NCLEX RN Prioritization Exam Questions
And Correct Answers (Verified Answers)
Plus Rationales 2026 Q&A | Instant
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1. A client admitted 2 hours ago with acute asthma exacerbation suddenly
develops absent breath sounds over the right lung, tracheal deviation to the
left, and severe dyspnea. Which action should the nurse take first?
A. Administer a nebulized bronchodilator immediately.
B. Prepare for immediate needle decompression.
C. Obtain a stat portable chest x-ray.
D. Increase the oxygen flow rate to 15 L/min via nonrebreather mask.
Rationale: The sudden loss of breath sounds, tracheal deviation, and severe
dyspnea indicate a tension pneumothorax, a life-threatening complication
requiring immediate decompression to relieve pressure on the heart and
great vessels. Airway and breathing are the highest priorities; needle
decompression restores ventilation and cardiac output. Delaying this
intervention for medications, imaging, or oxygen alone risks cardiac arrest.
2. The emergency department nurse receives report on four clients. Which
client should be assessed first?
A. A 28-year-old with a fractured tibia and a palpable pedal pulse, rating pain
7/10.
B. A 55-year-old with a history of cirrhosis who is vomiting coffee-ground
emesis and has a heart rate of 110 bpm.
C. A 70-year-old with pneumonia, oxygen saturation 91% on 2 L oxygen,
respiratory rate 24/min.
D. A 42-year-old who sustained a bee sting 15 minutes ago, with stridor and
swelling of the lips and tongue.
Rationale: Stridor, lip and tongue swelling indicate anaphylaxis with airway
, compromise, which is the highest priority per the ABC (airway, breathing,
circulation) framework. The airway must be secured immediately. The
cirrhosis client has a potential GI bleed and is tachycardic (circulation
concern), but airway takes precedence. Pneumonia patient has mild hypoxia
that can be addressed next; the fracture is a pain issue and least urgent.
3. The nurse is caring for four clients on a medical-surgical unit. Which client
should the nurse see first?
A. A client with heart failure who has 2+ pitting edema and crackles in the
bases after ambulating to the bathroom.
B. A client with diabetes mellitus whose blood glucose at 11:00 AM is 65
mg/dL and who is diaphoretic.
C. A client who had a total thyroidectomy 6 hours ago and reports difficulty
swallowing and a feeling of pressure in the neck.
D. A client with chronic obstructive pulmonary disease who is using pursed-
lip breathing and has an oxygen saturation of 90%.
Rationale: Post-thyroidectomy difficulty swallowing and neck pressure
suggest a hematoma formation causing tracheal compression, a potential
airway emergency. Airway patency is the top priority. The hypoglycemic
client (B) is urgent but breathing is intact; the heart failure client has lung
sounds that need assessment but not an immediate airway threat; COPD
patient is stable with expected saturation.
4. An unlicensed assistive personnel (UAP) reports that a client’s blood
pressure is 88/52 mmHg, heart rate 118 bpm, and the client is pale and
clammy. The client had an abdominal surgery 8 hours ago. What should the
nurse do first?
A. Delegate the UAP to recheck vital signs in 15 minutes.
B. Assess the client’s surgical incision and abdomen.
C. Notify the health care provider immediately.
D. Place the client in Trendelenburg position.
Rationale: The nurse must first assess the client for the source of hypovolemic
shock, likely hemorrhage. Postoperative hypotension and tachycardia
indicate possible internal bleeding. Assessing the surgical site and abdomen
, (B) is the first step of the nursing process and provides data before notifying
the provider. Delegating reassessment delays intervention, and positioning
alone does not identify cause.
5. The charge nurse is making assignments for the upcoming shift. Which client
should be assigned to the most experienced registered nurse (RN)?
A. A client with pneumonia receiving intravenous antibiotics via a peripheral
line.
B. A client with a new diagnosis of type 2 diabetes who needs teaching about
insulin self-administration.
C. A client with a traumatic brain injury who has intracranial pressure (ICP)
monitoring in place and a Glasgow Coma Scale score of 8.
D. A client with chronic hypertension whose blood pressure has been stable
on oral medications.
Rationale: A client with traumatic brain injury, ICP monitoring, and a GCS of 8
requires complex neurological assessments, management of increased ICP,
and potential airway compromise. This patient is unstable and requires the
expertise of the most experienced RN. The other clients are stable or have
straightforward needs that can be managed by a less experienced nurse.
6. The nurse is triaging victims of a mass casualty incident in the emergency
department. Which client should be treated first?
A. A client with a sucking chest wound and respiratory rate of 36/min who is
able to walk.
B. A client with a penetrating abdominal wound, heart rate 128 bpm,
capillary refill 5 seconds, and who moans to pain.
C. A client with an open fracture of the femur, palpable pulse, and severe
pain.
D. A client with full-thickness burns to 40% of the body, hoarse voice, and
carbonaceous sputum.
Rationale: The client with penetrating abdominal wound and signs of shock
(tachycardia, delayed capillary refill) has a life-threatening condition that is
salvageable with immediate intervention (Class I, Red tag in START triage).
The client with a sucking chest wound and tachypnea can walk (delayed,
, Yellow tag). The burn victim with airway involvement (hoarseness,
carbonaceous sputum) is critical; however, in mass casualty, this victim might
be considered expectant depending on resources. The question indicates
triage prioritization; the abdominal injury with shock is the highest priority
for immediate treatment to prevent death.
7. The nurse is evaluating a client 30 minutes after a cardiac catheterization via
the femoral artery. The client reports sudden severe back pain and
numbness in the right leg. Which action should the nurse take first?
A. Medicate the client for pain as ordered.
B. Assess the femoral puncture site and distal pulses.
C. Notify the health care provider.
D. Apply a warm compress to the back.
Rationale: Sudden back pain with leg numbness after femoral catheterization
suggests retroperitoneal bleeding with nerve compression or arterial
occlusion. Immediate assessment of the insertion site and peripheral vascular
status (pulses, color, temperature) is essential to detect hemorrhage or
hematoma. This assessment data must be gathered before notifying the
provider. Medication may mask symptoms.
8. The home health nurse is visiting four clients. Which client should be seen
first?
A. A client with COPD whose home oxygen concentrator is set at 3 L/min,
SpO2 93%.
B. A client with type 1 diabetes who has a fasting blood glucose of 140
mg/dL.
C. A client with congestive heart failure who reports a 4-pound weight gain
overnight and increased dyspnea.
D. A client with a stage 2 pressure ulcer on the sacrum that is being treated
with a hydrocolloid dressing.
Rationale: A 4-pound weight gain overnight and increased dyspnea indicate
acute decompensated heart failure, which can rapidly progress to respiratory
failure. This client needs immediate assessment and intervention
(airway/breathing priority). The COPD client is stable with an acceptable
And Correct Answers (Verified Answers)
Plus Rationales 2026 Q&A | Instant
Download Pdf
1. A client admitted 2 hours ago with acute asthma exacerbation suddenly
develops absent breath sounds over the right lung, tracheal deviation to the
left, and severe dyspnea. Which action should the nurse take first?
A. Administer a nebulized bronchodilator immediately.
B. Prepare for immediate needle decompression.
C. Obtain a stat portable chest x-ray.
D. Increase the oxygen flow rate to 15 L/min via nonrebreather mask.
Rationale: The sudden loss of breath sounds, tracheal deviation, and severe
dyspnea indicate a tension pneumothorax, a life-threatening complication
requiring immediate decompression to relieve pressure on the heart and
great vessels. Airway and breathing are the highest priorities; needle
decompression restores ventilation and cardiac output. Delaying this
intervention for medications, imaging, or oxygen alone risks cardiac arrest.
2. The emergency department nurse receives report on four clients. Which
client should be assessed first?
A. A 28-year-old with a fractured tibia and a palpable pedal pulse, rating pain
7/10.
B. A 55-year-old with a history of cirrhosis who is vomiting coffee-ground
emesis and has a heart rate of 110 bpm.
C. A 70-year-old with pneumonia, oxygen saturation 91% on 2 L oxygen,
respiratory rate 24/min.
D. A 42-year-old who sustained a bee sting 15 minutes ago, with stridor and
swelling of the lips and tongue.
Rationale: Stridor, lip and tongue swelling indicate anaphylaxis with airway
, compromise, which is the highest priority per the ABC (airway, breathing,
circulation) framework. The airway must be secured immediately. The
cirrhosis client has a potential GI bleed and is tachycardic (circulation
concern), but airway takes precedence. Pneumonia patient has mild hypoxia
that can be addressed next; the fracture is a pain issue and least urgent.
3. The nurse is caring for four clients on a medical-surgical unit. Which client
should the nurse see first?
A. A client with heart failure who has 2+ pitting edema and crackles in the
bases after ambulating to the bathroom.
B. A client with diabetes mellitus whose blood glucose at 11:00 AM is 65
mg/dL and who is diaphoretic.
C. A client who had a total thyroidectomy 6 hours ago and reports difficulty
swallowing and a feeling of pressure in the neck.
D. A client with chronic obstructive pulmonary disease who is using pursed-
lip breathing and has an oxygen saturation of 90%.
Rationale: Post-thyroidectomy difficulty swallowing and neck pressure
suggest a hematoma formation causing tracheal compression, a potential
airway emergency. Airway patency is the top priority. The hypoglycemic
client (B) is urgent but breathing is intact; the heart failure client has lung
sounds that need assessment but not an immediate airway threat; COPD
patient is stable with expected saturation.
4. An unlicensed assistive personnel (UAP) reports that a client’s blood
pressure is 88/52 mmHg, heart rate 118 bpm, and the client is pale and
clammy. The client had an abdominal surgery 8 hours ago. What should the
nurse do first?
A. Delegate the UAP to recheck vital signs in 15 minutes.
B. Assess the client’s surgical incision and abdomen.
C. Notify the health care provider immediately.
D. Place the client in Trendelenburg position.
Rationale: The nurse must first assess the client for the source of hypovolemic
shock, likely hemorrhage. Postoperative hypotension and tachycardia
indicate possible internal bleeding. Assessing the surgical site and abdomen
, (B) is the first step of the nursing process and provides data before notifying
the provider. Delegating reassessment delays intervention, and positioning
alone does not identify cause.
5. The charge nurse is making assignments for the upcoming shift. Which client
should be assigned to the most experienced registered nurse (RN)?
A. A client with pneumonia receiving intravenous antibiotics via a peripheral
line.
B. A client with a new diagnosis of type 2 diabetes who needs teaching about
insulin self-administration.
C. A client with a traumatic brain injury who has intracranial pressure (ICP)
monitoring in place and a Glasgow Coma Scale score of 8.
D. A client with chronic hypertension whose blood pressure has been stable
on oral medications.
Rationale: A client with traumatic brain injury, ICP monitoring, and a GCS of 8
requires complex neurological assessments, management of increased ICP,
and potential airway compromise. This patient is unstable and requires the
expertise of the most experienced RN. The other clients are stable or have
straightforward needs that can be managed by a less experienced nurse.
6. The nurse is triaging victims of a mass casualty incident in the emergency
department. Which client should be treated first?
A. A client with a sucking chest wound and respiratory rate of 36/min who is
able to walk.
B. A client with a penetrating abdominal wound, heart rate 128 bpm,
capillary refill 5 seconds, and who moans to pain.
C. A client with an open fracture of the femur, palpable pulse, and severe
pain.
D. A client with full-thickness burns to 40% of the body, hoarse voice, and
carbonaceous sputum.
Rationale: The client with penetrating abdominal wound and signs of shock
(tachycardia, delayed capillary refill) has a life-threatening condition that is
salvageable with immediate intervention (Class I, Red tag in START triage).
The client with a sucking chest wound and tachypnea can walk (delayed,
, Yellow tag). The burn victim with airway involvement (hoarseness,
carbonaceous sputum) is critical; however, in mass casualty, this victim might
be considered expectant depending on resources. The question indicates
triage prioritization; the abdominal injury with shock is the highest priority
for immediate treatment to prevent death.
7. The nurse is evaluating a client 30 minutes after a cardiac catheterization via
the femoral artery. The client reports sudden severe back pain and
numbness in the right leg. Which action should the nurse take first?
A. Medicate the client for pain as ordered.
B. Assess the femoral puncture site and distal pulses.
C. Notify the health care provider.
D. Apply a warm compress to the back.
Rationale: Sudden back pain with leg numbness after femoral catheterization
suggests retroperitoneal bleeding with nerve compression or arterial
occlusion. Immediate assessment of the insertion site and peripheral vascular
status (pulses, color, temperature) is essential to detect hemorrhage or
hematoma. This assessment data must be gathered before notifying the
provider. Medication may mask symptoms.
8. The home health nurse is visiting four clients. Which client should be seen
first?
A. A client with COPD whose home oxygen concentrator is set at 3 L/min,
SpO2 93%.
B. A client with type 1 diabetes who has a fasting blood glucose of 140
mg/dL.
C. A client with congestive heart failure who reports a 4-pound weight gain
overnight and increased dyspnea.
D. A client with a stage 2 pressure ulcer on the sacrum that is being treated
with a hydrocolloid dressing.
Rationale: A 4-pound weight gain overnight and increased dyspnea indicate
acute decompensated heart failure, which can rapidly progress to respiratory
failure. This client needs immediate assessment and intervention
(airway/breathing priority). The COPD client is stable with an acceptable
