Prioritizing Client Care: NCLEX Practice Test-2 Leave a Comment / NCLEX-RN Practice Tests / By Nurse Preceptors 0% Professional Standards in Nursing - NCLEX-RN Practice TestGet comprehensive coverage of all topics related to the NCLEX-RN exam and increase your chances of success. Note: Get a new set of questions on restart Prioritizing Client Care 1 / 20 1. Which clients should the nurse in a cardiac ICU prioritize for immediate intervention? (Select all that apply.) a) A client scheduled for a routine echocardiogram b) A client with controlled hypertension c) A client with chest pain unrelieved by nitroglycerin d) A client post-MI with a BP of 90/60 mmHg e) A client with a new onset of atrial fibrillation with rapid ventricular response f) A client with stable angina on telemetry Rationale: In a cardiac ICU, the nurse should prioritize clients who are experiencing acute or potentially life-threatening conditions that require immediate intervention. The clients who should be prioritized for immediate intervention are: A client with a new onset of atrial fibrillation with rapid ventricular response: This condition can lead to hemodynamic instability and increase the risk of thromboembolism. Rapid intervention is needed to control the heart rate and prevent complications. A client post-MI with a BP of 90/60 mmHg: This client is hypotensive, which could indicate cardiogenic shock, ongoing ischemia, or other complications. The client needs immediate assessment and intervention to stabilize. A client with chest pain unrelieved by nitroglycerin: This suggests that the client may be experiencing ongoing myocardial ischemia or a potential myocardial infarction that is not being adequately managed with current treatment. Immediate intervention is required to prevent further cardiac damage. These clients present with symptoms and conditions that could quickly deteriorate and lead to severe complications or death without prompt intervention. The other clients, while they may need close monitoring and ongoing care, do not present with conditions that require immediate intervention: A client with stable angina on telemetry: This client is currently stable and does not require immediate intervention unless there is a change in their condition. A client with controlled hypertension: This client is stable with managed hypertension and does not require urgent intervention. A client scheduled for a routine echocardiogram: This client is scheduled for a diagnostic procedure and does not have an acute condition requiring immediate intervention. 2 / 20 2. The nurse is working in a post-anesthesia care unit (PACU). Which client should the nurse prioritize? a) A client with difficulty breathing and a history of asthma b) A client with controlled hypertension who needs discharge instructions c) A client requesting water after surgery d) A client recovering from a minor surgical procedure Rationale: A client recovering from a minor surgical procedure: While postoperative monitoring is crucial for all patients, immediate attention is required for a patient with breathing difficulties and a history of asthma due to the potential for respiratory compromise. A client with difficulty breathing and a history of asthma: This client should be prioritized because difficulty breathing in a client with asthma can indicate an exacerbation or other serious respiratory issue requiring immediate intervention to prevent respiratory distress or failure. A client with controlled hypertension who needs discharge instructions: While discharge instructions are important, they are not as urgent as addressing acute respiratory distress. A client requesting water after surgery: While providing fluids after surgery is important for hydration, it is not as urgent as addressing acute respiratory symptoms. Therefore, the client with difficulty breathing and a history of asthma should be the nurse's top priority in the PACU. 3 / 20 3. A nurse in a trauma unit is managing care for multiple clients. Who should the nurse prioritize? a) A client with a sprained ankle requesting ice packs b) A client with a fractured femur awaiting surgery c) A client with a minor head injury needs observation d) A client with controlled pain requesting pain medication Rationale: A client with a minor head injury needing observation: While observation is important for clients with head injuries to monitor for signs of deterioration, addressing a fractured femur awaiting surgery takes precedence due to the risk of further injury or complications if not managed promptly. A client with a fractured femur awaiting surgery: This client should be prioritized because a fractured femur can cause significant pain and disability, and surgical intervention is often required to prevent additional damage and facilitate proper healing. A client with controlled pain requesting pain medication: While pain management is important, it is not as urgent as addressing the needs of a client with a fractured femur awaiting surgery. A client with a sprained ankle requesting ice packs: While providing comfort measures for a sprained ankle is necessary, it is not as urgent as addressing the needs of a client with a fractured femur awaiting surgery. Therefore, the client with a fractured femur awaiting surgery should be the nurse's top priority in a trauma unit. 4 / 20 4. In a post-anesthesia care unit (PACU), which client should the nurse prioritize? a) A client postoperative day 1 after orthopedic surgery requiring physical therapy b) A client postoperative day 1 after appendectomy requesting discharge instructions c) A client postoperative day 1 after open-heart surgery with unstable vital signs d) A client with controlled pain requesting pain medication Rationale: A client postoperative day 1 after open-heart surgery with unstable vital signs: This client should be prioritized as unstable vital signs could indicate potential complications such as hemorrhage, cardiac dysfunction, or inadequate oxygenation, requiring immediate assessment and intervention. A client with controlled pain requesting pain medication: While pain management is important, it is not as urgent as addressing unstable vital signs. A client postoperative day 1 after appendectomy requesting discharge instructions: While providing discharge instructions is necessary, it is not as urgent as addressing unstable vital signs. A client postoperative day 1 after orthopedic surgery requiring physical therapy: While physical therapy is important for postoperative recovery, it is not as urgent as addressing unstable vital signs. Therefore, the client's postoperative day 1 after open-heart surgery with unstable vital signs should be the nurse's top priority in a post-anesthesia care unit (PACU). 5 / 20 5. A nurse in a medical-surgical unit is managing care for four clients. Who should the nurse assess first? a) A client with controlled hypertension requesting dietary advice b) A client with diabetes complaining of blurred vision c) A client with a urinary tract infection needing antibiotic administration d) A client postoperative day 1 after bowel resection needing ambulation Rationale: A client with diabetes complaining of blurred vision: This client should be assessed first as blurred vision in a diabetic client may indicate hyperglycemia or other serious complications such as diabetic retinopathy, which require immediate attention to prevent further deterioration. A client postoperative day 1 after bowel resection needing ambulation: While ambulation is important for postoperative recovery, it is not as urgent as addressing potential complications related to diabetes. A client with controlled hypertension requesting dietary advice: While dietary advice is important for managing hypertension, it is not as urgent as addressing potential complications related to diabetes. A client with a urinary tract infection needing antibiotic administration: While urinary tract infections require timely treatment, addressing blurred vision in a diabetic client takes precedence due to the potential for vision loss and other serious complications. Therefore, the nurse should assess the client with diabetes complaining of blurred vision first in a medical-surgical unit. 6 / 20 6. A nurse is caring for clients in a mental health facility. Which client should the nurse prioritize? a) A client who needs assistance with activities of daily living b) A client attending an art therapy session c) A client with a history of migraines requesting pain medication d) A client with suicidal ideation Rationale: A client who needs assistance with activities of daily living: While assistance with activities of daily living is important, it is not as urgent as addressing the safety of a client with suicidal ideation. A client with suicidal ideation: This client should be prioritized because suicidal ideation indicates a serious risk to the client's safety and requires immediate assessment and intervention to ensure their safety and prevent self-harm. A client with a history of migraines requesting pain medication: While pain management is important, it is not as urgent as addressing suicidal ideation. A client attending an art therapy session: While participation in therapy is important for the client's well-being, it is not as urgent as addressing a client's suicidal ideation. Therefore, the client with suicidal ideation should be the nurse's top priority in a mental health facility. 7 / 20 7. In a neurology unit, which client should the nurse prioritize? a) A client with Parkinson's disease experiencing tremors after medication dose b) A client with a seizure disorder requesting assistance with ambulation c) A client with a new diagnosis of multiple sclerosis needs education d) A client with a headache rated 8/10 requesting pain medication Rationale: A client with a seizure disorder requesting assistance with ambulation: While assistance with ambulation is important for clients with mobility issues, addressing tremors in a client with Parkinson's disease takes precedence as it may indicate inadequate medication control and can significantly impact the client's quality of life. A client with a new diagnosis of multiple sclerosis needing education: While education for clients with new diagnoses is important, it is not as urgent as addressing tremors in a client with Parkinson's disease. A client with a headache rated 8/10 requesting pain medication: While pain management is important, it is not as urgent as addressing tremors in a client with Parkinson's disease. A client with Parkinson's disease experiencing tremors after medication dose: This client should be prioritized because tremors in Parkinson's disease can be distressing and may indicate a need for medication adjustment or additional interventions to manage symptoms effectively. Therefore, the client with Parkinson's disease experiencing tremors after medication dose should be the nurse's top priority in a neurology unit. 8 / 20 8. In an orthopedic unit, which client should the nurse prioritize? a) A client postoperative day 1 after total hip replacement with signs of deep vein thrombosis (DVT) b) A client with a fractured wrist awaiting cast application c) A client with a history of osteoarthritis requesting dietary counseling d) A client with pain 7/10 requesting pain medication Rationale: A client postoperative day 1 after total hip replacement with signs of deep vein thrombosis (DVT): This client should be prioritized as signs of DVT following surgery require immediate assessment and intervention to prevent potential complications such as pulmonary embolism or further thrombus formation. A client with pain 7/10 requesting pain medication: While managing pain is important for client comfort, it is not as urgent as addressing signs of DVT post-surgery. A client with a history of osteoarthritis requesting dietary counseling: While dietary counseling may be beneficial for managing osteoarthritis, it is not as urgent as addressing signs of DVT post-surgery. A client with a fractured wrist awaiting cast application: While awaiting cast application is important for managing a fractured wrist, it is not as urgent as addressing signs of DVT post-surgery. Therefore, the client postoperative day 1 after total hip replacement with signs of deep vein thrombosis (DVT) should be the nurse's top priority in an orthopedic unit. 9 / 20 9. In a neurology unit, which client should the nurse prioritize? a) A client with a suspected stroke presenting with sudden-onset weakness on one side b) A client with a history of migraines requesting pain medication c) A client with epilepsy requesting a refill on antiepileptic medication d) A client with a minor head injury awaiting discharge instructions Rationale: A client with a suspected stroke presenting with sudden-onset weakness on one side: This client should be prioritized as a suspected stroke is a medical emergency requiring immediate assessment and intervention to minimize potential brain damage and improve outcomes. A client with a history of migraines requesting pain medication: While addressing pain in clients with migraines is important, it is not as urgent as assessing and managing a suspected stroke. A client with epilepsy requesting a refill on antiepileptic medication: While ensuring medication compliance is important for clients with epilepsy, it is not as urgent as addressing a suspected stroke. A client with a minor head injury awaiting discharge instructions: While providing discharge instructions for clients with minor head injuries is important, it is not as urgent as assessing and managing a suspected stroke. Therefore, the client with a suspected stroke presenting with sudden-onset weakness on one side should be the nurse's top priority in a neurology unit. 10 / 20 10. The nurse is currently employed at a pediatric clinic. Whom should the nurse prioritize for assessment? a) A child with a minor abrasion on the knee b) A child with a history of asthma and difficulty breathing c) A child with a sore throat d) A child with a temperature of 100.5°F (38.1°C) Rationale: A child with a temperature of 100.5°F (38.1°C): While a fever is concerning and needs to be addressed, it is not immediately life-threatening. A child with a minor abrasion on the knee: This is a minor injury that can wait for more urgent issues to be addressed. A child with a history of asthma and difficulty breathing: This client should be assessed first because difficulty breathing in a child with a history of asthma can indicate an asthma exacerbation, which can be life-threatening if not promptly treated. Immediate assessment and intervention are critical to ensure the child's airway and breathing are maintained. A child with a sore throat: While this needs evaluation, it is generally not as urgent as a potential asthma exacerbation. Therefore, a child with a history of asthma and difficulty breathing should be the nurse's top priority. 11 / 20 11. A nurse in a surgical unit is managing care for multiple clients. Who should the nurse prioritize? a) A client postoperative day 1 after appendectomy with signs of infection b) A client with a history of heart disease complaining of chest discomfort c) A client with a surgical wound infection needing wound care d) A client with controlled pain requesting pain medication Rationale: A client postoperative day 1 after appendectomy with signs of infection: This client should be prioritized as signs of infection following surgery require immediate assessment and intervention to prevent further complications. A client with a history of heart disease complaining of chest discomfort: While chest discomfort in a client with a history of heart disease is concerning, it is not as urgent as addressing signs of infection post-surgery. A client with a surgical wound infection needing wound care: While wound care for a surgical wound infection is important, it is not as urgent as addressing signs of infection in a postoperative client. A client with controlled pain requesting pain medication: While managing pain is important for client comfort, it is not as urgent as addressing signs of infection post-surgery. Therefore, the client postoperative day 1 after appendectomy with signs of infection should be the nurse's top priority in a surgical unit. 12 / 20 12. A nurse in the ICU is assessing four clients. Which client should the nurse prioritize? a) A client with septic shock requiring vasopressors b) A client with a history of atrial fibrillation requiring telemetry monitoring c) A client post-abdominal surgery with controlled pain d) A client post-cardiac surgery with a blood pressure of 110/70 mmHg Rationale: A client post-cardiac surgery with a blood pressure of 110/70 mmHg: While monitoring blood pressure post-cardiac surgery is important, it is not as urgent as managing a client in septic shock requiring vasopressors. A client with septic shock requiring vasopressors: This client should be prioritized because septic shock is a life-threatening condition that requires immediate intervention to stabilize blood pressure and prevent organ failure. A client with a history of atrial fibrillation requiring telemetry monitoring: While telemetry monitoring is important for clients with cardiac arrhythmias, it is not as urgent as managing a client in septic shock. A client post-abdominal surgery with controlled pain: While pain management is important for post-operative recovery, it is not as urgent as managing a client in septic shock. Therefore, the client with septic shock requiring vasopressors should be the nurse's top priority in the ICU. 13 / 20 13. In a pediatric ICU, the nurse should prioritize care for a __________ with acute respiratory distress syndrome requiring __________. a) toddler, bronchodilator therapy b) adolescent, mechanical ventilation c) newborn, surfactant replacement therapy d) child, continuous positive airway pressure (CPAP) Rationale: newborn, surfactant replacement therapy: While surfactant replacement therapy is critical for newborns with respiratory distress syndrome, it is typically more urgent in neonates rather than in a pediatric ICU setting where an adolescent with ARDS requiring mechanical ventilation would take precedence. toddler, bronchodilator therapy: Bronchodilator therapy is important for conditions like asthma, but it is less urgent than ARDS requiring mechanical ventilation. child, continuous positive airway pressure (CPAP): CPAP is significant for respiratory support, but mechanical ventilation in an adolescent with ARDS is more critical. adolescent, mechanical ventilation: Mechanical ventilation for ARDS is a high priority due to the severity of the condition and the immediate need for advanced respiratory support. Thus, the client in most urgent need of prioritization is the adolescent requiring mechanical ventilation for ARDS. 14 / 20 14. In an oncology unit, a client experiencing neutropenia after chemotherapy takes precedence over a client with chemotherapy-induced nausea. a) True b) False Rationale: Neutropenia, a condition characterized by abnormally low levels of neutrophils (a type of white blood cell), can significantly compromise the immune system, leaving the individual vulnerable to infections, including potentially life-threatening ones. Therefore, it requires immediate attention and intervention, such as administration of growth factors or antibiotics, to prevent or manage infections. Chemotherapy-induced nausea, while distressing, is generally manageable with antiemetic medications and supportive care. In an oncology unit, the priority would be to address the neutropenia to prevent serious complications before addressing symptoms like nausea. 15 / 20 15. A nurse in a long-term care facility is deciding which client to prioritize. a) A client who requires a medication refill b) A client who is experiencing sudden confusion and agitation c) A client who wants help with grooming d) A client who needs assistance with feeding Rationale: A client who needs assistance with feeding: While important for the client’s nutrition and well-being, this is a routine task that is not immediately life-threatening. A client who wants help with grooming: Grooming assistance is important for dignity and hygiene but is not an urgent need. A client who requires a medication refill: While ensuring medications are refilled is important, it generally does not require immediate attention unless the medication is critically time-sensitive. A client who is experiencing sudden confusion and agitation: This client should be prioritized because sudden changes in mental status can be indicative of a serious underlying condition such as delirium, infection (like a urinary tract infection or sepsis), hypoxia, or other medical emergencies that require immediate assessment and intervention. Therefore, the client experiencing sudden confusion and agitation should be the nurse's top priority. 16 / 20 16. In a cardiovascular ICU, a client with unstable angina takes precedence over a client with atrial fibrillation. a) True b) False Rationale: Unstable angina represents an acute coronary syndrome and is considered a medical emergency due to the increased risk of myocardial infarction. Therefore, a client with unstable angina requires immediate attention and intervention to prevent further cardiac complications. Atrial fibrillation, while also significant, may not be as immediately life-threatening as unstable angina. Hence, in a cardiovascular ICU, the nurse should prioritize the client with unstable angina over the client with atrial fibrillation. 17 / 20 17. In a burn unit, which client should the nurse prioritize? a) A client with second-degree burns to the lower extremities b) A client with a history of diabetes requesting blood sugar monitoring c) A client with a minor burn on the hand needing wound care d) A client with a sunburn requesting pain medication Rationale: A client with second-degree burns to the lower extremities: This client should be prioritized as second-degree burns can lead to complications such as infection and impaired wound healing, especially when located on the lower extremities where mobility can be affected. Prompt assessment and management are necessary to prevent complications and promote healing. A client with a history of diabetes requesting blood sugar monitoring: While blood sugar monitoring is important for clients with diabetes, it is not as urgent as addressing the acute needs of a client with second-degree burns. A client with a minor burn on the hand needing wound care: While wound care is necessary, it is not as urgent as attending to a client with more severe burns. A client with a sunburn requesting pain medication: Sunburns, while painful, are typically not as serious as second-degree burns and can usually be managed with over-the-counter pain medication and topical treatments. Therefore, the client with second-degree burns to the lower extremities should be the nurse's top priority in a burn unit. 18 / 20 18. Which clients in a respiratory unit should the nurse prioritize for immediate intervention? (Select all that apply) a) A client with a cough and cold symptoms b) A client with asthma and wheezing unrelieved by medication c) A client with pneumonia and a respiratory rate of 32 d) A client with a tracheostomy and thick secretions e) A client with stable pulmonary fibrosis f) A client with chronic obstructive pulmonary disease (COPD) on home oxygen Rationale: In a respiratory unit, the nurse should prioritize clients who are experiencing acute or potentially life-threatening conditions that require immediate intervention. The clients who should be prioritized for immediate intervention are: A client with pneumonia and a respiratory rate of 32: This client is experiencing tachypnea, which can indicate respiratory distress or inadequate oxygenation. Immediate intervention is necessary to manage the underlying infection and ensure adequate breathing and oxygenation. A client with a tracheostomy and thick secretions: This client is at risk for airway obstruction due to the thick secretions. Immediate intervention is needed to clear the airway and prevent respiratory compromise. A client with asthma and wheezing unrelieved by medication: This client is experiencing an asthma exacerbation that is not responding to initial treatment, which can lead to severe respiratory distress or failure. Immediate intervention is required to control the asthma attack and improve breathing. These clients present with conditions that could rapidly deteriorate and lead to severe complications or death without prompt intervention. The other clients, while they need monitoring and ongoing care, do not present with conditions that require immediate intervention: A client with chronic obstructive pulmonary disease (COPD) on home oxygen: This client is likely stable on their home oxygen regimen and does not have an immediate change in condition requiring urgent intervention. A client with stable pulmonary fibrosis: This client is stable and does not require immediate intervention compared to those with acute respiratory issues. A client with a cough and cold symptoms: This is a relatively minor condition that does not require immediate intervention in a respiratory unit setting. 19 / 20 19. Which clients in an orthopedic unit should the nurse prioritize for immediate intervention? (Select all that apply) a) A client with a new onset of compartment syndrome symptoms b) A client with controlled pain from a fractured arm c) A client with a cast reporting severe pain and numbness d) A client with mild pain and swelling in the ankle e) A client with a stable femur fracture in traction f) A client postoperative day 1 after total hip replacement with signs of DVT Rationale: In an orthopedic unit, the nurse should prioritize clients who are experiencing acute or potentially life-threatening conditions that require immediate intervention. The clients who should be prioritized for immediate intervention are: A client postoperative day 1 after total hip replacement with signs of DVT: Deep vein thrombosis (DVT) can lead to serious complications such as pulmonary embolism. Immediate intervention is necessary to assess and treat the DVT to prevent life-threatening complications. A client with a new onset of compartment syndrome symptoms: Compartment syndrome is a medical emergency that can lead to permanent muscle and nerve damage if not promptly treated. Immediate intervention is required to relieve the pressure and restore circulation. A client with a cast reporting severe pain and numbness: Severe pain and numbness in a client with a cast can indicate compartment syndrome or compromised circulation. Immediate assessment and intervention are crucial to prevent permanent damage. These clients present with conditions that could rapidly deteriorate and lead to severe complications or permanent damage without prompt intervention. The other clients, while they need monitoring and ongoing care, do not present with conditions that require immediate intervention: A client with a stable femur fracture in traction: This client is stable and does not have an acute condition requiring immediate intervention. A client with controlled pain from a fractured arm: This client is stable with managed pain and does not require urgent intervention. A client with mild pain and swelling in the ankle: This client has a relatively minor issue that does not require immediate intervention compared to those with more acute and severe symptoms. 20 / 20 20. A nurse in a cardiovascular unit is managing care for multiple clients. Who should the nurse prioritize? a) A client with a history of myocardial infarction experiencing chest pain b) A client post-cardiac catheterization needing bed rest c) A client with controlled hypertension requesting discharge instructions d) A client with heart failure requesting a dietary consultation Rationale: A client with a history of myocardial infarction experiencing chest pain: This client should be prioritized as chest pain in someone with a history of myocardial infarction raises concerns for recurrent ischemia or myocardial infarction, requiring immediate assessment and intervention to prevent further cardiac damage. A client post-cardiac catheterization needing bed rest: While bed rest post-cardiac catheterization is important for preventing complications, addressing chest pain in a client with a history of myocardial infarction takes precedence. A client with controlled hypertension requesting discharge instructions: While discharge instructions are important for client education, they are not as urgent as addressing chest pain. A client with heart failure requesting a dietary consultation: While dietary consultation is important for managing heart failure, it is not as urgent as addressing chest pain in a client with a history of myocardial infarction. Therefore, a client with a history of myocardial infarction experiencing chest pain should be the nurse's top priority in a cardiovascular unit. Your score is LinkedIn Facebook 0% Restart quiz Exit
