Grade A+ NCLEX Prioritization Questions and Rationales 2025
the oncoming nurse is receiving report on 4 clients. which should
be the priority assessment
A.) client who has a carotid endarterectomy that day with a blood
A.) pressure of 160/88 mm Hg
client who has a carotid endarterectomy that day with a blood
pressure of 160/88 mm Hg
Rationale: clients post carotid endarterectomy are at risk for cere-
B.) client who is 1 day post bowel resection with absent bowel
bral ischemia and infarction as well as hemorrhage. systolic blood
sounds
pressure is maintained at 100-150 mm Hg to ensure adequate
C.) client with a pulse of 109/min who has history of atrial fibrilla-
cerebral perfusion and reduce the likelihood of hematoma forma-
tion
tion or hemorrhage at the surgical site
D.) client with pancreatitis whose total parenteral nutrition is al-
most finished
the nurse in the emergency department receives 4 clients. which
client should the nurse see first
A.) child who is confused and irritable and whose parents claims
A.) child who is confused and irritable and whose parents claims
2 glyburide pills are missing
2 glyburide pills are missing
B.) child with an abscess on the buttock that is red, swollen, and
Rationale: injection of anti diabetic drugs by a non diabetic client
warm to the touch
is an emergency as severe hypoglycemia can result in coma and
C.) child with immune thrombocytopenia who fell off a bike and
or death
reports shoulder pain
D.) child with low grade fever, barking cough, and running nose
who has mild retractions
the nurse receives report for clients on the neurology floor. which
client is important for the nurse to assess first
D.) a 78 year old dementia patient who has new onset agitation
A.) a 25 year old client with multiple sclerosis who had bladder
and confusion
incontinence last night
B.) a 37 year old client with Guillain-Barre syndrome who has a 0
Rationale: a change in LOC from baseline is concerning even
deep tendon patellar reflexes
when the patient has dementia
C.) a 58 year old client with Parkinson's who is drooling
D.) a 78 year old dementia patient who has new onset agitation
and confusion
the nurse is planning to assess 4 assigned clients. which cleat sit-
uation is of greatest concern and warrants immediate assessment
client scheduled for hemodialysis in an hour who has a serum
A.) D.) client with an inguinal hernia who rates abdominal pain as a
creatine level of 9.2 mg/dL and refuses to take prescribed med-
10 on a 0-10n scale and reports bloating, nausea, and vomitting
ications
B.) client taking diphenhydramine for urticaria who reports diffi-
Rationale: intestinal obstruction strangulated bowel are life threat-
culty urinating and increasing lower abdominal pain
ening complications associated with an incarcerated hernia and
C.) client with an infected venous leg ulcer prescribed IV van-
requires immediate evaluation and urgent surgical intervention
comycin who has a dressing saturated with yellow, foul-smelling
draninage
D.) client with an inguinal hernia who rates abdominal pain as a
10 on a 0-10n scale and reports bloating, nausea, and vomitting
the nurse reviews the most current laboratory results of assigned
clients. which findings is the highest priority for the nurse to report
to health care provider
D.) serum glucose of 68 mg/dL in a client with radiation enteritis
who is receiving total parenteral nutrition
A.) CD4 cell count of 500/mm in a client with oral candidiasis is
and HIV who is receiving fluconazole orally
Rationale: the recommended target for serum glucose range for
B.) hemoglobin A of 7.3 in a client with community acquired
clients receiving nutritional support is 140-180 mg/dL. the nurse
pneumonia and type 2 diabetes who is receiving IV levofloxacin
should monitor the client receiving TPN for hyperglycemia and
C.) platelet count of 148,000/mm in a client with a venous throm-
hypoglycemia. hypoglycemia is life threatening
bosis who is receiving a continuous heparin infusion
D.) serum glucose of 68 mg/dL in a client with radiation enteritis
who is receiving total parenteral nutrition
the nurse is caring for pediatric client in an acute care setting.
which of these clients should the nurse see first D.) a 6 year old client with epiglottis who is drooling and has a
severe sore throat
A.) a 1 day post tubal myringotomy client with purulent tympanic
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the oncoming nurse is receiving report on 4 clients. which should
be the priority assessment
A.) client who has a carotid endarterectomy that day with a blood
A.) pressure of 160/88 mm Hg
client who has a carotid endarterectomy that day with a blood
pressure of 160/88 mm Hg
Rationale: clients post carotid endarterectomy are at risk for cere-
B.) client who is 1 day post bowel resection with absent bowel
bral ischemia and infarction as well as hemorrhage. systolic blood
sounds
pressure is maintained at 100-150 mm Hg to ensure adequate
C.) client with a pulse of 109/min who has history of atrial fibrilla-
cerebral perfusion and reduce the likelihood of hematoma forma-
tion
tion or hemorrhage at the surgical site
D.) client with pancreatitis whose total parenteral nutrition is al-
most finished
the nurse in the emergency department receives 4 clients. which
client should the nurse see first
A.) child who is confused and irritable and whose parents claims
A.) child who is confused and irritable and whose parents claims
2 glyburide pills are missing
2 glyburide pills are missing
B.) child with an abscess on the buttock that is red, swollen, and
Rationale: injection of anti diabetic drugs by a non diabetic client
warm to the touch
is an emergency as severe hypoglycemia can result in coma and
C.) child with immune thrombocytopenia who fell off a bike and
or death
reports shoulder pain
D.) child with low grade fever, barking cough, and running nose
who has mild retractions
the nurse receives report for clients on the neurology floor. which
client is important for the nurse to assess first
D.) a 78 year old dementia patient who has new onset agitation
A.) a 25 year old client with multiple sclerosis who had bladder
and confusion
incontinence last night
B.) a 37 year old client with Guillain-Barre syndrome who has a 0
Rationale: a change in LOC from baseline is concerning even
deep tendon patellar reflexes
when the patient has dementia
C.) a 58 year old client with Parkinson's who is drooling
D.) a 78 year old dementia patient who has new onset agitation
and confusion
the nurse is planning to assess 4 assigned clients. which cleat sit-
uation is of greatest concern and warrants immediate assessment
client scheduled for hemodialysis in an hour who has a serum
A.) D.) client with an inguinal hernia who rates abdominal pain as a
creatine level of 9.2 mg/dL and refuses to take prescribed med-
10 on a 0-10n scale and reports bloating, nausea, and vomitting
ications
B.) client taking diphenhydramine for urticaria who reports diffi-
Rationale: intestinal obstruction strangulated bowel are life threat-
culty urinating and increasing lower abdominal pain
ening complications associated with an incarcerated hernia and
C.) client with an infected venous leg ulcer prescribed IV van-
requires immediate evaluation and urgent surgical intervention
comycin who has a dressing saturated with yellow, foul-smelling
draninage
D.) client with an inguinal hernia who rates abdominal pain as a
10 on a 0-10n scale and reports bloating, nausea, and vomitting
the nurse reviews the most current laboratory results of assigned
clients. which findings is the highest priority for the nurse to report
to health care provider
D.) serum glucose of 68 mg/dL in a client with radiation enteritis
who is receiving total parenteral nutrition
A.) CD4 cell count of 500/mm in a client with oral candidiasis is
and HIV who is receiving fluconazole orally
Rationale: the recommended target for serum glucose range for
B.) hemoglobin A of 7.3 in a client with community acquired
clients receiving nutritional support is 140-180 mg/dL. the nurse
pneumonia and type 2 diabetes who is receiving IV levofloxacin
should monitor the client receiving TPN for hyperglycemia and
C.) platelet count of 148,000/mm in a client with a venous throm-
hypoglycemia. hypoglycemia is life threatening
bosis who is receiving a continuous heparin infusion
D.) serum glucose of 68 mg/dL in a client with radiation enteritis
who is receiving total parenteral nutrition
the nurse is caring for pediatric client in an acute care setting.
which of these clients should the nurse see first D.) a 6 year old client with epiglottis who is drooling and has a
severe sore throat
A.) a 1 day post tubal myringotomy client with purulent tympanic
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