NCLEX RN prioritization delegation assignment EXAM A+ GRADE ASSURED COMPLETE SOLUTIONS AND VERIFIED ANSWERS

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Prioritization NCLEX questions 2026 A+ GRADE ASSURE vc vc vc vc vc vc




D COMPLETE SOLUTIONS AND VERIFIED ANSWERS (6C3
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DD)




QUESTION 1 vc




A nurse has received the assignment for the day shift. After making initial rounds and ch
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ecking all of the assigned clients, which client should the nurse plan to care for first?
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a. A client who is ambulatory
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b. A client scheduled for physical therapy at 1 pm
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c. A client with a fever who is diaphoretic and restless
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d. A postoperative client who has just received pain medication
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ANSWER

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The nurse should plan to care for the client who has a fever and is diaphoretic and restless first becaus
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e this client's needs are the priority. The client who is ambulatory and the client scheduled for physical
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therapy later in the day do not have priority needs related to care. Waiting for pain medication to take e
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ffect before providing care to the postoperative client is best.
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QUESTION 2 vc




You are monitoring a 53-year-
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old client who is undergoing a treadmill stress test. Which client-
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finding will require the most immediate action? 1. Blood pressure of 152/ 88 mm Hg 2. H
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eart rate of 134 beats/ min 3. Oxygen saturation of 91% 4. Chest pain level of 3 (on a sca
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le of 10) vc vc




ANSWER

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Chest pain in a client undergoing a stress test indicates myocardial ischemia and is an indication to sto
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p the testing to avoid ongoing ischemia, injury, or infarction. Moderate elevations in blood pressure and
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heart rate and slight decreases in oxygen saturation are a normal response to exercise and are expected
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during stress testing. Focus: Prioritization
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, QUESTION 3 vc




You are reviewing the complete blood count for a patient who has been admitted for kne
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e arthroscopy. Which value is most important to report to the physician before surgery?
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1. Hematocrit of 33% 2. Hemoglobin level of 10.9 g/ dL 3. Platelet count of 426,000/ mm
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3 4. White blood cell count of 16,000/ mm3
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ANSWER

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Centers for Disease Control and Prevention (CDC) guidelines for the prevention of surgical site infectio
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ns indicate that surgery should be postponed when there is evidence of a pre-
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existing infection such as an elevation in white blood cell count. The other values are slightly abnormal,
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but would not be likely to cause postoperative problems for knee arthroscopy. Focus: Prioritization
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QUESTION 4 vc




What is the priority nursing diagnosis for a client experiencing a migraine headache? 1.
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Acute Pain related to biologic and chemical factors 2. Anxiety related to change in or thr
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eat to health status 3. Hopelessness related to deteriorating physiologic condition 4. Risk
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for Injury related to side effects of medical therapy
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ANSWER

1-
The priority for interdisciplinary care for the client experiencing a migraine headache is pain managem
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ent •All of the other nursing diagnoses are accurate, but none of them is urgent like the issue of pain, w
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hich is often incapacitating. Focus: Prioritization
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QUESTION 5 vc




•After the respiratory therapist performs suctioning on a patient who is intubated, the R
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N measures vital signs for the patient. Which vital sign value should the RN be most conc
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erned about? vc



A. Heart rate of 98 beats/min
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B. Respiratory rate of 24 breaths/min
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C. Blood pressure of 168/90 mm Hg
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D. Tympanic temperature of 101.4ºF (38.6ºC)
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ANSWER

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Infections are always a threat to the patient receiving mechanical ventilation. The endotracheal tube by
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passes the body's normal air-
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filtering mechanisms and provides a direct access route for bacteria or viruses to the lower part of the r
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espiratory system. vc




QUESTION 6 vc