,NCLEX-RN Ultimate Practice Exams
Series 1
Practice Exam 4
Advanced Prioritization & Clinical Judgment Exam
Topics Covered
Advanced Medical-Surgical Nursing
High-Level NCLEX Clinical Judgment
Prioritization & Delegation
Emergency & Trauma Nursing
Septic, Cardiogenic, Hemorrhagic, and Obstructive Shock
Advanced Respiratory Failure & Mechanical Ventilation
ARDS & ECMO
Neurological Emergencies & Increased Intracranial Pressure
Endocrine Emergencies (DKA, HHS, Adrenal Crisis)
Electrolyte Disorders & Cardiac Conduction Abnormalities
Oncology Emergencies (Tumor Lysis Syndrome, Febrile Neutropenia)
Organ Transplant Complications
Postoperative Critical Care
Massive Transfusion & Coagulopathies
Renal Replacement Therapy
Pharmacology & High-Alert Medications
Advanced ICU Nursing Concepts
Evidence-Based Critical Care Decision-Making
Question 1
A nurse is caring for four clients in the emergency department. Which client should the nurse assess first?
A. A client with acute cystitis reporting burning during urination
B. A client with pneumonia who is confused and has oxygen saturation of 84%
C. A client with migraine headache reporting photophobia
D. A client with stable angina whose chest pain resolved after nitroglycerin
Correct Answer: B. A client with pneumonia who is confused and has oxygen saturation of 84%
Rationale: Confusion with oxygen saturation of 84% indicates severe hypoxemia and possible respiratory
failure or sepsis-related deterioration. This client has an immediate airway and breathing problem and must be
,assessed first. Acute confusion is especially concerning because it may reflect reduced cerebral oxygen
delivery.*
Why Not the Other Options?
A. Dysuria is uncomfortable but not immediately life-threatening.
C. Migraine symptoms are painful but usually not emergent.
D. Resolved stable angina is less urgent than active hypoxemia.
Clinical Pearl: New confusion in infection often signals hypoxia, sepsis, or poor perfusion.
NCLEX Strategy: Prioritize unstable ABC findings over pain or teaching needs.
Learning Objective: Identify the highest-priority client using oxygenation and mental status cues.
Difficulty: ⭐⭐⭐⭐⭐
Question 2
A nurse is caring for a client with a suspected ruptured spleen after blunt abdominal trauma. Which finding is
most concerning?
A. Left upper quadrant tenderness
B. Referred pain to the left shoulder
C. Blood pressure 78/46 mmHg with cool clammy skin
D. Heart rate 104 beats/minute
Correct Answer: C. Blood pressure 78/46 mmHg with cool clammy skin
Rationale: Severe hypotension with cool clammy skin indicates hemorrhagic shock from internal bleeding. A
ruptured spleen can cause rapid blood loss into the abdominal cavity. Immediate intervention focuses on airway
support, oxygen, large-bore IV access, blood product preparation, and rapid surgical evaluation.*
Why Not the Other Options?
A. Tenderness supports the diagnosis but is not the most urgent sign.
B. Left shoulder pain may occur from diaphragmatic irritation but is less urgent than shock.
D. Tachycardia is concerning but less severe than hypotension with poor perfusion.
Clinical Pearl: Trauma plus hypotension should be treated as internal bleeding until proven otherwise.
NCLEX Strategy: In trauma, circulation-threatening findings take priority.
Learning Objective: Recognize hemorrhagic shock after abdominal trauma.
Difficulty: ⭐⭐⭐⭐⭐
Question 3
A client receiving IV phenytoin reports burning at the IV site. The nurse observes purple discoloration and
swelling of the hand distal to the catheter. What is the nurse’s priority action?
, A. Slow the infusion and reassess in 15 minutes
B. Stop the infusion immediately and assess circulation to the extremity
C. Flush the IV line with normal saline
D. Elevate the hand and continue the infusion
Correct Answer: B. Stop the infusion immediately and assess circulation to the extremity
Rationale: Purple discoloration, swelling, and burning during IV phenytoin administration suggest purple glove
syndrome or serious local tissue injury. The infusion should be stopped immediately, and neurovascular status
should be assessed. Continuing or flushing the line may worsen tissue injury.*
Why Not the Other Options?
A. Slowing the infusion still exposes tissue to the medication.
C. Flushing may push more medication into compromised tissue.
D. Elevation alone does not stop the injury.
Clinical Pearl: IV phenytoin requires careful monitoring because extravasation can cause severe tissue damage.
NCLEX Strategy: Stop irritating or vesicant infusions when local tissue injury appears.
Learning Objective: Manage complications of high-risk IV medication administration.
Difficulty: ⭐⭐⭐⭐⭐
Question 4
A nurse is caring for a client with acute adrenal crisis. Which assessment finding supports this diagnosis?
A. Hypertension, hypernatremia, and hyperglycemia
B. Hypotension, hyponatremia, hyperkalemia, and hypoglycemia
C. Bradycardia, hypocalcemia, and polyuria
D. Severe hypertension, tremors, and heat intolerance
Correct Answer: B. Hypotension, hyponatremia, hyperkalemia, and hypoglycemia
Rationale: Acute adrenal crisis results from severe cortisol and aldosterone deficiency. Clients develop
hypotension from volume depletion, hyponatremia from sodium loss, hyperkalemia from reduced aldosterone
activity, and hypoglycemia from cortisol deficiency. Treatment requires IV hydrocortisone and isotonic fluids.*
Why Not the Other Options?
A. These findings are more consistent with excess corticosteroid activity.
C. Hypocalcemia and polyuria do not define adrenal crisis.
D. Heat intolerance and tremors suggest thyroid storm.
Clinical Pearl: Addisonian crisis is a shock state treated with steroids and saline.
NCLEX Strategy: Match endocrine emergencies with their characteristic electrolyte patterns.
Learning Objective: Recognize adrenal crisis manifestations.
Series 1
Practice Exam 4
Advanced Prioritization & Clinical Judgment Exam
Topics Covered
Advanced Medical-Surgical Nursing
High-Level NCLEX Clinical Judgment
Prioritization & Delegation
Emergency & Trauma Nursing
Septic, Cardiogenic, Hemorrhagic, and Obstructive Shock
Advanced Respiratory Failure & Mechanical Ventilation
ARDS & ECMO
Neurological Emergencies & Increased Intracranial Pressure
Endocrine Emergencies (DKA, HHS, Adrenal Crisis)
Electrolyte Disorders & Cardiac Conduction Abnormalities
Oncology Emergencies (Tumor Lysis Syndrome, Febrile Neutropenia)
Organ Transplant Complications
Postoperative Critical Care
Massive Transfusion & Coagulopathies
Renal Replacement Therapy
Pharmacology & High-Alert Medications
Advanced ICU Nursing Concepts
Evidence-Based Critical Care Decision-Making
Question 1
A nurse is caring for four clients in the emergency department. Which client should the nurse assess first?
A. A client with acute cystitis reporting burning during urination
B. A client with pneumonia who is confused and has oxygen saturation of 84%
C. A client with migraine headache reporting photophobia
D. A client with stable angina whose chest pain resolved after nitroglycerin
Correct Answer: B. A client with pneumonia who is confused and has oxygen saturation of 84%
Rationale: Confusion with oxygen saturation of 84% indicates severe hypoxemia and possible respiratory
failure or sepsis-related deterioration. This client has an immediate airway and breathing problem and must be
,assessed first. Acute confusion is especially concerning because it may reflect reduced cerebral oxygen
delivery.*
Why Not the Other Options?
A. Dysuria is uncomfortable but not immediately life-threatening.
C. Migraine symptoms are painful but usually not emergent.
D. Resolved stable angina is less urgent than active hypoxemia.
Clinical Pearl: New confusion in infection often signals hypoxia, sepsis, or poor perfusion.
NCLEX Strategy: Prioritize unstable ABC findings over pain or teaching needs.
Learning Objective: Identify the highest-priority client using oxygenation and mental status cues.
Difficulty: ⭐⭐⭐⭐⭐
Question 2
A nurse is caring for a client with a suspected ruptured spleen after blunt abdominal trauma. Which finding is
most concerning?
A. Left upper quadrant tenderness
B. Referred pain to the left shoulder
C. Blood pressure 78/46 mmHg with cool clammy skin
D. Heart rate 104 beats/minute
Correct Answer: C. Blood pressure 78/46 mmHg with cool clammy skin
Rationale: Severe hypotension with cool clammy skin indicates hemorrhagic shock from internal bleeding. A
ruptured spleen can cause rapid blood loss into the abdominal cavity. Immediate intervention focuses on airway
support, oxygen, large-bore IV access, blood product preparation, and rapid surgical evaluation.*
Why Not the Other Options?
A. Tenderness supports the diagnosis but is not the most urgent sign.
B. Left shoulder pain may occur from diaphragmatic irritation but is less urgent than shock.
D. Tachycardia is concerning but less severe than hypotension with poor perfusion.
Clinical Pearl: Trauma plus hypotension should be treated as internal bleeding until proven otherwise.
NCLEX Strategy: In trauma, circulation-threatening findings take priority.
Learning Objective: Recognize hemorrhagic shock after abdominal trauma.
Difficulty: ⭐⭐⭐⭐⭐
Question 3
A client receiving IV phenytoin reports burning at the IV site. The nurse observes purple discoloration and
swelling of the hand distal to the catheter. What is the nurse’s priority action?
, A. Slow the infusion and reassess in 15 minutes
B. Stop the infusion immediately and assess circulation to the extremity
C. Flush the IV line with normal saline
D. Elevate the hand and continue the infusion
Correct Answer: B. Stop the infusion immediately and assess circulation to the extremity
Rationale: Purple discoloration, swelling, and burning during IV phenytoin administration suggest purple glove
syndrome or serious local tissue injury. The infusion should be stopped immediately, and neurovascular status
should be assessed. Continuing or flushing the line may worsen tissue injury.*
Why Not the Other Options?
A. Slowing the infusion still exposes tissue to the medication.
C. Flushing may push more medication into compromised tissue.
D. Elevation alone does not stop the injury.
Clinical Pearl: IV phenytoin requires careful monitoring because extravasation can cause severe tissue damage.
NCLEX Strategy: Stop irritating or vesicant infusions when local tissue injury appears.
Learning Objective: Manage complications of high-risk IV medication administration.
Difficulty: ⭐⭐⭐⭐⭐
Question 4
A nurse is caring for a client with acute adrenal crisis. Which assessment finding supports this diagnosis?
A. Hypertension, hypernatremia, and hyperglycemia
B. Hypotension, hyponatremia, hyperkalemia, and hypoglycemia
C. Bradycardia, hypocalcemia, and polyuria
D. Severe hypertension, tremors, and heat intolerance
Correct Answer: B. Hypotension, hyponatremia, hyperkalemia, and hypoglycemia
Rationale: Acute adrenal crisis results from severe cortisol and aldosterone deficiency. Clients develop
hypotension from volume depletion, hyponatremia from sodium loss, hyperkalemia from reduced aldosterone
activity, and hypoglycemia from cortisol deficiency. Treatment requires IV hydrocortisone and isotonic fluids.*
Why Not the Other Options?
A. These findings are more consistent with excess corticosteroid activity.
C. Hypocalcemia and polyuria do not define adrenal crisis.
D. Heat intolerance and tremors suggest thyroid storm.
Clinical Pearl: Addisonian crisis is a shock state treated with steroids and saline.
NCLEX Strategy: Match endocrine emergencies with their characteristic electrolyte patterns.
Learning Objective: Recognize adrenal crisis manifestations.
