KAPLAN PRIORITIZATION AND DELEGATION
PRACTICE EXAM 100 Management of Care
Questions with Rationales
SECTION 1: PRIORITIZATION – ABCs & MASLOW
1. A nurse is caring for four clients on a medical-surgical unit. Which client
should the nurse assess FIRST?
A. A client with diabetes who has a blood glucose of 180 mg/dL.
B. A client with a new tracheostomy who has thick, yellow secretions and a
SpO2 of 88%.
C. A client with a fractured femur who is reporting pain of 7/10.
D. A client with a urinary tract infection who has a temperature of 100.4°F.
Correct Answer: B
Rationale: Airway is always the priority. The client with a new tracheostomy and
low SpO2 (88%) has an actual or potential airway compromise. The other clients
have stable conditions: hyperglycemia (A) requires treatment but is not
immediately life-threatening; pain (C) and low-grade fever (D) are important but
lower priority.
2. A nurse receives report on four clients. Which client should the nurse see
FIRST?
A. A client who is 2 days post-operative from a hip replacement and is requesting
pain medication.
,B. A client with a chest tube who has 200 mL of sanguineous drainage in the past
2 hours.
C. A client with a new diagnosis of pneumonia who has a temperature of 101.2°F.
D. A client with a colostomy who needs assistance with pouching.
Correct Answer: B
Rationale: The client with a chest tube and 200 mL of sanguineous drainage in 2
hours is at risk for hypovolemic shock or hemorrhage. This is a physiological
stability issue (ABCs—circulation). The other clients have stable needs that can be
addressed after assessing the unstable client.
3. A nurse is caring for a client with a head injury. The client's intracranial
pressure (ICP) is 22 mmHg. Which finding requires immediate intervention?
A. The client's blood pressure is 130/80 mmHg.
B. The client's pupils are unequal and sluggish.
C. The client's heart rate is 88 beats/min.
D. The client's temperature is 98.6°F.
Correct Answer: B
Rationale: Unequal and sluggish pupils indicate impending herniation—a life-
threatening emergency requiring immediate intervention. Normal ICP is 5-15
mmHg; 22 is elevated. BP (A), HR (C), and temperature (D) are within normal limits
for this client but do not indicate acute deterioration.
4. The nurse is caring for a client with a massive pulmonary embolism. Which
assessment finding requires immediate action?
A. The client's respiratory rate is 24 breaths/min.
B. The client's heart rate is 110 beats/min.
,C. The client's blood pressure is 80/50 mmHg.
D. The client's SpO2 is 92% on 2 L/min oxygen.
Correct Answer: C
Rationale: A blood pressure of 80/50 mmHg indicates obstructive shock from the
pulmonary embolism. This is a life-threatening circulatory compromise requiring
immediate intervention (fluids, vasopressors, possible thrombolytics). The other
findings are abnormal but not immediately life-threatening.
5. A nurse is caring for a client who is 6 hours post-operative from a
thyroidectomy. The client reports a "tight feeling" in the throat and is hoarse.
What is the priority action?
A. Administer prescribed pain medication.
B. Assess the client's respiratory status and prepare for possible airway
obstruction.
C. Notify the healthcare provider.
D. Place the client in a supine position.
Correct Answer: B
Rationale: Hoarseness and a tight throat sensation after thyroidectomy can
indicate laryngeal edema, hematoma, or hypocalcemia-induced laryngospasm—
all of which can lead to life-threatening airway obstruction. The priority is to
assess respiratory status and prepare emergency equipment (tracheostomy tray).
The provider is notified after immediate airway assessment.
6. A nurse is caring for a client with a new diagnosis of anaphylaxis. Which
finding requires immediate intervention?
A. The client's heart rate is 100 beats/min.
B. The client is wheezing and has stridor.
, C. The client's blood pressure is 100/70 mmHg.
D. The client's skin is flushed and warm.
Correct Answer: B
Rationale: Wheezing and stridor indicate bronchospasm and upper airway
edema—the most life-threatening manifestations of anaphylaxis. Airway is always
the priority. Tachycardia (A), hypotension (C), and flushing (D) are also signs of
anaphylaxis but are not as immediately life-threatening as airway compromise.
7. A nurse is caring for a client with a suspected stroke. The client's last known
well time was 2 hours ago. Which finding is most concerning?
A. The client has slurred speech.
B. The client is unable to swallow and is drooling.
C. The client's blood pressure is 160/90 mmHg.
D. The client has left-sided weakness.
Correct Answer: B
Rationale: Inability to swallow and drooling indicate loss of airway protective
reflexes, placing the client at high risk for aspiration and airway obstruction. This is
an airway priority. Slurred speech (A), hypertension (C), and unilateral weakness
(D) are concerning but do not immediately threaten the airway.
8. A nurse is caring for a client with a small bowel obstruction. Which finding is
most concerning?
A. Abdominal distension and cramping.
B. Hyperactive bowel sounds.
C. Fecal vomiting.
D. Nausea and vomiting of bilious fluid.
PRACTICE EXAM 100 Management of Care
Questions with Rationales
SECTION 1: PRIORITIZATION – ABCs & MASLOW
1. A nurse is caring for four clients on a medical-surgical unit. Which client
should the nurse assess FIRST?
A. A client with diabetes who has a blood glucose of 180 mg/dL.
B. A client with a new tracheostomy who has thick, yellow secretions and a
SpO2 of 88%.
C. A client with a fractured femur who is reporting pain of 7/10.
D. A client with a urinary tract infection who has a temperature of 100.4°F.
Correct Answer: B
Rationale: Airway is always the priority. The client with a new tracheostomy and
low SpO2 (88%) has an actual or potential airway compromise. The other clients
have stable conditions: hyperglycemia (A) requires treatment but is not
immediately life-threatening; pain (C) and low-grade fever (D) are important but
lower priority.
2. A nurse receives report on four clients. Which client should the nurse see
FIRST?
A. A client who is 2 days post-operative from a hip replacement and is requesting
pain medication.
,B. A client with a chest tube who has 200 mL of sanguineous drainage in the past
2 hours.
C. A client with a new diagnosis of pneumonia who has a temperature of 101.2°F.
D. A client with a colostomy who needs assistance with pouching.
Correct Answer: B
Rationale: The client with a chest tube and 200 mL of sanguineous drainage in 2
hours is at risk for hypovolemic shock or hemorrhage. This is a physiological
stability issue (ABCs—circulation). The other clients have stable needs that can be
addressed after assessing the unstable client.
3. A nurse is caring for a client with a head injury. The client's intracranial
pressure (ICP) is 22 mmHg. Which finding requires immediate intervention?
A. The client's blood pressure is 130/80 mmHg.
B. The client's pupils are unequal and sluggish.
C. The client's heart rate is 88 beats/min.
D. The client's temperature is 98.6°F.
Correct Answer: B
Rationale: Unequal and sluggish pupils indicate impending herniation—a life-
threatening emergency requiring immediate intervention. Normal ICP is 5-15
mmHg; 22 is elevated. BP (A), HR (C), and temperature (D) are within normal limits
for this client but do not indicate acute deterioration.
4. The nurse is caring for a client with a massive pulmonary embolism. Which
assessment finding requires immediate action?
A. The client's respiratory rate is 24 breaths/min.
B. The client's heart rate is 110 beats/min.
,C. The client's blood pressure is 80/50 mmHg.
D. The client's SpO2 is 92% on 2 L/min oxygen.
Correct Answer: C
Rationale: A blood pressure of 80/50 mmHg indicates obstructive shock from the
pulmonary embolism. This is a life-threatening circulatory compromise requiring
immediate intervention (fluids, vasopressors, possible thrombolytics). The other
findings are abnormal but not immediately life-threatening.
5. A nurse is caring for a client who is 6 hours post-operative from a
thyroidectomy. The client reports a "tight feeling" in the throat and is hoarse.
What is the priority action?
A. Administer prescribed pain medication.
B. Assess the client's respiratory status and prepare for possible airway
obstruction.
C. Notify the healthcare provider.
D. Place the client in a supine position.
Correct Answer: B
Rationale: Hoarseness and a tight throat sensation after thyroidectomy can
indicate laryngeal edema, hematoma, or hypocalcemia-induced laryngospasm—
all of which can lead to life-threatening airway obstruction. The priority is to
assess respiratory status and prepare emergency equipment (tracheostomy tray).
The provider is notified after immediate airway assessment.
6. A nurse is caring for a client with a new diagnosis of anaphylaxis. Which
finding requires immediate intervention?
A. The client's heart rate is 100 beats/min.
B. The client is wheezing and has stridor.
, C. The client's blood pressure is 100/70 mmHg.
D. The client's skin is flushed and warm.
Correct Answer: B
Rationale: Wheezing and stridor indicate bronchospasm and upper airway
edema—the most life-threatening manifestations of anaphylaxis. Airway is always
the priority. Tachycardia (A), hypotension (C), and flushing (D) are also signs of
anaphylaxis but are not as immediately life-threatening as airway compromise.
7. A nurse is caring for a client with a suspected stroke. The client's last known
well time was 2 hours ago. Which finding is most concerning?
A. The client has slurred speech.
B. The client is unable to swallow and is drooling.
C. The client's blood pressure is 160/90 mmHg.
D. The client has left-sided weakness.
Correct Answer: B
Rationale: Inability to swallow and drooling indicate loss of airway protective
reflexes, placing the client at high risk for aspiration and airway obstruction. This is
an airway priority. Slurred speech (A), hypertension (C), and unilateral weakness
(D) are concerning but do not immediately threaten the airway.
8. A nurse is caring for a client with a small bowel obstruction. Which finding is
most concerning?
A. Abdominal distension and cramping.
B. Hyperactive bowel sounds.
C. Fecal vomiting.
D. Nausea and vomiting of bilious fluid.
