NR 452 Capstone Course: Prioritization and Clinical Judgment Practice
Pack 2026 |Chamberlain College
1. A nurse is receiving a report on four clients. Which client should the nurse
assess first?
A. A client with chronic obstructive pulmonary disease (COPD) and an oxygen saturation of 91%
B. A client with a blood glucose level of 150 mg/dL
C. A client who is 2 days post-operative and requesting pain medication
D. A client with a new-onset of stridor after a thyroidectomy
Answer: D
Rationale: Stridor indicates an acute airway obstruction, which is a life-threatening
priority following the ABC (Airway, Breathing, Circulation) framework.
2. Which task is most appropriate for the nurse to delegate to an unlicensed
assistive personnel (UAP)?
A. Feeding a client with a high risk for aspiration
B. Performing a sterile dressing change on a post-operative wound
C. Assisting a stable client with ambulation for the first time after surgery
D. Obtaining a set of vital signs on a stable client who is 4 hours post-operative
Answer: D
Rationale: UAPs can perform routine tasks such as vital signs on stable clients. Aspiration
risks, sterile procedures, and first-time ambulation require nursing judgment or specialized
skill.
,3. A nurse is caring for a group of clients. Which of the following findings should
be reported to the provider immediately?
A. A client with a blood pressure of 190/110 mmHg and a severe headache
B. A client with a potassium level of 3.8 mEq/L
C. A client with heart failure who gained 1 lb in 24 hours
D. A client with a history of asthma reporting occasional dry cough
Answer: A
Rationale: This blood pressure indicates a hypertensive crisis, which can lead to organ
damage or stroke, requiring immediate intervention.
4. A nurse on a surgical unit is prioritizing care for four clients. Which client
should the nurse see first?
A. A client who had a gastrectomy 6 hours ago and has a heart rate of 120 bpm
B. A client scheduled for discharge in 2 hours needing education
C. A client with an incentive spirometer volume of 500 mL
D. A client reporting nausea after receiving morphine 1 hour ago
Answer: A
Rationale: Tachycardia (120 bpm) following major surgery like a gastrectomy could
indicate hemorrhage or shock, making this the highest priority.
5. A nurse is planning care for a client who is post-operative. Which intervention
should the nurse prioritize to prevent respiratory complications?
A. Administering prophylactic antibiotics
B. Ensuring the client remains on bed rest for 48 hours
C. Encouraging the use of an incentive spirometer every hour while awake
D. Monitoring the surgical site for drainage
Answer: C
Rationale: Incentive spirometry prevents atelectasis and pneumonia, which are common
post-operative respiratory complications.
, 6. Which of the following clients should the triage nurse categorize as
‘Emergent’ (Red Tag) during a mass casualty incident?
A. A client with a compound fracture of the femur and a pedal pulse
B. A client with minor abrasions and a sprained ankle
C. A client with an open pneumothorax and severe respiratory distress
D. A client who is unresponsive with a fixed pupil and no respirations
Answer: C
Rationale: The Red Tag is for life-threatening injuries that are treatable. An open
pneumothorax requires immediate attention to survive.
7. A nurse is caring for a client with a potassium level of 6.5 mEq/L. Which of the
following actions is the priority?
A. Reviewing the client’s dietary intake for the last 24 hours
B. Obtaining an electrocardiogram (ECG)
C. Administering a dose of oral potassium supplement
D. Documenting the result in the medical record
Answer: B
Rationale: Hyperkalemia (K+ > 5.0) can cause lethal cardiac arrhythmias. An ECG is
necessary to assess for cardiac changes such as peaked T waves.
8. A nurse is assigned to four clients. Which client requires the most immediate
intervention?
A. A client with a casted leg reporting itching under the cast
B. A client with a deep vein thrombosis (DVT) reporting sudden chest pain and shortness of breath
C. A client with diabetes whose morning blood glucose was 110 mg/dL
D. A client with a urinary tract infection who has dark yellow urine
Answer: B
Rationale: Sudden chest pain and dyspnea in a client with DVT are signs of a pulmonary
embolism, a life-threatening emergency.
Pack 2026 |Chamberlain College
1. A nurse is receiving a report on four clients. Which client should the nurse
assess first?
A. A client with chronic obstructive pulmonary disease (COPD) and an oxygen saturation of 91%
B. A client with a blood glucose level of 150 mg/dL
C. A client who is 2 days post-operative and requesting pain medication
D. A client with a new-onset of stridor after a thyroidectomy
Answer: D
Rationale: Stridor indicates an acute airway obstruction, which is a life-threatening
priority following the ABC (Airway, Breathing, Circulation) framework.
2. Which task is most appropriate for the nurse to delegate to an unlicensed
assistive personnel (UAP)?
A. Feeding a client with a high risk for aspiration
B. Performing a sterile dressing change on a post-operative wound
C. Assisting a stable client with ambulation for the first time after surgery
D. Obtaining a set of vital signs on a stable client who is 4 hours post-operative
Answer: D
Rationale: UAPs can perform routine tasks such as vital signs on stable clients. Aspiration
risks, sterile procedures, and first-time ambulation require nursing judgment or specialized
skill.
,3. A nurse is caring for a group of clients. Which of the following findings should
be reported to the provider immediately?
A. A client with a blood pressure of 190/110 mmHg and a severe headache
B. A client with a potassium level of 3.8 mEq/L
C. A client with heart failure who gained 1 lb in 24 hours
D. A client with a history of asthma reporting occasional dry cough
Answer: A
Rationale: This blood pressure indicates a hypertensive crisis, which can lead to organ
damage or stroke, requiring immediate intervention.
4. A nurse on a surgical unit is prioritizing care for four clients. Which client
should the nurse see first?
A. A client who had a gastrectomy 6 hours ago and has a heart rate of 120 bpm
B. A client scheduled for discharge in 2 hours needing education
C. A client with an incentive spirometer volume of 500 mL
D. A client reporting nausea after receiving morphine 1 hour ago
Answer: A
Rationale: Tachycardia (120 bpm) following major surgery like a gastrectomy could
indicate hemorrhage or shock, making this the highest priority.
5. A nurse is planning care for a client who is post-operative. Which intervention
should the nurse prioritize to prevent respiratory complications?
A. Administering prophylactic antibiotics
B. Ensuring the client remains on bed rest for 48 hours
C. Encouraging the use of an incentive spirometer every hour while awake
D. Monitoring the surgical site for drainage
Answer: C
Rationale: Incentive spirometry prevents atelectasis and pneumonia, which are common
post-operative respiratory complications.
, 6. Which of the following clients should the triage nurse categorize as
‘Emergent’ (Red Tag) during a mass casualty incident?
A. A client with a compound fracture of the femur and a pedal pulse
B. A client with minor abrasions and a sprained ankle
C. A client with an open pneumothorax and severe respiratory distress
D. A client who is unresponsive with a fixed pupil and no respirations
Answer: C
Rationale: The Red Tag is for life-threatening injuries that are treatable. An open
pneumothorax requires immediate attention to survive.
7. A nurse is caring for a client with a potassium level of 6.5 mEq/L. Which of the
following actions is the priority?
A. Reviewing the client’s dietary intake for the last 24 hours
B. Obtaining an electrocardiogram (ECG)
C. Administering a dose of oral potassium supplement
D. Documenting the result in the medical record
Answer: B
Rationale: Hyperkalemia (K+ > 5.0) can cause lethal cardiac arrhythmias. An ECG is
necessary to assess for cardiac changes such as peaked T waves.
8. A nurse is assigned to four clients. Which client requires the most immediate
intervention?
A. A client with a casted leg reporting itching under the cast
B. A client with a deep vein thrombosis (DVT) reporting sudden chest pain and shortness of breath
C. A client with diabetes whose morning blood glucose was 110 mg/dL
D. A client with a urinary tract infection who has dark yellow urine
Answer: B
Rationale: Sudden chest pain and dyspnea in a client with DVT are signs of a pulmonary
embolism, a life-threatening emergency.
