NCLEX Test Sample Questions & Practice Tests | Try it Now

This question tests priority using the ABC framework (Airway, Breathing, Circulation). An oxygen saturation of 86% indicates hypoxia, which can quickly lead to: brain injury cardiac arrest respiratory failure Confusion and restlessness are early signs of oxygen deprivation, especially in older adults. Why the other options are wrong: a. Fever and cough - expected with pneumonia, not immediately life-threatening b. Edema and fatigue - chronic heart failure symptoms d. Pain - important, but not life-threatening Hypoxia is always priority.

Morphine is an opioid that can cause respiratory depression, which can be fatal. Normal respiratory rate: 12–20 breaths per minute A rate of 8 breaths per minute is dangerously low and indicates opioid-induced respiratory depression. This can lead to hypoxia, cardiac arrest and death. Immediate action is required.

Chest pain and shortness of breath may indicate: myocardial infarction (heart attack) pulmonary embolism cardiac ischemia These conditions can rapidly lead to death if untreated. This patient requires: immediate ECG oxygen cardiac monitoring

This patient is showing signs of shock, indicated by: low blood pressure high heart rate This could indicate: internal bleeding hypovolemia hemorrhage Shock reduces blood flow to organs and can cause organ failure and death.

Tuberculosis spreads through airborne transmission, meaning infectious particles remain suspended in the air. A negative pressure room prevents contaminated air from escaping into hallways and infecting others. This is the most important environmental safety intervention.

Urinary catheter insertion introduces a foreign object directly into the bladder, which is normally sterile. Using sterile technique prevents introducing bacteria into the urinary tract, which can cause catheter-associated urinary tract infections (CAUTI).

Recapping needles significantly increases the risk of needlestick injury, which can transmit: HIV Hepatitis B Hepatitis C Needles should be disposed of immediately in a sharps container without recapping.

Soap and water physically remove spores from the hands. This is the most effective method of preventing transmission.

Measles is one of the most highly contagious airborne diseases. It spreads through airborne particles that can remain in the air for up to 2 hours.

This question tests your understanding of priority, transmission risk, and source control. The key phrase is: "has not yet been placed on isolation precautions." Meningitis especially bacterial meningitis is transmitted via respiratory droplets and can spread rapidly to: Healthcare workers Other patients Visitors If isolation precautions have not yet been initiated, this patient poses an immediate transmission threat. The nurse must act immediately to: Initiate droplet precautions Provide a surgical mask to the patient Protect others from exposure This is a priority safety intervention to prevent an outbreak.