Nclex Cris-3-30
The home care nurse visits a client in a large apartment complex. During the visit, the
area experiences a major earthquake. Which of the following clients should the nurse
see FIRST?
1. A restless client with a rigid abdomen and absent bowel sounds.
2. An unconscious client with left-sided tracheal shift from midline.
3. A client complaining of excruciating pain with an obvious deformity of the left leg.
4. A client clutching her chest and complaining of severe chest pain - answer Strategy:
Determine the most unstable client.
(1) likely has injuries to abdominal organs, resulting in hemorrhage and severe
circulatory compromise and requires emergent evaluation; airway and breathing take
priority
(2) CORRECT—first sign of a tension pneumothorax; airway and breathing take priority
(3) assess for neurovascular compromise; client with breathing difficulties takes priority
(4) circulatory problem; airway/breathing problems take priority
The nurse cares for clients in the outpatient clinic. The nurse returns to the desk to find
four phone messages. Which of the following messages should the nurse respond to
FIRST?
1. The mother of a 15-year-old reports her son is threatening to jump off a bridge and
has access to a gun.
2. A 20-year-old female reports she has lost 2 lb this week and eats only two meals a
day.
3. A 45-year-old male with a history of depression who is out of Prozac.
4. A 75-year-old male complains of insomnia and irritability after the death of his wife. -
answerStrategy: Determine the most unstable client.
(1) CORRECT— using Maslow Hierarchy of Needs theory to prioritize, physiological
issues take priority over psychological issues; patient is at risk for self harm and must
be seen first; observe for safety
(2) does not require immediate attention
(3) does not require immediate attention
(4) may be a normal part of grieving; nurse should assess but is not the priority
, The nurse receives report on the medical/surgical unit. Which of the following clients
should the nurse see FIRST?
1. A client with an IV of normal saline infusing at 125 ml per hour complaining of slight
swelling at the IV insertion site.
2. A client 3 days post right knee replacement complaining of right calf pain with
movement.
3. A client with a respiratory rate of 24 and an oxygen saturation of 94% on room air.
4. A client 12 hours after a hysterectomy complaining of nausea. - answerStrategy:
Determine the most unstable client.
(1) assess site for client's comfort and to prevent complications associated with IV
infusion, probable DVT takes priority
(2) CORRECT—assessment for possible DVT should be performed and reported to the
physician immediately
(3) respiratory status is stable at present
(4) administer antiemetics; client with calf pain takes priority
The triage nurse at an urgent care center notes that four clients have signed in, each
complaining of a sore throat. Which of the following clients should the nurse see
FIRST?
1. A 7-year-old whose sibling was recently treated for "strep throat."
2. A 10-year-old with a history of chronic allergies.
3. A 21-year-old with a history of chronic sinus infections.
4. A 55-year-old receiving 5-fluorouracil (5-FU). - answerStrategy: Determine the most
unstable client.
(1) child has likely contracted strep from his sibling; treatment should begin as soon as
possible; does not take priority
(2) likely experiencing irritation as a result of sinus drainage; does not take priority
(3) likely experiencing irritation as a result of sinus drainage; does not take priority
(4) CORRECT— because many chemotherapy agents may result in neutropenia,
clients receiving drugs are more susceptible to infection, less likely to be able to fight
the infection; symptomatic clients require immediate evaluation and treatment
The nurse cares for clients on the pain management unit. Which of the following clients
should the nurse see FIRST?
The home care nurse visits a client in a large apartment complex. During the visit, the
area experiences a major earthquake. Which of the following clients should the nurse
see FIRST?
1. A restless client with a rigid abdomen and absent bowel sounds.
2. An unconscious client with left-sided tracheal shift from midline.
3. A client complaining of excruciating pain with an obvious deformity of the left leg.
4. A client clutching her chest and complaining of severe chest pain - answer Strategy:
Determine the most unstable client.
(1) likely has injuries to abdominal organs, resulting in hemorrhage and severe
circulatory compromise and requires emergent evaluation; airway and breathing take
priority
(2) CORRECT—first sign of a tension pneumothorax; airway and breathing take priority
(3) assess for neurovascular compromise; client with breathing difficulties takes priority
(4) circulatory problem; airway/breathing problems take priority
The nurse cares for clients in the outpatient clinic. The nurse returns to the desk to find
four phone messages. Which of the following messages should the nurse respond to
FIRST?
1. The mother of a 15-year-old reports her son is threatening to jump off a bridge and
has access to a gun.
2. A 20-year-old female reports she has lost 2 lb this week and eats only two meals a
day.
3. A 45-year-old male with a history of depression who is out of Prozac.
4. A 75-year-old male complains of insomnia and irritability after the death of his wife. -
answerStrategy: Determine the most unstable client.
(1) CORRECT— using Maslow Hierarchy of Needs theory to prioritize, physiological
issues take priority over psychological issues; patient is at risk for self harm and must
be seen first; observe for safety
(2) does not require immediate attention
(3) does not require immediate attention
(4) may be a normal part of grieving; nurse should assess but is not the priority
, The nurse receives report on the medical/surgical unit. Which of the following clients
should the nurse see FIRST?
1. A client with an IV of normal saline infusing at 125 ml per hour complaining of slight
swelling at the IV insertion site.
2. A client 3 days post right knee replacement complaining of right calf pain with
movement.
3. A client with a respiratory rate of 24 and an oxygen saturation of 94% on room air.
4. A client 12 hours after a hysterectomy complaining of nausea. - answerStrategy:
Determine the most unstable client.
(1) assess site for client's comfort and to prevent complications associated with IV
infusion, probable DVT takes priority
(2) CORRECT—assessment for possible DVT should be performed and reported to the
physician immediately
(3) respiratory status is stable at present
(4) administer antiemetics; client with calf pain takes priority
The triage nurse at an urgent care center notes that four clients have signed in, each
complaining of a sore throat. Which of the following clients should the nurse see
FIRST?
1. A 7-year-old whose sibling was recently treated for "strep throat."
2. A 10-year-old with a history of chronic allergies.
3. A 21-year-old with a history of chronic sinus infections.
4. A 55-year-old receiving 5-fluorouracil (5-FU). - answerStrategy: Determine the most
unstable client.
(1) child has likely contracted strep from his sibling; treatment should begin as soon as
possible; does not take priority
(2) likely experiencing irritation as a result of sinus drainage; does not take priority
(3) likely experiencing irritation as a result of sinus drainage; does not take priority
(4) CORRECT— because many chemotherapy agents may result in neutropenia,
clients receiving drugs are more susceptible to infection, less likely to be able to fight
the infection; symptomatic clients require immediate evaluation and treatment
The nurse cares for clients on the pain management unit. Which of the following clients
should the nurse see FIRST?
