Question 1

The intensive care unit (ICU) nurse receives a phone call stating a client diagnosed with a head trauma must undergo admission. There are no empty beds. Which client is most stable and eligible for a transfer to the step-down neurological unit?

Accepted Answer

Answer reason: Triage and bed management prioritize keeping ICU-level care for clients at highest risk of rapid neurologic or airway deterioration. A client 3 days post–cervical spinal injury in halo traction is typically hemodynamically and neurologically more stable once acute swelling and immediate post-injury instability have passed, and ongoing care is focused on immobilization and monitoring that can be managed in a neuro step-down setting. In contrast, increased ICP with a GCS of 8 signals severe brain injury with high risk for herniation and need for intensive neurologic monitoring/airway support. A CVA with a subdural hematoma just 1 day ago is also early and unstable, with significant risk for expanding bleed and worsening mental status requiring ICU resources.

Question 2

Several patients are taking antipsychotic medications and are having medication side effects. Place the following patients in priority order for additional assessment and appropriate interventions, with 1 being the most critical and 4 being the least?

Accepted Answer

Answer reason: A patient who is taking trifluoperazine and has a temperature of 103.6°F (39.8°C) with tachycardia, muscular rigidity, and dysphagia These findings are classic for neuroleptic malignant syndrome, a life-threatening antipsychotic reaction requiring immediate emergency assessment, medication discontinuation, and rapid supportive care (airway/ventilation, cooling, IV fluids) to prevent rhabdomyolysis, renal failure, and cardiovascular collapse. The combination of high fever, severe “lead-pipe” rigidity, autonomic instability (tachycardia), and dysphagia signals imminent airway and systemic risk. By comparison, clozapine-associated agranulocytosis is also dangerous but typically allows rapid protective isolation and urgent provider notification rather than the same immediate physiologic instability. Anticholinergic effects and tardive dyskinesia are important but are generally less immediately life-threatening than NMS.

Question 3

The nurse in the pediatric clinic is triaging telephone messages. The nurse should call the parent of which child first?

Accepted Answer

Answer reason: Ear pain after adenotonsillectomy can reflect referred throat pain but also can accompany edema, infection, or evolving bleeding risk, so the nurse should screen for airway symptoms, hydration status, and any signs of hemorrhage. A foreign body in the outer ear without respiratory distress is typically nonurgent and can usually wait for a scheduled evaluation. The request for a school note after 24 hours of antibiotics and the question about returning to sports at day 5 are administrative/activity guidance issues and are lower priority than a potential post-op complication.

Question 4

The nurse has received report on 4 clients. Which client should the nurse see first?

Accepted Answer

Answer reason: Acute pyelonephritis often requires prompt parenteral therapy, and loss of a functioning line can quickly delay treatment. The other situations are important but are not immediately threatening: a leaking ostomy appliance is a comfort/skin-integrity issue, questions before surgery can be addressed after immediate physiologic needs are stabilized, and no bowel movement for 2 days post-op is common constipation without signs of obstruction. Restoring reliable IV access and assessing the infiltration site should be prioritized first.

Question 5

A nurse on a cardiovascular unit has received a morning report stating that all clients were stable overnight with stable vital signs. Which client does the nurse assess first?

Accepted Answer

Answer reason: At 8 hours after admission, this client is still in a high-risk window for recurrent chest pain, evolving ECG changes, and complications from anticoagulants/antiplatelets, so early reassessment is the safest triage choice. Pre-op CABG within an hour is important but typically follows a structured preoperative checklist and monitoring while awaiting transport, and sudden deterioration is less likely than with an active MI. A client 24 hours post-stent is farther from the highest-risk immediate post-procedure period, and dialysis/holding a beta-blocker can be addressed after the highest-acuity cardiac assessment.

Question 6

The nurse is receiving handoff of care report on 4 clients. Which client should the nurse assess first?

Accepted Answer

Answer reason: New shivering and chills shortly after thyroid surgery can signal acute hypermetabolic decompensation and/or early systemic infection, both of which can quickly destabilize vital signs and oxygenation. This client needs immediate assessment of temperature, heart rate, blood pressure, mental status, and airway/neck for swelling or bleeding to determine if emergency interventions are needed. In contrast, expected incisional pain and mild sore throat 1 hour after parathyroidectomy are common postoperative findings without immediate red-flag features.

Question 7

The nurse has been made aware that the following 4 clients require assistance. The nurse should first assist the client who had?

Accepted Answer

Answer reason: This condition can rapidly progress to severe hypertension, stroke, seizures, or dysrhythmias unless the trigger is removed and blood pressure is treated promptly. The other situations are important but more stable: postoperative pain after hysterectomy is expected, numb feet 2 days post-laminectomy is concerning but typically not as immediately life-threatening, and a disconnected TURP catheter requires correction to maintain irrigation/drainage but is less urgent than a potential autonomic crisis. Therefore, this client must be assessed and managed first with immediate vital signs/BP evaluation and rapid intervention.

Question 8

The nurse in the emergency department (ED) is assessing a client with multiple injuries that occurred as a result of a motor vehicle collision. Which of the following nursing observations should receive highest priority?

Accepted Answer

Answer reason: A neck hematoma can rapidly expand and compress the airway or indicate major vascular injury (eg, carotid or jugular), making sudden deterioration possible. The other findings represent significant extremity injuries or superficial bleeding but are less likely to cause abrupt airway obstruction in the first moments of assessment. Therefore this observation requires the most urgent evaluation and airway preparedness.

Question 9

The nurse has received change-of-shift report about the following patients on the progressive care unit. Which patient should the nurse see first?

Accepted Answer

Answer reason: This patient may be unstable or deteriorating and needs prompt evaluation of rhythm, hemodynamics, oxygenation, and potential reversible causes (e.g., ischemia, electrolyte abnormalities), as well as timely antiarrhythmic therapy. Amiodarone is commonly used to suppress recurrent ventricular tachyarrhythmias and delaying it increases risk of further shocks and cardiac arrest. By comparison, the post-cardioversion patient is currently in sinus rhythm, the controlled-rate new AF patient awaiting warfarin is not an acute threat, and the type I second-degree AV block with dizziness is concerning but typically less immediately lethal than recurrent ICD firing.

Question 10

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

Accepted Answer

Answer reason: Postpartum assessment priorities follow ABCs and immediate threats, with hemorrhage being a leading cause of maternal morbidity and mortality. Soaking multiple peri-pads suggests heavy lochia and possible uterine atony or retained products, requiring urgent evaluation of fundal tone, vitals, and ongoing blood loss. This finding can rapidly progress to hypovolemic shock, making it higher priority than expected discomforts or feeding difficulties. Pain with urination may indicate irritation or UTI, and emotional/attachment or breastfeeding concerns need support, but they are not as immediately life-threatening as suspected hemorrhage.

Question 11

The following clients arrive for their appointments at the diabetic clinic. Who should the nurse see first?

Accepted Answer

Answer reason: Fruity (acetone) breath with symptoms such as headache suggests ketosis with metabolic acidosis, a potentially life-threatening emergency requiring rapid assessment and intervention. This presentation is most consistent with diabetic ketoacidosis (or impending DKA), which can progress to dehydration, electrolyte derangements (notably potassium shifts), and altered mental status. The other clients describe non-urgent or already-addressed concerns (e.g., mild hypoglycemia being treated with carbohydrates, routine wound care, and diet teaching). Prioritizing the client with signs of acute metabolic decompensation follows triage principles of addressing the most unstable, high-risk condition first.

Question 12

The nurse receives handoff of care report on four clients. Which client should the nurse see first?

Accepted Answer

Answer reason: A new, progressive drop in blood pressure in a client with pericarditis raises concern for evolving cardiac tamponade, which can rapidly impair ventricular filling and cardiac output. This trend requires immediate bedside evaluation for additional tamponade findings (eg, tachycardia, JVD, muffled heart sounds, pulsus paradoxus) and urgent escalation for interventions. The atrial fibrillation with a rate of 122/min and the pneumonia leukocytosis indicate instability/infection but are generally less immediately life-threatening than a potential obstructive shock process.

Question 13

The nurse on the neurotrauma unit receives report on 4 clients. Which client should the nurse assess first?

Accepted Answer

Answer reason: A subdural hematoma can expand or worsen edema, so new focal signs and vital-sign changes are treated as unstable until proven otherwise. The concussion client has a normal GCS and expected post-concussive symptoms, making them lower priority. Central diabetes insipidus with high urine output and hypernatremia is serious but typically allows brief time for targeted labs/therapy compared with signs of acute neurologic deterioration.

Question 14

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client?

Accepted Answer

Answer reason: Chest pain can represent acute coronary syndrome and requires rapid assessment, vital signs, ECG, and timely intervention even if a benign explanation like reflux seems plausible. The other presentations (ankle sprain pain request, minor finger laceration) are lower acuity and typically stable. A headache with myalgias and a seizure history is concerning but does not indicate an active airway/breathing/circulation compromise as clearly as current chest pain, so it is not the top priority in triage without signs of an ongoing seizure or instability.

Question 15

A nurse reports for duty and receives report on her clients for the day. After report is received which client should the nurse see first?

Accepted Answer

Answer reason: Exertional dyspnea that newly appears after ambulation suggests an acute change in cardiopulmonary status rather than a chronic baseline symptom. Stable angina, COPD, and morbid obesity can cause exertional dyspnea, but these are generally expected patterns unless accompanied by acute instability signs. Prioritizing this client follows triage principles to see the highest risk for sudden deterioration first.

Question 16

The night nurse on a medical floor has just received report. On which of the following clients should the nurse make rounds FIRST?

Accepted Answer

Answer reason: A new cough plus agitation/restlessness can be an early sign of declining oxygenation and impending respiratory distress, requiring prompt assessment of lung sounds, SpO2, and need for oxygen/diuretics. The other clients have expected or non-urgent findings (mild pancreatitis pain, dysuria after TURP often due to irritation, and localized cellulitis inflammation) that are less likely to decompensate quickly. Prioritizing the highest risk for rapid deterioration follows ABCs and acute change-from-baseline triage principles.

Question 17

After receiving a change-of-shift report about these patients, which patient should the nurse assess first?

Accepted Answer

Answer reason: Excess thyroid hormone effect from levothyroxine (especially in older adults) can precipitate atrial fibrillation or other dangerous dysrhythmias, making immediate assessment of rhythm, blood pressure, symptoms, and need for urgent intervention the priority. A glucose of 244 mg/dL is elevated but not typically an immediate threat without symptoms of DKA/HHS. Mild hyponatremia in SIADH (130 mEq/L) and a scheduled steroid dose in stable Addison’s disease are important but generally less immediately life-threatening than an irregular pulse at 134.

Question 18

The nurse in the pediatric clinic is triaging telephone messages. The nurse should call the parent of which child first?

Accepted Answer

Answer reason: In triage, postoperative symptoms take priority over administrative requests or stable, minor problems because they can deteriorate quickly at home. A small plastic piece in the outer ear is typically non-urgent unless there is canal trauma, severe pain, or the object is deep/caustic. Return-to-school paperwork and return-to-sports questions are lowest acuity and can safely wait after urgent clinical concerns are addressed.

Question 19

A nurse hears various alarms sounding from different client rooms. Which alarm will the nurse address first?

Accepted Answer

Answer reason: This is an ABCs/airway-breathing emergency and must be assessed and corrected immediately (check patient first, then tubing/connections). A respiratory rate of 11/min can be normal for some adults and is less urgent than a potential ventilator disconnection. Occlusion alarms on heparin or enteral feeding pumps indicate interrupted therapy/flow but typically do not create the same immediate life-threatening risk as loss of ventilation.

Question 20

The spouse brings a client to the emergency department due to erratic behavior and expressions of despair. The emergency department is extremely busy with many clients. When the triage nurse asks if the client feels suicidal now, the client shrugs the shoulders. What initial action should the triage nurse take?

Accepted Answer

Answer reason: In a busy ED, the priority is to prevent self-harm by ensuring continuous observation in a controlled, visible area while further assessment is performed. Safety contracts are not reliable and do not reduce suicide risk in an acute setting. Sending the client back to the waiting room or documenting “not suicidal” is unsafe because the client has not clearly denied intent and is demonstrating concerning behavior and despair.

Question 21

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

Accepted Answer

Answer reason: Pursed-lip breathing may be a baseline COPD coping strategy, but new bleeding shifts this client into a potentially unstable status needing prompt evaluation of oxygenation, work of breathing, vital signs, and amount of blood. By comparison, the post-lung surgery positioning issues are important but are less immediately life-threatening if the client is otherwise stable, and the wedge resection client described is appropriately positioned. The heart failure client’s restlessness could indicate hypoxia, but hemoptysis is a more specific red-flag finding for sudden deterioration that should be assessed first.

Question 22

The nurse has received report on 4 pediatric clients on a telemetry unit. Which client should the nurse assess first?

Accepted Answer

Answer reason: With a VSD, pulmonary overcirculation can worsen during feeding and trigger acute respiratory distress and fatigue, requiring immediate assessment of respiratory status, oxygenation, and signs of heart failure. The other findings are more consistent with chronic or expected manifestations (diminished femoral pulses in coarctation, classic PDA murmur, finger clubbing in long-standing cyanotic disease) without an acute change described. In triage, the newest or most unstable respiratory symptom takes precedence over stable baseline cardiovascular findings.

Question 23

The nurse is triaging clients in the emergency department. Which client needs to be seen first?

Accepted Answer

Answer reason: Triage prioritizes conditions with the highest risk of rapid deterioration and death over potentially serious but less immediately fatal problems. This client needs emergent assessment, hemodynamic monitoring, large-bore IV access, and rapid surgical/vascular evaluation. By comparison, symptoms consistent with UTI or diverticulitis typically allow a brief delay for evaluation, and even peritonitis signs require urgent care but are generally less instantly fatal than a suspected rupturing aneurysm.

Question 24

A nurse working in the newborn nursery receives report on a group of newborn clients. Which client does the nurse assess first?

Accepted Answer

Answer reason: Neonatal hypoglycemia is an urgent physiologic risk because the newborn brain relies on glucose and low levels can rapidly progress to jitteriness, lethargy, seizures, and apnea if not recognized and treated. A large-for-gestational-age infant is at higher risk for hypoglycemia (often related to hyperinsulinemia), and a borderline/low point-of-care glucose requires prompt reassessment and intervention (feeding and repeat glucose, escalation if symptomatic or persistently low). The other findings are within expected transitional ranges for many newborns: HR 158 and RR 56 are normal, and a temperature of 97.6°F shortly after a bath is mildly low but typically addressed with warming measures and reassessment after immediate glucose concerns are ruled out. Post-circumcision feeding needs are important, but they are not as time-critical as a potentially deteriorating glucose level in a high-risk infant.

Question 25

The nurse in the outpatient clinic is reviewing phone messages. Which client should the nurse call back first?

Accepted Answer

Answer reason: White oral plaques are consistent with opportunistic oral candidiasis, which can extend to esophagitis, impair intake, and signal broader immune compromise requiring prompt evaluation and treatment/medication adjustment. In contrast, fatigue in chronic valve disease is typically subacute unless accompanied by red-flag cardiopulmonary symptoms, and an inflamed draining bite site usually needs timely care but is less immediately high-risk than infection in a transplant recipient. Cold/nasal congestion in a client with hypertension is generally the lowest priority and can often be managed with education about safe OTC choices.

Question 26

The registered nurse is triaging pediatric clients in the emergency department. Which client is a priority for diagnostic testing and definitive care?

Accepted Answer

Answer reason: These symptoms in a child with type 1 diabetes are classic red flags for diabetic ketoacidosis, a time-sensitive endocrine emergency requiring immediate labs (glucose, ketones, electrolytes, venous blood gas) and definitive treatment with IV fluids, insulin, and close monitoring. DKA can rapidly progress to severe dehydration, electrolyte derangements (especially potassium shifts), shock, and cerebral edema if care is delayed. While severe sickle cell pain needs prompt analgesia and evaluation, the presentation given does not signal an immediately life-threatening instability as strongly as suspected DKA. Constipation and an abdominal mass are concerning but are typically less acute than a potential metabolic crisis requiring emergent stabilization and diagnostics.

Question 27

A triage nurse is in an emergency department when several hundred clients who were injured in a train collision arrive at the facility for treatment. The nurse should determine that which of the following clients requires immediate treatment?

Accepted Answer

Answer reason: Epigastric discomfort with radiation to the left arm plus diaphoresis is a classic high-risk presentation of myocardial ischemia that can rapidly deteriorate into lethal dysrhythmias or cardiogenic shock without prompt evaluation and treatment. This client requires immediate ECG, oxygenation/monitoring, IV access, and time-sensitive therapies. In contrast, stable respirations with facial ecchymosis or isolated neck pain on immobilization suggests potential injury but not an immediately decompensating ABC problem in the absence of distress or neurologic compromise. Pregnancy with abdominal pain is concerning, but at 2 months gestation the uterus is still protected in the pelvis and the presentation is less immediately predictive of sudden collapse than active ischemia signs.

Question 28

The nurse has received the following information about assigned clients who have had surgery within the past 8 hours. The nurse should first assess the client?

Accepted Answer

Answer reason: Feeling hot with tachycardia shortly after surgery is an early warning pattern that warrants immediate assessment to identify fever, dysrhythmias, hypertension, and evolving decompensation. The lobectomy finding of tidaling with a respiratory rate of 20 is expected with a functioning chest tube and does not indicate urgent deterioration. Pink-tinged urine after TURP and mild thirst with a glucose of 160 mg/dL are common/less emergent postoperative findings compared with potential thyroid storm.

Question 29

The nurse provides care for clients in the outpatient clinic and receives four phone calls. Which call does the nurse return first?

Accepted Answer

Answer reason: Airway/breathing threats and time-sensitive ingestion risks are triaged first because a foreign body can obstruct the airway or lodge in the esophagus and rapidly deteriorate. A swallowed coin in a toddler requires immediate assessment for choking, drooling, stridor, respiratory distress, and prompt referral for urgent evaluation/imaging as indicated. The ankle swelling/warmth without injury could suggest DVT or infection and is concerning but is typically less immediately life-threatening than a potential airway-compromising ingestion. The headache and the rash with sore throat are important but generally allow for later follow-up unless additional red-flag symptoms are present.

Question 30

A nurse working on a medical nursing unit during an external disaster is called to assist with care for clients coming into the hospital emergency department. Using principles of triage, the nurse initiates immediate care for a client with which of the following injuries?

Accepted Answer

Answer reason: Bright red bleeding from a neck wound suggests arterial bleeding that can lead to exsanguination and loss of airway integrity within minutes, requiring instant hemorrhage control and airway management. A penetrating abdominal injury is serious but may be temporized if there is no immediate airway compromise or massive external bleeding. A fractured tibia is typically delayed, and an open massive head injury with deep coma is often categorized as expectant when resources are limited because the likelihood of survival is low.

Question 31

The psychiatric inpatient unit has four new admissions. Which client does the nurse see first?

Accepted Answer

Answer reason: In psychiatric triage, the nurse prioritizes clients with the highest immediate safety risk, especially potential self-harm. Recent exposure to suicide in a close family member substantially increases suicide risk due to grief, contagion effects, and heightened access/ideation in vulnerable periods. Concurrent major stressors and depressive symptoms further elevate risk for acute deterioration, warranting first assessment for suicidal ideation, plan, means, and level of supervision needed. The other clients describe significant stress, anxiety, or PTSD features but do not include this strong, time-sensitive suicide-risk indicator.

Question 32

After receiving report, which patient admitted to the emergency department should the nurse assess first?

Accepted Answer

Answer reason: In ED triage, patients with potential airway/breathing/circulation collapse and time-sensitive catastrophic diagnoses are assessed first because delays markedly increase mortality. Black stools on anticoagulants indicate probable GI bleeding and requires urgent evaluation, but it is often less immediately fatal than suspected aortic catastrophe unless there are signs of hemodynamic instability. Calf pain after a long flight suggests DVT and needs prompt treatment to prevent PE, but it is typically not as immediately unstable as suspected dissection; the gangrenous ulcer is serious but usually a slower-evolving threat unless septic or acutely ischemic.

Question 33

The nurse receives the following client set: 50 year old male with Chest pain, 13 year old with asthma attack, 2 month old that is fussy and a 90 year old female with cyclical vomiting. Which client should the nurse see first?

Accepted Answer

Answer reason: An acute asthma attack can progress quickly to severe bronchospasm, fatigue, and impending respiratory failure, making immediate assessment and intervention critical. Cyclical vomiting and fussiness may reflect discomfort or dehydration risk but are typically less immediately life-threatening than compromised ventilation. Chest pain is high priority, but without additional cues of instability (e.g., diaphoresis, hypotension, respiratory distress), the actively compromised breathing scenario is the most urgent to assess first.

Question 34

The nurse has just received a change-of-shift report about these clients on the coronary step-down unit. Which one will the nurse assess first?

Accepted Answer

Answer reason: Constrictive cardiomyopathy limits ventricular filling; sudden symptoms may reflect worsening low cardiac output, pulmonary congestion, or another time-sensitive deterioration. By contrast, a scheduled valvuloplasty is planned care without acute instability, and a low-grade fever 2 days post-CABG is commonly monitored but is not as immediately life-threatening. Occasional post-stent chest pain warrants prompt evaluation, but the sudden onset dyspnea with agitation is the most urgent indicator of impending compromise.

Question 35

A nurse is short-staffed because two people did not show up for work. Of the following four patients, which one would the nurse care for first?

Accepted Answer

Answer reason: Initial triage prioritizes threats to airway, breathing, and circulation and conditions with high risk of rapid neurologic deterioration. A newly admitted head-injury patient requires immediate baseline neuro assessment (LOC, pupils, motor response), evaluation for rising ICP, and confirmation that IV access/fluids/meds are correctly ordered and running, because deterioration can be sudden and irreversible. The abdominal pain/possible cholecystitis and nephritic syndrome with edema are important but are typically less immediately life-threatening if currently stable and already being monitored. The confused restrained patient needs prompt safety checks and reassessment, but without evidence of airway/respiratory compromise or acute neurologic injury, this is a lower priority than a new head trauma admission.

Question 36

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

Accepted Answer

Answer reason: Severe tachypnea plus “diminished wheezing” can indicate markedly reduced airflow (“silent chest”) as bronchospasm worsens and fatigue develops, which is more dangerous than audible wheezing. This client needs immediate assessment for work of breathing, oxygenation, mental status changes, and rapid escalation to bronchodilators, steroids, oxygen, and possible ventilatory support. By comparison, a stable COPD patient being discharged on oxygen and a ready-for-transport angiogram patient are not as immediately life-threatening in the moment.

Question 37

The home-health nurse is assigned to the following clients who live within 3 miles (4.8 km) of one another. The nurse should first see the?

Accepted Answer

Answer reason: 4-year-old client with cerebral palsy who is receiving continuous tube feedings at 60 mL/hr and has a temperature of 100.8° F (38.2° C) Prioritization in home care uses ABCs and risk of rapid deterioration, with special attention to aspiration and sepsis risk. Fever in a child receiving continuous enteral feeds suggests possible aspiration pneumonia, feeding intolerance, or other infection that can quickly compromise airway and breathing, requiring prompt assessment and potential holding feeds. The BPD client’s vomiting is concerning for dehydration/aspiration but is not accompanied by new respiratory distress data and is lower acuity than an active febrile child on tube feeds. The ALL client is leukopenic with mucositis but has no fever given (infection is possible yet not demonstrated as urgent in the stem), and the nephrotic syndrome findings are expected/ongoing unless severe respiratory compromise or infection signs are present.

Question 38

A nurse is assigned to multiple clients. Which client should the nurse reassess as a priority after administering IV morphine for pain relief?

Accepted Answer

Answer reason: IV morphine can cause dose-dependent respiratory depression, and patients with obstructive sleep apnea have reduced baseline airway patency and higher sensitivity to opioid-induced hypoventilation. Prioritization after opioid administration focuses on airway and breathing risks (RR, depth, sedation level, and SpO2), making this client highest risk for rapid deterioration. The other clients still require reassessment for pain control and adverse effects, but they do not carry the same immediate, predictable vulnerability to opioid-related ventilatory compromise. Early recognition of oversedation and hypoventilation in this high-risk client prevents respiratory arrest and the need for emergency reversal.

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The intensive care unit (ICU) nurse receives a phone call stating a client diagnosed with a head trauma must undergo admission. There are no empty beds. Which client is most stable and eligible for a transfer to the step-down neurological unit?

Several patients are taking antipsychotic medications and are having medication side effects. Place the following patients in priority order for additional assessment and appropriate interventions, with 1 being the most critical and 4 being the least?

The nurse in the pediatric clinic is triaging telephone messages. The nurse should call the parent of which child first?

The nurse has received report on 4 clients. Which client should the nurse see first?

A nurse on a cardiovascular unit has received a morning report stating that all clients were stable overnight with stable vital signs. Which client does the nurse assess first?

The nurse is receiving handoff of care report on 4 clients. Which client should the nurse assess first?

The nurse has been made aware that the following 4 clients require assistance. The nurse should first assist the client who had?

The nurse in the emergency department (ED) is assessing a client with multiple injuries that occurred as a result of a motor vehicle collision. Which of the following nursing observations should receive highest priority?

The nurse has received change-of-shift report about the following patients on the progressive care unit. Which patient should the nurse see first?

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

The following clients arrive for their appointments at the diabetic clinic. Who should the nurse see first?

The nurse receives handoff of care report on four clients. Which client should the nurse see first?

The nurse on the neurotrauma unit receives report on 4 clients. Which client should the nurse assess first?

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client?

A nurse reports for duty and receives report on her clients for the day. After report is received which client should the nurse see first?

The night nurse on a medical floor has just received report. On which of the following clients should the nurse make rounds FIRST?

After receiving a change-of-shift report about these patients, which patient should the nurse assess first?

The nurse in the pediatric clinic is triaging telephone messages. The nurse should call the parent of which child first?

A nurse hears various alarms sounding from different client rooms. Which alarm will the nurse address first?

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

The nurse has received report on 4 pediatric clients on a telemetry unit. Which client should the nurse assess first?

The nurse is triaging clients in the emergency department. Which client needs to be seen first?

A nurse working in the newborn nursery receives report on a group of newborn clients. Which client does the nurse assess first?

The nurse in the outpatient clinic is reviewing phone messages. Which client should the nurse call back first?

The registered nurse is triaging pediatric clients in the emergency department. Which client is a priority for diagnostic testing and definitive care?

A triage nurse is in an emergency department when several hundred clients who were injured in a train collision arrive at the facility for treatment. The nurse should determine that which of the following clients requires immediate treatment?

The nurse has received the following information about assigned clients who have had surgery within the past 8 hours. The nurse should first assess the client?

The nurse provides care for clients in the outpatient clinic and receives four phone calls. Which call does the nurse return first?

A nurse working on a medical nursing unit during an external disaster is called to assist with care for clients coming into the hospital emergency department. Using principles of triage, the nurse initiates immediate care for a client with which of the following injuries?

The psychiatric inpatient unit has four new admissions. Which client does the nurse see first?

After receiving report, which patient admitted to the emergency department should the nurse assess first?

The nurse receives the following client set: 50 year old male with Chest pain, 13 year old with asthma attack, 2 month old that is fussy and a 90 year old female with cyclical vomiting. Which client should the nurse see first?

The nurse has just received a change-of-shift report about these clients on the coronary step-down unit. Which one will the nurse assess first?

A nurse is short-staffed because two people did not show up for work. Of the following four patients, which one would the nurse care for first?

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

The home-health nurse is assigned to the following clients who live within 3 miles (4.8 km) of one another. The nurse should first see the?

A nurse is assigned to multiple clients. Which client should the nurse reassess as a priority after administering IV morphine for pain relief?

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