NURS 121L-B Medical-Surgical Nursing: Clinical Judgment,
Prioritization & Delegation 2026 |WCU
1. Which patient should the nurse assess first after receiving the morning shift
report?
A. A 65-year-old with heart failure who has 2+ pitting edema.
B. A 45-year-old post-abdominal surgery with a heart rate of 115 bpm.
C. A 70-year-old with chronic obstructive pulmonary disease (COPD) and an SpO2 of 90%.
D. A 30-year-old with a fractured femur reporting 7/10 pain.
Answer: B
Rationale: Tachycardia in a post-operative patient is a sign of potential hemorrhage or
shock (Circulation), which takes priority over stable edema, chronic COPD levels, or non-
emergent pain.
2. Which task is most appropriate for the RN to delegate to an unlicensed
assistive personnel (UAP)?
A. Evaluating the effectiveness of a patient’s PRN pain medication.
B. Assisting a stable patient with oral hygiene and a partial bed bath.
C. Adjusting the flow rate of an oxygen nasal cannula based on SpO2.
D. Providing discharge instructions regarding wound care.
Answer: B
Rationale: Hygiene and ADLs for stable patients are within the UAP’s scope. Evaluation,
clinical adjustment of therapy, and teaching are RN responsibilities.
,3. A patient with a traumatic brain injury has a blood pressure of 160/90, heart
rate of 50, and irregular respirations. What is the nurse’s priority action?
A. Notify the healthcare provider immediately.
B. Document the findings and continue monitoring.
C. Administer the prescribed antihypertensive medication.
D. Elevate the foot of the bed to 45 degrees.
Answer: A
Rationale: These signs (widening pulse pressure, bradycardia, irregular breathing)
constitute Cushing’s Triad, indicating a life-threatening increase in intracranial pressure.
4. Which patient requires the most immediate intervention by the charge
nurse?
A. A patient with a chest tube that has 50 mL of serosanguinous drainage in 2 hours.
B. A patient with a casted leg who reports ‘pins and needles’ and is pale.
C. A patient with a tracheostomy who has frequent moist-sounding coughs.
D. A patient on a heparin drip with a PTT of 1.5 times the control.
Answer: B
Rationale: Paresthesia and pallor in a casted limb are early signs of Compartment
Syndrome, a neurovascular emergency requiring immediate action to prevent permanent
damage.
5. The nurse is caring for a group of patients. Which task can be delegated to a
Licensed Practical Nurse (LPN)?
A. Administering a dose of subcutaneous insulin to a stable diabetic patient.
B. Initiating the initial nursing care plan for a newly admitted patient.
C. Performing an admission assessment on a patient transferred from the ICU.
D. Teaching a patient how to use a patient-controlled analgesia (PCA) pump.
Answer: A
, Rationale: LPNs can administer medications via common routes (PO, SC, IM) to stable
patients. Assessment, care planning, and complex teaching are RN roles.
6. Using the ABC framework, which patient should the nurse see first?
A. A patient with a suspected deep vein thrombosis who has a warm, red calf.
B. A patient with acute pancreatitis who has a rigid, board-like abdomen.
C. A patient with anaphylaxis who is experiencing stridor.
D. A patient with end-stage renal disease who missed a dialysis treatment.
Answer: C
Rationale: Stridor indicates an upper airway obstruction (Airway), which is the highest
priority in the ABC (Airway-Breathing-Circulation) hierarchy.
7. The nurse receives a lab report for a patient on Digoxin. The potassium level
is 3.1 mEq/L. What is the nurse’s priority action?
A. Administer the Digoxin as ordered.
B. Encourage the patient to eat a banana.
C. Hold the next dose of Digoxin and notify the provider.
D. Recheck the potassium level in 4 hours.
Answer: C
Rationale: Hypokalemia (K+ < 3.5) significantly increases the risk of Digoxin toxicity. The
nurse must hold the med and alert the provider.
8. A UAP reports that a patient’s blood pressure is 88/50 mmHg. What should
the nurse do first?
A. Ask the UAP to retake the blood pressure in 15 minutes.
B. Instruct the UAP to lower the head of the bed.
C. Call the physician to request an IV fluid bolus.
D. Assess the patient’s level of consciousness and skin temperature.
Answer: D
Prioritization & Delegation 2026 |WCU
1. Which patient should the nurse assess first after receiving the morning shift
report?
A. A 65-year-old with heart failure who has 2+ pitting edema.
B. A 45-year-old post-abdominal surgery with a heart rate of 115 bpm.
C. A 70-year-old with chronic obstructive pulmonary disease (COPD) and an SpO2 of 90%.
D. A 30-year-old with a fractured femur reporting 7/10 pain.
Answer: B
Rationale: Tachycardia in a post-operative patient is a sign of potential hemorrhage or
shock (Circulation), which takes priority over stable edema, chronic COPD levels, or non-
emergent pain.
2. Which task is most appropriate for the RN to delegate to an unlicensed
assistive personnel (UAP)?
A. Evaluating the effectiveness of a patient’s PRN pain medication.
B. Assisting a stable patient with oral hygiene and a partial bed bath.
C. Adjusting the flow rate of an oxygen nasal cannula based on SpO2.
D. Providing discharge instructions regarding wound care.
Answer: B
Rationale: Hygiene and ADLs for stable patients are within the UAP’s scope. Evaluation,
clinical adjustment of therapy, and teaching are RN responsibilities.
,3. A patient with a traumatic brain injury has a blood pressure of 160/90, heart
rate of 50, and irregular respirations. What is the nurse’s priority action?
A. Notify the healthcare provider immediately.
B. Document the findings and continue monitoring.
C. Administer the prescribed antihypertensive medication.
D. Elevate the foot of the bed to 45 degrees.
Answer: A
Rationale: These signs (widening pulse pressure, bradycardia, irregular breathing)
constitute Cushing’s Triad, indicating a life-threatening increase in intracranial pressure.
4. Which patient requires the most immediate intervention by the charge
nurse?
A. A patient with a chest tube that has 50 mL of serosanguinous drainage in 2 hours.
B. A patient with a casted leg who reports ‘pins and needles’ and is pale.
C. A patient with a tracheostomy who has frequent moist-sounding coughs.
D. A patient on a heparin drip with a PTT of 1.5 times the control.
Answer: B
Rationale: Paresthesia and pallor in a casted limb are early signs of Compartment
Syndrome, a neurovascular emergency requiring immediate action to prevent permanent
damage.
5. The nurse is caring for a group of patients. Which task can be delegated to a
Licensed Practical Nurse (LPN)?
A. Administering a dose of subcutaneous insulin to a stable diabetic patient.
B. Initiating the initial nursing care plan for a newly admitted patient.
C. Performing an admission assessment on a patient transferred from the ICU.
D. Teaching a patient how to use a patient-controlled analgesia (PCA) pump.
Answer: A
, Rationale: LPNs can administer medications via common routes (PO, SC, IM) to stable
patients. Assessment, care planning, and complex teaching are RN roles.
6. Using the ABC framework, which patient should the nurse see first?
A. A patient with a suspected deep vein thrombosis who has a warm, red calf.
B. A patient with acute pancreatitis who has a rigid, board-like abdomen.
C. A patient with anaphylaxis who is experiencing stridor.
D. A patient with end-stage renal disease who missed a dialysis treatment.
Answer: C
Rationale: Stridor indicates an upper airway obstruction (Airway), which is the highest
priority in the ABC (Airway-Breathing-Circulation) hierarchy.
7. The nurse receives a lab report for a patient on Digoxin. The potassium level
is 3.1 mEq/L. What is the nurse’s priority action?
A. Administer the Digoxin as ordered.
B. Encourage the patient to eat a banana.
C. Hold the next dose of Digoxin and notify the provider.
D. Recheck the potassium level in 4 hours.
Answer: C
Rationale: Hypokalemia (K+ < 3.5) significantly increases the risk of Digoxin toxicity. The
nurse must hold the med and alert the provider.
8. A UAP reports that a patient’s blood pressure is 88/50 mmHg. What should
the nurse do first?
A. Ask the UAP to retake the blood pressure in 15 minutes.
B. Instruct the UAP to lower the head of the bed.
C. Call the physician to request an IV fluid bolus.
D. Assess the patient’s level of consciousness and skin temperature.
Answer: D
