Adult Health Nursing III – Prioritization &
Clinical Decision-Making Questions
140 NCLEX-Style Clinical Judgment, Prioritization, Delegation, Safety, and
Decision-Making Questions
Questions 1–35
Question 1:
A nurse receives report on four clients. Which client should the nurse assess first?
A. A client with heart failure who has 2+ bilateral ankle edema
B. A client with COPD whose oxygen saturation is 91% on the prescribed oxygen
C. A client with pneumonia who is newly confused and has a respiratory rate of
32/min
D. A client with diabetes whose blood glucose is 184 mg/dL before breakfast
Correct Answer: C. A client with pneumonia who is newly confused and has a
respiratory rate of 32/min
Rationale: New confusion and tachypnea in a client with pneumonia may indicate
worsening hypoxemia or sepsis. Airway and breathing problems take priority over
stable chronic findings. The nurse should immediately assess oxygenation,
respiratory effort, vital signs, and signs of clinical deterioration.
,Question 2:
A postoperative client suddenly reports shortness of breath and sharp chest pain.
The oxygen saturation is 84% on room air. What should the nurse do first?
A. Apply oxygen and assess respiratory status
B. Encourage the client to ambulate
C. Administer the scheduled analgesic
D. Obtain a routine chest x-ray
Correct Answer: A. Apply oxygen and assess respiratory status
Rationale: Sudden dyspnea, pleuritic chest pain, and hypoxemia may indicate
pulmonary embolism. The immediate priority is supporting oxygenation and
assessing airway and breathing while activating appropriate emergency evaluation.
Diagnostic testing and anticoagulation follow stabilization and provider assessment.
Question 3:
The nurse is caring for four clients. Which finding requires immediate intervention?
A. A client with chronic kidney disease reporting mild fatigue
B. A client with a new tracheostomy who has noisy respirations and increasing
work of breathing
C. A client with osteoarthritis reporting pain of 6/10
D. A client with controlled hypertension whose blood pressure is 142/86 mmHg
,Correct Answer: B. A client with a new tracheostomy who has noisy respirations
and increasing work of breathing
Rationale: Noisy respirations and increased work of breathing after tracheostomy
may indicate airway obstruction from secretions, edema, or tube displacement.
Airway compromise is an immediate threat to life. The nurse should assess patency,
provide oxygen, suction when indicated, and urgently escalate care.
Question 4:
A nurse is caring for a client receiving IV heparin for a pulmonary embolism.
Which finding requires immediate action?
A. Platelet count of 42,000/mm³
B. Mild bruising at an IV site
C. Heart rate of 92/min
D. Oxygen saturation of 95%
Correct Answer: A. Platelet count of 42,000/mm³
Rationale: Severe thrombocytopenia during heparin therapy raises concern for
heparin-induced thrombocytopenia, which can cause life-threatening thrombosis.
The nurse should stop the heparin infusion according to protocol, notify the
provider immediately, and anticipate alternative anticoagulation.
Question 5:
, A client with sepsis has a blood pressure of 82/48 mmHg, heart rate of 124/min, and
cool extremities. Which intervention should the nurse prioritize?
A. Restrict fluid intake
B. Administer prescribed isotonic IV fluids
C. Place the client in a chair
D. Delay treatment until culture results return
Correct Answer: B. Administer prescribed isotonic IV fluids
Rationale: Hypotension and poor perfusion in sepsis suggest septic shock. Rapid
administration of prescribed isotonic crystalloid fluids supports circulating volume
and tissue perfusion. Cultures should be obtained promptly when feasible, but
treatment should not be delayed while awaiting results.
Question 6:
A client receiving a blood transfusion develops chills, fever, and back pain 15
minutes after the transfusion begins. What is the nurse's priority action?
A. Slow the transfusion
B. Stop the transfusion immediately
C. Administer acetaminophen
D. Continue the transfusion and reassess in 30 minutes
Correct Answer: B. Stop the transfusion immediately
Clinical Decision-Making Questions
140 NCLEX-Style Clinical Judgment, Prioritization, Delegation, Safety, and
Decision-Making Questions
Questions 1–35
Question 1:
A nurse receives report on four clients. Which client should the nurse assess first?
A. A client with heart failure who has 2+ bilateral ankle edema
B. A client with COPD whose oxygen saturation is 91% on the prescribed oxygen
C. A client with pneumonia who is newly confused and has a respiratory rate of
32/min
D. A client with diabetes whose blood glucose is 184 mg/dL before breakfast
Correct Answer: C. A client with pneumonia who is newly confused and has a
respiratory rate of 32/min
Rationale: New confusion and tachypnea in a client with pneumonia may indicate
worsening hypoxemia or sepsis. Airway and breathing problems take priority over
stable chronic findings. The nurse should immediately assess oxygenation,
respiratory effort, vital signs, and signs of clinical deterioration.
,Question 2:
A postoperative client suddenly reports shortness of breath and sharp chest pain.
The oxygen saturation is 84% on room air. What should the nurse do first?
A. Apply oxygen and assess respiratory status
B. Encourage the client to ambulate
C. Administer the scheduled analgesic
D. Obtain a routine chest x-ray
Correct Answer: A. Apply oxygen and assess respiratory status
Rationale: Sudden dyspnea, pleuritic chest pain, and hypoxemia may indicate
pulmonary embolism. The immediate priority is supporting oxygenation and
assessing airway and breathing while activating appropriate emergency evaluation.
Diagnostic testing and anticoagulation follow stabilization and provider assessment.
Question 3:
The nurse is caring for four clients. Which finding requires immediate intervention?
A. A client with chronic kidney disease reporting mild fatigue
B. A client with a new tracheostomy who has noisy respirations and increasing
work of breathing
C. A client with osteoarthritis reporting pain of 6/10
D. A client with controlled hypertension whose blood pressure is 142/86 mmHg
,Correct Answer: B. A client with a new tracheostomy who has noisy respirations
and increasing work of breathing
Rationale: Noisy respirations and increased work of breathing after tracheostomy
may indicate airway obstruction from secretions, edema, or tube displacement.
Airway compromise is an immediate threat to life. The nurse should assess patency,
provide oxygen, suction when indicated, and urgently escalate care.
Question 4:
A nurse is caring for a client receiving IV heparin for a pulmonary embolism.
Which finding requires immediate action?
A. Platelet count of 42,000/mm³
B. Mild bruising at an IV site
C. Heart rate of 92/min
D. Oxygen saturation of 95%
Correct Answer: A. Platelet count of 42,000/mm³
Rationale: Severe thrombocytopenia during heparin therapy raises concern for
heparin-induced thrombocytopenia, which can cause life-threatening thrombosis.
The nurse should stop the heparin infusion according to protocol, notify the
provider immediately, and anticipate alternative anticoagulation.
Question 5:
, A client with sepsis has a blood pressure of 82/48 mmHg, heart rate of 124/min, and
cool extremities. Which intervention should the nurse prioritize?
A. Restrict fluid intake
B. Administer prescribed isotonic IV fluids
C. Place the client in a chair
D. Delay treatment until culture results return
Correct Answer: B. Administer prescribed isotonic IV fluids
Rationale: Hypotension and poor perfusion in sepsis suggest septic shock. Rapid
administration of prescribed isotonic crystalloid fluids supports circulating volume
and tissue perfusion. Cultures should be obtained promptly when feasible, but
treatment should not be delayed while awaiting results.
Question 6:
A client receiving a blood transfusion develops chills, fever, and back pain 15
minutes after the transfusion begins. What is the nurse's priority action?
A. Slow the transfusion
B. Stop the transfusion immediately
C. Administer acetaminophen
D. Continue the transfusion and reassess in 30 minutes
Correct Answer: B. Stop the transfusion immediately
