NCLEX-RN Clinical Judgment & Prioritization Practice | 120 Original
Questions with Answers and Rationales
Case 1 Sepsis and Deteriorating Perfusion
An adult hospitalized with pneumonia develops temperature 39°C, heart rate
122/min, respiratory rate 30/min, blood pressure 82/46 mm Hg, new confusion,
and urine output 15 mL/hour. Oxygen saturation is 89% on room air.
1. Which cue most strongly indicates organ dysfunction?
A. Productive cough alone
B. Request for a blanket
C. History of smoking
D. New confusion with oliguria and hypotension
Answer: D
Rationale: Altered mentation, low urine output, and hypotension suggest impaired
organ perfusion rather than infection alone.
2. Which complication is the priority concern?
A. Chronic arthritis
B. Seasonal allergy
C. Systemic infection with shock physiology
D. Uncomplicated insomnia
Answer: C
Rationale: Infection accompanied by severe hypotension and organ dysfunction
suggests sepsis with circulatory compromise.
3. Which goal should guide immediate care?
A. Normalize appetite before treatment
B. Delay all interventions until cultures return
C. Complete discharge paperwork
D. Improve oxygenation and perfusion promptly
Answer: D
Rationale: Immediate stabilization targets breathing and circulation while the
infection is evaluated and treated.
4. Which nursing action is most appropriate now?
A. Activate urgent assistance, support oxygenation, and prepare prescribed
resuscitation
B. Wait for routine rounds
C. Encourage unsupported walking
,D. Give a large meal
Answer: A
Rationale: The unstable client needs immediate escalation and coordinated oxygen,
vascular access, fluids, and treatment as ordered.
5. Cultures are ordered with urgent antibiotics. Which plan is best?
A. Give antibiotics only after fever resolves
B. Cancel cultures automatically
C. Wait several hours for every specimen
D. Obtain cultures promptly without materially delaying antibiotics
Answer: D
Rationale: Cultures help identify the pathogen, but collection must not delay
necessary emergency antimicrobial treatment.
6. Which finding best indicates improvement?
A. Increasing confusion
B. Progressive hypotension
C. Urine output rises and mentation improves as pressure stabilizes
D. New cyanosis
Answer: C
Rationale: Improved renal output and cognition reflect better perfusion when
interpreted with blood pressure and overall status.
,Case 2 Acute Stroke
A client suddenly develops facial droop, left arm weakness, and slurred speech. The
client was last observed at baseline 45 minutes ago. Breathing is currently adequate.
7. Which cue requires immediate escalation?
A. Unchanged chronic back pain
B. Sudden focal neurological deficit
C. Use of reading glasses
D. Remote knee surgery
Answer: B
Rationale: Abrupt one-sided weakness and speech changes suggest an acute
cerebrovascular event.
8. What is the priority hypothesis?
A. Chronic hearing loss
B. Uncomplicated constipation
C. Routine fatigue
D. Acute stroke
Answer: D
Rationale: The sudden focal symptom pattern is consistent with stroke and
requires urgent evaluation.
9. Which information is essential to obtain?
A. A complete social history before activating help
B. Last-known-well time and relevant anticoagulant use
C. Favorite television program
D. Shoe size
Answer: B
Rationale: Timing and bleeding-risk medications influence treatment decisions.
Gathering information must not delay escalation.
10. What should the nurse do first?
A. Reassess next shift
B. Activate the stroke response and perform rapid assessment
C. Offer juice
D. Allow the client to drive home
Answer: B
Rationale: Time-sensitive stroke evaluation is essential. Bedside glucose and other
assessments occur within the response pathway.
, 11. A family member offers water. What should the nurse do?
A. Keep oral intake on hold until swallowing safety is assessed
B. Lay the client flat and feed
C. Use a straw without screening
D. Allow drinking immediately
Answer: A
Rationale: Stroke can impair swallowing and airway protection, creating aspiration
risk.
12. Which new finding requires immediate escalation during treatment?
A. Family asking questions
B. A request for a pillow
C. Sudden severe headache with declining consciousness
D. Stable weakness
Answer: C
Rationale: A sudden neurological decline may indicate hemorrhage, edema, or
another critical complication.
Questions with Answers and Rationales
Case 1 Sepsis and Deteriorating Perfusion
An adult hospitalized with pneumonia develops temperature 39°C, heart rate
122/min, respiratory rate 30/min, blood pressure 82/46 mm Hg, new confusion,
and urine output 15 mL/hour. Oxygen saturation is 89% on room air.
1. Which cue most strongly indicates organ dysfunction?
A. Productive cough alone
B. Request for a blanket
C. History of smoking
D. New confusion with oliguria and hypotension
Answer: D
Rationale: Altered mentation, low urine output, and hypotension suggest impaired
organ perfusion rather than infection alone.
2. Which complication is the priority concern?
A. Chronic arthritis
B. Seasonal allergy
C. Systemic infection with shock physiology
D. Uncomplicated insomnia
Answer: C
Rationale: Infection accompanied by severe hypotension and organ dysfunction
suggests sepsis with circulatory compromise.
3. Which goal should guide immediate care?
A. Normalize appetite before treatment
B. Delay all interventions until cultures return
C. Complete discharge paperwork
D. Improve oxygenation and perfusion promptly
Answer: D
Rationale: Immediate stabilization targets breathing and circulation while the
infection is evaluated and treated.
4. Which nursing action is most appropriate now?
A. Activate urgent assistance, support oxygenation, and prepare prescribed
resuscitation
B. Wait for routine rounds
C. Encourage unsupported walking
,D. Give a large meal
Answer: A
Rationale: The unstable client needs immediate escalation and coordinated oxygen,
vascular access, fluids, and treatment as ordered.
5. Cultures are ordered with urgent antibiotics. Which plan is best?
A. Give antibiotics only after fever resolves
B. Cancel cultures automatically
C. Wait several hours for every specimen
D. Obtain cultures promptly without materially delaying antibiotics
Answer: D
Rationale: Cultures help identify the pathogen, but collection must not delay
necessary emergency antimicrobial treatment.
6. Which finding best indicates improvement?
A. Increasing confusion
B. Progressive hypotension
C. Urine output rises and mentation improves as pressure stabilizes
D. New cyanosis
Answer: C
Rationale: Improved renal output and cognition reflect better perfusion when
interpreted with blood pressure and overall status.
,Case 2 Acute Stroke
A client suddenly develops facial droop, left arm weakness, and slurred speech. The
client was last observed at baseline 45 minutes ago. Breathing is currently adequate.
7. Which cue requires immediate escalation?
A. Unchanged chronic back pain
B. Sudden focal neurological deficit
C. Use of reading glasses
D. Remote knee surgery
Answer: B
Rationale: Abrupt one-sided weakness and speech changes suggest an acute
cerebrovascular event.
8. What is the priority hypothesis?
A. Chronic hearing loss
B. Uncomplicated constipation
C. Routine fatigue
D. Acute stroke
Answer: D
Rationale: The sudden focal symptom pattern is consistent with stroke and
requires urgent evaluation.
9. Which information is essential to obtain?
A. A complete social history before activating help
B. Last-known-well time and relevant anticoagulant use
C. Favorite television program
D. Shoe size
Answer: B
Rationale: Timing and bleeding-risk medications influence treatment decisions.
Gathering information must not delay escalation.
10. What should the nurse do first?
A. Reassess next shift
B. Activate the stroke response and perform rapid assessment
C. Offer juice
D. Allow the client to drive home
Answer: B
Rationale: Time-sensitive stroke evaluation is essential. Bedside glucose and other
assessments occur within the response pathway.
, 11. A family member offers water. What should the nurse do?
A. Keep oral intake on hold until swallowing safety is assessed
B. Lay the client flat and feed
C. Use a straw without screening
D. Allow drinking immediately
Answer: A
Rationale: Stroke can impair swallowing and airway protection, creating aspiration
risk.
12. Which new finding requires immediate escalation during treatment?
A. Family asking questions
B. A request for a pillow
C. Sudden severe headache with declining consciousness
D. Stable weakness
Answer: C
Rationale: A sudden neurological decline may indicate hemorrhage, edema, or
another critical complication.
