NCLEX Prioritization and Delegation Test Bank
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Graded A+
1. A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with a postoperative pain rating of 6/10
B. A client with a fever of 101°F and mild cough
C. A client with new onset shortness of breath and wheezing
D. A client scheduled for a routine dressing change
Answer: C
Rationale: Airway and breathing take priority over pain, fever, or routine care
according to the ABC principle.
2. Which task can a registered nurse safely delegate to a licensed practical
nurse (LPN)?
A. Administer IV push medications
B. Perform client teaching about new medications
C. Monitor a stable client’s vital signs
D. Insert a urinary catheter
Answer: D
Rationale: LPNs can perform routine procedures like catheter insertion, but IV
push medications and teaching are RN responsibilities.
3. A client with congestive heart failure reports sudden weight gain of 3
pounds in 24 hours. What should the nurse do first?
A. Document the finding
B. Notify the healthcare provider
C. Assess lung sounds
D. Encourage low-sodium diet
,Answer: C
Rationale: Sudden weight gain may indicate fluid overload. Assessing lung
sounds identifies early pulmonary edema, which is a priority.
4. Which client should the nurse see first during morning rounds?
A. A client requesting morning medications
B. A client with diabetes and a blood sugar of 250 mg/dL
C. A client with scheduled physical therapy
D. A client complaining of mild constipation
Answer: B
Rationale: High blood glucose requires prompt assessment to prevent
complications; it is more urgent than routine or comfort care.
5. Which nursing action is highest priority for a client with chest pain?
A. Take vital signs
B. Administer oxygen
C. Obtain an ECG
D. Ask about allergies
Answer: B
Rationale: Ensuring oxygenation is immediate priority (airway and breathing)
before diagnostics or medication administration.
6. A nurse is delegating tasks to unlicensed assistive personnel (UAP). Which
task is appropriate to assign?
A. Administer oral medications
B. Measure and record urine output
C. Assess a new wound
D. Perform nasogastric tube insertion
Answer: B
Rationale: UAPs can perform routine data collection but cannot perform
assessments or invasive procedures.
, 7. Which client requires immediate intervention by the nurse?
A. A client with stage 2 pressure ulcer reporting pain
B. A client with urinary retention for 8 hours
C. A client post-op day 3 with stable vitals
D. A client scheduled for discharge teaching
Answer: B
Rationale: Urinary retention can lead to acute complications and requires
timely assessment and intervention.
8. Which situation indicates the need to reassign a task back from LPN to RN?
A. LPN is preparing wound care for a stable patient
B. LPN is managing IV chemotherapy administration
C. LPN is checking vital signs on a stable patient
D. LPN is assisting with ambulation
Answer: B
Rationale: High-risk medications like IV chemotherapy require RN knowledge
and judgment.
9. A nurse is prioritizing care for four clients. Which client should be seen
first?
A. Post-op client 2 days after surgery reporting mild nausea
B. Client with COPD with O2 sat 88%
C. Client requesting morning bath
D. Client with scheduled lab work
Answer: B
Rationale: Oxygenation is a priority over comfort or routine care.
10. Which task is appropriate to delegate to a UAP?
A. Teach a diabetic client about insulin administration
B. Feed a client who is stable and alert
C. Assess a client’s neurological status
D. Administer oral medications
Exam Verified Questions, Correct Answers, and
Detailed Explanations for Students||Already
Graded A+
1. A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with a postoperative pain rating of 6/10
B. A client with a fever of 101°F and mild cough
C. A client with new onset shortness of breath and wheezing
D. A client scheduled for a routine dressing change
Answer: C
Rationale: Airway and breathing take priority over pain, fever, or routine care
according to the ABC principle.
2. Which task can a registered nurse safely delegate to a licensed practical
nurse (LPN)?
A. Administer IV push medications
B. Perform client teaching about new medications
C. Monitor a stable client’s vital signs
D. Insert a urinary catheter
Answer: D
Rationale: LPNs can perform routine procedures like catheter insertion, but IV
push medications and teaching are RN responsibilities.
3. A client with congestive heart failure reports sudden weight gain of 3
pounds in 24 hours. What should the nurse do first?
A. Document the finding
B. Notify the healthcare provider
C. Assess lung sounds
D. Encourage low-sodium diet
,Answer: C
Rationale: Sudden weight gain may indicate fluid overload. Assessing lung
sounds identifies early pulmonary edema, which is a priority.
4. Which client should the nurse see first during morning rounds?
A. A client requesting morning medications
B. A client with diabetes and a blood sugar of 250 mg/dL
C. A client with scheduled physical therapy
D. A client complaining of mild constipation
Answer: B
Rationale: High blood glucose requires prompt assessment to prevent
complications; it is more urgent than routine or comfort care.
5. Which nursing action is highest priority for a client with chest pain?
A. Take vital signs
B. Administer oxygen
C. Obtain an ECG
D. Ask about allergies
Answer: B
Rationale: Ensuring oxygenation is immediate priority (airway and breathing)
before diagnostics or medication administration.
6. A nurse is delegating tasks to unlicensed assistive personnel (UAP). Which
task is appropriate to assign?
A. Administer oral medications
B. Measure and record urine output
C. Assess a new wound
D. Perform nasogastric tube insertion
Answer: B
Rationale: UAPs can perform routine data collection but cannot perform
assessments or invasive procedures.
, 7. Which client requires immediate intervention by the nurse?
A. A client with stage 2 pressure ulcer reporting pain
B. A client with urinary retention for 8 hours
C. A client post-op day 3 with stable vitals
D. A client scheduled for discharge teaching
Answer: B
Rationale: Urinary retention can lead to acute complications and requires
timely assessment and intervention.
8. Which situation indicates the need to reassign a task back from LPN to RN?
A. LPN is preparing wound care for a stable patient
B. LPN is managing IV chemotherapy administration
C. LPN is checking vital signs on a stable patient
D. LPN is assisting with ambulation
Answer: B
Rationale: High-risk medications like IV chemotherapy require RN knowledge
and judgment.
9. A nurse is prioritizing care for four clients. Which client should be seen
first?
A. Post-op client 2 days after surgery reporting mild nausea
B. Client with COPD with O2 sat 88%
C. Client requesting morning bath
D. Client with scheduled lab work
Answer: B
Rationale: Oxygenation is a priority over comfort or routine care.
10. Which task is appropriate to delegate to a UAP?
A. Teach a diabetic client about insulin administration
B. Feed a client who is stable and alert
C. Assess a client’s neurological status
D. Administer oral medications
