NCLEX RN Priority and Delegation
Questions | NCLEX RN Practice
Questions with Rationales
1. Question
The nurse is managing care for several clients in the outpatient clinic. Among the
following clients who called, which one should the nurse prioritize in responding
to first?
A. A client with hepatitis A who states, “My arms and legs are itching.”
B. A client with a cast on the right leg who states, “I have a funny feeling in
my right leg.”
C. A client with osteomyelitis of the spine who states, “I am so nauseous that
I can’t eat.”
D. A client with rheumatoid arthritis who states, “I am having trouble
sleeping.”
Correct Answer: E. A client with a cast on the right leg who states, “I have a
funny feeling in my right leg.”
It may indicate neurovascular compromise, requiring immediate assessment.
Option A: Bilirubin levels in hepatitis A may increase, and itching is a common
symptom.
Option C: A client feeling nauseous may require consultation but is not a
priority.
Option D: Clients with rheumatoid arthritis may feel pain in the affected areas
at night. They may need a prescription for painkillers but it is not urgent.
2. 2. Question
, A nurse on the surgical floor is prioritizing care for clients after receiving the
report from the previous shift. Which of the following patients should the nurse
assess first?
A. A 35-year-old patient admitted three hours ago for a gunshot wound, with
a 1.5 cm area of dark drainage noted on the dressing.
B. A 43-year-old patient who underwent a mastectomy two days ago, with 23
ml of serosanguinous fluid in the Jackson-Pratt drain.
C. A 59-year-old patient with a history of a collapsed lung from an accident,
with no drainage noted in the chest tube in the past eight hours.
E. A 54-year-old patient with a total knee replacement two days ago, with
moderate swelling at the surgical site.
E. A 47-year-old patient who had a laparoscopic cholecystectomy yesterday,
complaining of mild pain at the incision site.
F. A 62-year-old patient who had an abdominal-perineal resection three days
ago, now reporting chills.
Correct Answer: F. A 62-year-old patient who had an abdominal-perineal
resection three days ago, now reporting chills.
The client is at risk for peritonitis; should be assessed for further symptoms and
infection.
3. 3. Question
A nurse in a post-surgical unit is monitoring a 46-year-old patient who
underwent a thyroidectomy 12 hours ago for the treatment of Grave’s disease.
Which of the following observations should most concern the nurse?
A. Blood pressure 138/82 mmHg, respirations 16 per minute, oral
temperature 37.2ºC or 99º F.
B. The patient carefully supports their head and neck when turning their head
to the right.
C. The patient expresses difficulty in swallowing but can manage liquids.
D. The patient appears drowsy and complains of a sore throat.
, E. The patient shows involuntary flexion of their wrist when blood pressure is
measured.
F. The patient has a hoarse voice when speaking.
Correct Answer: E. The patient shows involuntary flexion of their wrist when
blood pressure is measured.
Carpal spasms (Trousseau’s sign) indicate hypocalcemia which can occur after
thyroidectomy due to accidental removal or damage to the parathyroid glands.
Hypocalcemia is a serious complication and requires immediate attention. The
other options, while they might warrant monitoring, are not as immediately
concerning as a potential sign of hypocalcemia.
Option A: The vital signs are all within the normal range.
Option B: Supporting the head and neck while turning protects the surgical
site from dehiscence.
Option C: Common side effect of neck surgery.
Option D: Drowsiness may be a side effect of the anesthesia used during
surgery and will fade away eventually; a sore throat is a normal finding after
thyroid surgery.
Option F: Hoarseness of voice is a common side effect of post-op
thyroidectomy due to one or more of the nerves irritated during the procedure
of due to inflammation that occurs after surgery.
4. 4. Question
Category: Physiological Adaptation
A 38-year-old patient is admitted to the emergency department with severe pain
in the lower right quadrant of the abdomen, nausea, and a low-grade fever,
raising concerns about possible appendicitis. The nurse is considering pain relief
strategies. Which of the following actions should the nurse prioritize?
A. Encourage the patient to change positions frequently in bed.
B. Administer Demerol 50 mg IM q 4 hours and PRN, as prescribed.
C. Apply warmth to the abdomen with a heating pad.
D. Use comfort measures and pillows to position the patient comfortably.
E. Administer an antiemetic as prescribed for nausea relief.
Questions | NCLEX RN Practice
Questions with Rationales
1. Question
The nurse is managing care for several clients in the outpatient clinic. Among the
following clients who called, which one should the nurse prioritize in responding
to first?
A. A client with hepatitis A who states, “My arms and legs are itching.”
B. A client with a cast on the right leg who states, “I have a funny feeling in
my right leg.”
C. A client with osteomyelitis of the spine who states, “I am so nauseous that
I can’t eat.”
D. A client with rheumatoid arthritis who states, “I am having trouble
sleeping.”
Correct Answer: E. A client with a cast on the right leg who states, “I have a
funny feeling in my right leg.”
It may indicate neurovascular compromise, requiring immediate assessment.
Option A: Bilirubin levels in hepatitis A may increase, and itching is a common
symptom.
Option C: A client feeling nauseous may require consultation but is not a
priority.
Option D: Clients with rheumatoid arthritis may feel pain in the affected areas
at night. They may need a prescription for painkillers but it is not urgent.
2. 2. Question
, A nurse on the surgical floor is prioritizing care for clients after receiving the
report from the previous shift. Which of the following patients should the nurse
assess first?
A. A 35-year-old patient admitted three hours ago for a gunshot wound, with
a 1.5 cm area of dark drainage noted on the dressing.
B. A 43-year-old patient who underwent a mastectomy two days ago, with 23
ml of serosanguinous fluid in the Jackson-Pratt drain.
C. A 59-year-old patient with a history of a collapsed lung from an accident,
with no drainage noted in the chest tube in the past eight hours.
E. A 54-year-old patient with a total knee replacement two days ago, with
moderate swelling at the surgical site.
E. A 47-year-old patient who had a laparoscopic cholecystectomy yesterday,
complaining of mild pain at the incision site.
F. A 62-year-old patient who had an abdominal-perineal resection three days
ago, now reporting chills.
Correct Answer: F. A 62-year-old patient who had an abdominal-perineal
resection three days ago, now reporting chills.
The client is at risk for peritonitis; should be assessed for further symptoms and
infection.
3. 3. Question
A nurse in a post-surgical unit is monitoring a 46-year-old patient who
underwent a thyroidectomy 12 hours ago for the treatment of Grave’s disease.
Which of the following observations should most concern the nurse?
A. Blood pressure 138/82 mmHg, respirations 16 per minute, oral
temperature 37.2ºC or 99º F.
B. The patient carefully supports their head and neck when turning their head
to the right.
C. The patient expresses difficulty in swallowing but can manage liquids.
D. The patient appears drowsy and complains of a sore throat.
, E. The patient shows involuntary flexion of their wrist when blood pressure is
measured.
F. The patient has a hoarse voice when speaking.
Correct Answer: E. The patient shows involuntary flexion of their wrist when
blood pressure is measured.
Carpal spasms (Trousseau’s sign) indicate hypocalcemia which can occur after
thyroidectomy due to accidental removal or damage to the parathyroid glands.
Hypocalcemia is a serious complication and requires immediate attention. The
other options, while they might warrant monitoring, are not as immediately
concerning as a potential sign of hypocalcemia.
Option A: The vital signs are all within the normal range.
Option B: Supporting the head and neck while turning protects the surgical
site from dehiscence.
Option C: Common side effect of neck surgery.
Option D: Drowsiness may be a side effect of the anesthesia used during
surgery and will fade away eventually; a sore throat is a normal finding after
thyroid surgery.
Option F: Hoarseness of voice is a common side effect of post-op
thyroidectomy due to one or more of the nerves irritated during the procedure
of due to inflammation that occurs after surgery.
4. 4. Question
Category: Physiological Adaptation
A 38-year-old patient is admitted to the emergency department with severe pain
in the lower right quadrant of the abdomen, nausea, and a low-grade fever,
raising concerns about possible appendicitis. The nurse is considering pain relief
strategies. Which of the following actions should the nurse prioritize?
A. Encourage the patient to change positions frequently in bed.
B. Administer Demerol 50 mg IM q 4 hours and PRN, as prescribed.
C. Apply warmth to the abdomen with a heating pad.
D. Use comfort measures and pillows to position the patient comfortably.
E. Administer an antiemetic as prescribed for nausea relief.
