NURS 465 PRACTICE QUESTIONS ON
SETTING PRIORITIES. EXAM
QUESTIONS AND ANSWERS 100% PASS
A nurse is caring for a client who has dementia. The client is agitated and is having difficulty
staying in his chair. Which of the following actions should the nurse take first? - ANS place a
seat alarm in the client's chair
A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical
cord protruding from the vagina. Which of the following actions should the nurse perform first?
- ANS Insert a gloved hand into the vagina to relieve pressure on the cord
A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with
contrast media. For which of the following client finding should the nurse intervene first? -
ANS stridor
A nurse is caring for a client who has CHF and is taking digoxin daily. The client refused breakfast
and is complaining of nausea and weakness. Which of the following actions should the nurse
take first? - ANS check the client's vital signs
A nurse is removing PPE after giving direct care to a client who requires isolation. Which of the
following PPE items should the nurse remove first? - ANS Gloves
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,A nurse in an emergency department is caring for a client who has anaphylaxis following a bee
sting. Which of the following actions should the nurse take first? - ANS Auscultate for
wheezing
A nurse sees and assistive personnel (AP) entering the room of a client who requires
transmission based precautions without using the appropriate PPE. Which of the following
actions should the nurse take first? - ANS Provide the appropriate PPE to the AP
A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric
unit. Which of the following tasks should the nurse have the AP perform first? - ANS check to
see if the elbow restraint is in place for an infant who is postoperative from a surgical correction
of a cleft palate
A nurse is caring for a client who attacked one of her friends and is administered to the
psychiatric unit. Which of the following actions should the nurse take first? - ANS Set
behavioral limits for the client
A nurse is caring for a client who has a spinal cord injury and suspects the client is developing
autonomic dysreflexia. Which of the following actions should the nurse take first? - ANS Place
the client in a sitting position
A nurse is assessing four clients on a medical surgical unit. Which of the following client should
the nurse care for first? - ANS A client who has a cast on the left leg and reports numbness
and paresthesia
A nurse is caring for a client who develops a pulmonary embolism. Which of the following
interventions should the nurse implement first? - ANS Administer oxygen therapy
While caring for a client, the nurse experiences a needle stick injury. Which of the following
actions should the nurse take first? - ANS Wash the site of the injury with soap and water
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, A nurse is assessing a client's abdomen who reports stomach pain. Which of the following
actions should the nurse take first? - ANS Inspect
A nurse in a clinic is collecting a history from a client who reports that a member of his family
just received a diagnosis of pulmonary tuberculosis. The nurse should expect that the provider
will prescribe which of the following diagnostic tests first? - ANS Nucleic acid amplification
test (NAAT)
A nurse is caring for a client who is in active labor and notes late deceleration in the FHR. Which
of the following actions should the nurse take first? - ANS Change the client's position
A nurse has been reassigned from her regular area of work to a unit that is short staffed. Which
of the following actions should the nurse take first? - ANS Ask what she will be assigned to do
A nurse is bathing a toddler and notices that she has several bruises. Which of the following
actions should the nurse take first? - ANS Ask the parents what caused the bruises
A nurse is caring for a client who is vomiting. Which of the following actions should the nurse
take first? - ANS Prevent the client from aspirating
A nurse is caring for a client who has an endotracheal tube and is receiving mechanical
ventilation. The client pulls out his endotracheal tube. Which of the following actions should the
nurse take first? - ANS Assess the client's airway
A nurse is receiving change of shift report and is delegating tasks to the assistive personnel. The
nurse should tell the AP to complete which of the following tasks first? - ANS Perform blood
glucose monitoring of a client who has a prescription for short acting insulin prior to breakfast
3 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
SETTING PRIORITIES. EXAM
QUESTIONS AND ANSWERS 100% PASS
A nurse is caring for a client who has dementia. The client is agitated and is having difficulty
staying in his chair. Which of the following actions should the nurse take first? - ANS place a
seat alarm in the client's chair
A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical
cord protruding from the vagina. Which of the following actions should the nurse perform first?
- ANS Insert a gloved hand into the vagina to relieve pressure on the cord
A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with
contrast media. For which of the following client finding should the nurse intervene first? -
ANS stridor
A nurse is caring for a client who has CHF and is taking digoxin daily. The client refused breakfast
and is complaining of nausea and weakness. Which of the following actions should the nurse
take first? - ANS check the client's vital signs
A nurse is removing PPE after giving direct care to a client who requires isolation. Which of the
following PPE items should the nurse remove first? - ANS Gloves
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,A nurse in an emergency department is caring for a client who has anaphylaxis following a bee
sting. Which of the following actions should the nurse take first? - ANS Auscultate for
wheezing
A nurse sees and assistive personnel (AP) entering the room of a client who requires
transmission based precautions without using the appropriate PPE. Which of the following
actions should the nurse take first? - ANS Provide the appropriate PPE to the AP
A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric
unit. Which of the following tasks should the nurse have the AP perform first? - ANS check to
see if the elbow restraint is in place for an infant who is postoperative from a surgical correction
of a cleft palate
A nurse is caring for a client who attacked one of her friends and is administered to the
psychiatric unit. Which of the following actions should the nurse take first? - ANS Set
behavioral limits for the client
A nurse is caring for a client who has a spinal cord injury and suspects the client is developing
autonomic dysreflexia. Which of the following actions should the nurse take first? - ANS Place
the client in a sitting position
A nurse is assessing four clients on a medical surgical unit. Which of the following client should
the nurse care for first? - ANS A client who has a cast on the left leg and reports numbness
and paresthesia
A nurse is caring for a client who develops a pulmonary embolism. Which of the following
interventions should the nurse implement first? - ANS Administer oxygen therapy
While caring for a client, the nurse experiences a needle stick injury. Which of the following
actions should the nurse take first? - ANS Wash the site of the injury with soap and water
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, A nurse is assessing a client's abdomen who reports stomach pain. Which of the following
actions should the nurse take first? - ANS Inspect
A nurse in a clinic is collecting a history from a client who reports that a member of his family
just received a diagnosis of pulmonary tuberculosis. The nurse should expect that the provider
will prescribe which of the following diagnostic tests first? - ANS Nucleic acid amplification
test (NAAT)
A nurse is caring for a client who is in active labor and notes late deceleration in the FHR. Which
of the following actions should the nurse take first? - ANS Change the client's position
A nurse has been reassigned from her regular area of work to a unit that is short staffed. Which
of the following actions should the nurse take first? - ANS Ask what she will be assigned to do
A nurse is bathing a toddler and notices that she has several bruises. Which of the following
actions should the nurse take first? - ANS Ask the parents what caused the bruises
A nurse is caring for a client who is vomiting. Which of the following actions should the nurse
take first? - ANS Prevent the client from aspirating
A nurse is caring for a client who has an endotracheal tube and is receiving mechanical
ventilation. The client pulls out his endotracheal tube. Which of the following actions should the
nurse take first? - ANS Assess the client's airway
A nurse is receiving change of shift report and is delegating tasks to the assistive personnel. The
nurse should tell the AP to complete which of the following tasks first? - ANS Perform blood
glucose monitoring of a client who has a prescription for short acting insulin prior to breakfast
3 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
