Leadership NCLEX Questions - Prioritization

Leadership NCLEX Questions - Prioritization

A client arrives at the ED with GI bleeding and is in moderate distress. The priority nursing action is to:

• obtain vital signs
• ask the client about what happened prior to the symptoms occurring
• complete an abdominal physical assessment
• insert an NG tube - A.

The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with anothe rnurse. Just before beginning the transfusion, the nurse should assess which priority item?

• vital signs
• skin color
• urine output
• latest hematocrit level - A.

After change of shift, youare assigned to the following patients. Which one do you assess first?

• A 22 year old female who has had a fever and cough for 3 days
• A 60 year old male with COPD and O2 of 91% on room air
• A 48 year old with asthma who is still short of breath after using his rescue inhaler
• A 15 year old male who has a swollen ankle after a sports injury - C.

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?

• a client with asthma who requested a breathing treatment during the previous shift
• a client who is ambulatory demonstrating a steady gait

• a client requiring daily dressing changes of recent surgical incision
• a client who twisted her ankle when jogging and is requesting pain medication - A.

A 13 year old boy was riding his bike to school when he hit the curb and fell off his bike. He landed on his right leg. The school nurse was notified and found him alert and conscious, but in severe pain with a possible fractured femo. Which of the following is the FIRST action the nurse should take?

• Immobilize the right leg with a splint
• Make a thorough assessment of the circumstances leading up to the accident
• check pedal pulses in both legs
• place him in a semi-fowlers position for comfort - A.

You are monitoring a 53 year old client who is undergoing a stress unit using a treadmill. Which of these client symptoms will require the most immediate action?

• BP of 158/88
• HR of 134 bpm

C. O2 91%

• Chest pain level of 3 on a scale of 0/10 - D.

Rational: chest pain in a client undergoing a stress test indicates myocardial ischemia and is an indication to stop the testing to avoid ongoing ischemia, injury or infraction. Moderate elevations in blood pressure and heart rate and slightly decreases in oxygen saturation are a normal response to exercise and are expected during stress testing

While sitting in a chair, a 15 year old male has a clonic seizure. Which step should the nurse do first?

• Turn the patient onto his side
• Remove any restrictive clothing
• Safely lower the patient on the ground
• Stick a tongue blade into the patient's mouth - C.

A community experiences an outbreak of meningitis, and hospital beds are urgently needed. Which of the following clients should the nurse recommend for discharge?

• A client newly admitted with angina and a history of myocardial infaction a year ago
• A client who has type II DM and was admitted for rotator cuff surgery
• A client admitted the day before with pnemonia and dehydration
• A client who has a fractured hip and is scheduled for total hip replacement the next day - B.

A nurse arrives on the floor early for her assigned shift to review her assigned patients and to start planning her day, what is the first thing she should take into consideration in terms of prioritizing?

• Acute over chronic
• Patients that will be discharged
• Initial assessment
• Passing pain medications - A.