Introduction to Prioritization & Clinical Judgment for NCLEX-RN®

1. A nurse is caring for a client admitted with pneumonia. Which intervention should the nurse prioritize? • A. Administering the prescribed antibiotic • B. Obtaining a sputum culture • C. Encouraging increased fluid intake • D. Providing the client with a warm blanket Answer: B. Obtaining a sputum culture Rationale: Before administering antibiotics, it is crucial to obtain a sputum culture to identify the causative organism and ensure appropriate treatment. Administering the antibiotic without a culture could affect the results and lead to inappropriate treatment. While administering the antibiotic (A) and encouraging fluids (C) are important, obtaining a culture is the priority. ________________________________________ 2. The nurse is assessing a client who has just returned from surgery. Which of the following assessments requires immediate intervention? • A. The client's urine output is 40 mL/hr. • B. The client has cool, pale extremities. • C. The client's pain level is 6 out of 10. • D. The client has a heart rate of 98 beats/min. Answer: B. The client has cool, pale extremities Rationale: Cool, pale extremities may indicate decreased perfusion, which could be a sign of shock or poor circulation. This finding needs immediate intervention to prevent further complications. While pain and a slightly increased heart rate are important, they are not as critical as a potential perfusion issue. ________________________________________ 3. A client with congestive heart failure is experiencing shortness of breath and has an oxygen saturation of 88%. What should the nurse do first? • A. Increase the client's oxygen flow rate. • B. Place the client in a high-Fowler's position. • C. Call the healthcare provider immediately. • D. Administer a prescribed diuretic. Answer: B. Place the client in a high-Fowler's position Rationale: Placing the client in a high-Fowler’s position promotes lung expansion and may help alleviate shortness of breath. Increasing oxygen flow rate (A) may be appropriate, but positioning the client is the priority as it improves ventilation. Administering diuretics (D) will take time to have an effect, so it is not the first intervention. ________________________________________ 4. A nurse is caring for a client with a history of hypertension who reports a headache. Which action should the nurse prioritize? • A. Administer prescribed pain medication • B. Assess the client’s blood pressure • C. Provide a dark and quiet environment • D. Encourage the client to rest Answer: B. Assess the client’s blood pressure Rationale: For a client with a history of hypertension, a headache could indicate elevated blood pressure or hypertensive crisis. Assessing blood pressure is the priority to determine if the headache is related to hypertension. Administering pain medication (A) should only be done after assessing the cause. ________________________________________ 5. A client admitted with deep vein thrombosis (DVT) suddenly complains of chest pain and shortness of breath. What is the nurse’s priority action? • A. Administer prescribed pain medication • B. Notify the healthcare provider • C. Position the client in a high-Fowler's position • D. Administer oxygen therapy Answer: D. Administer oxygen therapy Rationale: The client’s symptoms suggest a pulmonary embolism, a potential complication of DVT. The nurse should first ensure oxygenation by administering oxygen. Notifying the healthcare provider (B) is important but secondary to stabilizing the client’s respiratory status. ________________________________________ 6. A nurse is caring for a client with an acute asthma exacerbation. The client's respiratory rate is 30 breaths/min, and they are using accessory muscles. Which of the following should the nurse do first? • A. Administer a bronchodilator via nebulizer • B. Notify the respiratory therapist • C. Position the client in a semi-Fowler's position • D. Encourage the client to use pursed-lip breathing Answer: A. Administer a bronchodilator via nebulizer Rationale: Administering a bronchodilator will open the airways and is the priority intervention in an acute asthma exacerbation. Positioning the client (C) and encouraging breathing techniques (D) are helpful but secondary to medication. ________________________________________ 7. The nurse is providing care for a client with a potassium level of 6.2 mEq/L. Which action should the nurse prioritize? • A. Administer a prescribed potassium supplement • B. Restrict the client’s potassium intake • C. Monitor the client’s cardiac rhythm • D. Encourage the client to eat a potassium-rich diet Answer: C. Monitor the client’s cardiac rhythm Rationale: Hyperkalemia (potassium level above 5.0 mEq/L) can cause life-threatening cardiac arrhythmias. Therefore, monitoring the client's cardiac rhythm is a priority. Restricting potassium intake (B) is appropriate, but cardiac monitoring is critical. ________________________________________ 8. A client is admitted to the emergency department with a possible stroke. What should the nurse prioritize during the initial assessment? • A. Assessing the client’s airway and breathing • B. Evaluating the client’s blood pressure • C. Asking the client about medical history • D. Performing a complete neurological assessment Answer: A. Assessing the client’s airway and breathing Rationale: In any emergency situation, airway, breathing, and circulation (ABC) are the top priorities. For a client with a possible stroke, ensuring airway patency and adequate oxygenation is critical before conducting further assessments. ________________________________________ 9. The nurse is preparing to administer a blood transfusion to a client. Which action is the most important to prevent a transfusion reaction? • A. Verify the client’s identity and blood type with another nurse • B. Assess the client’s vital signs before starting the transfusion • C. Check for the client's history of transfusion reactions • D. Administer acetaminophen before the transfusion Answer: A. Verify the client’s identity and blood type with another nurse Rationale: The most important action to prevent a transfusion reaction is ensuring that the correct blood type is given to the correct client by following verification procedures. Other interventions like assessing vital signs (B) are also necessary but do not prevent reactions. ________________________________________ 10. A nurse is caring for a client who is post-op day 1 from a hip replacement. The client reports a sudden onset of severe calf pain. What should the nurse do first? • A. Assess for signs of deep vein thrombosis • B. Elevate the client's leg • C. Administer prescribed analgesics • D. Encourage the client to ambulate Answer: A. Assess for signs of deep vein thrombosis Rationale: Severe calf pain after surgery may indicate deep vein thrombosis (DVT), which is a serious condition that could lead to complications such as a pulmonary embolism. The nurse should assess the client for DVT signs before taking other actions.