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WorksheetsNCLEX - Prioritiz and Delegration Day1
Total questions: 25
Worksheet time: 25mins
Name
Class
Date
1.
The nurse assesses 4 children in the clinic. Which assessment finding requires the nurse's priority action?
a)
A 3-month-old with fever, vomiting, high-pitched cry, and irritability
b)
A 9-month-old with diarrhea who is refusing fluids and cries without tears
c)
An 11-month-old with cold symptoms and an abdominal breathing pattern
d)
An 18-month-old who cries when the caregiver leaves
e)
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2.
Which client should the nurse assess first?
a)
Client with atrial fibrillation with a new prescription for warfarin
b)
Client with chronic obstructive pulmonary disease with an oxygen saturation of 91%
c)
Client with postoperative pain rated 8 out of 10
d)
Client with third-degree heart block with a pulse of 42/min
e)
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3.
The nurse in the emergency department is caring for assigned clients. The nurse should first assess the client who
a)
has chronic obstructive pulmonary disease, a cough productive of yellow sputum, and a pulse oximetry reading of 91%
b)
has a new-onset, bright-red rash on cheeks and an elevated temperature
c)
is unconscious, smells of alcohol, and has fresh vomit on the face
d)
is reporting vaginal itching and white, curd-like discharge
e)
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4.
The clinic nurse receives multiple phone calls regarding client status, Which call should the nurse return first?
a)
A 3-year-old diagnosed with Kawasaki disease 2 weeks ago developed skin peeling
b)
A 7-year-old has had a high fever, cough, and sore throat for the past 2 days
c)
A 14-year-old with asthma controlled with a corticosteroid inhaler developed oral white patches
d)
A 16-year-old diagnosed with mononucleosis 10 days ago reports abdominal pain
e)
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5.
The nurse in the emergency department is caring for assigned clients. The nurse should first assess the
a)
client who has had vomiting and diarrhea for the past 24 hours
b)
client who has a foreign body in the right ear
c)
client who had a tonsillectomy 3 days ago and is restless and pale
d)
client who has a second-degree burn to the arm and is crying inconsolably
e)
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6.
The nurse is caring for assigned clients. The nurse should first assess the client who
a)
has atrial fibrillation, a therapeutic INR, and is scheduled to receive warfarin now
b)
has had NPO status discontinued after 6 hours and is requesting to drink fluids now
c)
had a myocardial infarction 2 days ago, is experiencing ventricular bigeminy, and is scheduled to receive amiodarone now
d)
had coronary artery bypass surgery 2 days ago, has a temperature of 99 F (37.2 C), and is scheduled to receive vancomycin now
e)
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7.
The nurse is caring for assigned clients. The nurse should first assess the client with
a)
heart failure who has shortness of breath and cough productive of pink, frothy sputum
b)
a left-sided pleural effusion who has diminished breath sounds in the left lower lobe
c)
asthma who has an elevated heart rate after receiving an albuterol nebulizer treatment
d)
a venous leg ulcer who has a wound dressing saturated with serosanguineous drainage
e)
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8.
The nurse receives handoff of care report on four clients. Which client should the nurse assess first?
a)
Client who had an appendectomy today and reports severe nausea and 8 out of 10 pain
b)
Client with a diabetic foot ulcer who has current blood glucose level of 301 mg/dl (16.7 mmol/L)
c)
Client with a fever of unknown origin whose arterial blood gas reveals PaCO2 30 mm Hg (4.0 kPa)
d)
Client with persistent diarrhea who has continuous lactated Ringer solution IV infusing at 125 mL/hr
e)
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9.
The nurse is caring for assigned clients. Which of the following clients should the nurse check first?
a)
Client who had a cholecystectomy and is reporting incisional pain as 5 on a scale of 1–10
b)
Client who had an open reduction of the right femur and is reporting nausea
c)
Client with type 1 diabetes mellitus and a blood glucose level of 55 mg/dL (3.1 mmol/L)
d)
Client with type 2 diabetes mellitus and a blood glucose level of 250 mg/dL (13.9 mmol/L)
e)
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10.
The nurse has been made aware of laboratory test results for assigned clients. Which of the following test results would require immediate follow-up?
a)
WBC count of 12,000/mm3 (12 x 10⁹/L) for a client who had hip arthroplasty 2 days ago
b)
Serum creatinine of 3.6 mg/dL (318.3 µmol/L) for a client with end-stage renal disease
c)
Creatine kinase of 30,000 U/L for a client who was admitted for cocaine overdose
d)
B-type natriuretic peptide of 250 pg/mL for a client who is experiencing an acute exacerbation of heart failure
e)
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11.
The nurse in the prenatal clinic is caring for assigned clients. The nurse should first assess the client who is in the
a)
first trimester of pregnancy and is reporting fatigue and nasal congestion
b)
first trimester of pregnancy and is reporting frequent nausea and vomiting
c)
third trimester of pregnancy and is reporting dysuria and urinary frequency
d)
third trimester of pregnancy and is reporting right upper quadrant abdominal pain and nausea
e)
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12.
The charge nurse in an intensive care unit is rounding and reviewing hemodynamic data for clients in the unit. Which client requires immediate intervention?
a)
Client who is septic due to pneumonia with central venous pressure of 6 mm Hg
b)
Client who recently underwent a coronary artery bypass graft with cardiac output of 5 L/min
c)
Client with a gastrointestinal bleed and mean arterial pressure of 58 mm Hg
d)
Client with an adrenal gland tumor and blood pressure of 168/95 mm Hg
e)
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13.
The nurse is caring for assigned clients. The nurse should first assess the client with
a)
an acute exacerbation of heart failure who has edema of the lower extremities and is reporting fatigue
b)
an acute exacerbation of asthma who has accessory muscle use and a sudden decrease in wheezing
c)
chronic kidney disease who has crackles bilaterally and is scheduled for hemodialysis in 2 hours
d)
cellulitis of the right foot who received IV hydromorphone 1 hour ago and is reporting pain rated as 6 on a scale of 0–10
e)
-
14.
The clinic nurse receives phone calls about the following 4 clients. Which call should the nurse return first?
a)
A 6-month-old who received the diphtheria, tetanus, acellular pertussis vaccine 18 hours ago and developed fever of 102 F (38.9 C) and injection site redness
b)
An 11-month-old with inconsolable crying and drawing up of the legs toward the abdomen
c)
A 4-year-old diagnosed with right lung pneumonia 2 days ago who has chest pain when breathing deeply
d)
A 15-year-old whose eyes are red and itchy and have a yellow discharge
e)
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15.
A category 4 hurricane has disrupted a rural local health care system, creating a significant increase in emergency department admissions. Which client would the nurse assess first?
a)
55-year-old with type 2 diabetes mellitus complaining of a headache after being involved in a minor motor vehicle accident
b)
45-year-old with type 1 diabetes mellitus with a blood glucose of 690 mg/dl (38.3 mmol/L) complaining of abdominal pain and fatigue
c)
7-year-old with status asthmaticus and an oxygen saturation of 89%
d)
34-year-old with gestational diabetes, 11 weeks pregnant, who has not been able to "hold anything down" due to nausea and vomiting over the past 2 days
e)
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16.
An emergency department nurse is assigned to triage. Which client should the nurse assess first?
a)
Five-year-old with a superficial leg laceration
b)
Lethargic 3-month-old with diarrhea for the past 12 hours
c)
Seven-year-old with an elevated temperature of 101 F (38.3 C) and hematuria
d)
Seventeen-year-old with severe, acute abdominal pain
e)
-
17.
The nurse is reviewing laboratory test results for assigned clients. Which of the following test results would require immediate follow-up?
a)
A decreased blood glucose level for a client with radiation enteritis who is receiving total parenteral nutrition
b)
A decreased CD4+ cell count for a client with oral candidiasis and HIV who is receiving oral fluconazole
c)
An elevated hemoglobin A1c for a client with pneumonia and type 2 diabetes mellitus who is receiving IV levofloxacin
d)
An elevated WBC count for a client with primary adrenal insufficiency who is receiving oral methylprednisolone
e)
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18.
The nurse in a pulmonary clinic triages telephone messages left by several clients. Which client should the nurse call back first?
a)
Client with a history of asthma who reports scoring a peak flow of 45% of personal best
b)
Client with a pneumothorax who reports scant, clear drainage from the Heimlich valve
c)
Client with active tuberculosis reporting dark red-orange urine after starting rifampin
d)
Client with chronic obstructive pulmonary disease with an oxygen saturation of 90%
e)
-
19.
The nurse is caring for assigned clients. The nurse should first assess the client with
a)
chronic obstructive pulmonary disease who is maintaining a tripod position to facilitate breathing
b)
acute streptococcal pharyngitis who began receiving antibiotic therapy 12 hours ago
c)
amyotrophic lateral sclerosis who is experiencing increased dysphagia
d)
urolithiasis who is reporting wave-like flank pain and nausea
e)
-
20.
The nurse performs admission assessments on 4 clients. Which client assessment information is most concerning and needs priority care?
a)
17-year-old with suspected meningococcal meningitis who has a fever of 103 F (39.4 C), headache with photophobia, and stiff neck
b)
36-year-old who is an IV drug user with cellulitis of the arm, a fever of 103.2 F (39.6 C), and foul smelling drainage from self-injection sites
c)
45-year-old with diabetes mellitus and osteomyelitis of the foot who has a fever of 100.9 F (38.3 C) and a serum glucose of 295 mg/dL (16.4 mmol/L)
d)
76-year-old with chronic bronchitis who has a fever of 101 F (38.3 C) and a productive cough of thick green mucus
e)
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21.
An 87-year-old client is admitted with a UTI, agitation, and confusion. What is the most important nursing action?
a)
Encouraging frequent fluid intake
b)
Keeping the bed elevated and side rails raised
c)
Providing one-on-one supervision
d)
Turning the lights off in the client's room
e)
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22.
After a family therapy session, a client is punching the wall. Which defense mechanism is being used?
a)
Projection
b)
Displacement
c)
Rationalization
d)
Reaction formation
e)
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23.
A client asks, "Am I going to die?" before hearing biopsy results. The nurse has not received permission to disclose. What is the appropriate response?
a)
You seem upset. Tell me how you're feeling.
b)
Watch TV, it might help you relax.
c)
I'm sure it will all work out.
d)
The biopsy shows cancer, but it's treatable.
e)
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24.
Nurse hears staff ask client, "Why did you get angry when your spouse ignored you?" What should the nurse do?
a)
No intervention
b)
Encourage open-ended clarification
c)
Ask about hallucinations instead
d)
Intervene due to use of a "why" question
e)
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25.
A client with schizophrenia says, "There is a bad person in my room." What should the nurse say?
a)
Your illness is making you hallucinate.
b)
I know you're frightened, but I don't see anyone.
c)
Don't worry. The meds will make it go away.
d)
Let's play a board game in the dayroom.
e)
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