Introduction to Prioritization & Clinical Judgment for NCLEX-RN®
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Course
Nursing
Institution
Nursing
1. A nurse is caring for a client admitted with pneumonia. Which intervention should the nurse prioritize?
• A. Administering the prescribed antibiotic
• B. Obtaining a sputum culture
• C. Encouraging increased fluid intake
• D. Providing the client with a warm blanket
Answer: B. Obtai...
1. A nurse is caring for a client admitted with pneumonia. Which intervention
should the nurse prioritize?
• A. Administering the prescribed antibiotic
• B. Obtaining a sputum culture
• C. Encouraging increased fluid intake
• D. Providing the client with a warm blanket
Answer: B. Obtaining a sputum culture
Rationale: Before administering antibiotics, it is crucial to obtain a sputum culture to identify
the causative organism and ensure appropriate treatment. Administering the antibiotic without a
culture could affect the results and lead to inappropriate treatment. While administering the
antibiotic (A) and encouraging fluids (C) are important, obtaining a culture is the priority.
2. The nurse is assessing a client who has just returned from surgery. Which of
the following assessments requires immediate intervention?
• A. The client's urine output is 40 mL/hr.
• B. The client has cool, pale extremities.
• C. The client's pain level is 6 out of 10.
• D. The client has a heart rate of 98 beats/min.
Answer: B. The client has cool, pale extremities
Rationale: Cool, pale extremities may indicate decreased perfusion, which could be a sign of
shock or poor circulation. This finding needs immediate intervention to prevent further
complications. While pain and a slightly increased heart rate are important, they are not as
critical as a potential perfusion issue.
3. A client with congestive heart failure is experiencing shortness of breath and
has an oxygen saturation of 88%. What should the nurse do first?
• A. Increase the client's oxygen flow rate.
• B. Place the client in a high-Fowler's position.
• C. Call the healthcare provider immediately.
• D. Administer a prescribed diuretic.
Answer: B. Place the client in a high-Fowler's position
Rationale: Placing the client in a high-Fowler’s position promotes lung expansion and may help
alleviate shortness of breath. Increasing oxygen flow rate (A) may be appropriate, but
,positioning the client is the priority as it improves ventilation. Administering diuretics (D) will
take time to have an effect, so it is not the first intervention.
4. A nurse is caring for a client with a history of hypertension who reports a
headache. Which action should the nurse prioritize?
• A. Administer prescribed pain medication
• B. Assess the client’s blood pressure
• C. Provide a dark and quiet environment
• D. Encourage the client to rest
Answer: B. Assess the client’s blood pressure
Rationale: For a client with a history of hypertension, a headache could indicate elevated blood
pressure or hypertensive crisis. Assessing blood pressure is the priority to determine if the
headache is related to hypertension. Administering pain medication (A) should only be done
after assessing the cause.
5. A client admitted with deep vein thrombosis (DVT) suddenly complains of
chest pain and shortness of breath. What is the nurse’s priority action?
• A. Administer prescribed pain medication
• B. Notify the healthcare provider
• C. Position the client in a high-Fowler's position
• D. Administer oxygen therapy
Answer: D. Administer oxygen therapy
Rationale: The client’s symptoms suggest a pulmonary embolism, a potential complication of
DVT. The nurse should first ensure oxygenation by administering oxygen. Notifying the
healthcare provider (B) is important but secondary to stabilizing the client’s respiratory status.
6. A nurse is caring for a client with an acute asthma exacerbation. The client's
respiratory rate is 30 breaths/min, and they are using accessory muscles. Which
of the following should the nurse do first?
• A. Administer a bronchodilator via nebulizer
• B. Notify the respiratory therapist
• C. Position the client in a semi-Fowler's position
, • D. Encourage the client to use pursed-lip breathing
Answer: A. Administer a bronchodilator via nebulizer
Rationale: Administering a bronchodilator will open the airways and is the priority intervention
in an acute asthma exacerbation. Positioning the client (C) and encouraging breathing techniques
(D) are helpful but secondary to medication.
7. The nurse is providing care for a client with a potassium level of 6.2 mEq/L.
Which action should the nurse prioritize?
• A. Administer a prescribed potassium supplement
• B. Restrict the client’s potassium intake
• C. Monitor the client’s cardiac rhythm
• D. Encourage the client to eat a potassium-rich diet
Answer: C. Monitor the client’s cardiac rhythm
Rationale: Hyperkalemia (potassium level above 5.0 mEq/L) can cause life-threatening cardiac
arrhythmias. Therefore, monitoring the client's cardiac rhythm is a priority. Restricting
potassium intake (B) is appropriate, but cardiac monitoring is critical.
8. A client is admitted to the emergency department with a possible stroke. What
should the nurse prioritize during the initial assessment?
• A. Assessing the client’s airway and breathing
• B. Evaluating the client’s blood pressure
• C. Asking the client about medical history
• D. Performing a complete neurological assessment
Answer: A. Assessing the client’s airway and breathing
Rationale: In any emergency situation, airway, breathing, and circulation (ABC) are the top
priorities. For a client with a possible stroke, ensuring airway patency and adequate oxygenation
is critical before conducting further assessments.
9. The nurse is preparing to administer a blood transfusion to a client. Which
action is the most important to prevent a transfusion reaction?
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