NCLEX Prioritization Questions 81-85

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81. An emergency department nurse prepares a client who sustained a gunshot wound for surgery. The nurse removes the client's clothing and places a gown on the client to prepare the client for the surgical procedure. Which of the following indicates the appropriate nursing action regarding the client's clothing, which is stained with blood?

a) discard clothing
b) give the clothing to the family member or significant other
c) place the clothing in a paper bag
d) place the clothing in a plastic bag and in a locked cabinet

82. A nurse is assessing a client who has a suspected spinal cord injury. Which of the following is the priority assessment?

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

83. When delegating a task to a team member, the nurse as the team leader gives authority over the task by:

a) offering suggestions on how to complete the task
b) waiting for the team member to report the results of the completed task
c) completing the task for the team member
d) checking to be sure the task is complete

84. A nurse is assigned to care for a client with coronary artery disease (CAD) who is scheduled fro a cardiac catheterization. Following the catheterization, the priority nursing action is to assess the:

a) catheter insertion site
b) temperature
c) potassium level
d) urine output

85. A nurse in a day care center is told that a child with autism will be attending the center. The nurse collaborates with the staff of the day care center and plans activities that will meet the child's needs. The priority consideration in planning activities for the child is to ensure:

a) social interactions with other children in the same age-group
b) safety with activities
c) familiarity with all activities and providing orientation throughout the activities
d) activities that provide verbal stimulation





NCLEX Prioritization Questions
Answers and Rationale

81) C

- All evidence discovered during an examination is recorded. Documentation of evidence includes the bodily location from which the sample was obtained and when or to whom it was delivered. Evidence should be maintained in its original condition. Clothing is stored in a paper bag instead of plastic to prevent decomposition. If clothing needs to be cut off the client, special attention is taken not to destroy evidence inadvertently.

82) B

- All of the assessments in the options would be performed on a suspected spinal cord injury client; however, respiratory status is the priority.

83) B

Authority for task completion is given to the team member by not directing or participating, and allowing the team member to complete the task under her own responsibility. The team member then reports the results to the team leader. Options A, C, and D involve the team leader in task completion.

84) A

- During the post–cardiac catheterization period, priorities of nursing care include frequent monitoring of the blood pressure and pulse. The catheter insertion site is checked frequently for signs of bleeding and swelling. Distal pulses also are assessed. Potassium level, temperature, and urine output should also be monitored but are not the priority of the items identified in the options.

85) B

- Safety with all activities is a priority in planning activities with the child. The child with autism is unable to anticipate danger, has a tendency for self-mutilation, and has sensory perceptual deficits. Although social interactions, verbal communications, and providing familiarity with activities and orientation are also appropriate interventions, the priority is safety.


After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

NCLEX Prioritization Questions 1-5


Or proceed to the next set of questions:

NCLEX Prioritization Questions 86-90