Nursing 354 Prioritization Practice Exam
Questions And Correct Answers (Verified
Answers) Plus Rationales 2026 Q&A
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Question 1
The nurse receives report on four clients. Which client should the nurse assess
first?
A. A client with osteoarthritis reporting chronic knee pain
B. A client with pneumonia who has a respiratory rate of 32/min and oxygen
saturation of 86%
C. A client with diabetes mellitus whose blood glucose is 180 mg/dL
D. A client awaiting discharge instructions after treatment for hypertension
Answer: B. A client with pneumonia who has a respiratory rate of 32/min and
oxygen saturation of 86%
Rationale: Airway and breathing problems take priority. Tachypnea and
significant hypoxemia indicate impaired oxygenation requiring immediate
assessment and intervention.
Question 2
Which client should the nurse assess first after receiving morning report?
,A. A client with a temperature of 38.1°C (100.6°F) after surgery
B. A client requesting medication for incisional pain rated 6/10
C. A client who suddenly develops difficulty speaking and weakness of the right
arm
D. A client with nausea after receiving an opioid
Answer: C. A client who suddenly develops difficulty speaking and weakness of
the right arm
Rationale: Sudden neurologic deficits suggest an acute stroke. Rapid assessment
and intervention are essential because treatment is time-sensitive.
Question 3
The nurse is caring for four clients. Which finding requires immediate
intervention?
A. Blood pressure of 142/88 mmHg in a client with hypertension
B. Heart rate of 104/min after ambulation
C. Urine output of 20 mL/hr for two consecutive hours
D. Pain rated 5/10 after abdominal surgery
Answer: C. Urine output of 20 mL/hr for two consecutive hours
Rationale: Persistently low urine output may indicate inadequate renal
perfusion, hypovolemia, or another serious complication and requires prompt
assessment.
Question 4
Which client should the nurse see first?
A. A client with a chronic pressure injury requesting repositioning
B. A client with asthma who is wheezing and unable to speak in complete
sentences
,C. A client with constipation for three days
D. A client with controlled hypertension asking about diet
Answer: B. A client with asthma who is wheezing and unable to speak in
complete sentences
Rationale: Severe respiratory distress threatens airway and breathing. Inability
to speak in complete sentences is an important sign of significant respiratory
compromise.
Question 5
A nurse is prioritizing care for four clients. Which client has the highest priority?
A. A client with a potassium level of 3.4 mEq/L
B. A client with a sodium level of 134 mEq/L
C. A client with a potassium level of 6.8 mEq/L and peaked T waves
D. A client with a calcium level of 8.3 mg/dL
Answer: C. A client with a potassium level of 6.8 mEq/L and peaked T waves
Rationale: Severe hyperkalemia with electrocardiographic changes can cause
life-threatening dysrhythmias and requires immediate intervention.
Question 6
Which postoperative client should the nurse assess first?
A. A client reporting incisional pain of 7/10
B. A client with a respiratory rate of 8/min after receiving IV opioid medication
C. A client with a temperature of 37.8°C (100°F)
D. A client who has not passed flatus 12 hours after surgery
Answer: B. A client with a respiratory rate of 8/min after receiving IV opioid
medication
, Rationale: Respiratory depression is a potentially life-threatening opioid adverse
effect. Airway and breathing must be addressed immediately.
Question 7
Which client should the nurse prioritize?
A. A client with chronic heart failure and mild ankle edema
B. A client with heart failure who has pink, frothy sputum and severe dyspnea
C. A client with stable angina relieved by rest
D. A client with hypertension and a headache rated 3/10
Answer: B. A client with heart failure who has pink, frothy sputum and severe
dyspnea
Rationale: Pink, frothy sputum and severe dyspnea are consistent with acute
pulmonary edema, which threatens oxygenation and requires immediate
intervention.
Question 8
The nurse is caring for four clients. Which client should be assessed first?
A. A client with a cast who reports itching
B. A client with a fracture who reports increasing pain and numbness in the
affected extremity
C. A client requesting assistance with bathing
D. A client scheduled for physical therapy
Answer: B. A client with a fracture who reports increasing pain and numbness in
the affected extremity
Rationale: Increasing pain and sensory changes may indicate neurovascular
compromise or compartment syndrome. Immediate assessment is necessary to
prevent permanent injury.
Questions And Correct Answers (Verified
Answers) Plus Rationales 2026 Q&A
Instant Download Pdf
Question 1
The nurse receives report on four clients. Which client should the nurse assess
first?
A. A client with osteoarthritis reporting chronic knee pain
B. A client with pneumonia who has a respiratory rate of 32/min and oxygen
saturation of 86%
C. A client with diabetes mellitus whose blood glucose is 180 mg/dL
D. A client awaiting discharge instructions after treatment for hypertension
Answer: B. A client with pneumonia who has a respiratory rate of 32/min and
oxygen saturation of 86%
Rationale: Airway and breathing problems take priority. Tachypnea and
significant hypoxemia indicate impaired oxygenation requiring immediate
assessment and intervention.
Question 2
Which client should the nurse assess first after receiving morning report?
,A. A client with a temperature of 38.1°C (100.6°F) after surgery
B. A client requesting medication for incisional pain rated 6/10
C. A client who suddenly develops difficulty speaking and weakness of the right
arm
D. A client with nausea after receiving an opioid
Answer: C. A client who suddenly develops difficulty speaking and weakness of
the right arm
Rationale: Sudden neurologic deficits suggest an acute stroke. Rapid assessment
and intervention are essential because treatment is time-sensitive.
Question 3
The nurse is caring for four clients. Which finding requires immediate
intervention?
A. Blood pressure of 142/88 mmHg in a client with hypertension
B. Heart rate of 104/min after ambulation
C. Urine output of 20 mL/hr for two consecutive hours
D. Pain rated 5/10 after abdominal surgery
Answer: C. Urine output of 20 mL/hr for two consecutive hours
Rationale: Persistently low urine output may indicate inadequate renal
perfusion, hypovolemia, or another serious complication and requires prompt
assessment.
Question 4
Which client should the nurse see first?
A. A client with a chronic pressure injury requesting repositioning
B. A client with asthma who is wheezing and unable to speak in complete
sentences
,C. A client with constipation for three days
D. A client with controlled hypertension asking about diet
Answer: B. A client with asthma who is wheezing and unable to speak in
complete sentences
Rationale: Severe respiratory distress threatens airway and breathing. Inability
to speak in complete sentences is an important sign of significant respiratory
compromise.
Question 5
A nurse is prioritizing care for four clients. Which client has the highest priority?
A. A client with a potassium level of 3.4 mEq/L
B. A client with a sodium level of 134 mEq/L
C. A client with a potassium level of 6.8 mEq/L and peaked T waves
D. A client with a calcium level of 8.3 mg/dL
Answer: C. A client with a potassium level of 6.8 mEq/L and peaked T waves
Rationale: Severe hyperkalemia with electrocardiographic changes can cause
life-threatening dysrhythmias and requires immediate intervention.
Question 6
Which postoperative client should the nurse assess first?
A. A client reporting incisional pain of 7/10
B. A client with a respiratory rate of 8/min after receiving IV opioid medication
C. A client with a temperature of 37.8°C (100°F)
D. A client who has not passed flatus 12 hours after surgery
Answer: B. A client with a respiratory rate of 8/min after receiving IV opioid
medication
, Rationale: Respiratory depression is a potentially life-threatening opioid adverse
effect. Airway and breathing must be addressed immediately.
Question 7
Which client should the nurse prioritize?
A. A client with chronic heart failure and mild ankle edema
B. A client with heart failure who has pink, frothy sputum and severe dyspnea
C. A client with stable angina relieved by rest
D. A client with hypertension and a headache rated 3/10
Answer: B. A client with heart failure who has pink, frothy sputum and severe
dyspnea
Rationale: Pink, frothy sputum and severe dyspnea are consistent with acute
pulmonary edema, which threatens oxygenation and requires immediate
intervention.
Question 8
The nurse is caring for four clients. Which client should be assessed first?
A. A client with a cast who reports itching
B. A client with a fracture who reports increasing pain and numbness in the
affected extremity
C. A client requesting assistance with bathing
D. A client scheduled for physical therapy
Answer: B. A client with a fracture who reports increasing pain and numbness in
the affected extremity
Rationale: Increasing pain and sensory changes may indicate neurovascular
compromise or compartment syndrome. Immediate assessment is necessary to
prevent permanent injury.
