Prioritization, Delegation, and Assignment: Practice Exercises
for the NCLEX Examination, 4th Edition
Comprehensive Exam Bank: 210 Questions with Multiple Answers and
Detailed Rationales
Question 1
You are the charge nurse on a busy medical-surgical unit. A client with chronic pain reports to
you that the nurses have not been responding to requests for pain medication. What is your
initial action?
1. Check the medication administration records (MARs) for the past several days.
2. Ask the nurse educator to provide in-service training about pain management.
3. Perform a complete pain assessment on the client and take a pain history.
4. Have a conference with the nurses responsible for the care of this client.
Answer: 4
Rationale: As charge nurse, you must first assess the performance and attitude of the staff in
relation to this client. After data are gathered from the nurses, additional information can be
obtained from the records and the client as necessary. The educator may be of assistance if a
knowledge deficit or need for performance improvement is identified. This approach follows the
prioritization framework of addressing the team's performance before intervening directly with
the client when the concern involves staff behavior.
Question 2
A nurse is caring for four clients on a medical-surgical unit. Which client should the nurse assess
first?
1. A 68-year-old client who is 2 days post-operative after hip replacement surgery and
reports pain of 5/10.
2. A 72-year-old client with diabetes who has a blood glucose level of 180 mg/dL.
, 3. A 55-year-old client who had a cholecystectomy 1 day ago and has a temperature of
99.2°F (37.3°C).
4. A 45-year-old client with asthma who has an oxygen saturation of 89% on room air.
Answer: 4
Rationale: The client with an oxygen saturation of 89% is experiencing hypoxia, which is a life-
threatening condition requiring immediate intervention. According to the ABCs (Airway,
Breathing, Circulation), oxygenation takes priority over pain management, glucose control, or
low-grade fever. The other clients have stable findings that can be addressed after the hypoxic
client is stabilized.
Question 3
Which task can be safely delegated to an unlicensed assistive personnel (UAP) by the registered
nurse?
1. Administering oral medications to a stable client.
2. Assessing a client's post-operative wound.
3. Assisting a client with ambulation using a gait belt.
4. Evaluating the effectiveness of pain medication.
Answer: 3
Rationale: Assisting a client with ambulation using a gait belt is a routine, non-invasive task that
falls within the scope of practice for UAPs. Administering medications, performing assessments,
and evaluating client responses to interventions are nursing tasks that require clinical judgment
and cannot be delegated to UAPs. The RN retains accountability for delegation and must ensure
the UAP is competent to perform the assigned task.
Question 4
The nurse manager is making patient assignments for the shift. Which client should be assigned
to the most experienced registered nurse?
1. A client who is 1 day post-operative after an uncomplicated appendectomy.
2. A client who is receiving chemotherapy for breast cancer with no active complications.
3. A client who is 12 hours post-operative after a coronary artery bypass graft (CABG) with
unstable vital signs.
4. A client who requires teaching about newly diagnosed diabetes mellitus.
,Answer: 3
Rationale: The client who is 12 hours post-CABG with unstable vital signs is the most unstable
and requires the highest level of clinical judgment and assessment skills. This client should be
assigned to the most experienced RN who can rapidly detect subtle changes in condition and
initiate appropriate interventions. The other clients are more stable and can be assigned to less
experienced nurses or other team members.
Question 5
A client with heart failure is receiving furosemide (Lasix) 40 mg IV push. Which finding requires
the nurse to stop the infusion and notify the healthcare provider?
1. Urine output of 200 mL in the past 2 hours.
2. Serum potassium level of 3.8 mEq/L.
3. Blood pressure of 110/70 mm Hg.
4. Tinnitus and hearing loss.
Answer: 4
Rationale: Tinnitus and hearing loss are signs of ototoxicity, which is an adverse effect of loop
diuretics such as furosemide. This finding requires immediate discontinuation of the medication
and notification of the healthcare provider. The other findings are either expected (increased
urine output) or within acceptable parameters (potassium of 3.8 mEq/L, blood pressure of
110/70 mm Hg) and do not require stopping the medication.
Question 6
The nurse is prioritizing care for four clients. Which client should be seen first?
1. A client with pneumonia who has a respiratory rate of 28 breaths/min and an oxygen
saturation of 91%.
2. A client with diabetes who has a blood glucose level of 60 mg/dL and is diaphoretic.
3. A client with heart failure who has 2+ pitting edema in the lower extremities.
4. A client with a urinary tract infection who has a temperature of 100.4°F (38°C).
Answer: 2
Rationale: The client with a blood glucose of 60 mg/dL and diaphoresis is experiencing
hypoglycemia, which can rapidly progress to unconsciousness, seizures, or death if not treated
immediately. While the client with pneumonia has respiratory compromise, the oxygen
, saturation of 91% is not as immediately life-threatening as severe hypoglycemia. The other
clients have stable findings that can be addressed after the hypoglycemic client is stabilized.
Question 7
Which nursing action demonstrates appropriate delegation to a licensed practical/vocational
nurse (LPN/LVN)?
1. Performing the initial admission assessment on a newly admitted client.
2. Administering oral medications to stable clients on the unit.
3. Developing the plan of care for a client with complex needs.
4. Evaluating the outcomes of nursing interventions.
Answer: 2
Rationale: Administering oral medications to stable clients is within the scope of practice for
LPN/LVNs. Initial admission assessments, development of the plan of care, and evaluation of
outcomes are nursing actions that require the education and clinical judgment of the RN. The
RN retains accountability for the overall care of the client and must provide appropriate
supervision of the LPN/LVN.
Question 8
A client is brought to the emergency department with chest pain and shortness of breath. The
client's electrocardiogram (ECG) shows ST-segment elevation. What is the priority nursing
action?
1. Administer sublingual nitroglycerin as prescribed.
2. Obtain a detailed history of the chest pain.
3. Prepare the client for immediate transfer to the cardiac catheterization lab.
4. Draw blood for cardiac enzyme levels.
Answer: 3
Rationale: ST-segment elevation on ECG indicates an acute myocardial infarction (STEMI)
requiring immediate reperfusion therapy. The priority action is to prepare the client for transfer
to the cardiac catheterization lab for percutaneous coronary intervention (PCI). While
administering nitroglycerin, obtaining a history, and drawing cardiac enzymes are all important
actions, they should not delay the time-critical intervention of reperfusion therapy. "Time is
muscle" in STEMI management.
for the NCLEX Examination, 4th Edition
Comprehensive Exam Bank: 210 Questions with Multiple Answers and
Detailed Rationales
Question 1
You are the charge nurse on a busy medical-surgical unit. A client with chronic pain reports to
you that the nurses have not been responding to requests for pain medication. What is your
initial action?
1. Check the medication administration records (MARs) for the past several days.
2. Ask the nurse educator to provide in-service training about pain management.
3. Perform a complete pain assessment on the client and take a pain history.
4. Have a conference with the nurses responsible for the care of this client.
Answer: 4
Rationale: As charge nurse, you must first assess the performance and attitude of the staff in
relation to this client. After data are gathered from the nurses, additional information can be
obtained from the records and the client as necessary. The educator may be of assistance if a
knowledge deficit or need for performance improvement is identified. This approach follows the
prioritization framework of addressing the team's performance before intervening directly with
the client when the concern involves staff behavior.
Question 2
A nurse is caring for four clients on a medical-surgical unit. Which client should the nurse assess
first?
1. A 68-year-old client who is 2 days post-operative after hip replacement surgery and
reports pain of 5/10.
2. A 72-year-old client with diabetes who has a blood glucose level of 180 mg/dL.
, 3. A 55-year-old client who had a cholecystectomy 1 day ago and has a temperature of
99.2°F (37.3°C).
4. A 45-year-old client with asthma who has an oxygen saturation of 89% on room air.
Answer: 4
Rationale: The client with an oxygen saturation of 89% is experiencing hypoxia, which is a life-
threatening condition requiring immediate intervention. According to the ABCs (Airway,
Breathing, Circulation), oxygenation takes priority over pain management, glucose control, or
low-grade fever. The other clients have stable findings that can be addressed after the hypoxic
client is stabilized.
Question 3
Which task can be safely delegated to an unlicensed assistive personnel (UAP) by the registered
nurse?
1. Administering oral medications to a stable client.
2. Assessing a client's post-operative wound.
3. Assisting a client with ambulation using a gait belt.
4. Evaluating the effectiveness of pain medication.
Answer: 3
Rationale: Assisting a client with ambulation using a gait belt is a routine, non-invasive task that
falls within the scope of practice for UAPs. Administering medications, performing assessments,
and evaluating client responses to interventions are nursing tasks that require clinical judgment
and cannot be delegated to UAPs. The RN retains accountability for delegation and must ensure
the UAP is competent to perform the assigned task.
Question 4
The nurse manager is making patient assignments for the shift. Which client should be assigned
to the most experienced registered nurse?
1. A client who is 1 day post-operative after an uncomplicated appendectomy.
2. A client who is receiving chemotherapy for breast cancer with no active complications.
3. A client who is 12 hours post-operative after a coronary artery bypass graft (CABG) with
unstable vital signs.
4. A client who requires teaching about newly diagnosed diabetes mellitus.
,Answer: 3
Rationale: The client who is 12 hours post-CABG with unstable vital signs is the most unstable
and requires the highest level of clinical judgment and assessment skills. This client should be
assigned to the most experienced RN who can rapidly detect subtle changes in condition and
initiate appropriate interventions. The other clients are more stable and can be assigned to less
experienced nurses or other team members.
Question 5
A client with heart failure is receiving furosemide (Lasix) 40 mg IV push. Which finding requires
the nurse to stop the infusion and notify the healthcare provider?
1. Urine output of 200 mL in the past 2 hours.
2. Serum potassium level of 3.8 mEq/L.
3. Blood pressure of 110/70 mm Hg.
4. Tinnitus and hearing loss.
Answer: 4
Rationale: Tinnitus and hearing loss are signs of ototoxicity, which is an adverse effect of loop
diuretics such as furosemide. This finding requires immediate discontinuation of the medication
and notification of the healthcare provider. The other findings are either expected (increased
urine output) or within acceptable parameters (potassium of 3.8 mEq/L, blood pressure of
110/70 mm Hg) and do not require stopping the medication.
Question 6
The nurse is prioritizing care for four clients. Which client should be seen first?
1. A client with pneumonia who has a respiratory rate of 28 breaths/min and an oxygen
saturation of 91%.
2. A client with diabetes who has a blood glucose level of 60 mg/dL and is diaphoretic.
3. A client with heart failure who has 2+ pitting edema in the lower extremities.
4. A client with a urinary tract infection who has a temperature of 100.4°F (38°C).
Answer: 2
Rationale: The client with a blood glucose of 60 mg/dL and diaphoresis is experiencing
hypoglycemia, which can rapidly progress to unconsciousness, seizures, or death if not treated
immediately. While the client with pneumonia has respiratory compromise, the oxygen
, saturation of 91% is not as immediately life-threatening as severe hypoglycemia. The other
clients have stable findings that can be addressed after the hypoglycemic client is stabilized.
Question 7
Which nursing action demonstrates appropriate delegation to a licensed practical/vocational
nurse (LPN/LVN)?
1. Performing the initial admission assessment on a newly admitted client.
2. Administering oral medications to stable clients on the unit.
3. Developing the plan of care for a client with complex needs.
4. Evaluating the outcomes of nursing interventions.
Answer: 2
Rationale: Administering oral medications to stable clients is within the scope of practice for
LPN/LVNs. Initial admission assessments, development of the plan of care, and evaluation of
outcomes are nursing actions that require the education and clinical judgment of the RN. The
RN retains accountability for the overall care of the client and must provide appropriate
supervision of the LPN/LVN.
Question 8
A client is brought to the emergency department with chest pain and shortness of breath. The
client's electrocardiogram (ECG) shows ST-segment elevation. What is the priority nursing
action?
1. Administer sublingual nitroglycerin as prescribed.
2. Obtain a detailed history of the chest pain.
3. Prepare the client for immediate transfer to the cardiac catheterization lab.
4. Draw blood for cardiac enzyme levels.
Answer: 3
Rationale: ST-segment elevation on ECG indicates an acute myocardial infarction (STEMI)
requiring immediate reperfusion therapy. The priority action is to prepare the client for transfer
to the cardiac catheterization lab for percutaneous coronary intervention (PCI). While
administering nitroglycerin, obtaining a history, and drawing cardiac enzymes are all important
actions, they should not delay the time-critical intervention of reperfusion therapy. "Time is
muscle" in STEMI management.
