,Advanced Prep NCLEX-RN: Master
Complex Clinical Judgment & Nursing
Prioritization Practice Questions
Subject: NCLEX-RN High-Stakes Clinical Judgment, Pharmacology, and
Prioritization
Question 1: An RN is caring for a client who is 4 hours post-thyroidectomy. The client suddenly
reports "tightness" in the throat and develops a high-pitched, stridorous sound upon inspiration.
Which action by the nurse is the priority?
A) Administer the prescribed PRN analgesic for throat pain.
B) Contact the surgeon immediately to report signs of laryngeal edema.
C) Increase the rate of the IV fluids to improve systemic perfusion.
D) Elevate the head of the bed to 45 degrees and prepare for emergency intubation.
Correct Answer: D) Elevate the head of the bed to 45 degrees and prepare for emergency
intubation.
Explanation: Stridor post-thyroidectomy is an ominous sign of airway obstruction, likely due to
hematoma formation or laryngeal edema. While notifying the surgeon (Option B) is necessary,
the nurse’s immediate priority is to maintain airway patency by positioning and preparing
equipment for emergency airway management. Analgesics (Option A) will not relieve airway
obstruction, and IV fluids (Option C) do nothing to address the mechanical obstruction of the
airway.
Question 2: A client with type 1 diabetes mellitus is prescribed a sliding scale of regular insulin.
The nurse receives an order for 6 units of regular insulin if blood glucose is between 200 and 250
mg/dL. The current reading is 220 mg/dL. Which action by the nurse is most appropriate?
A) Administer the 6 units of insulin and document the dose.
B) Verify the order with the provider, as regular insulin is contraindicated in type 1 diabetes.
C) Administer the insulin and verify the glucose level again in 30 minutes.
D) Assess the client for signs of hyperglycemia before administering the insulin.
Correct Answer: A) Administer the 6 units of insulin and document the dose.
, Explanation: Regular insulin is a short-acting insulin appropriate for sliding scale coverage in
type 1 diabetes. Since the glucose level falls within the specified range (200-250 mg/dL), the
nurse should administer the ordered dose. Assessment (Option D) is standard, but the order is
specific, and the nurse must carry it out based on the blood glucose reading. Option B is
incorrect as regular insulin is standard for this condition.
Question 3: A nurse is caring for a client with heart failure receiving furosemide 40 mg IV push.
Which assessment finding indicates a therapeutic response to the medication?
A) Development of peripheral edema.
B) Decrease in urine output from 50 mL/hour to 20 mL/hour.
C) Presence of S3 heart sounds on auscultation.
D) Reduction in bilateral bibasilar crackles.
Correct Answer: D) Reduction in bilateral bibasilar crackles.
Explanation: Furosemide is a loop diuretic used to reduce fluid volume in heart failure. The
therapeutic effect is evidenced by the clearing of pulmonary congestion, which is manifested as a
reduction in crackles. Peripheral edema (Option A) and S3 heart sounds (Option C) are clinical
indicators of heart failure that should decrease, not increase. Decreased urine output (Option B)
indicates a lack of therapeutic effect or potential renal compromise.
Question 4: A nurse is delegating care to an LPN/LVN. Which task is appropriate for the
LPN/LVN to perform for a client with pneumonia?
A) Developing the initial plan of care for the client.
B) Administering oral and intravenous medications as prescribed.
C) Performing the admission assessment and identifying nursing diagnoses.
D) Evaluating the effectiveness of oxygen therapy titration.
Correct Answer: B) Administering oral and intravenous medications as prescribed.
Explanation: Within many states’ scope of practice, LPNs/LVNs can administer medications.
However, developing the initial care plan, performing admission assessments, and evaluating
clinical interventions (Options A, C, and D) require the advanced education and critical thinking
skills of the RN and cannot be delegated.
Question 5: A client is receiving a blood transfusion and develops flank pain, fever, and dark-
colored urine. What is the nurse's priority?
Complex Clinical Judgment & Nursing
Prioritization Practice Questions
Subject: NCLEX-RN High-Stakes Clinical Judgment, Pharmacology, and
Prioritization
Question 1: An RN is caring for a client who is 4 hours post-thyroidectomy. The client suddenly
reports "tightness" in the throat and develops a high-pitched, stridorous sound upon inspiration.
Which action by the nurse is the priority?
A) Administer the prescribed PRN analgesic for throat pain.
B) Contact the surgeon immediately to report signs of laryngeal edema.
C) Increase the rate of the IV fluids to improve systemic perfusion.
D) Elevate the head of the bed to 45 degrees and prepare for emergency intubation.
Correct Answer: D) Elevate the head of the bed to 45 degrees and prepare for emergency
intubation.
Explanation: Stridor post-thyroidectomy is an ominous sign of airway obstruction, likely due to
hematoma formation or laryngeal edema. While notifying the surgeon (Option B) is necessary,
the nurse’s immediate priority is to maintain airway patency by positioning and preparing
equipment for emergency airway management. Analgesics (Option A) will not relieve airway
obstruction, and IV fluids (Option C) do nothing to address the mechanical obstruction of the
airway.
Question 2: A client with type 1 diabetes mellitus is prescribed a sliding scale of regular insulin.
The nurse receives an order for 6 units of regular insulin if blood glucose is between 200 and 250
mg/dL. The current reading is 220 mg/dL. Which action by the nurse is most appropriate?
A) Administer the 6 units of insulin and document the dose.
B) Verify the order with the provider, as regular insulin is contraindicated in type 1 diabetes.
C) Administer the insulin and verify the glucose level again in 30 minutes.
D) Assess the client for signs of hyperglycemia before administering the insulin.
Correct Answer: A) Administer the 6 units of insulin and document the dose.
, Explanation: Regular insulin is a short-acting insulin appropriate for sliding scale coverage in
type 1 diabetes. Since the glucose level falls within the specified range (200-250 mg/dL), the
nurse should administer the ordered dose. Assessment (Option D) is standard, but the order is
specific, and the nurse must carry it out based on the blood glucose reading. Option B is
incorrect as regular insulin is standard for this condition.
Question 3: A nurse is caring for a client with heart failure receiving furosemide 40 mg IV push.
Which assessment finding indicates a therapeutic response to the medication?
A) Development of peripheral edema.
B) Decrease in urine output from 50 mL/hour to 20 mL/hour.
C) Presence of S3 heart sounds on auscultation.
D) Reduction in bilateral bibasilar crackles.
Correct Answer: D) Reduction in bilateral bibasilar crackles.
Explanation: Furosemide is a loop diuretic used to reduce fluid volume in heart failure. The
therapeutic effect is evidenced by the clearing of pulmonary congestion, which is manifested as a
reduction in crackles. Peripheral edema (Option A) and S3 heart sounds (Option C) are clinical
indicators of heart failure that should decrease, not increase. Decreased urine output (Option B)
indicates a lack of therapeutic effect or potential renal compromise.
Question 4: A nurse is delegating care to an LPN/LVN. Which task is appropriate for the
LPN/LVN to perform for a client with pneumonia?
A) Developing the initial plan of care for the client.
B) Administering oral and intravenous medications as prescribed.
C) Performing the admission assessment and identifying nursing diagnoses.
D) Evaluating the effectiveness of oxygen therapy titration.
Correct Answer: B) Administering oral and intravenous medications as prescribed.
Explanation: Within many states’ scope of practice, LPNs/LVNs can administer medications.
However, developing the initial care plan, performing admission assessments, and evaluating
clinical interventions (Options A, C, and D) require the advanced education and critical thinking
skills of the RN and cannot be delegated.
Question 5: A client is receiving a blood transfusion and develops flank pain, fever, and dark-
colored urine. What is the nurse's priority?
