Of these findings in four postoperative clients, the one that needs the nurse's action first is:

New inability to move the toes after a lumbar laminectomy

40 mL of serosanguineous drainage in a drain after mastectomy

Light pink urine with small clots during bladder irrigation after TURP

Right shoulder pain after a laparoscopic cholecystectomy

A client with heart failure weighs 82 kg at 0800, up from 80.5 kg yesterday. The client reports needing three pillows to breathe, has new crackles at both lung bases and an SpO2 of 91%. IV furosemide is prescribed. What should the nurse do first?

Place the client in high-Fowler's position

Report the weight gain to the provider

Give the prescribed IV furosemide

Limit the oral fluid intake to 1.5 L a day

A 3-month-old infant is admitted with respiratory syncytial virus bronchiolitis. The finding that needs the nurse's action first is:

Pauses in breathing lasting 20 seconds

Clear, copious nasal secretions

Taking smaller feeds than usual since yesterday

Prioritising clients and care by acuity

68 NCLEX-RN practice questions on Prioritising clients and care by acuity, part of Management of Care. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Hard
Of these findings in four postoperative clients, the one that needs the nurse's action first is:
1. ANew inability to move the toes after a lumbar laminectomy
2. B40 mL of serosanguineous drainage in a drain after mastectomy
3. CLight pink urine with small clots during bladder irrigation after TURP
4. DRight shoulder pain after a laparoscopic cholecystectomy
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Answer: A · New inability to move the toes after a lumbar laminectomy
New loss of movement in the legs after spinal surgery suggests spinal cord or nerve compression, such as from an epidural hematoma, and needs urgent surgical review. Light pink urine with small clots is expected during continuous irrigation after TURP. Shoulder pain after laparoscopy comes from carbon dioxide irritating the diaphragm, and modest serosanguineous drainage is expected after a mastectomy. This item tests recognising cues: unexpected versus expected postoperative findings.
- B: Moderate serosanguineous drain output is expected after mastectomy.
- C: Light pink urine with small clots is expected during irrigation after TURP.
- D: Referred shoulder pain from carbon dioxide is expected after laparoscopy.
Question 2 · Hard
A client with heart failure weighs 82 kg at 0800, up from 80.5 kg yesterday. The client reports needing three pillows to breathe, has new crackles at both lung bases and an SpO2 of 91%. IV furosemide is prescribed. What should the nurse do first?
1. AReport the weight gain to the provider
2. BGive the prescribed IV furosemide
3. CLimit the oral fluid intake to 1.5 L a day
4. DPlace the client in high-Fowler's position
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Answer: D · Place the client in high-Fowler's position
The client has fluid overload with pulmonary congestion. Sitting the client upright is the quickest action the nurse can take, because it lowers venous return to the heart and improves lung expansion within moments. Furosemide is given next and acts over minutes, and the provider is updated on the change. Fluid restriction is a longer-term measure. This item tests generating solutions and taking action in the right order.
- A: The provider is notified after the nurse takes the immediate actions within scope.
- B: Furosemide is essential but is given right after positioning, which helps at once.
- C: Fluid restriction is a longer-term measure, not the first action.
Question 3 · Medium
A 3-month-old infant is admitted with respiratory syncytial virus bronchiolitis. The finding that needs the nurse's action first is:
1. APauses in breathing lasting 20 seconds
2. BTemperature of 100.4 F (38 C)
3. CClear, copious nasal secretions
4. DTaking smaller feeds than usual since yesterday
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Answer: A · Pauses in breathing lasting 20 seconds
Apnea is a known complication of RSV in young infants, and a pause of 20 seconds or more is a breathing emergency. The nurse stimulates the infant, supports breathing and gets help. Nasal secretions, a low-grade fever and poor feeding are expected in bronchiolitis and are managed with suction, comfort and fluids. This item tests recognising cues by the ABC framework.
- B: A low-grade fever is expected and not the first priority.
- C: Copious nasal secretions are expected in bronchiolitis and are suctioned.
- D: Smaller feeds are expected and are monitored for dehydration.
Question 4 · Medium
In a client with alcohol-related cirrhosis, the finding that needs the nurse's action first is:
1. AAscites unchanged in girth
2. BReddened palms of the hands
3. CSpider angiomas on the chest
4. DVomiting bright red blood
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Answer: D · Vomiting bright red blood
Vomiting bright red blood in cirrhosis suggests bleeding esophageal varices, which can cause rapid, fatal blood loss. It is an acute airway and circulation emergency. Stable ascites, palmar erythema and spider angiomas are chronic findings of liver disease. This item tests recognising cues: an acute change in a client with a chronic illness.
- A: Stable ascites is a chronic finding in cirrhosis.
- B: Palmar erythema is a chronic sign of liver disease.
- C: Spider angiomas are a chronic sign of raised estrogen in liver disease.
Question 5 · Medium
Fifteen minutes into a unit of packed red blood cells, a client reports chills and low back pain, and the temperature has risen from 98.6 F (37 C) to 100.9 F (38.3 C). What should the nurse do first?
1. ANotify the blood bank
2. BStop the transfusion
3. CGive prescribed acetaminophen
4. DSlow the infusion rate
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Answer: B · Stop the transfusion
Chills, fever and back pain early in a transfusion suggest an acute hemolytic reaction, and the first action is to stop the blood at once. The nurse then keeps the IV line open with normal saline using new tubing, checks vital signs, and notifies the provider and the blood bank. Slowing the rate still infuses incompatible cells. This item tests taking action: the first step in a transfusion reaction.
- A: The blood bank is notified after the transfusion is stopped.
- C: Treating the fever does not stop the reaction.
- D: Slowing the rate still gives more incompatible blood.
Question 6 · Medium
A client with a new forearm cast has pain that the prescribed opioid does not relieve and that worsens when the fingers are moved passively. The nurse recognizes a possible:
1. ACompartment syndrome
2. BAllergic skin reaction
3. CNormal fracture pain
4. DOpioid tolerance
Answer and explanation in LearnFree account
Question 7 · Hard
A client with an upper GI bleed has received 2 units of packed red blood cells. Before: HR 124/min, BP 88/50, Hgb 7.0 g/dL. After: HR 96/min, BP 112/70, Hgb 8.9 g/dL, new fine crackles at both bases. Which finding is the priority to act on now?
1. ANew fine crackles at both bases
2. BHeart rate down from 124 to 96/min
3. CHemoglobin up to 8.9 g/dL
4. DBlood pressure up to 112/70
Answer and explanation in LearnFree account
Question 8 · Hard
On a children's ward, the RN starting evening rounds must decide which child to examine before the others. Which child is it?
1. AA 10-year-old with an arm cast whose pain is relieved by medication
2. BA 6-year-old in sickle cell crisis with pain of 5/10 on a PCA pump
3. CA 3-year-old with sudden high fever who is drooling and leaning forward
4. DA 2-year-old with a barking cough and no stridor while at rest
Answer and explanation in LearnFree account
Question 9 · Easy
A client with long-standing COPD has an SpO2 of 89% on room air at rest. It is unchanged from the past 3 days and the client is not in distress. The nurse interprets this as:
1. AAn expected baseline for this client
2. BA sign of acute respiratory failure
3. CA cue to call the rapid response team
4. DA reason to give 100% oxygen at once
Answer and explanation in LearnFree account
Question 10 · Medium
Eighteen hours after a total thyroidectomy, the unexpected finding that needs prompt follow-up is:
1. AIncisional pain of 4/10
2. BTingling around the mouth and in the fingers
3. CMild hoarseness of the voice when speaking
4. DSore throat when swallowing
Answer and explanation in LearnFree account
Question 11 · Hard
A client is on day 2 after a bowel resection. At 0300: T 99.1 F (37.3 C), HR 92/min, RR 18/min, BP 128/76. At 0700: T 101.6 F (38.7 C), HR 118/min, RR 24/min, BP 98/60, new confusion, lactate 3.2 mmol/L (reference below 2). The priority hypothesis is:
1. AMild dehydration from the long NPO status
2. BAtelectasis from shallow breathing
3. CSepsis, possibly from an anastomotic leak
4. DUncontrolled incisional pain
Answer and explanation in LearnFree account
Question 12 · Medium
A client with atrial fibrillation takes warfarin. The INR today is 2.6 (target 2.0-3.0). The finding the nurse should report first is:
1. ABlack, tarry stools since this morning
2. BINR within the target range
3. CIrregular pulse of 84/min
4. DA few small bruises on both forearms
Answer and explanation in LearnFree account
Question 13 · Medium
A client with chronic kidney disease receives hemodialysis three times a week. The morning result that needs action first is:
1. ABUN of 58 mg/dL
2. BPotassium of 6.8 mEq/L
3. CHemoglobin of 9.6 g/dL
4. DCreatinine of 6.2 mg/dL
Answer and explanation in LearnFree account
Question 14 · Medium
A client was admitted at 0600 after a fall with a head injury. At 1000, which finding should the nurse report to the health care provider at once?
1. AHeadache rated 4/10 that is unchanged since admission
2. BPupils equal and briskly reactive
3. CGlasgow Coma Scale score fell from 14 to 11
4. DOne episode of nausea without vomiting
Answer and explanation in LearnFree account
Question 15 · Easy
Using Maslow's hierarchy of needs, which client need does the nurse meet first?
1. AAdequate oxygenation
2. BA visit from family
3. CTaking part in care decisions
4. DProtection from a fall
Answer and explanation in LearnFree account
Question 16 · Easy
When the airway-breathing-circulation framework is used to set priorities, which finding is addressed first?
1. ASystolic pressure of 88 mm Hg
2. BCapillary refill of 4 seconds
3. CInspiratory stridor
4. DHeart rate of 118/min
Answer and explanation in LearnFree account
Question 17 · Medium
A client with heart failure has received IV furosemide for 2 days. The finding the nurse should report to the health care provider first is:
1. AWeight down 1 kg since yesterday
2. BSerum potassium of 3.1 mEq/L
3. CBlood pressure of 118/70 mm Hg
4. DUrine output of 2,400 mL in 24 hours
Answer and explanation in LearnFree account
Question 18 · Medium
A client newly diagnosed with lung cancer is tearful and says, "I'm so scared." The respiratory rate is 32/min and the SpO2 is 87%. What should the nurse do first?
1. AOffer to call the hospital chaplain for support
2. BRaise the head of the bed and apply prescribed oxygen
3. CExplain the treatment plan to ease the anxiety
4. DSit with the client and explore the client's fears
Answer and explanation in LearnFree account
Question 19 · Hard
A nurse is planning care for four clients. Which client can the nurse safely see last?
1. AA client whose chest tube drained 150 mL of bright red blood in an hour
2. BA client with slurred speech that began 30 minutes ago
3. CA client with osteoarthritis due for a scheduled analgesic for pain of 5/10
4. DA client with a potassium of 5.9 mEq/L and peaked T waves
Answer and explanation in LearnFree account
Question 20 · Medium
A client was rescued from a house fire with burns to the face, neck and arms. The nurse's priority finding is:
1. AUrine output of 40 mL in the last hour
2. BPain rated 8/10 at the burn sites
3. CHoarse voice with singed nasal hair
4. DBlistered, painful burns on the arms
Answer and explanation in LearnFree account
Question 21 · Easy
Which client is best described as unstable?
1. AA client with a stage 2 pressure injury that is slowly healing
2. BA client with diabetes whose glucose is 142 mg/dL before lunch
3. CA postoperative client whose heart rate rose from 82 to 118/min
4. DA client with chronic back pain rated 4/10 on scheduled analgesia
Answer and explanation in LearnFree account
Question 22 · Hard
A nurse reviews the morning results for four clients. Which result needs action first?
1. AGlucose 180 mg/dL in a client taking a high dose of prednisone for an asthma flare
2. BBUN 24 mg/dL in a client admitted with vomiting and dehydration
3. CHemoglobin 10.2 g/dL in a client with chronic kidney disease
4. DWBC 2,100/mm3, 10 days after chemotherapy, with a temperature of 100.9 F (38.3 C)
Answer and explanation in LearnFree account
Question 23 · Hard
On a pulmonary step-down unit, oxygen saturation readings vary widely between patients. Whose breathing is the most urgent concern?
1. ALung cancer, chronic cough and SpO2 of 92% unchanged for days
2. BAsthma, SpO2 93%, speaking 2-3 words at a time, using neck muscles
3. CCOPD, SpO2 88% on 2 L oxygen, at baseline and talking in sentences
4. DPneumonia, T 101.2 F (38.4 C), productive cough and SpO2 of 94%
Answer and explanation in LearnFree account
Question 24 · Medium
A client with an acute asthma attack had loud wheezes on admission. An hour later the wheezes can no longer be heard and the client is drowsy. The nurse interprets this as:
1. AImprovement from the bronchodilator
2. BSevere airflow obstruction with tiring
3. CA sign the attack is resolving
4. DAn expected effect of the sedation
Answer and explanation in LearnFree account
Question 25 · Hard
On a busy medical-surgical floor, a newly licensed RN plans the first rounds of the day shift. Whose bedside comes first?
1. AA client with a GI bleed whose heart rate rose from 88 to 122/min in 2 hours
2. BA client with type 1 diabetes whose fasting glucose is 245 mg/dL before breakfast
3. CA client with COPD on 2 L oxygen whose SpO2 is 90%, unchanged since admission
4. DA client 6 hours after appendectomy who asks for pain medication for pain of 6/10
Answer and explanation in LearnFree account

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Prioritising clients and care by acuity

Of these findings in four postoperative clients, the one that needs the nurse's action first is:

A client with heart failure weighs 82 kg at 0800, up from 80.5 kg yesterday. The client reports needing three pillows to breathe, has new crackles at both lung bases and an SpO2 of 91%. IV furosemide is prescribed. What should the nurse do first?

A 3-month-old infant is admitted with respiratory syncytial virus bronchiolitis. The finding that needs the nurse's action first is:

In a client with alcohol-related cirrhosis, the finding that needs the nurse's action first is:

Fifteen minutes into a unit of packed red blood cells, a client reports chills and low back pain, and the temperature has risen from 98.6 F (37 C) to 100.9 F (38.3 C). What should the nurse do first?

A client with a new forearm cast has pain that the prescribed opioid does not relieve and that worsens when the fingers are moved passively. The nurse recognizes a possible:

A client with an upper GI bleed has received 2 units of packed red blood cells. Before: HR 124/min, BP 88/50, Hgb 7.0 g/dL. After: HR 96/min, BP 112/70, Hgb 8.9 g/dL, new fine crackles at both bases. Which finding is the priority to act on now?

On a children's ward, the RN starting evening rounds must decide which child to examine before the others. Which child is it?

A client with long-standing COPD has an SpO2 of 89% on room air at rest. It is unchanged from the past 3 days and the client is not in distress. The nurse interprets this as:

Eighteen hours after a total thyroidectomy, the unexpected finding that needs prompt follow-up is:

A client is on day 2 after a bowel resection. At 0300: T 99.1 F (37.3 C), HR 92/min, RR 18/min, BP 128/76. At 0700: T 101.6 F (38.7 C), HR 118/min, RR 24/min, BP 98/60, new confusion, lactate 3.2 mmol/L (reference below 2). The priority hypothesis is:

A client with atrial fibrillation takes warfarin. The INR today is 2.6 (target 2.0-3.0). The finding the nurse should report first is:

A client with chronic kidney disease receives hemodialysis three times a week. The morning result that needs action first is:

A client was admitted at 0600 after a fall with a head injury. At 1000, which finding should the nurse report to the health care provider at once?

Using Maslow's hierarchy of needs, which client need does the nurse meet first?

When the airway-breathing-circulation framework is used to set priorities, which finding is addressed first?

A client with heart failure has received IV furosemide for 2 days. The finding the nurse should report to the health care provider first is:

A client newly diagnosed with lung cancer is tearful and says, "I'm so scared." The respiratory rate is 32/min and the SpO2 is 87%. What should the nurse do first?

A nurse is planning care for four clients. Which client can the nurse safely see last?

A client was rescued from a house fire with burns to the face, neck and arms. The nurse's priority finding is:

Which client is best described as unstable?

A nurse reviews the morning results for four clients. Which result needs action first?

On a pulmonary step-down unit, oxygen saturation readings vary widely between patients. Whose breathing is the most urgent concern?

A client with an acute asthma attack had loud wheezes on admission. An hour later the wheezes can no longer be heard and the client is drowsy. The nurse interprets this as:

On a busy medical-surgical floor, a newly licensed RN plans the first rounds of the day shift. Whose bedside comes first?