Nursing Exit Exam | Prioritization in Nursing Care |
HESI & NCLEX RN | Questions with Rationales
Question 1
A client with COPD arrives in the ER with increasing shortness of breath and accessory muscle
use. Which action should the nurse take first?
A. Administer prescribed albuterol via nebulizer
B. Assess the client’s respiratory rate and SpO₂
C. Teach pursed-lip breathing technique
D. Encourage fluid intake
Correct Answer: B
Rationale:
Assessing vital signs and oxygenation status is the first priority to determine the severity of
respiratory compromise before implementing interventions.
Why the others are not correct:
A. Bronchodilation is important, but assessment must guide timing.
C. Teaching techniques is secondary to immediate assessment.
D. Fluid intake may support hydration but does not address oxygenation.
Question 2
A client reports chest pain 7/10 with diaphoresis and nausea. While preparing the client for ECG,
another client needs discharge teaching. Who should the nurse see first?
A. Client with chest pain
B. Client needing discharge teaching
C. Client requesting ice water
D. Client who is ready for transport
Correct Answer: A
Rationale:
Potential cardiac events require immediate assessment over educational or non-urgent needs.
Why the others are not correct:
A. Correct — life-threatening symptom needs priority.
B. Discharge teaching can wait.
, C. Non-urgent.
D. Transport task is non-urgent.
Question 3
A nurse has four assigned patients. Which one should be assessed first?
A. A client with blood glucose of 50 mg/dL who is diaphoretic and able to swallow
B. A client who is due for routine vital signs
C. A client requesting pain medication for 4/10 pain
D. A client asking about discharge instructions
Correct Answer: A
Rationale:
Hypoglycemia with symptoms requires immediate intervention (fast-acting carbohydrate) before
other tasks.
Why the others are not correct:
A. Correct — impaired glucose is unstable.
B. Routine vitals are lower priority.
C. Moderate pain is stable.
D. Non-urgent.
Question 4
A client with heart failure has bilateral crackles and SpO₂ 89%. Which parameter should the
nurse monitor first?
A. Lung sounds and oxygen saturation
B. Daily weights
C. Dietary sodium intake
D. BUN/creatinine trends
Correct Answer: A
Rationale:
Respiratory status is prioritized when pulmonary congestion and hypoxia are present.
Why the others are not correct:
A. Correct — immediate respiratory assessment is priority.
B. While valuable, weight change is secondary.
HESI & NCLEX RN | Questions with Rationales
Question 1
A client with COPD arrives in the ER with increasing shortness of breath and accessory muscle
use. Which action should the nurse take first?
A. Administer prescribed albuterol via nebulizer
B. Assess the client’s respiratory rate and SpO₂
C. Teach pursed-lip breathing technique
D. Encourage fluid intake
Correct Answer: B
Rationale:
Assessing vital signs and oxygenation status is the first priority to determine the severity of
respiratory compromise before implementing interventions.
Why the others are not correct:
A. Bronchodilation is important, but assessment must guide timing.
C. Teaching techniques is secondary to immediate assessment.
D. Fluid intake may support hydration but does not address oxygenation.
Question 2
A client reports chest pain 7/10 with diaphoresis and nausea. While preparing the client for ECG,
another client needs discharge teaching. Who should the nurse see first?
A. Client with chest pain
B. Client needing discharge teaching
C. Client requesting ice water
D. Client who is ready for transport
Correct Answer: A
Rationale:
Potential cardiac events require immediate assessment over educational or non-urgent needs.
Why the others are not correct:
A. Correct — life-threatening symptom needs priority.
B. Discharge teaching can wait.
, C. Non-urgent.
D. Transport task is non-urgent.
Question 3
A nurse has four assigned patients. Which one should be assessed first?
A. A client with blood glucose of 50 mg/dL who is diaphoretic and able to swallow
B. A client who is due for routine vital signs
C. A client requesting pain medication for 4/10 pain
D. A client asking about discharge instructions
Correct Answer: A
Rationale:
Hypoglycemia with symptoms requires immediate intervention (fast-acting carbohydrate) before
other tasks.
Why the others are not correct:
A. Correct — impaired glucose is unstable.
B. Routine vitals are lower priority.
C. Moderate pain is stable.
D. Non-urgent.
Question 4
A client with heart failure has bilateral crackles and SpO₂ 89%. Which parameter should the
nurse monitor first?
A. Lung sounds and oxygen saturation
B. Daily weights
C. Dietary sodium intake
D. BUN/creatinine trends
Correct Answer: A
Rationale:
Respiratory status is prioritized when pulmonary congestion and hypoxia are present.
Why the others are not correct:
A. Correct — immediate respiratory assessment is priority.
B. While valuable, weight change is secondary.
