NCLEX Review on Delegation and Prioritization Questions (1-5)

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1. A nurse from medical-surgical unit is asked to work on the orthopedic unit. The medical-surgical nurse has no orthopedic nursing
experience. Which client should be assigned to the medical-surgical nurse?
a) a client with a cast for a fractured femur and who has numbness and discoloration of the toes
b) a client with balanced skeletal traction and who needs assistance with morning care
c) a client who had an above-the-knee amputation yesterday and has a temperature of 101.4F
d) a client who had a total hip replacement 2 days ago and needs blood glucose monitoring

2. The nurse plans care for a client undergoing a colposcopy. Which of the following actions should the nurse take first?
a) discuss the client's fear regarding potential cervical cancer
b) assist with silver nitrate application to the cervix to control bleeding
c) provide instructions regarding douching and sexual relations
d) administer pain medication

3. A nurse is caring for four clients and is preparing to do her initial rounds. Which client should the nurse assess first?
a) a client with diabetes being discharged today
b) a client with tracheostomy and copious secretions
c) a client scheduled for physical therapy this morning
d) a client with a pressure ulcer that needs dressing change

4. A nurse enters a room and finds a client lying on the floor. Which action should the nurse perform first?
a) call for help to get the client back in bed
b) establish whether the client is responsive
c) assist the client back to bed
d) ask the client what happened

5. A nurse preceptor is working with a new nurse and notes that the new nurse is reluctant to delegate tasks to members of the care team. The
nurse preceptor recognizes that this reluctance most likely is due to:
a) role modeling behaviors of the preceptor
b) the philosophy of the new nurse's school of nursing
c) the orientation provided to the new nurse
d) lack of trust in the team members

6. A nurse is working in an emergency department and receives a client after a radiologic incident. Which task is a priority for the nurse to do
first?
a) decontaminate the client's clothing
b) decontaminate an open wound on the client's thigh
c) decontaminate the examination room the client is placed in
d) save the client's vomitus for analysis by the radiation safety staff

7. The nurse plans care for a client in the post-anesthesia care unit. Which assessment should the nurse make first?
a) respiratory status
b) level of consciousness
c) level of pain
d) reflexes and movement of extremities

8. A nurse in the clinic is reviewing the diet of a 28-year old female who reports several months of intermittent abdominal pain, abdominal
bloating, and flatulence. Which is a priority for the nurse to counsel the client to avoid in her diet?
a) fiber
b) broccoli
c) yogurt
d) simple carbohydrates

9. A nurse is developing the care plan for a client after bariatric surgery for morbid obesity. The nurse includes which of the following on the
care plan as the priority complication to prevent?
a) pain
b) wound infection
c) depression
d) thrombophlebitis


10. A client presents to the emergency room with dyspnea, chest pain, and syncope. The nurse assesses the client and notes that the client is
pale and diaphoretic with blood pressure 94/60, respiration 32. The client is anxious, fearing death. Which action should the nurse take first?
a) administer pain medication
b) administer IV fluids
c) administer dopamine
d) administer oxygen per nasal cannula

11. A nurse in a long term facility is planning care for an elderly client with confusion. Which action should the nurse take first?
a) sit the client in a geriatric chair with an activity
b) apply a vest restraint when the client is in a chair
c) apply bilateral wrist restraints when the client is in bed
d) have a staff member sit with the client at all times

12. The nurse is providing care in the emergency department to the client with chest pain. Which action is most important for the nurse to do
first?
a) perform venipuncture and start an IV line
b) administer oxygen via nasal cannula
c) administer morphine sulfate intravenously
d) start lidocaine (xylocaine) infusion

13. A nurse arrives on the scene of a multi-motor vehicle accident. The nurse determines that which of the following clients should be seen
first?
a) A 48 year old male who is pale, diaphoretic and reporting chest pain and shortness of breath
b) a 16 year old male with ecchymosis, pain, and swelling of the right arm
c) a 42 year old female who has a laceration on the forehead and is reporting neck and shoulder pain
d) an 8 year old child who is crying hysterically and reports abdominal pain

14. A child reports to the camp nurse's office after stepping on a bee. The child has pain, erythema, and edema of the lower aspect of the left
foot. As the nurse is observing the foot, the child says, "I feel like my throat is getting tight." The first action the nurse should take is:
a) assess the child's airway and breathing
b) call 911 and request an ambulance
c) administer subcutaneous epinephrine
d) remove the stinger from the foot

15. A nurse is working on a poison control hot-line and gets a call from a mother who reports her child has apparently taken part of a bottle of
adult acetaminophen capsules. The priority action for the nurse to take first is:
a) tell the mother to position the child lying down on her side
b) tell the mother to dial 911 and request an ambulance
c) have the mother give the child a glass of milk
d) instruct the mother on how to administer syrup of ipecac
16. A nurse receives a 10-month old child with a fracture of the left femur on the pediatric unit. Which action is important for the nurse to
take first?
a) call for a social worker to meet with the family
b) check the child's blood pressure, then pulse, respiration, and temperature
c) administer pain medication
d) speak with the parents about how the fracture occurred

17. A nurse on the cardiac unit is caring for four clients and is preparing to do initial rounds. Which client should the nurse assess first?
a) a client scheduled for cardiac ultrasound this morning
b) a client with syncope being discharged today
c) a client with chronic bronchitis on nasal oxygen
d) a client with a diabetic foot ulcer that needs a dressing change

18. A nurse enters a room and finds lying face down on the floor, bleeding from a gash in the head. Which action should the nurse perform
first?
a) determine level of consciousness
b) push the call button for help
c) turn the client face up to assess
d) go out in the hall to get the nursing assistant to stay with the client while the nurse calls the physician


19. A nurse is working on the night shift with a nursing assistant. The nursing assistant comes to the nurse stating that the other nurse
working on the unit is not assessing a client with abdominal pain despite multiple requests. Which of the following actions by the nurse is
best?
a) ask the other nurse if she needs any help
b) assess the client, and let the other nurse know what should be done
c) ask the client if he is satisfied with his care
d) contact the nursing supervisor to address the situation

20. The nurse is reviewing immunizations with the caregiver of a 72 year old client with a history of cerebral vascular disease. The caregiver
learns that which immunization is a priority for the client?
a) hepatitis A vaccine
b) lyme disease vaccine
c) hepatitis B vaccine
d) pneumococccal vaccine
21. A nurse delegates administration of an enema to a nursing assistant. The nurse should intervene if the nursing assistant:
a) advances the catheter 4 inches into the anal canal
b) hangs the enema bag 12 to 18 inches above the anus
c) lubricates 4 to 5 inches of the catheter tip
d) positions the client on the right side with head slightly elevated

22. A nurse is reviewing with a nursing assistant the care assignment for a client. Which of the following statements if made by the nurse
regarding care of a client with crutches is most appropriate?
a) the client needs to ambulate with crutches and a two-point gait
b) ambulate the client without weight bearing every 4 hours the length of the hall and back
c) ask the client if she understands how to use a two-point gait, if not, please explain it to the client
d) make sure the client does not bend the elbows when using the crutches

23. The home care nurse has four phone calls to answer. Which phone call should the home care nurse respond to first?
a) a client who received chemotherapy yesterday and is reporting nausea and vomiting
b) a client who was discharged two days ago with a urinary catheter after a transurethral prostactemomy and is reporting pink-tinged urine
c) a client with schizophrenia who says that the police has surrounded the house
d) the wife of a client with chronic heart disease who reports her husband is coughing frothy, white secretions and became confused during
the night

24. A nurse arrives on the scene of an apartment fire. Which of the following clients does the nurse attend to first?
a) a 3-year old child who cannot find her parents and is reporting a headache
b) a 48-year old male who has burns on both hands and reports severe pain
c) an 18-year old male who jumped from a second story window and is reporting severe arm pain
d) a 28-year old woman who has burns on the face and neck and reports difficulty swallowing

25. A female college student reports to the student health center very distressed after waking up in a male student's restroom and not
remembering what happened to the night before. The first action the nurse should take is:
a) obtain a rape kit
b) ask the client if she thinks she was raped
c) place the client in an examining room and leave her while she puts on a gown
d) provide a quiet, private area to use for initial assessment of the client
26. A nurse recently started working in a hospital that employs unlicensed assistant personnel (UAP). Which of the following are essential to
effective delegation?
a) give the UAP written instructions for assignments
b) make frequent walking rounds to assess clients
c) delegate tasks based on the experience of the UAP
d) take frequent mini-reports from the UAP
e) have the UAP repeat instructions
f) explain unexpected outcomes of delegated tasks to the UAP



27. A nurse is teaching a class regarding lead poisoning in children to student nurses. The nursing students learn to target which priority
group of children for screening?
a) those with sickle cell anemia
b) those who live in homes built in the 1960's
c) those who live in low-income families
d) adolescents living in the inner city

28. A nurse is attending an In-service training class on delegation. The nurse learns that proper delegation can involve which of the
following? Select all that apply
a) giving authority
b) delegating nursing process
c) delegating tasks
d) delegating accountability
e) delegating responsibility
f) giving orders

29. When developing the plan of care for a client with suicidal ideation, which of the following would the nurse anticipate as the priority?
a)Self-esteem
b)Sleep
c)Hygiene
d)Safety

30. A client in early labor is receiving oxytocin. When observing late decelerations in the fetal heart rate, the nurse should first:
a) Administer oxygen
b) Place her on her left side
c) Check the blood pressure
d) Discontinue the oxytocin infusion
31. A nurse employed in an emergency department is assigned to triage clients arriving to the emergency room for treatment on the evening
shift. The nurse should assign highest priority to which of the following clients?
a) a client complaining of muscle aches, a headache, and malaise
b) a client who twisted her ankle when she fell while rollerblading
c) a client with a minor laceration on the index finger sustained while cutting an eggplant
d) a client with chest pain who states that he just ate pizza that was made with a very spicy sauce

32. The RN is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing
assistant?
a) a client requiring colostomy irrigation
b) a client receiving continuous tube feedings
c) a client who requires urine specimen collections
d) a client with difficulty swallowing foods and fluids

33. The RN employed in a long-term care facility is planning assignments for the clients on a nursing unit. The RN needs to assign four
clients and has a licensed practical (vocational) nurse and three nursing assistants on a nursing team. Which of the following clients would the
nurse most appropriately assign to the licensed practical (vocational) nurse?
a) the client who requires a bed bath
b) an older client requiring frequent ambulation
c) a client who requires a 24-hour urine collection
d) a client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours

34. The RN has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client
will the RN plan to care for first?
a) A client who is ambulatory
b) a client scheduled for physical therapy at 1PM
c) a client with a fever who is diaphoretic and restless
d) a postoperative client who has just received pain and medication



35. The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?
a) a client scheduled for a chest x-ray
b) a client requiring daily dressing changes
c) a postoperative client preparing for discharge
d) a client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift
36. The nurse is giving a bed bath to an assigned client when a nursing assistant enters the client's room and tells the nurse that another
assigned client is in pain and needs pain medication. The appropriate nursing action is which of the following?
a) finish the bed bath and then administer the pain medication to the other client
b) ask the nursing assistant to find out when the last pain medication was given to the client
c) ask the nursing assistant to tell the client in pain that medication will be administered as soon as the bed bath is complete
d) cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client

37. A nurse is preparing to obtain an arterial blood gas specimen from a client and plans to preform the Allen's Test on the client. Arrange in
order of priority the steps for performing Allen's test. (Letter A is the first step and letter F is the last step.
a) document the findings
b) explain the procedure to the client
c) release pressure from the ulnar artery
d) apply pressure over the ulnar and radial arteries
e) ask the client to open and close the hand repeatedly
f) assess the color of the extremity distal to the pressure point

38. A nurse is monitoring a client receiving parenteral nutrition. The client suddenly develops respiratory distress, dyspnea, and chest pain,
and the nurse suspects air embolism. Arrange the actions that the nurse would take in order of priority (Letter A is the first action and letter F
is the last action).
a) administer oxygen
b) contact the physician
c) document the occurrence
d) take the client's vital signs
e) clamp the intravenous catheter
f) position the client in left trendelenburg position
39. A client has 1L bag of 5% dextrose in 0.9% sodium chloride hung at 3PM. The nurse making rounds at 3:45PM finds that the client is
complaining of pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV)
bag has 400 ml remaining. The nurse should take which of the following action first?
a) call the physician
b) slow the IV infusion
c) sit the client up in bed
d) remove the IV catheter

40. The nurse determines that he client is having a transfusion reaction. After the nurse stops the transfusion, which action should
immediately be taken next?
a) remove the IV line
b) run normal saline at a keep vein open rate
c) run a solution of 5% dextrose in water
d) obtain a culture of the tip of the catheter device removed from the client
Missing 41
42. A nurse on the day shift walks into a client's room and finds the client unresponsive. The client is not breathing and does not have a pulse,
and the nurse immediately calls out for help. The next nursing action is which of the following?
a) open the airway
b) give the client oxygen
c) start chest compressions
d) ventilate with a mouth-to-mask device




43. A nursing student is asked to describe the correct steps for performing adult cardiopulmonary resuscitation (CPR). Arrange in order of
priority the steps of adult CPR. (Letter A is the first step and letter F is the last step.)
a) initiate breathing
b) open the client's airway
c) determine breathlessness
d) perform chest compressions
e) check for a pulse at the carotid artery
f) determine unconsciousness by shaking the client and asking "Are you OK?"

44. A nurse receives a telephone call from the post-anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse
plans to do which of the following first on arrival of the client?
a) assess the patency of the airway
b) check tubes or drains for patency
c) check the dressing to assess for bleeding
d) assess the vital signs to compare with preoperative measurements.

45. A nurse is caring for a pregnant client with preeclampsia. The nurse prepares a plan of care for the client and documents in the plan that if
the client progresses for preeclampsia to eclampsia, the nurse's first action should be to:
a) administer oxygen by face mask
b) clear and maintain an open airway
c) administer magnesium sulfate intravenously
d) assess the blood pressure and fetal heart rate
46. A labor and delivery room nurse has just received report on four clients. The nurse should assess which client first?

a) a primiparous client in the active stage of labor
b) a multiparous client who was admitted for induction of labor
c) a client who is not contracting, but has suspected premature rupture
d) a client who has just received an IV loading dose of magnesium sulfate to stop preterm labor

47. A nurse in a newborn nursery receives a telephone call to prepare for the admission of a 43-week gestation newborn infant with Apgar
scores of 1 and 4. In planning for admission of this infant, the nurse's highest priority should be to:
a) turn on the apnea and cardiorespiratory monitors
b) connect the resuscitation bag to the oxygen outlet
c) set up the intravenous line with 5% dextrose in water
d) set the radiant warmer control temperature at 36.5C (97.6F)

48. A nurse is caring for a newborn infant with spina bifida (myelomeningocele) who is scheduled for surgical closure of the sac. In the
preoperative period, the priority nursing diagnosis would be risk for:
a) infection
b) aspiration
c) activity intolerance
d) altered growth and development

49. After a tonsillectomy, a child begins to vomit bright red blood. The initial nursing action is to:
a) notify the physician
b) turn the child to the side
c) maintain an NPO status
d) administer the prescribed antiemetic

50. The nurse manager is planning the clinical assignments for the day and avoids assigning which staff member to the client with herpes
zoster?
a) the nurse who never had rubeola
b) the nurse who never had mumps
c) the nurse who never had chickenpox
d) the nurse who never had german measles


51. A client with a wound infection and osteomyelitis is to receive hyperbaric oxygen therapy. During the therapy, the nurse implements
which priority intervention?
a) maintains an intravenous access
b) ensures that oxygen is being delivered
c) administers sedation to prevent claustrophobia
d) provides emotional support to the client's family

52. A nurse is caring for a client who had an orthopedic injury of the leg requiring surgery and application of a cast. Postoperatively, which
nursing assessment is of highest priority?
a) monitoring of heel breakdown
b) monitoring of bladder distention
c) monitoring of extremity shortening
d) monitoring for loss of blanching ability of toe nailbeds

53. A nurse hears the alarm sound on the telemetry monitor, looks at the monitor, and notes that a client is in ventricular tachycardia. The
nurse rushes to the client's room. Upon reaching the client's bedside, the nurse would take which action first?
a) call a code
b) prepare for cardioversion
c) prepare to defibrillate the client
d) check the client's level of consciousness

54. A nurse has just finished assisting the physician in placing a central intravenous (IV) line. Which of the following is a priority nursing
intervention after central line insertion?
a) prepare the client for a chest radiograph
b) assess the client's temperature to monitor for infection
c) label the dressing with the date and time of catheter insertion
d) monitor the blood pressure to assess for fluid volume overload

55. A nurse reviews the assessment data of a client admitted to the hospital with a diagnosis of anxiety. The nurse assigns priority to which
assessment finding?
a) temperature 99.4F, flat affect
b) fist clenched and pounding table
c) tearful, withdrawn, and isolated
d) blood pressure 160/100 mmHg; pulse 120 bpm, respirations 18 breaths per minute
56. A client is being brought into the emergency department after suffering a head injury. The first action by the nurse is to determine the
client's:
a) level of consciousness
b) pulse and blood pressure
c) respiratory rate and depth
d) ability to move extremities

57. A nurse is caring for a client scheduled for an arthroscopy. The nurse develops a postoperative plan of care and includes which priority
nursing action in the plan?
a) monitor intake and output
b) assess the tissue at the surgical site
c) monitor the area for numbness or tingling
d) assess the complete blood cell count results

58. A nurse is performing an assessment on a client who has a suspected spinal cord injury. Which of the following is the priority nursing
assessment?
a) pain level
b) mobility level
c) respiratory status
d) pupillary response




59. A 52-year old male client is seen in the physician's office for a physical examination after experiencing unusual fatigue over the last
several weeks. The client's height is 5 feet, 8 inches, and his weight is 220 pounds. Vital signs are: temperature 98F orally, pulse 86 beats per
minute, and respirations 18 breaths per minute. The blood pressure (BP) is 184/100 mmHg. Random blood sugar glucose is 122 mg?dL.
Which of the following questions should the nurse ask the client first?
a) do you exercise regularly?
b) are you considering trying to lose weight?
c) is there a history of diabetes mellitus in your family?
d) when was the last time you had your blood pressure checked?

60. A client admitted to the nursing unit from the emergency department has a spinal cord injury at the level of the fourth cervical vertebra
(C-4). Which assessment should the nurse perform first when admitting the client to the nursing unit?
a) listen to breath sounds
b) observe for dyskinesias
c) take the client's temperature
d) assess extremity muscle strength
61. A client received a thermal burn caused by the inhalation of steam. The client's mouth is edematous and the nurse notes
blisters in the client's mouth. The nurse first assesses which priority item(s)?
a) neurological status
b) level of consciousness
c) temperature via the rectal route
d) respiratory status and lung sounds

62. A registered nurse (RN) is planning the assignments for the day and is leading a team composed of a licensed practical
nurse (LPN) and a nursing assistant (NA). The nurse assigns which client to the LPN
a) client with dementia
b) a 1-day postoperative mastectomy client
c) a client who requires some assistance with bathing
d) a client who requires some assistance with ambulation

63. A client requests pain medication and the nurse administers a ventrogluteal intramuscular injection. After administration of
the injection, the nurse does which of the following first?
a) washes the hands
b) removes the gloves
c) applies gentle pressure to the injection site
d) places the syringe in the secure, puncture-resistant needle box container

64. A registered nurse is delegating activities to the nursing staff. Which activity is least appropriate for the nursing assistant?
a) collecting a urine specimen from a client
b) obtaining frequent oral temperatures on a client
c) accompanying a man being discharged
d) assisting a postcardiac catheterization client who needs to lie flat to eat lunch

65. A nurse is planning the client assignments for the shift. Which client would the nurse assign to the nursing assistant?
a) a client requiring dressing changes
b) a client requiring frequent ambulation
c) a client on a bowel management program requiring rectal suppositories and a daily enema
d) a client with diabetes mellitus requiring daily insulin and reinforcement of dietary measures
66. A client tells the home care nurse of a personal decision to refuse external cardiac resuscitation measures. Which of the following is the
most appropriate initial nursing action?
a) notify the physician of the client's request
b) discuss the client's request with the client's family
c) document the client's request in the home care nursing care plan
d) conduct a client conference with the home care staff to share the client's request
67. A nurse is caring for a client who is going to have an arthrogram using a contrast medium. Which preprocedure assessment would be of
highest priority?
a) allergy to iodine or shellfish
b) whether the client wishes to void before the procedure
c) ability of the client to remain still during the procedure
d) whether the client has any remaining questions about the procedure

68. A registered nurse (RN) asks a licensed practical nurse (LPN) to change the colostomy bag on a client. The LPN tells the RN that
although attendance at the hospital in-service was completed regarding this procedure, the LPN has never performed a colostomy bag change
on a client. The appropriate action by the RN is to:
a) perform the procedure with the LPN
b) request that the LPN observe another LPN perform the procedure
c) ask the LPN to review the materials from the in-service before performing the procedure
d) instruct the LPN to review the procedure in the hospital manual and take the written procedure into the client's room for reference

69. A nurse working on a medical nursing unit during an external disaster is called to assist with care for clients coming into the emergency
department. Using principles of triage, the nurse initiates immediate care for a client with which of the following injuries?
a) fractured tibia
b) penetrating abdominal injury
c) bright red bleeding from a neck wound
d) open massive head injury to deep coma

70. A nurse working on an adult nursing unit is told to review the client census to determine which client could be discharged if there are a
large number of admissions from a newly declared disaster. The nurse determines that the client with which of the following problems would
need to remain hospitalized?
a) laparoscopic cholecystectomy
b) fractured hip, pinned 5 days ago
c) diabetes mellitus with blood glucose at 180 mg/dL
d) ongoing ventricular dysrhythmias while receiving procainamide (Procanbid)
71. A nurse is called to a client's room by another nurse. When the nurse arrives at the room, she discovers that a fire has occurred in the
client's wastebasket. The first nurse removed the client from the room. What is the second nurse's next action?
a) confine the fire
b) evacuate the unit
c) extinguish the fire
d) activate the fire alarm

72. A client with type 2 diabetes mellitus is being discharge from the hospital after an occurrence of hyperglycemic hyperosmolar nonketotic
syndrome (HHNS). The nurse develops a discharge teaching plan for the client and identifies which of the following as a priority?
a) exercise routines
b) controlling dietary intake
c) keeping follow-up appointments
d) monitoring for signs of dehydration

73. A client is receiving intralipids (fat emulsion) intravenously at home, and the client's spouse manages the infusion. The health care nurse
makes a visit and discusses potential adverse reactions and the side effects of the therapy with the client and the spouse. After the discussion,
the nurse expects the spouse to verbalize that, in case of suspected adverse reaction, the priority action is to:
a) stop the infusion
b) contact the nurse
c) take the client's blood pressure
d) contact the local area emergency response team

74. The nurse caring for a client who is dying formulates a nursing diagnosis of Fear and identifies appropriate nursing interventions. From
the following list of nursing interventions, which intervention should the nurse implement first?
a) help the client express fears
b) assess the nature of the client's fear
c) help the client identify coping mechanisms that were successful in the past
d) document verbal and nonverbal expressions of fear and other significant data


75. A nurse reviews the preoperative teaching plan for a client scheduled for a radical neck dissection. When implementing the plan, the
nurse initially focuses on:
a) the financial status of the client
b) postoperative communication techniques
c) information given to the client by the surgeon
d) the client's support system and coping behaviors
76. A nurse in a rehabilitation center is planning the client assignments for the day. Which client would the nurse assign to the nursing
assistant?
a) a client on strict bedrest for whom a 24-hour urine specimen is being collected
b) a client scheduled for transfer to the hospital for coronary artery bypass surgery
c) a client scheduled for transfer to the hospital for an invasive diagnostic procedure
d) a client who is going through rehabilitation after undergoing a below-the-knee amputation (BKA)

77. A client has received electroconvulsive therapy (ECT). In the post-treatment area and upon the client's awakening, the nurse will perform
which intervention first?
a) assist the client from the stretcher to a wheelchair
b) orient the client and monitor the client's vital signs
c) offer the client frequent reassurance and repeat orientation statements
d) check for a gag reflex and then encourage the client to eat breakfast and resume activity

78. A nurse has assisted the physician in placing a central (subclavian) catheter. Following the procedure, the nurse takes which priority
action?
a) ensures that a chest radiograph is done
b) obtains a temperature reading to monitor for infection
c) labels the dressing with the date and time of catheter insertion
d) monitor the blood pressure (BP) to check for fluid volume overload

79. A nurse is caring for a hospitalized client with a diagnosis of abruptio placentae. The nurse develops a nursing care plan and suggests
measures to be implemented in the event of the development of shock. The nurse documents that the initial nursing action in the event of
shock is which of the following?
a) turn the client onto her side
b) check the client's blood pressure
c) monitor urinary output
d) check the client's heart rate

80. A nurse is assigned to care for a pregnant client with a diagnosis of sickle cell anemia. The nurse reviews the plan of care and notes
documentation of four nursing diagnoses. Which would the nurse select as the priority?
a) activity intolerance
b) ineffective coping
c) imbalanced nutrition: less than body requirements
d) deficient fluid volume
81. An emergency department nurse prepares a client who sustained a gunshot wound for surgery. The nurse removes the client's clothing and
places a gown on the client to prepare the client for the surgical procedure. Which of the following indicates the appropriate nursing action
regarding the client's clothing, which is stained with blood?
a) discard clothing
b) give the clothing to the family member or significant other
c) place the clothing in a paper bag
d) place the clothing in a plastic bag and in a locked cabinet

82. A nurse is assessing a client who has a suspected spinal cord injury. Which of the following is the priority assessment?
a) pupillary response
b) respiratory status
c) mobility
d) pain



83. When delegating a task to a team member, the nurse as the team leader gives authority over the task by:
a) offering suggestions on how to complete the task
b) waiting for the team member to report the results of the completed task
c) completing the task for the team member
d) checking to be sure the task is complete

84. A nurse is assigned to care for a client with coronary artery disease (CAD) who is scheduled fro a cardiac catheterization. Following the
catheterization, the priority nursing action is to assess the:
a) catheter insertion site
b) temperature
c) potassium level
d) urine output

85. A nurse in a day care center is told that a child with autism will be attending the center. The nurse collaborates with the staff of the day
care center and plans activities that will meet the child's needs. The priority consideration in planning activities for the child is to ensure:
a) social interactions with other children in the same age-group
b) safety with activities
c) familiarity with all activities and providing orientation throughout the activities
d) activities that provide verbal stimulation
86. A nurse employes in a rehabilitation center is planning the client assignments for the day. Which client would the nurse assign to the
nursing assistant?
a) a client who had a below-the-knee amputation
b) a client on a 24-hour urine collection who is on strict bedrest
c) a client scheduled to be transferred to the hospital for coronary artery bypass surgery
d) a client scheduled for transfer to the hospital for an invasive diagnostic procedure

87. The parents of an 18-month-old child arrive at the emergency department with the child. The child is unconscious. The physical
examination reveals bruises on the child's upper arms that resemble grip marks, and the nurse suspects child abuse. The first priority of the
nurse is to:
a) contact the appropriate state officials to report the abuse case
b) establish a trusting relationship with the parents
c) secure a safe environment for the child
d) stabilize the child's physical condition

88. A nurse is planning care for a client with an obsessive-compulsive disorder. The nurse would assign the highest priority to which of the
following nursing interventions?
a) educate the client about self-control techniques
b) establish a trusting nurse-client relationship
c) monitor the client for abnormal behavior
d) encourage participation in daily self-care and unit activities

89. A nurse has delegated several nursing tasks to staff members. The nurse's primary responsibility following delegation of the tasks is to:
a) allow each staff member to make judgements when performing the tasks
b) follow up with each staff member regarding the performance of the task and the outcomes related to implementing the task
c) document that the task was complemented
d) assign the tasks that were not completed to the next nursing shift

90. A client who has had abdominal surgery calls the nurse and reports that she felt that "something gave way" in the abdominal incision. The
nurse checks the abdominal incision and notes the presence of wound dehiscence. The nurse should take which action first?
a) contact the physician
b) document the findings
c) place the client inlow-fowler's position and instruct the client to lie quietly
d) cover the abdominal wound with a sterile dressing moistened with sterile saline solution



91. A nurse is caring for a client who just returned from the recovery room after a tonsillectomy and adenoidectomy. The client is restless and
the pulse rate is elevated. The nurse prepares to continue assessing the client, but the client begins to vomit large amounts of bright red blood.
The immediate nursing action is to:
a) notify the surgeon
b) continue with the assessment
c) check the client's temperature
d) obtain a flashlight, gauze, and a curved hemostat

92. A postoperative client suddenly develops chest pain and is experiencing dyspnea and tachypnea. The nurse suspects that the client has a
pulmonary embolism and immediately plans to:
a) ensure that the intravenous (IV) line is patent
b) prepare the client for a perfusion scan
c) administer nasal oxygen
d) place the client on a cardiac monitor

93. An older client with a history of hyperparathyroidism and severe osteoporosis is newly hospitalized. The nurse reviews the plan of care
for the client and selects which nursing diagnosis as the priority?
a) risk for injury
b) impaired urinary elimination
c) risk for constipation
d) ineffective health maintenance

94. A client arrives at the nursing unit following internal maxillary fixation (IMF) surgery. The immediate nursing action is to:
a) administer an anti-emetic to prevent vomiting
b) position the client on the side with the head slightly elevated
c) place wire cutters at the bedside
d) connect the nasogastric tube (NGT) to allow intermittent suction

95. A registered nurse is planning the client assignments for the day. Which of the following is the appropriate assignment for the nursing
assistant?
a) a client requiring frequent vital signs following a cardiac catheterization
b) a client who requires frequent ambulation
c) a client requiring wound irrigation
d) a client receiving continuous tube feedings
96. A registered nurse (RN) employed in a long-term care facility is planning assignments for the clients on a nursing unit. The RN needs to
assign four clients and has a licensed practical nurse (LPN) and three nursing assistants on a nursing team. Which of the following clients
would the nurse appropriately assign to the LPN?
a) a client with a right leg amputation who requires assistance with a shower
b) a client requiring a bed bath and frequent ambulation with a walker
c) a client who requires frequent temperatures taken
d) a client with a decubitus ulcer that requires a wound irrigation and dressing change

97. A registered nurse (RN) has received the assignment for the day shift. After making initial rounds and checking all the assigned clients,
which client will the RN plan to care for first?
a) a postoperative client with chest tubes who has just received pain medication
b) a client scheduled for a chest x-ray at 11:00 AM
c) a client who is scheduled for surgery at 1:00 PM
d) a client who is self-care

98. A nurse is assigned to care for four clients. In planning client rounds, which client would the nurse assess first?
a) a client admitted on the previous shift with a diagnosis of gastroenteritis
b) a client in skeletal traction
c) a client attached to a ventilator
d) a postoperative client preparing for discharge



99. A nurse on the day shift is assigned to care for four clients. Following report from the night shift, which client will the nurse plan to asses
first?
a) client scheduled for a cardiac catheterization at 10:00 AM
b) client newly diagnosed with diabetes mellitus who is scheduled for discharge to home
c) client with pulmonary edema who was treated with furosemide (Lasix) at 5:00 AM
d) client scheduled to have an electrocardiogram (ECG) at 9:00 AM

100. A registered nurse (RN) is planning the client assignments for the day. The RN assigns which of the following clients to the nursing
assistant?
a) a client who needs range-of-motion exercises every 4 hours
b) a client who needs to be catheterized every 12 hours
c) a client who needs to be suctioned as needed (PRN)
d) a client who needs a dressing change performed every 4 hours
101. A registered nurse (RN) is implementing a team nursing approach. The RN has a licensed practical nurse (LPN) and a nursing assistant
on the team and is planning the client assignments for the day. The RN appropriately assigns which of the following clients to the LPN?
a) a client who needs assistance with grooming
b) a client who needs frequent ambulation
c) a client who needs to be suctioned as needed (PRN)
d) a client who needs assistance with hygiene measures

102. A nurse is planning client assignments. Which of the following is the least appropriate assignment for the nursing assistant?
a) assisting a profoundly developmentally disabled child to eat lunch
b) obtaining frequent oral temperatures on a client
c) accompanying a 51-year old man, being discharged to home following a bowel resection
d) collecting a urine specimen from a 70-year old woman admitted 3 days ago

103. A nurse is assigned to care for four clients. In planning client rounds, which client would the nurse assess first?
a) a client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift
b) a postoperative client preparing fro discharge
c) a client scheduled for a chest x-ray
d) a client requiring daily dressing changes

104. A nurse is planning the client assignments for the shift. Which of the following clients would the nurse appropriately assign to the
nursing assistant?
a) a client requiring twice -daily dry dressing changes
b) a client requiring frequent ambulation with a walker
c) a client on a bowel management program requiring rectal suppositories and a daily enema
d) a client with diabetes mellitus requiring daily insulin and reinforcement of dietary measures

105. A client with a spinal cord injury develops a severe, pounding headache. The client is diaphoretic, hypertensive, and bradycardic and
complains of nausea and nasal congestion. The nurse determines that the client is experiencing autonomic hyperreflexia (autonomic
dysreflexia). Which action would the nurse take first?
a) notify the physician
b) document the findings
c) perform a rectal examination
d) place the client in a sitting position