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WorksheetsNCLEX - Prioritiz and Delegration Day1 (Part 1)
Total questions: 15
Worksheet time: 15mins
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
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
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
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
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
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
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
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
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)
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
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
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
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
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
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
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