Adult Health Nursing I – Clinical Judgment &
Prioritization Practice Questions
Question 1:
The nurse receives report on four clients. Which client should the nurse assess
first?
A. A client with osteoarthritis reporting knee pain of 5/10
B. A client with COPD who has an oxygen saturation of 82% and new confusion
C. A client with controlled hypertension requesting breakfast
D. A client with chronic heart failure who has mild ankle edema
Correct Answer: B. A client with COPD who has an oxygen saturation of 82%
and new confusion
Rationale: Severe hypoxemia combined with acute confusion indicates possible
respiratory failure and impaired cerebral oxygenation. Airway and breathing take
priority over chronic pain, routine dietary needs, and stable edema. The nurse
should immediately assess respiratory status and provide appropriate oxygen and
emergency support.
Question 2:
A postoperative client suddenly develops shortness of breath, chest pain, and a
heart rate of 128/minute. Which action should the nurse take first?
A. Encourage ambulation
B. Place the client flat
,C. Assess oxygenation and administer oxygen as indicated
D. Offer oral fluids
Correct Answer: C. Assess oxygenation and administer oxygen as indicated
Rationale: Sudden dyspnea and chest pain after surgery may indicate pulmonary
embolism. The immediate priority is supporting oxygenation and assessing airway
and breathing. The nurse should provide oxygen as indicated, obtain urgent
assistance, and prepare for diagnostic and anticoagulation interventions.
Question 3:
A client with heart failure suddenly develops severe dyspnea and pink, frothy
sputum. Which intervention is the priority?
A. Place the client in high-Fowler's position
B. Encourage oral fluids
C. Place the client supine
D. Encourage ambulation
Correct Answer: A. Place the client in high-Fowler's position
Rationale: Pink, frothy sputum with severe dyspnea strongly suggests acute
pulmonary edema. High-Fowler's positioning improves lung expansion and
decreases venous return. Oxygen and prescribed emergency medications should be
administered promptly while the nurse continuously monitors respiratory and
cardiovascular status.
Question 4:
A client with asthma is unable to speak more than one or two words at a time and
has markedly diminished breath sounds. What should the nurse do?
,A. Encourage oral fluids
B. Reassess in 30 minutes
C. Encourage the client to walk
D. Activate emergency respiratory support
Correct Answer: D. Activate emergency respiratory support
Rationale: Inability to speak and markedly diminished breath sounds indicate
severe airflow obstruction. A silent chest may occur when airflow becomes
critically limited. This client is at risk for respiratory failure and requires
immediate treatment, including prescribed bronchodilators, oxygen, and possible
advanced airway support.
Question 5:
A client with a suspected myocardial infarction reports crushing chest pain and
becomes pale and diaphoretic. Which assessment should receive priority?
A. Bowel sounds
B. Airway, breathing, circulation, and cardiac rhythm
C. Nutritional history
D. Skin integrity
Correct Answer: B. Airway, breathing, circulation, and cardiac rhythm
Rationale: Suspected myocardial infarction can rapidly cause lethal dysrhythmias,
cardiogenic shock, and cardiac arrest. Immediate assessment of ABCs and cardiac
rhythm is essential. The nurse should obtain vital signs, initiate cardiac monitoring,
administer prescribed therapies, and rapidly escalate care.
, Question 6:
A client receiving IV potassium chloride reports burning at the IV site. What
should the nurse do first?
A. Increase the infusion rate
B. Assess the IV site and stop the infusion if infiltration or irritation is suspected
C. Apply pressure without stopping the infusion
D. Continue the infusion because burning is expected
Correct Answer: B. Assess the IV site and stop the infusion if infiltration or
irritation is suspected
Rationale: IV potassium is irritating to veins and can cause significant tissue
injury if infiltration occurs. The nurse should immediately assess the site and
follow facility protocol for suspected infiltration or phlebitis. Potassium must never
be administered by IV push.
Question 7:
A client with chronic kidney disease has a potassium level of 6.9 mEq/L and
peaked T waves. Which action is the priority?
A. Encourage potassium-rich foods
B. Place the client on cardiac monitoring and notify the provider immediately
C. Encourage ambulation
D. Recheck the potassium next week
Correct Answer: B. Place the client on cardiac monitoring and notify the provider
immediately
Prioritization Practice Questions
Question 1:
The nurse receives report on four clients. Which client should the nurse assess
first?
A. A client with osteoarthritis reporting knee pain of 5/10
B. A client with COPD who has an oxygen saturation of 82% and new confusion
C. A client with controlled hypertension requesting breakfast
D. A client with chronic heart failure who has mild ankle edema
Correct Answer: B. A client with COPD who has an oxygen saturation of 82%
and new confusion
Rationale: Severe hypoxemia combined with acute confusion indicates possible
respiratory failure and impaired cerebral oxygenation. Airway and breathing take
priority over chronic pain, routine dietary needs, and stable edema. The nurse
should immediately assess respiratory status and provide appropriate oxygen and
emergency support.
Question 2:
A postoperative client suddenly develops shortness of breath, chest pain, and a
heart rate of 128/minute. Which action should the nurse take first?
A. Encourage ambulation
B. Place the client flat
,C. Assess oxygenation and administer oxygen as indicated
D. Offer oral fluids
Correct Answer: C. Assess oxygenation and administer oxygen as indicated
Rationale: Sudden dyspnea and chest pain after surgery may indicate pulmonary
embolism. The immediate priority is supporting oxygenation and assessing airway
and breathing. The nurse should provide oxygen as indicated, obtain urgent
assistance, and prepare for diagnostic and anticoagulation interventions.
Question 3:
A client with heart failure suddenly develops severe dyspnea and pink, frothy
sputum. Which intervention is the priority?
A. Place the client in high-Fowler's position
B. Encourage oral fluids
C. Place the client supine
D. Encourage ambulation
Correct Answer: A. Place the client in high-Fowler's position
Rationale: Pink, frothy sputum with severe dyspnea strongly suggests acute
pulmonary edema. High-Fowler's positioning improves lung expansion and
decreases venous return. Oxygen and prescribed emergency medications should be
administered promptly while the nurse continuously monitors respiratory and
cardiovascular status.
Question 4:
A client with asthma is unable to speak more than one or two words at a time and
has markedly diminished breath sounds. What should the nurse do?
,A. Encourage oral fluids
B. Reassess in 30 minutes
C. Encourage the client to walk
D. Activate emergency respiratory support
Correct Answer: D. Activate emergency respiratory support
Rationale: Inability to speak and markedly diminished breath sounds indicate
severe airflow obstruction. A silent chest may occur when airflow becomes
critically limited. This client is at risk for respiratory failure and requires
immediate treatment, including prescribed bronchodilators, oxygen, and possible
advanced airway support.
Question 5:
A client with a suspected myocardial infarction reports crushing chest pain and
becomes pale and diaphoretic. Which assessment should receive priority?
A. Bowel sounds
B. Airway, breathing, circulation, and cardiac rhythm
C. Nutritional history
D. Skin integrity
Correct Answer: B. Airway, breathing, circulation, and cardiac rhythm
Rationale: Suspected myocardial infarction can rapidly cause lethal dysrhythmias,
cardiogenic shock, and cardiac arrest. Immediate assessment of ABCs and cardiac
rhythm is essential. The nurse should obtain vital signs, initiate cardiac monitoring,
administer prescribed therapies, and rapidly escalate care.
, Question 6:
A client receiving IV potassium chloride reports burning at the IV site. What
should the nurse do first?
A. Increase the infusion rate
B. Assess the IV site and stop the infusion if infiltration or irritation is suspected
C. Apply pressure without stopping the infusion
D. Continue the infusion because burning is expected
Correct Answer: B. Assess the IV site and stop the infusion if infiltration or
irritation is suspected
Rationale: IV potassium is irritating to veins and can cause significant tissue
injury if infiltration occurs. The nurse should immediately assess the site and
follow facility protocol for suspected infiltration or phlebitis. Potassium must never
be administered by IV push.
Question 7:
A client with chronic kidney disease has a potassium level of 6.9 mEq/L and
peaked T waves. Which action is the priority?
A. Encourage potassium-rich foods
B. Place the client on cardiac monitoring and notify the provider immediately
C. Encourage ambulation
D. Recheck the potassium next week
Correct Answer: B. Place the client on cardiac monitoring and notify the provider
immediately
