answer reason: A 3-kg neonate draining 20 mL in 1 hour is a large, concerning amount (~6–7 mL/kg/hr) suggesting active bleeding after cardiac surgery, which can rapidly progress to hypovolemia and shock. This finding requires immediate assessment of vital signs, perfusion, chest tube patency, and prompt escalation to the surgical/cardiac team. By comparison, mild postoperative emesis after pyloromyotomy and severe pain 2 days after amputation are important but typically not as immediately life-threatening as possible postoperative bleeding in a neonate. The headache after craniotomy warrants neuro checks, but “crying calmly” without additional acute neuro changes is less urgent than suspected hemorrhage.

Question 23

The nurse had just received handover report. Which patient should the nurse attend to first? Select one?

Accepted Answer

Answer reason: Pink, frothy sputum is a classic sign of acute pulmonary edema, indicating impaired gas exchange and a potentially life-threatening airway/breathing problem. Using ABCs/triage principles, respiratory compromise is prioritized over non-emergent symptoms or expected medication effects. This patient may rapidly deteriorate and requires immediate assessment, oxygen/positioning, and urgent escalation for diuretics/vasodilators or ventilatory support as ordered. By comparison, weight gain over weeks suggests fluid retention but is not immediately unstable, orthostatic dizziness is concerning for falls but usually less urgent than hypoxia, and headache after nitroglycerin is a common adverse effect without immediate threat to airway or breathing.

Question 24

A nurse is receiving shift report for her patients and decides which patients to see first based their risk for endocarditis. Which of these patients is at the lowest risk for developing endocarditis? Select one?

Accepted Answer

Answer reason: Recent valve replacement places a patient at very high risk because prosthetic material is readily seeded and early postoperative bacteremia can rapidly lead to infection. Injection heroin use strongly increases risk via recurrent bloodstream contamination and is classically associated with endocarditis. Fever weeks after dental extraction raises concern for transient bacteremia with possible seeding in susceptible patients, whereas angina with newly diagnosed type 2 diabetes does not independently confer a high endocarditis risk compared with these scenarios.

Question 25

The psychiatric unit processed four new admissions on the previous shift. Which of the new patients should the admissions nurse see FIRST?

Accepted Answer

Answer reason: This statement signals possible suicidal ideation or imminent loss of coping, requiring rapid assessment for intent, plan, means, and need for 1:1 observation. The other clients describe depression or situational crisis without a direct expression suggesting immediate inability to maintain safety. Acute threat to life and safety is triaged before longer-term psychosocial support needs.

Question 26

A registered nurse in the emergency department is triaging a group of pediatric clients. Which of the following clients should be seen first?

Accepted Answer

Answer reason: This presentation suggests impending upper-airway obstruction, classically seen with epiglottitis, where airway can rapidly occlude and become fatal without immediate intervention. Drooling, muffled “hot potato” voice, and tripod positioning indicate inability to handle secretions and severe supraglottic swelling, making this an ABC priority. The nurse should prioritize immediate evaluation with airway equipment and minimize agitation or throat examination that could precipitate complete obstruction. In contrast, barking cough with sore throat is more consistent with croup, which is often less immediately life-threatening, while vomiting and a non-bleeding scalp laceration are typically lower-acuity unless accompanied by signs of shock or altered mental status.

Question 27

A nurse in the emergency department is assessing four clients. Which client should the nurse see first?

Accepted Answer

Answer reason: Sudden confusion and drowsiness after a head injury indicate possible increased intracranial pressure or acute neurological deterioration, which is life-threatening and requires immediate intervention. This takes priority over hypoxia at 90% (concerning but not immediately unstable), severe pain, or fever, based on ABCs and neurologic priority.

Question 28

Which of the following principle guides nurses' priorities at a disaster caused by a collapsed building in an earthquake?

Accepted Answer

Answer reason: In disaster triage (mass casualty incidents), the guiding principle is to achieve the greatest good for the greatest number. Clients with minor injuries (walking wounded) are often prioritized initially because they require minimal resources and can potentially assist responders or others. Care is not based on age or complexity alone, and while hemorrhage control is critical, triage prioritization follows systematic categorization rather than single-condition focus.

Question 29

A nurse is prioritizing care for four clients. Which client should the nurse assess first?

Accepted Answer

Answer reason: Chest pain is a potential indicator of life-threatening conditions such as myocardial infarction. Immediate assessment is required to prevent deterioration and initiate urgent interventions.

Question 30

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

Accepted Answer

Answer reason: A client who is 2 hours post-lobectomy with 150 mL of drainage requires the highest priority assessment because early postoperative bleeding or thoracic complications can become life-threatening quickly. Using priority principles, the nurse should assess the client with the greatest risk for airway, breathing, or circulation compromise first. The other findings are less urgent or more expected in comparison.

Question 31

Post-op Clients The nurse has four post-op clients. Who should be seen first?

Accepted Answer

Answer reason: Stridor after thyroidectomy indicates potential airway obstruction due to swelling or hematoma, which is a life-threatening emergency. Airway always takes priority over pain, expected drainage, or urinary retention.

Question 32

The nurse is starting the day shift and has completed initial rounds on all assigned patients. Which patient should be the nurse’s priority?

Accepted Answer

Answer reason: Fever (38.4°C) and leukocytosis (WBC 14,000/mm³) indicate a possible infection or systemic inflammatory response, which can rapidly deteriorate into sepsis. This patient requires immediate assessment and intervention. The other clients are stable or expected conditions without immediate life-threatening risk.

Question 33

Which nursing action aligns with “Prioritizing Hypotheses”?

Accepted Answer

Answer reason: Prioritizing hypotheses means deciding which patient problem is most urgent, unstable, or potentially life-threatening and should be addressed first. That is most consistent with identifying the most critical patient problem. Documentation, hygiene, and routine PRN medication administration are not examples of the prioritization step itself.

Question 34

A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

Accepted Answer

Answer reason: A client recently treated for hypoglycemia requires immediate reassessment to ensure the intervention was effective and to prevent deterioration such as seizures or loss of consciousness. The other clients are stable or involve non-urgent needs, making them lower priority.

Question 35

At 1900, the nurse begins the shift on a step-down unit. Which client requires immediate assessment?

Accepted Answer

Answer reason: Perioral and fingertip tingling after thyroidectomy is an early sign of hypocalcemia from inadvertent parathyroid injury or removal, which can rapidly progress to tetany, laryngospasm, and airway compromise. This requires immediate assessment for neuromuscular irritability (e.g., Chvostek/Trousseau), ECG changes (QT prolongation), and prompt preparation to administer calcium as ordered. The warfarin client with dark stools suggests possible GI bleeding and needs urgent evaluation, but the post-thyroidectomy finding has a higher immediate risk of sudden respiratory compromise. The COPD oxygenation and the cirrhosis discomfort are more consistent with stable/chronic or expected findings in the described context.

Question 36

A nurse is caring for four clients on a medical-surgical unit. Which client should the nurse assess FIRST?

Accepted Answer

Answer reason: g., hypoxemia, pulmonary embolism, opioid-induced respiratory depression, or evolving shock) and require immediate assessment using ABCs. Sudden restlessness is an early sign of hypoxia, and paired with tachycardia and shallow respirations indicates possible impending respiratory failure. The COPD client with SpO₂ 92% on low-flow oxygen is within an acceptable target range for many COPD patients and is not the most unstable presentation. The CKD-associated anemia and chronic diabetic neuropathy are non-urgent, expected chronic issues compared with acute postoperative respiratory compromise.

Question 37

A nurse at shift change just received report on four patients in the Emergency Department. Which patient should the nurse see first?

Accepted Answer

Answer reason: This patient has multiple high-risk indicators: bradycardia (possible cardiac instability) and an active blood transfusion (risk for transfusion reaction). Even though oxygen saturation is currently acceptable, the combination of cardiac changes and transfusion places this patient at highest risk for rapid deterioration. The other patients are stable or non-urgent.

Question 38

A 65-year-old patient arrived at the triage area with complaints of diaphoresis, dizziness, and left-sided chest pain. This patient should be prioritized into which category?

Accepted Answer

Answer reason: Chest pain with diaphoresis and dizziness suggests possible myocardial infarction. This is a life-threatening condition requiring immediate evaluation and intervention, placing the patient in the emergent category.

Question 39

The obstetrics unit currently has three active labors, two scheduled inductions, and a triage patient. The charge nurse is assessing fetal strips at the nurses’ station and determines which patient requires intervention?

Accepted Answer

Answer reason: In the setting of a trial of labor after cesarean, this pattern is especially concerning because it can accompany uterine rupture or catastrophic compromise, making prompt bedside assessment and emergency readiness critical. Early decelerations during pushing are typically benign and reflect head compression, not hypoxia. Minimal variability with accelerations is generally reassuring overall, whereas option A shows a clearly nonreassuring pattern needing urgent intervention.

Question 40

A nurse is assessing four neonates born several hours ago. Which of the following neonates should the nurse prioritize?

Accepted Answer

Answer reason: These findings suggest increased intracranial pressure, which is an urgent, potentially life-threatening neonatal problem requiring immediate assessment and intervention. A bulging fontanelle with “sunsetting” eyes is classic for hydrocephalus/ICP elevation, and a weak cry can indicate neurologic compromise. By contrast, acrocyanosis of hands/feet in the first day of life can be a normal transitional finding when central color and perfusion are otherwise stable. Normal newborn findings such as pink skin, alertness, and an intact Moro reflex are expected and do not take priority over possible neurologic emergency.

Question 41

As the shift begins, the nurse is assigned to care for the following patients. Which patient should the nurse assess first?

Accepted Answer

Answer reason: Marked bradycardia can reduce cardiac output and perfusion and may signal decompensation (e.g., severe hypothyroid effects or progression toward myxedema-related complications), so it requires prompt assessment and monitoring. The Graves patient’s heart rate of 94 is not tachycardic and suggests relative stability. The glucose of 137 mg/dL and +1 dependent edema are non-urgent findings compared with a potentially hemodynamically significant low heart rate.

Question 42

You are caring for four patients on a step-down unit. Which patient should the nurse assess first?

Accepted Answer

Answer reason: Perioral tingling with a positive Chvostek’s sign indicates acute hypocalcemia, a high-risk complication after thyroidectomy due to possible inadvertent parathyroid removal or injury. Hypocalcemia can rapidly progress to laryngospasm, stridor, seizures, and life-threatening airway compromise, making it the most urgent assessment. The heart failure patient’s exertional dyspnea and 2+ edema suggest chronic volume overload but not immediate instability if only symptomatic with activity. Urinary retention and frequent diarrhea require timely care, but they are generally less immediately life-threatening than evolving hypocalcemic tetany/airway compromise in the post-thyroidectomy patient.

Question 43

The nurse is triaging clients in the emergency department (ED). Which client should the nurse recommend to the primary healthcare provider (PHCP) to be assigned to the intensive care unit (ICU)?

Accepted Answer

Answer reason: ICU triage prioritizes patients with actual or impending airway compromise, rising intracranial pressure risk, and need for continuous neurologic and hemodynamic monitoring. Bacterial meningitis can deteriorate rapidly with seizures, decreased level of consciousness, and respiratory failure, and a GCS of 13 indicates altered mentation requiring frequent neuro checks and potential escalation of airway protection. By contrast, uncomplicated cholecystitis on PCA is typically managed on a medical-surgical unit with routine monitoring. Patients already enrolled in hospice (decompensated heart failure on hospice) generally have goals focused on comfort rather than ICU-level life-prolonging interventions, and metastatic cancer symptoms are often managed with palliative measures rather than intensive monitoring unless unstable.

Question 44

A 15-year-old male client was sent to the emergency unit following a small laceration on the forehead. The client says that he can’t move his legs. Upon assessment, respiratory rate of 20, strong pulses, and capillary refill time of less than 2 seconds. Which triage category would this client be assigned to?

Accepted Answer

Answer reason: This client has stable respirations (20/min) and adequate perfusion (strong pulses, cap refill

Question 45

The nurse in an inpatient psychiatric unit receives the following client reports during shift handoff. Which client should the nurse assess first?

Accepted Answer

Answer reason:  A stated “plan” in the context of depression is a high-risk indicator for imminent self-harm and requires immediate suicide risk assessment and safety interventions. This wording suggests potential intent, planning, and possible access to means, which elevates urgency above other psychiatric symptoms that are not clearly life-threatening at the moment. Command hallucinations would be prioritized if they included directives to self-harm or harm others, but “worthless” alone signals distress without explicit imminent danger. The OCD handwashing causing bleeding needs prompt assessment and treatment, but it is generally less immediately lethal than suspected active suicidal planning.

Question 46

The nurse is caring for four clients in a medical-surgical unit. Which client should the nurse assess first?

Accepted Answer

Answer reason: Symptomatic hypoglycemia is an immediate, potentially life-threatening problem because neuroglycopenia can rapidly progress to confusion, seizure, coma, and airway compromise if not treated promptly. A glucose of 65 mg/dL with shakiness indicates the body is already showing adrenergic warning signs requiring rapid assessment and treatment (e.g., fast-acting carbohydrate if able to swallow, or glucagon/IV dextrose per protocol). The pneumonia client’s SpO2 of 91% is concerning but is generally less immediately unstable than active hypoglycemia and can be addressed after the most urgent threat is controlled. Severe pain and discharge teaching are important but are not as time-critical as preventing deterioration from low blood glucose.

Question 47

The nurse in a medical-surgical unit is assigned to four clients. After receiving the handoff report, which client should the nurse assess first? Clients?

Accepted Answer

Answer reason: Client with AIDS who has a temperature of 38.3°C (101°F) and a white blood cell (WBC) count of 3,000/mm³. Fever in an immunocompromised client with leukopenia signals possible severe infection/sepsis and can deteriorate rapidly without prompt assessment and cultures/antibiotics per protocol. A WBC of 3,000/mm³ indicates limited ability to mount an immune response, so even a moderate fever is high risk. The SLE findings suggest nephritic/nephrotic involvement but are typically less immediately life-threatening than potential neutropenic sepsis unless accompanied by respiratory distress or hemodynamic instability. The etanercept symptoms warrant evaluation for infection, and latex allergy requires planning for a latex-free setup, but both are generally less urgent than an AIDS client with fever and low WBC.

Question 48

The nurse in the labor and delivery unit is assigned to four clients. After receiving the handoff report, which client should the nurse assess first?

Accepted Answer

Answer reason: Persistent headache and visual changes in a hypertensive pregnant client are severe features suggesting progression toward preeclampsia with risk of seizure (eclampsia) and stroke, making this the most urgent assessment. This presentation requires immediate evaluation of blood pressure trend, neurologic status, and other end-organ findings, and rapid escalation of care if severe-range pressures are present. The magnesium sulfate client has reassuring respirations and normal reflexes, which argues against toxicity requiring emergent intervention. The other two clients have expected/benign findings (latent labor pattern without change; normal postpartum involution/lochia), so they are lower priority.

Question 49

Nurse Kelly, a triage nurse encountered a client who complained of mid-sternal chest pain, dizziness, and diaphoresis. Which of the following nursing action should take priority?

Accepted Answer

Answer reason: Rapid ECG monitoring provides real-time rhythm surveillance and enables prompt recognition of STEMI or malignant arrhythmias that demand emergent interventions. Oxygen is not automatically the first action unless hypoxemia is present; monitoring and obtaining an ECG guide safe, targeted treatment. Notifying the provider is appropriate after initiating urgent triage measures, and completing a full history should not delay time-sensitive cardiac evaluation.

Question 50

Four children are brought to the emergency department. Which child should be assessed first?

Accepted Answer

Answer reason: This presentation is a potential airway/breathing/circulation-threatening head injury red flag and should be prioritized in triage over stable, expected reactions. Post-vaccination fever at this level is common and generally non-urgent, and painful lymphadenopathy suggests a localized infection without immediate instability. Ingestion of multivitamins is often benign unless large iron-containing amounts are confirmed, but the head-injury sign indicates a higher likelihood of time-sensitive complications.

Train with a large NCLEX question bank and jump into a full exam-style simulator

Triage NCLEX Practice Test

Continue Learning