NCLEX Quiz: Prioritize & Take Action (NCJMM) First

1. A stroke patient arrives within 3 hours of symptom onset. Priority action?

Obtain stat CT scan and assess for thrombolytic eligibility

Start aspirin immediately

Begin physical therapy

Insert feeding tube

2. A patient with acute pancreatitis has severe abdominal pain. First nursing action?

Keep NPO, establish IV access, administer pain medication

Encourage oral intake

Perform abdominal massage

Order high-fat diet

3. A newborn shows signs of respiratory distress syndrome. Immediate action?

Provide oxygen, position supine, notify neonatology

Feed the infant

Place in isolette

Obtain chest X-ray only

4. A patient with hypertensive crisis presents with BP 210/140. Priority action?

Administer IV antihypertensive and monitor closely

Give oral antihypertensive medication

Restrict sodium intake

Perform a full physical exam

5. A post-op patient has sudden leg swelling and calf pain. First intervention?

Assess for DVT, elevate leg, notify physician

Massage the calf

Apply heat to the area

Order compression stockings

6. A patient reports chest pain radiating to the left arm. What do you do first?

Place on oxygen, obtain 12-lead ECG, establish IV access

Administer nitroglycerin

Send to imaging

Contact cardiology

7. A client with acute kidney injury has a potassium level of 6.8 mEq/L. Priority action?

Administer calcium gluconate and insulin with dextrose

Restrict potassium intake

Schedule dialysis

Obtain repeat labs

8. A patient on digoxin reports nausea, weakness, and visual disturbances. First step?

Check digoxin level and assess for toxicity

Hold the next digoxin dose

Administer an antiemetic

Increase potassium intake

9. A child with epiglottitis shows drooling and tripod positioning. Immediate action?

Keep child calm, maintain airway, prepare for intubation

Examine the throat with a tongue blade

Administer antibiotics

Obtain a neck X-ray

10. A patient with pulmonary embolism presents with chest pain and dyspnea. First action?

Administer oxygen, establish IV, notify physician

Start anticoagulation therapy

Perform D-dimer test

Give pain medication

11. A patient with acute MI reports chest pain and dyspnea. What is your first action?

Administer oxygen and place on continuous cardiac monitor

Start an IV line

Obtain a 12-lead ECG

Notify the physician

12. A hospitalized patient has signs of septic shock. First intervention?

Initiate rapid fluid resuscitation and obtain blood cultures

Administer broad-spectrum antibiotics

Place central venous catheter

Start vasopressors

13. A client experiences anaphylaxis after antibiotic administration. Immediate action?

Administer IM epinephrine and establish IV access

Give antihistamines

Place in Trendelenburg position

Apply warm compresses

14. A patient with COPD is in acute respiratory distress. What is your first step?

Place on high-flow oxygen and elevate head of bed

Administer bronchodilators via nebulizer

Intubate the patient

Draw arterial blood gas

15. A post-op patient has stridor and respiratory distress. Priority intervention?

Maintain airway, give oxygen, notify surgeon

Administer antihistamines

Apply ice to the neck

Prepare for tracheostomy

16. A diabetic patient is unresponsive with a blood glucose of 45 mg/dL. First action?

Administer 50% dextrose IV push

Give oral juice or glucose tablets

Check for medical alert bracelet

Perform CPR

17. A client reports sudden severe headache and neck stiffness. What do you do first?

Isolate the patient and notify infection control

Perform a lumbar puncture

Administer antibiotics

Check vital signs and assess neurologic status

18. A patient on warfarin presents with an INR of 9. Which action comes first?

Assess for bleeding and notify the physician

Administer vitamin K immediately

Draw labs to confirm the result

Hold the next warfarin dose

19. During labor, the fetal heart rate drops to 80 bpm. What is the first intervention?

Position mother on left side and increase IV fluids

Prepare for emergency cesarean delivery

Administer oxygen to the mother

Call for anesthesia consultation

20. A client with severe burns arrives at the ED. What takes priority?

Establish airway and begin fluid resuscitation

Apply topical antibiotics to wounds

Assess for compartment syndrome

Provide pain management

NCLEX Quiz: Do You Know Which Action to Take First?