NCLEX Prioritization Questions 76-80

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76. A nurse in a rehabilitation center is planning the client assignments for the day. Which client would the nurse assign to the nursing assistant?
a) a client on strict bedrest for whom a 24-hour urine specimen is being collected
b) a client scheduled for transfer to the hospital for coronary artery bypass surgery
c) a client scheduled for transfer to the hospital for an invasive diagnostic procedure
d) a client who is going through rehabilitation after undergoing a below-the-knee amputation (BKA)

77. A client has received electroconvulsive therapy (ECT). In the post-treatment area and upon the client's awakening, the nurse will perform which intervention first?

a) assist the client from the stretcher to a wheelchair
b) orient the client and monitor the client's vital signs
c) offer the client frequent reassurance and repeat orientation statements
d) check for a gag reflex and then encourage the client to eat breakfast and resume activity

78. A nurse has assisted the physician in placing a central (subclavian) catheter. Following the procedure, the nurse takes which priority action?

a) ensures that a chest radiograph is done
b) obtains a temperature reading to monitor for infection
c) labels the dressing with the date and time of catheter insertion
d) monitor the blood pressure (BP) to check for fluid volume overload

79. A nurse is caring  for a hospitalized client with a diagnosis of abruptio placentae. The nurse develops a nursing care plan and suggests measures to be implemented in the event of the development of shock. The nurse documents that the initial nursing action in the event of shock is which of the following?

a) turn the client onto her side
b) check the client's blood pressure
c) monitor urinary output
d) check the client's heart rate

80. A nurse is assigned to care for a pregnant client with a diagnosis of sickle cell anemia. The nurse reviews the plan of care and notes documentation of four nursing diagnoses. Which would the nurse select as the priority?

a) activity intolerance
b) ineffective coping
c) imbalanced nutrition: less than body requirements
d) deficient fluid volume





NCLEX Prioritization Questions
Answers and Rationale

76) A

- The nurse must assign tasks based on the guidelines of nursing practice acts and the job description of the employing agency. A client who had a BKA, a client scheduled to be transferred to the hospital for coronary artery bypass surgery, and a client scheduled for an invasive diagnostic procedure will require strategies to meet both physiological and psychosocial needs. The nursing assistant has been trained to care for a client on bedrest and to maintain 24-hour urine collections. The nurse would provide instructions to the nursing assistant regarding the tasks, but the tasks required for this client are within the role description of a nursing assistant.

77) B

- The nurse would first monitor vital signs, orient the client, and review with the client that he or she just received an ECT treatment. The posttreatment area should include accessibility to the anesthesia staff, oxygen, suction, pulse oximeter, vital sign monitoring, and emergency equipment. The nursing interventions outlined in options A, C, and D will follow accordingly.

78) A

- A major risk associated with central catheter insertion is the possibility of a pneumothorax developing from an accidental puncture of the lung. Obtaining a chest radiograph and checking the results is the best method to determine if this complication has occurred and to verify catheter tip placement before initiating intravenous (IV) therapy. While a client may develop an infection at the central catheter site, a temperature elevation would not likely occur immediately after placement. While BP assessment is always important in checking a client's status after an invasive procedure, fluid volume overload is not a concern until IV fluids are started. Labeling the dressing site is important, but it is not a priority action in this situation.

79) A

- With a client in shock, the goal is to increase perfusion to the placenta. The priority nursing action would be to turn the client onto her side. This would increase blood flow to the placenta by relieving pressure from the gravid uterus on the great vessels. Options B, C, and D are also interventions that would be implemented following this initial action.

80) D

- For the client with sickle cell anemia, dehydration will precipitate sickling of the red blood cells. Sickling can lead to life-threatening consequences for the pregnant woman and for the fetus, such as an interruption of blood flow to the respiratory system and placenta. Deficient fluid volume would be the priority nursing diagnosis followed by Imbalanced nutrition. Activity intolerance and Ineffective coping may compete regarding the third and fourth priorities depending on the specific client symptoms at the time of care.


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Best NCLEX Reviewer about Delegation and Prioritization Questions 71-75

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71. A nurse is called to a client's room by another nurse. When the nurse arrives at the room, she discovers that a fire has occurred in the client's wastebasket. The first nurse removed the client from the room. What is the second nurse's next action?

a) confine the fire
b) evacuate the unit
c) extinguish the fire
d) activate the fire alarm


72. A client with type 2 diabetes mellitus is being discharge from the hospital after an occurrence of hyperglycemic hyperosmolar nonketotic syndrome (HHNS). The nurse develops a discharge teaching plan for the client and identifies which of the following as a priority?

a) exercise routines
b) controlling dietary intake
c) keeping follow-up appointments
d) monitoring for signs of dehydration

73. A client is receiving intralipids (fat emulsion) intravenously at home, and the client's spouse manages the infusion. The health care nurse makes a visit and discusses potential adverse reactions and the side effects of the therapy with the client and the spouse. After the discussion, the nurse expects the spouse to verbalize that, in case of suspected adverse reaction, the priority action is to:

a) stop the infusion
b) contact the nurse
c) take the client's blood pressure
d) contact the local area emergency response team

74. The nurse caring for a client who is dying formulates a nursing diagnosis of Fear and identifies appropriate nursing interventions. From the following list of nursing interventions, which intervention should the nurse implement first?

a) help the client express fears
b) assess the nature of the client's fear
c) help the client identify coping mechanisms that were successful in the past
d) document verbal and nonverbal expressions of fear and other significant data

75. A nurse reviews the preoperative teaching plan for a client scheduled for a radical neck dissection. When implementing the plan, the nurse initially focuses on:

a) the financial status of the client
b) postoperative communication techniques
c) information given to the client by the surgeon
d) the client's support system and coping behaviors





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Answers and Rationale

71) D

- Remember the acronym RACE (i.e., rescue, alarm, confine, extinguish) to set priorities if a fire occurs. In this situation, the client has been rescued from the immediate vicinity of the fire. The next action is to activate the fire alarm.

72) D

- Clients at risk for HHNS should immediately report signs and symptoms of dehydration to health care providers. Dehydration can be severe, and it may progress rapidly. Although options A, B, and C are components of the teaching plan, for the client with HHNS, dehydration is the priority.

73) A

- Fat-emulsion therapy can cause overloading syndrome (i.e., focal seizures, fever, and shock) and adverse effects, including chest pain, chills, and shock. The priority action is to stop the infusion to limit the adverse response. Although options B, C, and D are correct interventions, the priority is to stop the infusion.

74) B

- Fear can range from a paralyzing, overwhelming feeling to a mild concern. Therefore, the nurse would first assess the nature of the client's fears to know how best to help the client. Next, the nurse would help the client express his or her fears. The client's fear may not be limited to the fear of dying, and the nurse needs this information to help the client. After the nurse is aware of the client's fears, the methods that the client used to cope with fear in the past are identified. From the interventions listed, the nurse would document verbal and nonverbal expressions of fear and any other significant data as a final intervention.

75) D

The first step in client teaching is establishing what the client already knows. This allows the nurse not only to correct any misinformation but also to determine the starting point for teaching and to implement the education at the client's level. Although options A, B, and D may be components of the plan, they are not the initial focus.


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Best NCLEX Reviewer about Delegation and Prioritization Questions 66-70

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66. A client tells the home care nurse of a personal decision to refuse external cardiac resuscitation measures. Which of the following is the most appropriate initial nursing action?

a) notify the physician of the client's request
b) discuss the client's request with the client's family
c) document the client's request in the home care nursing care plan
d) conduct a client conference with the home care staff to share the client's request

67. A nurse is caring for a client who is going to have an arthrogram using a contrast medium. Which preprocedure assessment would be of highest priority?

a) allergy to iodine or shellfish
b) whether the client wishes to void before the procedure
c) ability of the client to remain still during the procedure
d) whether the client has any remaining questions about the procedure

68. A registered nurse (RN) asks a licensed practical nurse (LPN) to change the colostomy bag on a client. The LPN tells the RN that although attendance at the hospital in-service was completed regarding this procedure, the LPN has never performed a colostomy bag change on a client. The appropriate action by the RN is to:

a) perform the procedure with the LPN
b) request that the LPN observe another LPN perform the procedure
c) ask the LPN to review the materials from the in-service before performing the procedure
d) instruct the LPN to review the procedure in the hospital manual and take the written procedure into the client's room for reference

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

a) fractured tibia
b) penetrating abdominal injury
c) bright red bleeding from a neck wound
d) open massive head injury to deep coma

70. A nurse working on an adult nursing unit is told to review the client census to determine  which client could be discharged if there are a large number of admissions from a newly declared disaster. The nurse determines that the client with which of the following problems would need to remain hospitalized?

a) laparoscopic cholecystectomy
b) fractured hip, pinned 5 days ago
c) diabetes mellitus with blood glucose at 180 mg/dL
d) ongoing ventricular dysrhythmias while receiving procainamide (Procanbid)





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Answers and Rationale

66) A

- External cardiac resuscitation is a life-saving treatment that a client may refuse. The most appropriate initial nursing action is to notify the physician, because a written "do not resuscitate" (DNR) order from the physician is needed to ensure that the client's wishes are followed. The DNR order must be reviewed or renewed on a regular basis per agency policy. Although options B, C, an D may be appropriate, remember that obtaining a written physician's DNR order must be completed first.

67) A

- Because of the risk associated with allergy to contrast medium, the nurse places highest priority on assessing whether the client has an allergy to iodine or shellfish. The nurse also reinforces information about the test, tells the client about the need to remain still during the procedure, and encourages the client to void before the procedure for comfort.

68) A

- The RN must remember that, even though a task may be delegated to someone, the nurse who delegates maintains accountability for the overall nursing care of the client. Only the task, not the ultimate accountability, may be delegated to another. The RN is responsible for ensuring that competent and accurate care is delivered to the client. Requesting that the LPN observe another LPN perform the procedure does not ensure that the procedure will be done correctly. Because colostomy bag change is a new procedure for this LPN, the RN should accompany the LPN, provide guidance, and answer questions following the procedure. Although it is appropriate to review the in-service materials and the hospital procedure manual, it is best for the RN to accompany the LPN to perform the procedure.

69) C

- The client with bright red (arterial) bleeding from a neck wound is in "immediate" need of treatment to save the client's life. This client is classified as an emergent client and would wear a color tag of red from the triage process. The client with a penetrating abdominal injury would be tagged yellow and classified as "delayed," requiring intervention within 30 to 60 minutes. A green or "minimal" designation would be given to the client with a fractured tibia, who requires intervention but who can provide self-care if needed. A designation of "expectant" would be applied to the client with massive injuries and minimal chance of survival. This client would be color-coded "black" in the triage process. The client who is color-coded "black" is given supportive care and pain management but is given definitive treatment last.

70) D

- The client with ongoing ventricular dysrhythmias requires ongoing medical evaluation and treatment because of potentially lethal complications of the problem. Each of the other problems listed may be managed at home with appropriate agency referrals for home care services and support from the family at home.



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Best NCLEX Reviewer about Delegation and Prioritization Questions 61-65

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61. A client received a thermal burn caused by the inhalation of steam. The client's mouth is edematous and the nurse notes blisters in the client's mouth. The nurse first assesses which priority item(s)?

a) neurological status
b) level of consciousness
c) temperature via the rectal route
d) respiratory status and lung sounds

62. A registered nurse (RN) is planning the assignments for the day and is leading a team composed of a licensed practical nurse (LPN) and a nursing assistant (NA). The nurse assigns which client to the LPN

a) client with dementia
b) a 1-day postoperative mastectomy client
c) a client who requires some assistance with bathing
d) a client who requires some assistance with ambulation

63. A client requests pain medication and the nurse administers a ventrogluteal intramuscular injection. After administration of the injection, the nurse does which of the following first?

a) washes the hands
b) removes the gloves
c) applies gentle pressure to the injection site
d) places the syringe in the secure, puncture-resistant needle box container

64. A registered nurse is delegating activities to the nursing staff. Which activity is least appropriate for the nursing assistant?

a) collecting a urine specimen from a client
b) obtaining frequent oral temperatures on a client
c) accompanying a man being discharged
d) assisting a postcardiac catheterization client who needs to lie flat to eat lunch

65. A nurse is planning the client assignments for the shift. Which client would the nurse assign to the nursing assistant?

a) a client requiring dressing changes
b) a client requiring frequent ambulation
c) a client on a bowel management program requiring rectal suppositories and a daily enema
d) a client with diabetes mellitus requiring daily insulin and reinforcement of dietary measures





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Answers and Rationale

61) D

- Thermal burns to the lower airways can occur with the inhalation of steam or explosive gases or with the aspiration of scalding liquids. Thermal burns to the upper airways are more common and generally appear erythematous and edematous with mucosal blisters or ulcerations. The mucosal edema can lead to upper airway obstruction, particularly during the first 24 to 48 hours after burn injury. Assessment of respiratory status is the priority. Although the nurse would check the client's temperature and the client's neurological status, respiratory status is the priority.

62) B

- Assignment of tasks needs to be implemented based on the job description of the LPN and NA, the level of education and clinical competence, and state law. The 1-day postoperative mastectomy client will need care that requires the skill of a licensed nurse. The nursing assistant has the skills to care for a client with dementia, a client who requires some assistance with bathing, and a client who requires some assistance with ambulation.

63) C

- Following administration of an intramuscular injection, the nurse would apply gentle pressure to the site to assist in medication absorption and prevent bleeding. Then, the nurse assists the client to a comfortable position. The uncapped needle and syringe are discarded in a secure, puncture-resistant container, gloves are removed, and the hands are washed. Of the options provided, the nurse would perform option C first.

64) D

- Work that is delegated to others must be consistent with the individual's level of expertise and licensure, if any. Based on the options provided, the least appropriate activity for a nursing assistant would be assisting the postcardiac catheterization client. Because this client needs to eat while lying flat, the client is at risk for aspiration. The remaining three options do not include situations that indicate that these activities carry foreseeable risk.

65) B

- Assignment of tasks to the nursing assistant needs to be made based on job description, level of clinical competence, and state law. Options A, C, and D involve care that requires the skill of a licensed nurse. The client described in option 2 has needs that can be met by a nursing assistant.


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Best NCLEX Reviewer about Delegation and Prioritization Questions 56-60

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56. A client is being brought into the emergency department after suffering a head injury. The first action by the nurse is to determine the client's:

a) level of consciousness
b) pulse and blood pressure
c) respiratory rate and depth
d) ability to move extremities

57. A nurse is caring for a client scheduled for an arthroscopy. The nurse develops a postoperative plan of care and includes which priority nursing action in the plan?

a) monitor intake and output
b) assess the tissue at the surgical site
c) monitor the area for numbness or tingling
d) assess the complete blood cell count results

58. A nurse is performing an assessment  on a client who has a suspected spinal cord injury. Which of the following is the priority nursing assessment?

a) pain level
b) mobility level
c) respiratory status
d) pupillary response

59. A 52-year old male client is seen in the physician's office for a physical examination after experiencing unusual fatigue over the last several weeks. The client's height is 5 feet, 8 inches, and his weight is 220 pounds. Vital signs are: temperature 98F orally, pulse 86 beats per minute, and respirations 18 breaths per minute. The blood pressure (BP) is 184/100 mmHg. Random blood sugar glucose is 122 mg?dL. Which of the following questions should the nurse ask the client first?

a) do you exercise regularly?
b) are you considering trying to lose weight?
c) is there a history of diabetes mellitus in your family?
d) when was the last time you had your blood pressure checked?

60. A client admitted to the nursing unit from the emergency department has a spinal cord injury at the level of the fourth cervical vertebra (C-4). Which assessment should the nurse perform first when admitting the client to the nursing unit?

a) listen to breath sounds
b) observe for dyskinesias
c) take the client's temperature
d) assess extremity muscle strength





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Answers and Rationale

56) C

- The first action of the nurse is to ensure that the client has an adequate airway and respiratory status. In rapid sequence, the client's circulatory status is evaluated (option B), followed by evaluation of the neurological status (options A and D).

57) C

- The priority nursing action is to monitor the affected area for numbness or tingling. Options A, B, and D are also a component of postoperative care, but, from the options presented, are not the priority.

58) C

- All of these assessments would be performed on a client with a suspected spinal cord injury. However, respiratory status is the priority.

59) D

- The client is hypertensive, which is a known major modifiable risk factor for coronary artery disease (CAD). The other major modifiable risk factors not exhibited by this client include smoking and hypercholesterolemia. The client is overweight, which is a contributing risk factor. The client's nonmodifiable risk factors are age and gender. Because the client presents with several risk factors, the nurse places priority of attention on the client's major modifiable risk factors.

60) A

- Because compromise of respiration is a leading cause of death in cervical spinal cord injury, respiratory assessment is the highest priority. Assessment of temperature and strength can be done after adequate oxygenation is assured. Dyskinesias occur in cerebellar disorders, so they are not as important in spinal cord-injured clients, unless head injury accompanies the spinal cord injury.



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Best NCLEX Reviewer about Delegation and Prioritization Questions 51-55

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51. A client with a wound infection and osteomyelitis is to receive hyperbaric oxygen therapy. During the therapy, the nurse implements which priority intervention?

a) maintains an intravenous access
b) ensures that oxygen is being delivered
c) administers sedation to prevent claustrophobia
d) provides emotional support to the client's family

52. A nurse is caring for a client who had an orthopedic injury of the leg requiring surgery and application of a cast. Postoperatively, which nursing assessment is of highest priority?

a) monitoring of heel breakdown
b) monitoring of bladder distention
c) monitoring of extremity shortening
d) monitoring for loss of blanching ability of toe nailbeds

53. A nurse hears the alarm sound on the telemetry monitor, looks at the monitor, and notes that a client is in ventricular tachycardia. The nurse rushes to the client's room. Upon reaching the client's bedside, the nurse would take which action first?

a) call a code
b) prepare for cardioversion
c) prepare to defibrillate the client
d) check the client's level of consciousness

54. A nurse has just finished assisting the physician in placing a central intravenous (IV) line. Which of the following is a priority nursing intervention after central line insertion?

a) prepare the client for a chest radiograph
b) assess the client's temperature to monitor for infection
c) label the dressing with the date and time of catheter insertion
d) monitor the blood pressure to assess for fluid volume overload

55. A nurse reviews the assessment data of a client admitted to the hospital with a diagnosis of anxiety. The nurse assigns priority to which assessment finding?

a) temperature 99.4F, flat affect
b) fist clenched and pounding table
c) tearful, withdrawn, and isolated
d) blood pressure 160/100 mmHg; pulse 120 bpm, respirations 18 breaths per minute




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Answers and Rationale

1) B

- Hyperbaric oxygen therapy is a process by which oxygen is administered at greater than atmospheric pressure. When oxygen is inhaled under pressure, the level of tissue oxygen is greatly increased. The high levels of oxygen promote the action of phagocytes and promote healing of the wound. Because the client is placed in a closed chamber, the administration of oxygen is of primary importance. Although options 1, 3, and 4 may be appropriate interventions, option 2 is the priority.

2) D

- With cast application, concern for compartment syndrome development is of the highest priority. If postsurgical edema compromises circulation, the client will demonstrate numbness, tingling, loss of blanching of toenail beds, and pain that will not be relieved by opioids. Although bladder distention, extremity lengthening or shortening, or heel breakdown can occur, these complications are not potentially life-threatening complications.

3) D

- Determining unresponsiveness is the first assessment action to take. When a client is in ventricular tachycardia, there is a significant decrease in cardiac output. However, assessing for unresponsiveness helps to determine whether the client is affected by the decreased cardiac output. If the client is unconscious, then the ABCDs—airway, breathing, circulation, defibrillation—of cardiopulmonary resuscitation or basic life support are initiated.

4) A

- A major risk associated with central line placement is the possibility of a pneumothorax developing from an accidental puncture of the lung. Assessing the results of a chest radiograph is one of the best methods to determine if this complication has occurred and to verify catheter tip placement before initiating intravenous (IV) therapy. A temperature elevation related to central line insertion would not likely occur immediately after placement. Labeling the dressing site is important but is not the priority. Although BP assessment is always important in assessing a client's status after an invasive procedure, fluid volume overload is not a c5oncern until IV fluids are started.

 5) B

- Anxiety can lead to behavior that is harmful to the client and others. If safety is threatened, this is the priority. Tearfulness, withdrawal, isolation, and elevated vital signs are abnormal findings. However, these findings are not life-threatening, although they should be monitored. After the client's mental status is addressed and the client's safety is ensured, the nurse should attend to the elevated vital signs.


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