NSG 4800 Highest Priority Questions and Answers
| 2026 Update | 100% Correct.
NSG 4800 Highest Priority Practice Exam
Part 1: Transfusion Reactions & Medication Administration
1. A client is receiving a unit of packed red blood cells (PRBCs). The client
experiences tingling in the fingers and a headache. What is the nurse's priority
action?
A) Call the physician
B) Stop the transfusion
C) Slow the infusion rate
D) Assess the IV site for infiltration
Correct Answer: B) Stop the transfusion
Explanation: A sudden headache and paresthesia are early signs of an acute
hemolytic transfusion reaction. The priority is to immediately stop the transfusion,
maintain IV access with normal saline, and then notify the provider and blood
bank . This is a life-threatening emergency.
2. A client is ordered to receive morphine via patient-controlled analgesia (PCA).
Before beginning administration of this medication, what is the priority
assessment?
A) Temperature
B) Neurological status
,C) Respirations
D) Urinary output
Correct Answer: C) Respirations
Explanation: Morphine is a potent opioid that can cause respiratory depression.
The priority assessment before initiating PCA is the client's respiratory rate and
depth . The ABC (Airway, Breathing, Circulation) framework guides this
prioritization. While neurological status and urinary output are also important,
they are secondary to respiratory assessment.
3. A 58-year-old adult client presents to the Emergency Department with a
nosebleed. After applying pressure, which of the following is the priority nursing
action?
A) Collect a medication history
B) Check the blood pressure
C) Instruct not to pick the nose
D) Check the pulse
Correct Answer: B) Check the blood pressure
Explanation: After applying direct pressure to control a nosebleed, the priority is
to assess for hypertension, which is a common cause of epistaxis . Uncontrolled
hypertension can lead to continued bleeding. While medication history and pulse
are important, blood pressure assessment directly guides immediate
interventions.
4. A client had a liver biopsy performed. The nursing action of highest priority to
prevent postprocedure hemorrhage would be to place the client:
A) Supine and flat in bed
B) In a sitting position
,C) On the right side
D) On the left side
Correct Answer: C) On the right side
Explanation: After a liver biopsy, the client should be placed on the right side to
apply pressure to the liver capsule and reduce the risk of hemorrhage . This
position also promotes hemostasis by compressing the biopsy site against the
chest wall.
5. A nurse receives reports on the following clients. Which client is the highest
priority to see?
A) 25-year-old male client with a hemoglobin of 15.9
B) 56-year-old female client on warfarin with an INR of 7.5
C) 38-year-old female client with a serum calcium level of 9.4
D) 45-year-old male client with a BUN of 20 and creatinine of 1.1
Correct Answer: B) 56-year-old female client on warfarin with an INR of 7.5
Explanation: An INR of 7.5 is critically elevated and indicates a high risk of
bleeding . This client requires immediate assessment for signs of hemorrhage and
intervention. The other values are within normal ranges (hemoglobin 15.9 is
normal for male; calcium 9.4 is normal; BUN 20 and creatinine 1.1 are within
normal limits).
6. A client is determined to be having an impending anaphylactic reaction
secondary to a drug hypersensitivity. Which of the following is the nurse's
priority action?
A) Administer oxygen
B) Insert an IV catheter
C) Take the vital signs
D) Obtain an arterial blood gas analysis
, Correct Answer: A) Administer oxygen
Explanation: In an impending anaphylactic reaction, airway and breathing are the
highest priorities . Administering oxygen ensures adequate tissue perfusion while
other interventions (epinephrine, IV access, etc.) are being prepared. The ABC
framework guides this prioritization.
7. A client's chest tube has accidentally dislodged. What is the nursing action of
highest priority?
A) Lay the client down on the left side
B) Lay the client down on the right side
C) Apply a petroleum gauze dressing over the site
D) Prepare to reinsert a new chest tube
Correct Answer: C) Apply a petroleum gauze dressing over the site
Explanation: The priority is to prevent a tension pneumothorax . Covering the site
with a sterile occlusive dressing taped on three sides creates a one-way valve that
allows air to escape during expiration but prevents air from entering during
inspiration . This is the immediate priority until the provider can reinsert the chest
tube.
8. A client who had a cardiac catheterization through the femoral artery is found
to have a large amount of blood under his buttocks. After donning gloves, which
action should the nurse take first?
A) Apply pressure to the site
B) Obtain vital signs
C) Change the client's gown and bed linens
D) Assess the catheterization site
Correct Answer: A) Apply pressure to the site
| 2026 Update | 100% Correct.
NSG 4800 Highest Priority Practice Exam
Part 1: Transfusion Reactions & Medication Administration
1. A client is receiving a unit of packed red blood cells (PRBCs). The client
experiences tingling in the fingers and a headache. What is the nurse's priority
action?
A) Call the physician
B) Stop the transfusion
C) Slow the infusion rate
D) Assess the IV site for infiltration
Correct Answer: B) Stop the transfusion
Explanation: A sudden headache and paresthesia are early signs of an acute
hemolytic transfusion reaction. The priority is to immediately stop the transfusion,
maintain IV access with normal saline, and then notify the provider and blood
bank . This is a life-threatening emergency.
2. A client is ordered to receive morphine via patient-controlled analgesia (PCA).
Before beginning administration of this medication, what is the priority
assessment?
A) Temperature
B) Neurological status
,C) Respirations
D) Urinary output
Correct Answer: C) Respirations
Explanation: Morphine is a potent opioid that can cause respiratory depression.
The priority assessment before initiating PCA is the client's respiratory rate and
depth . The ABC (Airway, Breathing, Circulation) framework guides this
prioritization. While neurological status and urinary output are also important,
they are secondary to respiratory assessment.
3. A 58-year-old adult client presents to the Emergency Department with a
nosebleed. After applying pressure, which of the following is the priority nursing
action?
A) Collect a medication history
B) Check the blood pressure
C) Instruct not to pick the nose
D) Check the pulse
Correct Answer: B) Check the blood pressure
Explanation: After applying direct pressure to control a nosebleed, the priority is
to assess for hypertension, which is a common cause of epistaxis . Uncontrolled
hypertension can lead to continued bleeding. While medication history and pulse
are important, blood pressure assessment directly guides immediate
interventions.
4. A client had a liver biopsy performed. The nursing action of highest priority to
prevent postprocedure hemorrhage would be to place the client:
A) Supine and flat in bed
B) In a sitting position
,C) On the right side
D) On the left side
Correct Answer: C) On the right side
Explanation: After a liver biopsy, the client should be placed on the right side to
apply pressure to the liver capsule and reduce the risk of hemorrhage . This
position also promotes hemostasis by compressing the biopsy site against the
chest wall.
5. A nurse receives reports on the following clients. Which client is the highest
priority to see?
A) 25-year-old male client with a hemoglobin of 15.9
B) 56-year-old female client on warfarin with an INR of 7.5
C) 38-year-old female client with a serum calcium level of 9.4
D) 45-year-old male client with a BUN of 20 and creatinine of 1.1
Correct Answer: B) 56-year-old female client on warfarin with an INR of 7.5
Explanation: An INR of 7.5 is critically elevated and indicates a high risk of
bleeding . This client requires immediate assessment for signs of hemorrhage and
intervention. The other values are within normal ranges (hemoglobin 15.9 is
normal for male; calcium 9.4 is normal; BUN 20 and creatinine 1.1 are within
normal limits).
6. A client is determined to be having an impending anaphylactic reaction
secondary to a drug hypersensitivity. Which of the following is the nurse's
priority action?
A) Administer oxygen
B) Insert an IV catheter
C) Take the vital signs
D) Obtain an arterial blood gas analysis
, Correct Answer: A) Administer oxygen
Explanation: In an impending anaphylactic reaction, airway and breathing are the
highest priorities . Administering oxygen ensures adequate tissue perfusion while
other interventions (epinephrine, IV access, etc.) are being prepared. The ABC
framework guides this prioritization.
7. A client's chest tube has accidentally dislodged. What is the nursing action of
highest priority?
A) Lay the client down on the left side
B) Lay the client down on the right side
C) Apply a petroleum gauze dressing over the site
D) Prepare to reinsert a new chest tube
Correct Answer: C) Apply a petroleum gauze dressing over the site
Explanation: The priority is to prevent a tension pneumothorax . Covering the site
with a sterile occlusive dressing taped on three sides creates a one-way valve that
allows air to escape during expiration but prevents air from entering during
inspiration . This is the immediate priority until the provider can reinsert the chest
tube.
8. A client who had a cardiac catheterization through the femoral artery is found
to have a large amount of blood under his buttocks. After donning gloves, which
action should the nurse take first?
A) Apply pressure to the site
B) Obtain vital signs
C) Change the client's gown and bed linens
D) Assess the catheterization site
Correct Answer: A) Apply pressure to the site
