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. A nurse in a respiratory unit is managing care for multiple clients. The nurse should prioritize a client with __________ requiring __________. a) asthma exacerbation, nebulizer treatment b) chronic obstructive pulmonary disease (COPD), bronchodilator therapy c) acute respiratory distress syndrome (ARDS), mechanical ventilation d) pneumonia, oxygen therapy Rationale: acute respiratory distress syndrome (ARDS), mechanical ventilation: ARDS is a life-threatening condition that causes severe respiratory failure. Mechanical ventilation is critical to ensure adequate oxygenation and to prevent further respiratory compromise. chronic obstructive pulmonary disease (COPD), bronchodilator therapy: While bronchodilator therapy is important for managing COPD, it is generally not as immediately life-threatening as ARDS requiring mechanical ventilation. pneumonia, oxygen therapy: Oxygen therapy is crucial for pneumonia patients, especially those with significant hypoxia, but the need is not as urgent as mechanical ventilation for ARDS. asthma exacerbation, nebulizer treatment: Asthma exacerbations can be serious and require prompt nebulizer treatment, but ARDS with the need for mechanical ventilation presents a more immediate critical situation. Therefore, the nurse should prioritize the client with ARDS requiring mechanical ventilation due to the acute and potentially life-threatening nature of the condition. 2 / 20 2. In a geriatric unit, the nurse should prioritize care for a client with __________ requiring __________. a) dementia, aggressive behavior management b) osteoarthritis, pain medication c) urinary incontinence, toileting assistance d) hypertension, blood pressure monitoring Rationale: dementia, aggressive behavior management: Aggressive behavior in dementia patients poses immediate risks to the safety of the patient and others, requiring prompt intervention to ensure a safe environment. urinary incontinence, toileting assistance: While important for maintaining comfort and dignity, toileting assistance for urinary incontinence may not present an immediate threat to the client's safety compared to managing aggressive behavior in dementia. osteoarthritis, pain medication: Pain management for osteoarthritis is essential for the client's comfort but may not require urgent attention unless the pain is severe and uncontrolled. hypertension, blood pressure monitoring: Monitoring blood pressure in hypertensive clients is important for overall health management, but it may not be as immediately urgent as managing aggressive behavior in dementia. Therefore, the nurse should prioritize care for the client with dementia requiring aggressive behavior management due to the potential risks associated with uncontrolled aggression. 3 / 20 3. In the emergency department, which clients should the nurse prioritize for immediate care? (Select all that apply.) a) A client with chest pain and diaphoresis b) A client with a broken arm and controlled pain c) A client with a mild headache d) A client with severe abdominal pain e) A client with shortness of breath and cyanosis f) A client with a small laceration on the hand Rationale: In the emergency department, clients should be prioritized based on the severity and potentially life-threatening nature of their conditions. According to the principles of triage, the nurse should prioritize clients who require immediate intervention to prevent significant harm or death. Given this, the clients who should be prioritized for immediate care are: A client with chest pain and diaphoresis: This client could be experiencing a myocardial infarction (heart attack) or another serious cardiac event. Chest pain accompanied by diaphoresis (sweating) is a red flag that warrants immediate evaluation and intervention. A client with shortness of breath and cyanosis: This client is showing signs of respiratory distress and hypoxia, which are potentially life-threatening conditions. Immediate assessment and treatment are crucial to ensure adequate oxygenation and to address the underlying cause. A client with severe abdominal pain: While the exact cause is not specified, severe abdominal pain can indicate serious conditions such as appendicitis, bowel obstruction, or a ruptured aneurysm, which require prompt evaluation and treatment. These clients present with symptoms that could indicate serious, potentially life-threatening conditions and should be prioritized for immediate care. The other clients, while they may still require medical attention, do not exhibit symptoms that suggest immediate life-threatening conditions: A client with a mild headache: Typically not life-threatening and can often be managed with standard analgesics and further evaluation if necessary. A client with a broken arm and controlled pain: Although painful, a broken arm with controlled pain is generally not life-threatening and can be managed with proper splinting and analgesia. A client with a small laceration on the hand: This is typically a minor injury that can be managed with cleaning, suturing, or bandaging and is not immediately life-threatening. 4 / 20 4. In a pediatric ICU, the nurse should prioritize care for a __________ with acute respiratory distress syndrome requiring __________. a) child, continuous positive airway pressure (CPAP) b) newborn, surfactant replacement therapy c) adolescent, mechanical ventilation d) toddler, bronchodilator therapy 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. 5 / 20 5. In a neonatal intensive care unit (NICU), which client should the nurse prioritize? a) A neonate with a feeding tube in place requiring formula b) A preterm infant requiring phototherapy for jaundice c) An infant with bronchiolitis needing oxygen support d) A newborn with stable vital signs awaiting discharge Rationale: A preterm infant requiring phototherapy for jaundice: While phototherapy for jaundice is important for preterm infants, addressing bronchiolitis and the need for oxygen support takes precedence due to the potential for respiratory compromise and hypoxia. A newborn with stable vital signs awaiting discharge: While discharge planning is important for newborns, addressing bronchiolitis and the need for oxygen support in an infant is more urgent. An infant with bronchiolitis needing oxygen support: This client should be prioritized because bronchiolitis can cause respiratory distress and hypoxia, requiring immediate intervention to ensure adequate oxygenation and prevent complications. A neonate with a feeding tube in place requiring formula: While feeding is important for neonates, addressing respiratory distress in an infant takes precedence due to the potential for compromised oxygenation. Therefore, the infant with bronchiolitis needing oxygen support should be the nurse's top priority in a neonatal intensive care unit (NICU). 6 / 20 6. A nurse in the emergency department is managing care for multiple clients. Who should the nurse prioritize? a) A client with a suspected stroke presenting with slurred speech b) A client with a history of migraines requesting pain medication c) A client with controlled hypertension requesting a blood pressure check d) A client with a minor laceration on the hand needing suturing Rationale: A client with a suspected stroke presenting with slurred speech: This client should be prioritized because a suspected stroke is a medical emergency requiring immediate assessment and intervention aimed at minimizing potential brain damage and enhancing overall outcomes. A client with a minor laceration on the hand needing suturing: While laceration repair is important, it is not as urgent as addressing a suspected stroke. A client with a history of migraines requesting pain medication: While addressing pain is important, it is not as urgent as assessing a client with a suspected stroke. A client with controlled hypertension requesting a blood pressure check: While monitoring blood pressure is important, it is not as urgent as assessing a client with a suspected stroke. Therefore, the client with a suspected stroke presenting with slurred speech should be the nurse's top priority in the emergency department. 7 / 20 7. A nurse is currently attending to four clients. Which of these clients should the nurse prioritize seeing first? a) A client with a fever of 102°F (38.9°C) b) A client with a sprained ankle c) A client with a history of hypertension complaining of severe headache d) A client requesting pain medication after surgery Rationale: A client with a sprained ankle: This is generally a less urgent condition compared to the others listed unless there are complications not mentioned (e.g., severe pain, compromised circulation). A client with a fever of 102°F (38.9°C): While a fever is a concern and needs to be addressed, it might not be immediately life-threatening compared to the potential urgency of a severe hypertension-related headache. A client with a history of hypertension complaining of severe headache: This client should be seen first because a headache in the context of hypertension could indicate a hypertensive crisis or other serious complications such as stroke or preeclampsia (if the client is pregnant). Immediate assessment and intervention might be necessary to prevent severe outcomes. A client requesting pain medication after surgery: Pain management is important, but it is generally not as urgent as the potential complications related to hypertension. Thus, the client with a history of hypertension and a headache represents the highest priority due to the potential for severe complications. 8 / 20 8. Which clients in a psychiatric unit should the nurse prioritize for immediate intervention? (Select all that apply) a) A client with mild depression b) A client with bipolar disorder in a manic state c) A client with a history of substance abuse and current withdrawal symptoms d) A client with major depressive disorder expressing thoughts of self-harm e) A client with schizophrenia experiencing auditory hallucinations f) A client with anxiety requesting to talk to the nurse Rationale: In a psychiatric 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 care are: A client with major depressive disorder expressing thoughts of self-harm: This client is at immediate risk for self-harm or suicide. Immediate intervention is necessary to ensure their safety and provide appropriate treatment. A client with bipolar disorder in a manic state: This client may exhibit impulsive, risky behaviors, agitation, or aggression, which can endanger themselves or others. Immediate intervention is needed to stabilize their mood and ensure safety. A client with a history of substance abuse and current withdrawal symptoms: Withdrawal can lead to severe and potentially life-threatening symptoms such as seizures, delirium tremens, or severe agitation. Immediate intervention is necessary to address withdrawal symptoms and prevent complications. These clients present with conditions that could rapidly deteriorate and lead to severe complications or safety concerns 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 schizophrenia experiencing auditory hallucinations: While this client may need close monitoring and treatment, auditory hallucinations alone do not necessarily require immediate intervention unless they are commanding the client to harm themselves or others. A client with anxiety requesting to talk to the nurse: This client should be attended to, but their condition is not as urgent as those with immediate safety risks or severe withdrawal symptoms. A client with mild depression: This client requires ongoing support and treatment but does not have an immediate safety risk or severe symptoms requiring urgent intervention. 9 / 20 9. A nurse in a trauma unit is managing care for multiple clients. The nurse should prioritize a client with __________ requiring immediate __________. a) concussion, observation b) head injury, neurosurgical intervention c) fracture, splinting d) laceration, suturing Rationale: head injury, neurosurgical intervention: A head injury that requires neurosurgical intervention is a critical situation that needs immediate attention due to the potential for life-threatening complications such as increased intracranial pressure or bleeding. fracture, splinting: While fractures need prompt care, splinting can typically be managed after more life-threatening conditions are addressed. laceration, suturing: Suturing a laceration is important for wound care but is generally not as urgent as a severe head injury requiring neurosurgery. concussion, observation: Concussions require monitoring, but they do not typically require immediate intervention unless there are severe symptoms indicating a more serious injury. Therefore, the nurse should prioritize the client with a head injury requiring immediate neurosurgical intervention due to the critical nature of the condition. 10 / 20 10. 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 post-cardiac surgery with a blood pressure of 110/70 mmHg c) A client with a history of atrial fibrillation requiring telemetry monitoring d) A client post-abdominal surgery with controlled pain 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. 11 / 20 11. In a burn unit, which clients should the nurse prioritize for immediate care? (Select all that apply) a) A client with partial-thickness burns over 20% of the body b) A client with a minor burn on the hand c) A client with circumferential burns on the chest d) A client with singed nasal hairs and soot in the mouth e) A client with full-thickness burns over 5% of the body f) A client with superficial burns on the arms Rationale: In a burn unit, the nurse should prioritize clients who are experiencing potentially life-threatening conditions or severe symptoms that require immediate intervention. The clients who should be prioritized for immediate care are: A client with circumferential burns of the chest: Circumferential burns can cause constriction due to eschar formation, potentially leading to respiratory compromise and impaired circulation. Immediate intervention is required to prevent life-threatening complications. A client with singed nasal hairs and soot in the mouth: These findings indicate possible inhalation injury, which can lead to airway compromise. Immediate assessment and intervention are crucial to secure the airway and prevent respiratory failure. A client with partial-thickness burns over 20% of the body: Burns covering a large surface area can lead to significant fluid loss, hypovolemia, and shock. Immediate intervention is necessary to initiate fluid resuscitation and manage the burn wounds. These clients present with conditions that could quickly 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 full-thickness burns over 5% of the body: While this client requires careful management, the burns are not as extensive and do not present an immediate life-threatening condition compared to larger burns or airway injuries. A client with superficial burns on the arms: Superficial burns are less severe and typically do not require immediate intervention compared to deeper or more extensive burns. A client with a minor burn on the hand: This is a minor injury that can be managed after more critical cases are addressed. 12 / 20 12. A nurse in a long-term care facility is deciding which client to prioritize. a) A client who needs assistance with feeding b) A client who wants help with grooming c) A client who is experiencing sudden confusion and agitation d) A client who requires a medication refill 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. 13 / 20 13. 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 postoperative day 1 after total hip replacement with signs of DVT c) A client with controlled pain from a fractured arm d) A client with a stable femur fracture in traction e) A client with a cast reporting severe pain and numbness f) A client with mild pain and swelling in the ankle 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. 14 / 20 14. A nurse on a medical unit is caring for clients. Which client should the nurse prioritize during the round? a) A client who needs assistance with repositioning b) A client who just returned from surgery and needs a pain assessment c) A client with a urinary tract infection needs antibiotics d) A client with a rash and itching Rationale: A client with a rash and itching: This is typically a non-urgent condition that can be addressed after more critical needs are met. A client with a urinary tract infection needing antibiotics: While timely administration of antibiotics is important, it is generally not immediately life-threatening compared to post-surgical complications. A client who needs assistance with repositioning: Repositioning is important for comfort and preventing pressure injuries, but it is not as urgent as assessing a post-surgical client. A client who just returned from surgery and needs pain assessment: This client should be prioritized because post-surgical patients are at risk for complications such as hemorrhage, infection, and severe pain. Immediate assessment is crucial to ensure their recovery is progressing safely and to address any complications early. Therefore, the client who just returned from surgery and needs pain assessment should be the nurse's top priority. 15 / 20 15. In a neonatal intensive care unit (NICU), the nurse should prioritize care for a __________ with severe jaundice requiring __________. a) preterm infant, phototherapy b) premature infant, exchange transfusion c) newborn, vitamin K injection d) term infant, blood transfusion Rationale: preterm infant, phototherapy: Phototherapy is a common treatment for mild to moderate jaundice in preterm infants but is not as critical as severe jaundice requiring an exchange transfusion. term infant, blood transfusion: While a blood transfusion can be critical in certain situations, it is not specifically the standard treatment for severe jaundice. newborn, vitamin K injection: Vitamin K injections are given to prevent bleeding disorders in newborns and are not a treatment for jaundice. premature infant, exchange transfusion: Exchange transfusion is a critical and life-saving procedure for treating severe jaundice, especially in premature infants, to prevent bilirubin encephalopathy. Therefore, the nurse should prioritize the premature infant with severe jaundice requiring exchange transfusion due to the urgency and seriousness of the condition. 16 / 20 16. In a respiratory unit, a client with acute exacerbation of chronic obstructive pulmonary disease (COPD) takes precedence over a client with pneumonia. a) False b) True Rationale: Acute exacerbations of chronic obstructive pulmonary disease (COPD) can rapidly deteriorate respiratory function and lead to life-threatening complications. Therefore, they often require urgent intervention, such as bronchodilator therapy, corticosteroids, and oxygen therapy, to stabilize the client's condition and improve breathing. Pneumonia, while serious, may not always require immediate intervention depending on its severity and the client's overall clinical status. In a respiratory unit, prioritizing the client with acute exacerbation of COPD ensures timely management to prevent respiratory failure and other complications. 17 / 20 17. 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. 18 / 20 18. In an orthopedic unit, which client should the nurse prioritize? a) A client with a fractured wrist awaiting cast application b) A client postoperative day 1 after total hip replacement with signs of deep vein thrombosis (DVT) c) A client with pain 7/10 requesting pain medication d) A client with a history of osteoarthritis requesting dietary counseling 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. 19 / 20 19. A nurse in a medical-surgical unit is managing care for multiple clients. Who should the nurse prioritize? a) A client with controlled hypertension needs blood pressure monitoring b) A client with a urinary tract infection requesting antibiotic administration c) A client postoperative day 1 after bowel resection experiencing abdominal pain d) A client with diabetes requesting dietary counseling Rationale: A client postoperative day 1 after bowel resection experiencing abdominal pain: This client should be prioritized as abdominal pain in a postoperative client could indicate complications such as infection, bleeding, or bowel obstruction, requiring immediate assessment and intervention. A client with diabetes requesting dietary counseling: While dietary counseling is important for managing diabetes, it is not as urgent as addressing postoperative pain. A client with controlled hypertension needing blood pressure monitoring: While blood pressure monitoring is important for clients with hypertension, it is not as urgent as addressing postoperative pain. A client with a urinary tract infection requesting antibiotic administration: While antibiotic administration is necessary for treating urinary tract infections, it is not as urgent as addressing postoperative pain. Therefore, the client's postoperative day 1 after bowel resection experiencing abdominal pain should be the nurse's top priority in a medical-surgical unit. 20 / 20 20. A nurse in a cardiovascular ICU is managing care for multiple clients. Who should the nurse prioritize? a) A client with aortic dissection requiring immediate surgical intervention b) A client with stable angina requesting nitroglycerin for chest discomfort c) A client with controlled hypertension needs blood pressure monitoring d) A client post-percutaneous coronary intervention (PCI) with controlled chest pain Rationale: A client with aortic dissection requiring immediate surgical intervention: This client should be prioritized as aortic dissection is a life-threatening emergency that requires immediate surgical intervention to prevent further complications such as aortic rupture or organ ischemia. A client post-percutaneous coronary intervention (PCI) with controlled chest pain: While chest pain in a client post-PCI requires attention, it is not as urgent as addressing aortic dissection. A client with stable angina requesting nitroglycerin for chest discomfort: While addressing angina symptoms is important, it is not as urgent as managing aortic dissection. A client with controlled hypertension needing blood pressure monitoring: While blood pressure monitoring is important for clients with hypertension, it is not as urgent as addressing aortic dissection. Therefore, a client with aortic dissection requiring immediate surgical intervention should be the nurse's top priority in a cardiovascular ICU. Your score is LinkedIn Facebook 0% Restart quiz Exit
