Quiz · Hard
NCLEX-style questions on who to see first, airway-breathing-circulation, Maslow, delegation, isolation precautions and emergency first actions. Each rationale explains why the other choices come second.
The nurse receives report on four clients. Which client should the nurse see first?
A client 1 day after appendectomy rating incisional pain 6/10, due for pain medication in 30 minutes
A client 2 days after hip surgery with sudden shortness of breath, chest pain and SpO₂ of 88%
A client with type 2 diabetes asking questions about discharge teaching
A client with a casted wrist who reports itching under the cast
Sudden dyspnea, chest pain and hypoxemia after orthopedic surgery suggest a pulmonary embolism, a threat to breathing and circulation. Pain is important but expected and soon treatable; teaching and itching are stable concerns.
Using Maslow's hierarchy, which nursing concern has the highest priority?
Anxiety about the diagnosis
Ineffective airway clearance
Risk for social isolation
Deficient knowledge about medications
Physiological needs (airway, breathing, circulation) come before safety, love and belonging, and esteem. Anxiety and knowledge deficits matter, but they are addressed once the airway is secure.
A client with diabetes is shaky, sweaty and slightly confused but able to swallow. Capillary glucose is 52 mg/dL. What should the nurse do first?
Give the client's scheduled insulin
Give 15 g of fast-acting carbohydrate, such as 4 oz (120 mL) of juice
Notify the provider before taking any action
Recheck the glucose in 1 hour
Rule of 15: give 15 g of fast-acting carbohydrate, recheck in 15 minutes, and repeat if glucose is still below 70 mg/dL. Treat first, then notify. Insulin would make the hypoglycemia worse.
Which task can the RN delegate to unlicensed assistive personnel (UAP)?
Teaching a client to self-inject insulin
Helping a stable postoperative client walk to the bathroom
Completing the admission assessment of a new client
Evaluating a client's response to IV pain medication
UAP can do routine, standard tasks for stable clients (ambulating, bathing, vital signs on stable clients). Assessment, teaching and evaluation require nursing judgment and stay with the RN.
Six hours after a thyroidectomy, which finding requires the nurse's immediate action?
Incisional pain rated 4/10
A small amount of serosanguineous drainage on the dressing
A sore throat when swallowing
New hoarseness and high-pitched noisy breathing (stridor)
Stridor signals airway obstruction from swelling, a hematoma, laryngeal nerve injury or hypocalcemic laryngospasm, and it is an emergency. A tracheostomy tray should be at the bedside. Mild pain, minimal drainage and a sore throat from intubation are expected.
A client's chest tube becomes disconnected from the drainage system. What should the nurse do first?
Submerge the end of the tube about 2 cm (1 inch) in a bottle of sterile water
Clamp the tube near the insertion site and leave it clamped until the provider arrives
Remove the chest tube and apply pressure
Notify the provider and wait for instructions
Placing the end under sterile water creates an immediate water seal so air cannot enter the pleural space. Prolonged clamping can cause a tension pneumothorax. After the seal, set up a new sterile system and notify the provider.
A client on a heparin infusion has bleeding gums and blood in the urine. The aPTT is far above the therapeutic range. What is the nurse's first action?
Give vitamin K
Recheck the aPTT in 6 hours
Stop the heparin infusion
Apply ice to the gums and continue the infusion
Stopping the drug that is causing the bleeding comes first; then notify the provider, who may order protamine sulfate, the heparin antidote. Vitamin K reverses warfarin, not heparin.
Which precautions are correct for a client with Clostridioides difficile diarrhea?
Alcohol-based hand rub alone
Droplet precautions with a surgical mask
Airborne precautions in a negative-pressure room
Contact precautions, with hand hygiene using soap and water
C. diff spreads by contact, and its spores are not reliably killed by alcohol. Washing with soap and water removes them mechanically. Gown and gloves are worn for all contact with the client and room.
Which client requires an airborne infection isolation (negative-pressure) room?
A client with influenza
A client with suspected pulmonary tuberculosis
A client with an MRSA wound infection
A client with bacterial meningitis caused by Neisseria meningitidis
Airborne diseases include tuberculosis, measles and varicella (chickenpox), and require an N95 respirator. Influenza and meningococcal meningitis need droplet precautions, and MRSA needs contact precautions.
A client with a new forearm cast reports severe pain not relieved by morphine and pain when the nurse passively extends the fingers. What is the priority action?
Notify the provider immediately, because this suggests compartment syndrome
Elevate the arm well above heart level and recheck in 1 hour
Give another dose of morphine
Apply ice directly over the cast and reassess next shift
Pain out of proportion to the injury and pain on passive stretch are early signs of compartment syndrome; permanent damage can occur within hours. Keep the limb at heart level (raising it above reduces blood flow) and prepare for cast splitting or fasciotomy.
One hour after a vaginal birth, the nurse finds a boggy fundus 2 cm above the umbilicus and heavy lochia. What is the first action?
Notify the provider
Start a second IV line
Massage the fundus
Document the findings and recheck in 1 hour
Uterine atony is the most common cause of postpartum hemorrhage, and fundal massage helps the uterus contract right away. Then the nurse can have the client void if the bladder is full, give uterotonics as ordered and notify the provider if bleeding continues.
For a client with suspected sepsis and otherwise stable vital signs, the provider orders blood cultures, IV ceftriaxone and a chest X-ray. Which should the nurse do first?
Draw the blood cultures
Give the IV ceftriaxone
Send the client for the chest X-ray
Give acetaminophen for the fever
Cultures are drawn before the first antibiotic dose so the antibiotic does not mask the organism. The antibiotic should follow quickly, within the first hour. The X-ray can wait, and acetaminophen was not ordered.
A client with terminal cancer says, "I'm going to die, aren't I?" Which response is most therapeutic?
"Don't worry, you are getting the best care possible."
"Why do you think that?"
"You sound worried. Tell me what you have been thinking about."
"You should ask your doctor about that."
Reflecting feelings and using an open-ended prompt invites the client to share. False reassurance shuts the conversation down, why questions sound judgmental, and redirecting to the doctor avoids the client's concern.
A client with chronic kidney disease has a serum potassium of 6.8 mEq/L. Which finding is the nurse's priority?
Serum creatinine of 3.1 mg/dL
Peaked T waves on the cardiac monitor
Generalized fatigue
2+ pedal edema
Severe hyperkalemia can cause fatal dysrhythmias, and peaked T waves show it is already affecting the heart. The other findings are expected with chronic kidney disease and are not immediately life-threatening.
A fire breaks out in a client's room. Using RACE, what does the nurse do first?
Rescue: move the client out of immediate danger
Activate the fire alarm
Close the doors to contain the fire
Use the fire extinguisher
RACE stands for Rescue, Alarm, Contain, Extinguish (or Evacuate). Client safety comes first. When using an extinguisher, remember PASS: Pull, Aim, Squeeze, Sweep.
