Archer Prioritization

Which of the following is a priority that must be considered and critically thought about by the nurse before referring a client to a healthcare setting or service external to their current healthcare setting? A. The external healthcare setting's or service's cultural values and beliefs. B. The external healthcare setting's or service's admission criteria. C. The current healthcare facility's actual and potential census. D. The current healthcare facility's actual and potential case mix. Submit Answer

Choice B is correct. The external healthcare setting's or service's admission criteria is the priority that must be considered and critically thought about by the nurse before referring a client to a healthcare setting or service external to their current healthcare setting. Choice A is incorrect. Although the external healthcare setting's or service's cultural values and beliefs should be considered, it is not the priority that must be found and critically thought about by the nurse before referring a client to a healthcare setting or service external to their current healthcare setting. Choice C and D are incorrect. The current healthcare facility's actual and potential census is not a consideration that the nurse should think about before referring a client to a healthcare setting or service external to their current healthcare setting; it is the client's needs that must be considered. Last Updated - 25, Jan 2022

While working in the pediatric emergency department, you receive a 2-year-old patient from EMS who has ingested an unknown amount of a household chemical. You will be the nurse caring for this patient. Place the following interventions in order from highest priority to lowest priority. Assess the client Ensure no further exposure to poison Administer the antidote if available Identify the specific type of poison Submit Answer

Explanation Assess the client is the first action. Poisoning is a frequent cause of admission to pediatric emergency departments. The priority of nursing action will always be to assess the client. Follow the "ABCs" (airway, breathing, and circulation) and intervene as appropriate. If the child does not have an airway, establish one. If they are not breathing, manually ventilate them. If circulation is inadequate, provide fluid boluses or vasopressors for support as prescribed by the health care provider. The next priority nursing action is to ensure there is no further exposure to the poison. Is the chemical present near their mouth? Is the poison on their skin? Ensure that it is completely removed before proceeding. Next, the nurse needs to take action to identify the specific type of poison. This could mean asking the parents or whoever witnessed what happened, or looking at the chemical bottle themselves if the parents or EMS brought it along. The last priority action is to administer the antidote if available. If an antidote is available, correctly administer this medication to the client to prevent ongoing tissue damage from the poison that was ingested. Learning Objective Prioritize the order of emergency Department care based on assessment of the affected pediatric client. Additional Info The nurse should be able to recognize that the most significant risk to the victim of an accidental poisoning is airway compromise and respiratory failure. The nurse should response by assessing their client and ensuring there is no further poison risk to the client or staff caring for the client who ingested the poison. The nurse should further respond by placing an IV line and ensuring patency of the established IV and ensure that there is emergency resuscitation equipment readily available. The nurse should contact poi

The charge nurse of a medical-surgical unit is informed that the nursing unit is short-staffed. Which task should the charge nurse delay in order to meet all client needs? A. Medication administration B. Daily baths C. Vital sign collection D. Hourly safety rounds Submit Answer

Explanation Choice B is correct. When the nursing unit is short-staffed, non-essential tasks may be delayed. Daily baths are a non-essential task compared to medication administration, vital sign collection, and hourly safety rounds. Choices A, C, and D are incorrect. Medication administration cannot be delayed because of staffing issues. This would result in the deterioration of client care. Vital sign collection is essential to determine a client's stability. Additionally, vital signs are often necessary to perform a safe medication administration (for example, the need to have a recent blood pressure before giving an antihypertensive). Safety cannot be compromised because of short staffing. The safety rounds must be completed. Additional Info Last Updated - 10, Nov 2022

The nurse is caring for the following assigned clients. The nurse should follow up on which client first? A client who has A. mechanical ventilation and the low-pressure alarm sounds. B. a new colostomy and refuses to participate in care. C. acute glomerulonephritis and has periorbital edema. D. atrial fibrillation and an irregular pulse. Submit Answer

Explanation Choice A is correct. A client receiving mechanical ventilation requires multiple assessments. The low-pressure alarm is concerning for ventilator disconnection or low cuff pressure. The high-pressure alarm is concerning for obstruction such as secretions. This client should be assessed first under the priority model of "ABCs" = airway, breathing, circulation. Choices B, C, and D are incorrect. A client with a new colostomy may be indifferent when caring for themselves as they adjust to the change in body image. Further, a client with acute glomerulonephritis will exhibit periorbital edema and high blood pressure. Finally, an irregular pulse is consistent with atrial fibrillation. Additional Info The client receiving mechanical ventilation should always be assessed over the alarm. The nurse needs to ensure these alarms are functional, but the client's assessment is the priority if the alarm sound goes off. The low pressure alarm may sound for a cuff leak or disconnection. The high pressure alarm may be triggered for obstruction (client biting on the tube, secretions in the airway). Last Updated - 15, Dec 2022

The nurse is caring for the following assigned clients. The nurse should initially follow-up on the client who A. taking lithium that reports nausea and vomiting. B. refusing their prescribed quetiapine. C. reporting a headache following the first dose of citalopram. D. gets drowsy following a dose of alprazolam. Submit Answer

Explanation Choice A is correct. A client taking lithium needs to be monitored closely for nausea and vomiting. These are early manifestations of lithium toxicity. Lithium toxicity must be recognized promptly as it may lead to more severe symptoms. Choices B, C, and D are incorrect. A client refusing a medication should always be followed up on because the client needs to be counseled on the purpose of the medication and its effects. Further, the nurse should inquire as to why the client is refusing the medication. A headache following the administration of citalopram is a common side-effect and warrants no immediate follow-up. Finally, drowsiness following the administration of a benzodiazepine is an expected finding. Drowsiness is the most common side-effect associated with a benzodiazepine. Additional Info Lithium levels should be maintained between 0.6 - 1.2 mEq/L. The patient should be educated on the following points - - Lithium requires the patient to maintain adequate fluid and salt. Failing to do so for the patient may result in lithium toxicity. - Lab findings expected with lithium include leukocytosis and hypothyroidism (long-term use). - The patient should avoid medications such as diuretics, NSAIDs, and ACE inhibitors, as these medications may cause lithium toxicity. - Lithium levels should be drawn twelve hours following the patient's last dose. If not, this may falsely elevate the lithium level. Lithium toxicity signs and symptoms include nausea, vomiting, lethargy, confusion, delirium, coma, seizures, and hypotension. Last Updated - 29, Aug 2022

The hospital's disaster plan is initiated due to a nearby factory fire. One of the victims is responsive but unable to walk, with a respiratory rate of 28 and capillary refill <2 seconds. What color tag would the ED triage nurse assign to this patient? A. Yellow B. Red C. Black D. Green Submit Answer

Explanation Choice A is correct. A yellow triage tag indicates the victim has injuries that are not immediately life-threatening and can wait up to an hour before receiving treatment. This patient is responsive, with adequate respiratory function (respirations below 30/minute) and perfusion intact (capillary refill under 2 seconds). This patient could wait until the most severe injuries are treated before receiving treatment. Choice B is incorrect. A red triage tag indicates the patient has life-threatening injuries, but a high chance of survival once stabilized, such as large lacerations or compromised lung function due to trauma. These patients are the highest priority and require immediate treatment. Choice C is incorrect. A black triage tag indicates the patient's injuries are so severe that there is little to no chance of survival, such as being unresponsive with multiple severe injuries or extensive blood loss. Choice D is incorrect. A green triage tag indicates the patient has minor injuries such as cuts or abrasions and can wait several hours before receiving treatment. NCSBN Client need: Topic: Physiological Integrity, Sub-topic: Reduction of Risk Potential Last Updated - 26, Nov 2021

The nurse is caring for a client who intentionally overdosed on amitriptyline. What action should the nurse prioritize? A. Obtain a 12-lead electrocardiogram B. Request a prescription to consult psychiatry C. Determine the reasoning for the overdose D. Establish a therapeutic relationship Submit Answer

Explanation Choice A is correct. Amitriptyline is a tricyclic antidepressant (TCA) and, when taken in excess, may cause cardiac dysrhythmias. TCA toxicity's most severe cardiac effects include QT interval prolongation, torsade de pointes, and sudden cardiac death. The essential action is to address the patient's physiological needs by assessing if the patient has catastrophic dysrhythmias. Choices B, C, and D are incorrect. A consultation with psychiatry is highly likely considering the intentionality of the overdose. However, the priority is the patient's physiological needs. Determining the reasoning for the overdose and establishing a therapeutic relationship is not a priority over the patient's physical needs. Additional Info TCAs are indicated for depressive and obsessive disorders. Considering they are profoundly anticholinergic, the toxicity of these medications may be fatal. Drugs in this class include amitriptyline, nortriptyline, and imipramine. Clinical features of an overdose include dysrhythmias, hypotension, confusion, and hyperthermia. The nurse should immediately determine hemodynamic stability through continuous cardiac and blood pressure monitoring. Last Updated - 07, Nov 2022

The nurse has just finished receiving the shift report from the night nurse. Which patient should the nurse see first? A. A 90-year-old patient with pneumonitis who is getting restless but is currently afebrile. B. A 20-year-old patient with influenza who is febrile and complaining of a headache. C. A 40-year-old patient with hemothorax in the right lung who is attached to a chest drainage system that is tidaling. D. A 27-year-old with sinusitis having green drainage from his nose. Submit Answer

Explanation Choice A is correct. Elderly clients do not show "typical" symptoms of pneumonia, such as fever. The nurse should watch for altered levels of consciousness or behavioral changes as these may indicate decreased oxygenation to the brain from sepsis. Therefore, the nurse should see this client first. Choice B is incorrect. The client is showing the expected signs and symptoms of influenza. This patient does not require the nurse's immediate attention. Choice C is incorrect. Tidaling in a water-seal system is expected; therefore, the nurse would not need to see this client first. Choice D is incorrect. Drainage from the nose in a patient with a sinus infection is expected. Additional Info Last Updated - 07, Feb 2022

After administering an insulin injection to a patient on a sliding scale, the nurse realizes that a high dose was erroneously given. Which of the following would be the best response by the charge nurse to prevent future errors? A. Discuss events preceding the error with the nurse B. Complete an incident report and place it in the patient's chart C. Inform the patient, family, and physician of error D. Monitor the patient for adverse effects Submit Answer

Explanation Choice A is correct. Events preceding the error should be discussed with the nurse. This is the only response that focuses on preventing future errors. It would be most important to determine factors that contributed to the error, such as rushing, lack of knowledge/education, improper staffing caseload/patient acuity, or communication issues. Choice B is incorrect. Incident reports are legal, confidential documents and are not placed in the chart. They should be reported based on facility policy. Choice C is incorrect. It would be appropriate for the nurse to notify the patient, family, and physician per facility policy, but this action does not prevent future errors. Choice D is incorrect. The nurse should closely monitor for any adverse effects of the patient receiving the wrong dose, but this action does not prevent future errors. NCSBN Client need: Topic: Physiological Integrity, Sub-topic: Reduction of Risk Potential Last Updated - 04, Feb 2022

A 56-year-old female client presents to the emergency department (ED) who reports dyspnea, fatigue, and indigestion. The nurse should take which priority action? A. Obtain a 12-lead electrocardiogram B. Provide supplemental nasal cannula oxygen C. Established intravenous (IV) access D. Auscultate lung sounds Submit Answer

Explanation Choice A is correct. Obtaining a 12-lead electrocardiogram is the priority as the client is exhibiting classic symptoms of acute coronary syndrome (ACS). Women over the age of 50 are at a higher risk of developing this potentially fatal syndrome. Women may exhibit manifestations other than substernal chest pain. The ECG will help determine if the client has a STEMI or an NSTEMI. Choices B, C, and D are incorrect. Supplemental oxygen, establishing intravenous access, and a respiratory assessment will need to occur. However, they do not prioritize establishing the severity of the ACS as the ECG will determine if the client has a STEMI. Additionally, the client reported difficulty with breathing, which does not necessarily indicate that she is hypoxic. The standard of care is to obtain a 12-lead electrocardiogram within ten minutes of symptom presentation. Additional Info Unstable ACS (STEMI) may present with typical and atypical clinical features. Typical clinical features of ACS include: Substernal chest pain with a gradual onset. Pain that radiates to the arm or jaw. Chest pain that is not relieved with rest. Diaphoresis and pallor may be additional findings. Atypical clinical features of ACS include: Nausea and vomiting Dyspnea Significant fatigue Epigastric pain Atypical features are found in women and individuals with diabetes mellitus. Individuals with diabetes mellitus have attenuated chest pain because of neuropathy. Last Updated - 08, Nov 2022

The nurse is caring for the following assigned clients. It would be a priority for the nurse to assess the client A. being evaluated for chest pain and requesting an antacid for indigestion. B. reporting nervousness following the administration of albuterol. C. requesting pain medication for their chronic knee and back pain. D. awaiting discharge teaching on their insulin pump and glucometer. Submit Answer

Explanation Choice A is correct. Reports of indigestion could be a symptom associated with myocardial infarction. This atypical sign is concerning because the client is already being evaluated for chest pain. Thus, the nurse needs to follow up with this client. Choices A, B, and D are incorrect. Nervousness following the administration of albuterol is an expected finding because albuterol stimulates beta-adrenergic receptors. Pain medication for chronic pain is a priority but not the initial priority because the nurse should always prioritize acute needs over chronic needs. Discharge teaching is a low-priority task for the nurse. Additional Info When prioritizing client care, the nurse should always see clients who report acute changes, appear unstable, or have imminent safety concerns. Unstable patients will have abnormal vital signs or exhibit signs such as restlessness which is a non-reassuring finding in any client as it could be hypoxia, increased intracranial pressure, etc. Last Updated - 28, Aug 2022

The nurse in the emergency department (ED) has a client with suspected septic shock. The priority intervention for this client is to A. establish a peripheral vascular access device. B. obtain the prescribed consult with infectious disease. C. provide frequent updates regarding the client's care. D. perform a physical assessment for the potential source of infection. Submit Answer

Explanation Choice A is correct. Shock is a medical emergency and indicates a significant loss in bodily perfusion. In clients with septic shock, a common feature is a severe hypovolemia, necessitating rapid fluid resuscitation. Additionally, intravenous broad-spectrum antibiotic therapy should start within one hour of presentation. The nurse must act quickly to establish peripheral vascular access, which will be vital to obtaining the necessary laboratory specimens (blood cultures, lactic acid) and delivering fluid resuscitation along with broad-spectrum antibiotics. Two large bore IV access should be established within five minutes of presentation, one for fluid resuscitation and the other for antibiotic delivery. If peripheral intravenous access can not be obtained, the nurse should attempt to get intraosseous access. Choices B, C, and D are incorrect. Obtaining a consult with infectious disease is a crucial intervention so that this specialist may determine the appropriate medical management. However, staying with the client and restoring circulating volume is vital when a client is in shock. Frequent updates regarding the client's care would be a psychosocial need. This does not prioritize the client's physical instability. The source of the infection is essential, but performing a physical assessment would take away time from the necessary intervention of establishing vascular access to deliver life-saving treatment. Learning Objective Recognize that septic shock is a distributive shock requiring immediate intravenous fluids administration, obtaining blood cultures, and infusing parenteral antibiotics. Getting quick and adequate IV access is a critical necessity. Additional Info Source : Archer Review Treatment goals for a client with septic shock include the following: · Optimal perfusion as demonstrated b

A nurse in the emergency department of a children's hospital is triaging patients. Which patient should the nurse arrange for the doctor to see first? A. A febrile 8-year-old girl complaining of pain during urination. B. A child diagnosed with leukemia displaying petechiae. C. A child diagnosed with acute epiglottitis two days ago and is drooling. D. A child with otitis media having fever. Submit Answer

Explanation Choice C is correct. Drooling in epiglottitis means that the child is having difficulty swallowing. This increases the risk of airway compromise. This patient should be seen by a physician immediately, and an emergency bedside tracheostomy prepared. Choice A is incorrect. A child with a urinary tract infection is expected to display dysuria and fever. This client should not be a priority over a patient in an emergency. Choice B is incorrect. The child diagnosed with leukemia is expected to have petechiae. This client should not be a priority over a patient in an emergency. Choice D is incorrect. A child with otitis media is expected to have a fever. This client should not be a priority over a patient in an emergency. Last Updated - 21, Oct 2021

The nurse is triaging phone calls for the primary healthcare provider (PHCP). Which client situation requires immediate notification to the PHCP? A. A client with heart failure that reports an overnight weight gain of three pounds. B. A client with peritoneal dialysis who has not had a bowel movement in two days. C. A client with irritable bowel syndrome (IBS) that reports frequent diarrhea. D. A client with nephrolithiasis that reports bloody urine and flank pain. Submit Answer

Explanation Choice A is correct. The PHCP should be immediately notified about the client who gained three pounds overnight. Two pounds convert to one kilogram, and that converts to one liter of fluid. Thus, this client is retaining a significant amount of fluid and requires immediate follow-up to ensure they do not develop complications such as pulmonary edema. Choices B, C, and D are incorrect. A client with peritoneal dialysis should be evaluated for their complaints of constipation because it is a major cause of poor outflow. A client with IBS reporting frequent diarrhea is an expected finding, as this condition is manifested by constipation, diarrhea, and abdominal spasms. Nephrolithiasis characteristically presents with hematuria and flank pain. Each client calls about symptoms expected with the corresponding disease process; thus, they do not need to be reported immediately to the PHCP. Additional Info It is essential for a client with heart failure to weigh themselves daily. This weight should be completed first thing in the morning and after the morning void. The weight should be obtained with the same amount of clothing each day. The client should report a weight gain of 1-2 pounds overnight or 3-5 pounds in a week. Last Updated - 13, Feb 2022

The registered nurse is on a shift in the emergency department of a pediatric hospital. There are four patients in the ED; which patient would the nurse see first? A. A 1-month-old infant that is crying with retractions during inspiration. [79%] B. A 5-year-old with pneumonia with 95% pulse oxygen saturation. [2%] C. A 10-year-old with diarrhea and vomiting with a potassium level of 3.6 mEq/L. [7%] D. A 15-year-old diabetic with a blood glucose level of 190 mg/dL. [

Explanation Choice A is correct. The child with inspiratory retractions indicates respiratory distress in the child and should be assessed first. Choice B is incorrect. The child with pneumonia is stable. The nurse does not need to assess this patient urgently. Choice C is incorrect. The child still has an average potassium level even though he is having diarrhea and vomiting. The nurse does not need to assess this child first. Choice D is incorrect. A glucose level of 190 mg/dL is not threatening. The nurse does not need to assess this child first. Last Updated - 15, Feb 2022

The nurse is caring for the following assigned clients. It would be a priority to follow up with a client who A. has atrial fibrillation and a heart rate of 112/minute. B. has glomerulonephritis with a blood pressure of 137/86 mm Hg. C. is receiving amphotericin b, and the most recent temperature is 100.4°F (38°C). D. has chronic obstructive pulmonary disease (COPD) with an oxygen saturation of 91% on room air. Submit Answer

Explanation Choice A is correct. The client with atrial fibrillation and has two treatment goals. 1. The prevention of a stroke 2. Rate control between 60-100. The client with atrial fibrillation with an elevated heart rate requires priority follow-up because the increased rate likely means the client has atrial fibrillation with a rapid ventricular response. The client with this type of arrhythmia requires medications such as diltiazem or amiodarone to achieve rate control. Choices B, C, and D are incorrect. These clients are experiencing expected findings and do not require follow-up. A client with glomerulonephritis will have elevated blood pressure, proteinuria, and hematuria. An infusion of amphotericin b would cause a client to experience fever and chills and does not require imminent follow-up. This side effect can be avoided by the client being premedicated with isotonic fluids and acetaminophen. An oxygen saturation of 88% or greater is optimal for a client with COPD. Additional Info The primary goal for a client with atrial fibrillation is to maintain rate control (60-100). Medications such as diltiazem, digoxin, amiodarone, and dronedarone may be utilized to achieve rate control. Anticoagulants are also indicated as ischemic strokes are commonly associated with atrial fibrillation. Anticoagulants commonly used include rivaroxaban, apixaban, and warfarin. Last Updated - 20, Dec 2022

The nurse is caring for a client diagnosed with multiple myeloma. The nurse reviews the client's lab values and notes a serum calcium level of 14 mg/dL. What is the priority action the nurse should take? A. Notify the physician B. Document the finding C. Continue to monitor the patient D. Remove the patient from the telemetry monitor Submit Answer

Explanation Choice A is correct. The normal range for serum calcium is 9-10.5 mg/dL. This client's serum calcium level is above 10.5 mg/dL; therefore, the client is experiencing hypercalcemia. At a calcium level of 14 mg/dL, most clients may experience symptoms. Often, these may include polyuria, polydipsia, and dehydration. If not addressed, clients may develop renal failure and altered mental status. The nurse must notify the physician regarding this abnormal lab value. Choices B and C are incorrect. It is inappropriate for the nurse to document the finding or just continue to monitor. The nurse has correctly identified that this lab value is out of the normal range and must report the finding to the attending physician. Choice D is incorrect. It is inappropriate for the nurse to remove the client from the telemetry monitor. Not only has the nurse identified that this finding falls outside of normal limits and needs to notify the attending physician, but the nurse should also be aware that a client experiencing hypercalcemia may have EKG changes such as a shortened QT interval and a prolonged PR interval. Cardiac monitoring is essential for this client. Additional Info Source : Archer Review Last Updated - 17, Jan 2022

The patient has a history of chronic venous insufficiency, atrial fibrillation, and varicose veins. Upon assessment, the RN finds the patient to be afebrile with left calf edema, pain, and erythema that is warm to the touch. What is the RN's most urgent concern? A. Deep vein thrombosis (DVT) B. Cellulitis C. Osteomyelitis D. Lymphedema Submit Answer

Explanation Choice A is correct. The patient has a history of chronic venous insufficiency, atrial fibrillation, and varicose veins, which are all risk factors for developing blood clots. The patient is also presenting with hallmark signs of deep vein thrombosis (unilateral lower leg pain, swelling, and redness). DVT is an emergency because a clot may dislodge and travel, causing a stroke or myocardial infarction. Of the choices, DVT is the most emergent situation. Choice B is incorrect. Cellulitis is an infection in the soft tissue. Although it is typically unilateral, it would not be as urgent as a blood clot. The patient's history of venous problems would not be a relevant risk factor for developing cellulitis. Choice C is incorrect. Osteomyelitis is an infection of the bone, caused by an external pathogen that usually enters the blood or tissue via an open wound. The patient's history of venous problems would not be a relevant risk factor for developing osteomyelitis. Choice D is incorrect. Lymphedema would cause bilateral swelling that is not warm to the touch. NCSBN Client Need Topic: Prioritization, Subtopic: Potential for complications from health alterations, pathophysiology, illness management, medical emergencies Last Updated - 07, Feb 2022

The nurse has received the following prescriptions for newly admitted clients. The nurse should initially implement which of the following? See the image below. A. initiate intravenous fluids to a client with anorexia nervosa. B. administer venlafaxine to a client with persistent depressive disorder. C. consult the social worker to begin discharge planning for a client. D. obtain a blood sample to evaluate a client's lithium level. Submit Answer

Explanation Choice A is correct. The priority is to attend to a client's physiological needs. Initiating intravenous fluids for a client with anorexia nervosa prioritizes over the other prescriptions because of the condition's ability to cause dehydration and severe fluid and electrolyte disturbances. Choices B, C, and D are incorrect. Administering venlafaxine for a client with a chronic depressive disorder is not the priority. This is a chronic problem, and acute problems come first. Consulting with the social worker for discharge planning is a low-priority task and is akin to providing discharge teaching. Obtaining a blood sample to evaluate a client's lithium level does not prioritize over a client-ordered intravenous fluid for a circulation problem. Additional Info Prioritizing client care is central to functioning as a nurse. High-priority patient situations include a client who is unstable or reporting an acute change. The nurse should always address high-priority items and appropriately delegate intermediate to low-priority items, if necessary. Focus on the model of airway, breathing, circulation, and problems that may arise associated with each. In this question, anorexia nervosa is a circulation issue, and the treatment of intravenous fluids should be promptly initiated. Last Updated - 12, Nov 2022

The nurse is caring for a client receiving prescribed diltiazem. The client has the following tracing on the electrocardiogram shown in the exhibit. The nurse should perform which priority action? See the exhibit. A. Discontinue the diltiazem infusion. B. Notify the primary healthcare physician (PHCP). C. Assess the client's oxygen saturation and respiratory rate (RR). D. Prepare a prescription of intravenous (IV) atropine. Submit Answer

Explanation Choice A is correct. The tracing shows sinus bradycardia. The priority action would be to discontinue the diltiazem infusion as this medication is a calcium channel blocker that lowers heart rate and blood pressure. If the infusion were to continue, it would lower the heart rate further. Choices B, C, and D are incorrect. The physician should be notified, and oxygen saturation should be assessed. However, the priority action is to discontinue the offending agent first, the diltiazem. IV atropine is inappropriate as the offending agent (diltiazem) must be discontinued. Additional Info Diltiazem is a calcium channel blocker prescribed to treat hypertension and atrial fibrillation. When given continuously in an infusion, the nurse must closely monitor the client's blood pressure and heart rate. Diltiazem may cause dangerously low blood pressure and bradycardia. Other calcium channel blockers include amlodipine, nifedipine, and verapamil. Only verapamil and diltiazem lower both the blood pressure and heart rate. Last Updated - 26, Apr 2022

The nurse is performing medication administration for four clients. Which client and medication should be administered first? See the image below. A. Client one B. Client two C. Client three D. Client four

Explanation Choice A is correct. This medication is prescribed for a client with an asthma exacerbation which is an acute problem. Additionally, this acute problem deals with the client's breathing problem (asthma), prioritizing a fever, diabetes, and chronic alcoholism. Choices B, C, and D are incorrect. The client with a fever prescribed acetaminophen will require treatment but does not prioritize the acute respiratory ailment of an asthma exacerbation. Diabetes and alcoholism are chronic medical problems that would not require immediate administration of the prescribed medications when competing with a client with an acute asthma exacerbation. Additional Info Acute problems prioritize over chronic problems. Further, when faced with multiple acute problems using the approach of ABC (airway, breathing, circulation) is an additional framework that can be used to determine which client situation should be addressed first. Last Updated - 03, Nov 2022

An emergency room nurse is assigned to triage. Four people check-in at the same time. Which patient should receive immediate priority care? A. A 29-year-old female two-day post-cesarean section that complains of a headache and leg swelling. B. A 15-year-old female with LLQ pain for three days. C. A 55-year-old male with dull RUQ pain & history of pancreatitis. D. A 2-year-old female child with pain upon urination. Submit Answer

Explanation Choice A is correct. This patient is at risk for pre-eclampsia which is a severe condition that can lead to seizures, stroke, and other complications if not promptly treated. Pregnant women are at risk for preeclampsia anytime through pregnancy as well as 6-10 weeks post-partum. Post-partum pre-eclampsia usually develops in 48 hours post-partum but the risk can extend up to 6 to 10 weeks. Symptoms include headache, blurred vision, proteinuria, swelling in the hands/face, and high blood pressure. If treatment is started, this condition can be controlled. Choices B, C, and D are incorrect. These patients are less of a priority compared to the patient described in choice A. The patient in choice B had pain for 3 days, which is likely not an immediate threat. The other answer choices do not mention any altered sensorium, high fever, or sepsis findings. NCSBN client needs Topic: Management of care; Sub-topic: Establishing Priorities.

An emergency room nurse is assigned to triage. Four people check-in at the same time. Which patient should receive priority care? A. A 29-year-old female two-week post-cesarean section that complains of a headache and leg swelling B. An 8-year-old female with LLQ pain for three days C. A 55-year-old male with RUQ pain & a history of pancreatitis D. A 3-year-old female with pain upon urination Submit Answer

Explanation Choice A is correct. This patient is at risk for preeclampsia, which is a severe condition that can lead to seizures. The woman is at risk for preeclampsia anytime throughout pregnancy, as well as six weeks post-partum. Symptoms include headache, blurred vision, proteinuria, swelling in the hands/face, and high blood pressure. If treatment is started, this condition can be controlled. Choices B, C, and D are incorrect. These patients are less of a priority. The patient with preeclampsia is most important in this situation. The patient in answer choice B most likely has constipation issues. The patient in answer choice C is most likely having a pancreatitis flare-up, but this can wait longer than the 29-year old with preeclampsia. The patient in answer choice D is most likely suffering from a UTI, which is common at this age because of potty training, female anatomy, not wiping correctly. She will need an antibiotic, but this is not urgent. NCSBN Client Need Topic: Safe and Effective Care Environment; Sub-topic: Care Management Additional Info Source : Archer Review Last Updated - 10, Nov 2022

The patient with history of right mastectomy is receiving maintenance IV fluids via peripherally inserted intravenous line in the left cephalic vein. The patient complains of pain at the IV site, and the nurse notes that the infusion has slowed and assesses swelling and erythema at the IV site. Which action should the nurse take first? A. Stop the infusion and remove the IV catheter B. Insert new IV in left intermediate basilic vein. C. Prepare the patient for PICC line placement. D. Elevate the right arm to reduce swelling. Submit Answer

Explanation Choice A is correct. This patient's IV site shows signs of phlebitis: redness, swelling, pain, and slowed infusion rate. The first priority action is to remove the current IV catheter to reduce the risk of further complications. Localized symptoms of phlebitis typically resolve after discontinuation of the catheter. Choice B is incorrect. Since this patient is not a candidate for IV access in the opposite arm due to a history of right mastectomy, the nurse should remove the current IV, and then attempt to insert a new IV proximal from the original site, but the current IV site should be discontinued first, prior to initiating any other interventions. Choice C is incorrect. This patient may be a candidate for PICC line placement if attempts to insert IVs at new sites are unsuccessful, but the current IV site should be discontinued first, prior to initiating any other interventions. Choice D is incorrect. Although phlebitis symptoms can be relieved by elevating the affected limb, applying a warm compress application, and administering analgesics, the current IV site should be discontinued first, prior to initiating any other interventions. NCSBN Client need: Topic: Physiological Integrity, Sub-topic: Pharmacological and Parenteral Therapies Last Updated - 08, Feb 2022

The nurse has received word that their patient is leaving the postoperative unit and being transferred to the medical-surgical floor. Upon arrival, the nurse would be correct to perform which of the following priority actions? A. Assess the patient for a patent airway. B. Check the patient's abdomen for bowel sounds. C. Order laboratory draws to check hemoglobin levels. D. Compare preoperative vital signs with current vital signs. Submit Answer

Explanation Choice A is correct. Upon receiving a patient from the post-operative unit, the priority action is to assess the patient for a patent airway and respiratory status. The nurse would be correct in performing this action immediately. By using ABC ( airway, breathing, circulation) prioritization strategy, one can answer these questions by first focusing on the airway options. Choice B is incorrect. While appropriate during the initial post-operative assessment, checking for bowel sounds is not the necessary action in this situation. Choice C is incorrect. Ordering labs is a job for the primary health care provider. Tracking down labs and their associated results takes away prime time to assess the patient's airway, thus putting them at risk for respiratory complications. Choice D is incorrect. While vital signs should be taken and compared to the preoperative measurements, this should be performed after the patient's airway status has been established. Counting respiratory rate alone does not give information regarding impending airway obstruction or respiration pattern. NCSBN client need Topic: Reduction of Risk Potential: Potential for Complications for Surgical Procedures and Health Alterations Last Updated - 27, Oct 2021

You have been asked to present a class about priority setting to a group of new graduate nurses. Whose theory should you include in this class? A. Maslow's theory B. Piaget's theory C. Orem's theory D. Skinner's theory Submit Answer

Explanation Choice A is correct. You should include Maslow's Hierarchy of Needs theory in this class about priority setting. Maslow's approach is the most popular and most frequently used theory to determine priorities from the most basic physical needs to the most advanced self-actualization needs. The argument is often presented as a five-level pyramid. When answering NCLEX questions, it is important to note that basic/lower-level needs are of "HIGHEST" priority. Choice B is incorrect. Piaget's theory addresses the cognitive development of infants and children along the life span and would not be included in a class about priority setting. Choice C is incorrect. Orem's theory addresses the self-care needs of clients and would not be included in a class about priority setting. Choice D is incorrect. Skinner's theory addresses operant conditioning and would not be included in a class about priority setting.

Your client has continuous intravenous fluid replacement at 75 mL per hour. At 2 pm, the client complains about the intravenous line and states, "The IV is hurting me." You assess the site and note that it is red with a streak. You palpate the area and you can barely feel a venous cord. What would you suspect and what is the first thing that you would do? A. Grade 3 phlebitis: You would immediately stop the intravenous fluid infusion. B. Grade 4 phlebitis: You would immediately place a cool compress on the site. C. Infiltration: You would immediately stop the intravenous fluid infusion. D. Catheter embolus: You would immediately tourniquet the area distal to the site. Submit Answer

Explanation Choice A is correct. You would suspect a grade 3 phlebitis and you would immediately stop the intravenous fluid. Grade 3 phlebitis is characterized by pain, a visible streak, site redness, and a palpable venous cord less than 1 inch. Grade 4 phlebitis is characterized by pain, a visible streak, site redness, a palpable venous cord more than 1 inch, and possible drainage. Lastly, as with all intravenous therapy, any suspicion of a complication is immediately addressed with the discontinuation of the intravenous line. Choice B is incorrect. The signs and symptoms in this question indicate the presence of phlebitis. However, it is not a grade 4 phlebitis. Additionally, after discontinuing the intravenous line, you would apply heat and not a cold compress onto the IV site. Choice C is incorrect. Although you would immediately stop the intravenous fluid infusion when an intravenous therapy complication occurs, this complication is not infiltration according to the signs and symptoms that are in the question. Choice D is incorrect. The signs and symptoms that are in the question do not indicate the presence of a catheter embolus; these signs and symptoms indicate the presence of another intravenous therapy complication. Additionally, when a catheter embolus occurs, a tourniquet would be placed proximal to the site to prevent migration and further damage. Last Updated - 15, Feb 2022

Your client is on complete bed rest for 7 days. Which of the following is the highest priority nursing diagnosis for this client? A. At risk for severe sensory deprivation related to complete bed rest. B. At risk for venous stasis related to complete bed rest. C. At risk for decreased muscular strength related to complete bed rest. D. At risk for urinary stasis related to complete bed rest. Submit Answer

Explanation Choice B is correct. "At risk for venous stasis related to complete bed rest" is the highest priority nursing diagnosis for a client who is on complete bed rest for seven days. Venous stasis adversely affects the circulatory system, and this venous stasis can lead to life-threatening complications such as venous stasis and pulmonary emboli. According to the "ABCs" of the airway, breathing, and cardiovascular status, Maslow's Hierarchy of Needs, and the MAA-U-AR method of priority setting method, all establish the highest priorities as A: Airway, B: Breathing, and C: Circulation in that decreasing order of preference. Choice A is incorrect. "At risk for severe sensory deprivation related to complete bed rest" is not the highest priority nursing diagnosis for a client who is on complete bed rest for seven days. Choice C is incorrect. "At risk for decreased muscular strength related to complete bed rest" is not the highest priority nursing diagnosis for a client who is on complete bed rest for seven days. Choice D is incorrect. "At risk for urinary stasis related to complete bed rest" is not the highest priority nursing diagnosis for a client who is on complete bed rest for seven days. Last Updated - 15, Feb 2022

The nurse is reviewing tasks for assigned clients. Which action is a priority to implement? A. Visual acuity test for a client reporting blurred vision in one eye. B. 12-lead electrocardiogram for a client reporting chest pain. C. Orthostatic vital signs for a client complaining of syncope. D. Discharge teaching for a client newly diagnosed with hypertension. Submit Answer

Explanation Choice B is correct. A 12-lead electrocardiogram (ECG) is essential for a client endorsing chest pain. This test will help determine if the client has an acute myocardial infarction by showing ST elevations. In suspected acute myocardial infarction (MI), guidelines recommend obtaining an ECG within 10 minutes of the client's arrival in the emergency room. If the client is experiencing an ST-elevation myocardial infarction (STEMI), a delay in obtaining a diagnosis and/ or therapeutic intervention can lead to poor clinical outcomes ( increased morbidity and mortality). Choices A, C, and D are incorrect. It is important to obtain orthostatic vital signs in a client with syncope. Still, it is not more of a priority than obtaining an electrocardiogram in a client with suspected MI. A visual acuity test using a Snellen chart is not a priority for a client complaining of blurred vision in one eye. This is also true for the client awaiting discharge teaching as this is low-priority. Additional Info The client's complaint of chest pain may likely indicate a circulation problem and thus is the nurse's initial priority. In this case, the client experiencing chest pain is potentially threatening their circulation. When prioritizing client needs, the strategy of "ABCs" airway, breathing, and circulation may be used. A 12-lead electrocardiogram (ECG) may identify ST-changes which are associated with myocardial damage. Last Updated - 06, Dec 2022

The nurse is working on the pediatric clinic and checks the list of clients who are lined up to see the physician for today. Which client would warrant the nurse's attention? A. A 5-year-old who sustained a fall and is complaining of leg pain. B. A 2-year-old who is drooling and does not want to swallow. C. An 8-year-old child with a headache for 2 days. D. A 10-year-old child who is always thirsty and has lost weight. Submit Answer

Explanation Choice B is correct. A child who is drooling and does not want to swallow is indicative of epiglottitis, which can be a life-threatening situation. The nurse should assess this child first and inform the physician in case an emergency tracheostomy is required. Choice A is incorrect. The nurse should check for urgent or life-threatening situations. The child who fell might have a fracture and would need an x-ray. However, this is not a life-threatening situation. Choice C is incorrect. This child should be assessed but should not be prioritized over the child with epiglottitis. Choice D is incorrect. The client may have type 1 diabetes mellitus, but this is not a life-threatening situation. Last Updated - 08, Feb 2022

Which nursing diagnosis would be the highest priority for a patient with a medical diagnosis of Bell's palsy? A. Risk for infection B. Risk for disturbed sensory perception C. Risk for disturbed body image D. Risk for ineffective tissue perfusion Submit Answer

Explanation Choice B is correct. Bell's palsy is due to the lower motor neuron pathology of the facial nerve. A client with Bell's palsy typically has ipsilateral ( same side) facial paralysis, but gustatory and auditory sensory disturbances are also noted. While formulating a nursing diagnosis, the nurse should apply Maslow's hierarchy of needs theory to prioritize and plan client's care based on patient-centric outcomes. The nurse must first identify the client's physiological and safety needs and plan nursing care and nursing interventions to address those. According to Maslow, basic physiological needs must be met before higher needs ( self-esteem, aesthetic needs) can be achieved. In this client, motor and sensory deficits are the priority. Bell's palsy causes acute facial paralysis or weakness in the muscles supplied by cranial nerve VII ( facial nerve), which can result in difficulty closing the eyelid, increased sound sensitivity (hyperacusis), altered sense of taste on the affected side of the tongue (gustatory sensation), pain, and difficulty chewing/swallowing. The nurse should plan interventions such as applying artificial tears/ lubricants to the affected eye to prevent corneal dryness/ abrasion ( safety needs). A referral to a physical therapist may be made to help the client with facial muscle exercises. The nurse should provide a soft diet to help with chewing and educate the client to chew on the unaffected side. Choice A is incorrect. Bell's palsy may be caused by inflammation and viral infections, but the patient would not be at a higher risk for developing an infection due to facial muscle weakness. Choice C is incorrect. Bell's palsy causes facial asymmetry. Therefore, the patient would be at risk for disturbed body image, but this would be a psychological nursing diagnosis and would not be a high

Which of the following is the first nursing action for a patient experiencing dyspnea? A. Remove pillows from under the patient's head B. Elevate the head of the bed C. Elevate the foot of the bed D. Take the patient's blood pressure Submit Answer

Explanation Choice B is correct. Elevating the head of the bed allows the abdominal organs to descend, giving the diaphragm more room and facilitating lung expansion. Dyspnea is difficult or labored breathing. A dyspneic patient usually has rapid, shallow respirations. Because of this "shallow" breathing, ventilation is affected, and Co2 accumulates. Dyspneic clients can often breathe better in an upright position. When standing or sitting, gravity pulls the abdominal organs down and away from the diaphragm, creating more space in the thoracic cavity. This allows the lungs more room for expansion and allows the client to take more air with each breath ( better ventilation). Choices A, C, and D. None of these answer choices are appropriate as the first nursing action for a patient experiencing dyspnea. Recumbent positions ( Choices A and C) limit expiratory flow and cause a decrease in elastic recoil of the lung. Therefore, such positions do not improve ventilation. The nurse should check the client's blood pressure ( Choice D), but the priority action should be to position the client to reduce breathlessness and the effort of breathing. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential - Respiratory Depth and Rhythm Learning Objective Understand the positioning techniques to help dyspneic patients reduce the work of breathing. Upright and sitting positions provide more room for the lungs to expand and provide mechanical advantage, thereby reducing the work of breathing. Additional Info Patients may be dyspneic because of several reasons. COPD is one of the commonest causes. In clients with Chronic Obstructive Pulmonary Disease ( COPD), the lungs are hyper-inflated. Because of decreased elastic recoil of the lungs, the air is trapped in the lungs leading to poor ventilation. Be

The nurse is caring for a patient with a history of hyperparathyroidism who is complaining of nausea. Upon assessment, the nurse notes the patient is tachycardic, with a QT interval of 0.3 seconds and slight abdominal distention. What action should the nurse take first? A. Encourage intake of vitamin D-rich foods B. Notify primary healthcare provider ( PHCP) C. Hold patient's scheduled furosemide D. Assess for Chvostek's sign Submit Answer

Explanation Choice B is correct. Hyperparathyroidism can result in elevated calcium levels due to overproduction of the parathyroid hormone, increased intestinal absorption of calcium, and bone resorption. The client's QT interval is shortened at 0.3 seconds ( normal QTc is 0.4 to 0.44 seconds). This client is showing symptoms and signs of hypercalcemia: nausea, abdominal distention, tachycardia (likely ventricular tachycardia), and shortened QT interval. Hypercalcemia causes prolongation of the PR segment and shortening of the QT interval, leading to bradycardia. While bradycardia is more common with hypercalcemia, tachycardia may occur as well. Tachycardia in severe hypercalcemia is ventricular in origin and it happens because of ventricular irritability. Therefore, hypercalcemia can cause either bradycardia or tachycardia depending on which site of the heart it affects. The nurse has assessed the patient's presentation and cardiovascular status, and should immediately notify the physician of the change in status. Choice A is incorrect. This patient is showing signs of hypercalcemia. Increasing intake of vitamin D-rich foods would be expected to increase the calcium level further due to vitamin D's supportive action in calcium absorption. Choice C is incorrect. Furosemide is a loop diuretic that can be used to treat hypercalcemia by enhancing renal calcium exertion. Thiazide diuretics may cause increased serum calcium levels. Choice D is incorrect. Renal failure can cause low levels of serum calcium due to calcium loss and reduced intestinal calcium absorption from impaired vitamin D activation. A positive Chvostek's sign is an indication of hypocalcemia, and would not give relevant assessment data when hypercalcemia is suspected. NCSBN Client need: Topic: Physiological Integrity, Sub-topic: Reduction of Risk Potent

An emergency response nurse has just arrived on the scene of a 911 call. The patient is unconscious and without a pulse. The nurse's priority action is to: A. Administer two rescue breaths. B. Begin chest compressions. C. Check the patient for a patent airway. D. Ask another health care professional to check the carotid artery. Submit Answer

Explanation Choice B is correct. If the nurse has found an unconscious and pulseless patient, they should begin chest compressions. Immediate chest compressions are the most effective way to maintain total body oxygenation. Choice A is incorrect. Rescue breaths, while important, should not be initiated at this point. Instead, rescue breaths should be started if the patient is apneic and after chest compressions have been undertaken. Choice C is incorrect. While checking a pulseless patient for a patent airway is a reasonable step, it is not the best action at this point. Choice D is incorrect. Asking another health care professional to check for pulselessness delays necessary treatment. NCSBN client need Topic: Safety and Infection Control: Emergency Response Plan Last Updated - 11, Feb 2022

The nurse arrives to assist victims following an earthquake. Which victim would the nurse recognize as the highest priority for immediate treatment? A. 74-year-old with several heavily bleeding wounds who is lethargic and pale. B. 37-year-old who appears anxious and is using neck muscles to breathe. C. 16-year-old who is confused, holding her head, and complaining of nausea. D. 65-year-old who rates his pain at 10/10 and is guarding his right leg. Submit Answer

Explanation Choice B is correct. In the setting of a mass casualty or disaster, triage systems are essential to prioritize patients. Triage deals with the appropriate allocation of limited resources during a disaster. In a disaster, the highest priority is given to the person with life-threatening injuries who has a high chance of survival if stabilized. The client in option B presents with symptoms highly suspicious of traumatic pneumothorax, using accessory muscles for breathing, and anxiety (due to difficulty getting enough air). Use of accessory muscles indicates severe respiratory distress. This patient would be the nurse's highest priority and requires rapid chest decompression to allow lung expansion. A needle thoracostomy and subsequent tube thoracostomy could be life-saving in this situation. Choice A is incorrect. This person is likely in hypovolemic shock due to blood loss. The chance of survival is low compared to the patient with a suspected pneumothorax, so this person would not be the highest priority for treatment. Choice C is incorrect. This person presents with signs of a concussion, and the chance of survival is high, but the injuries are not as severe or emergent as the patient with suspected pneumothorax. Choice D is incorrect. This person likely has a minor injury such as a broken bone. The chance of survival is high, but the damage would not require the most immediate attention and could be delayed until the more severely injured are stabilized. NCSBN Client need: Topic: Physiological Integrity, Sub-topic: Reduction of Risk Potential Last Updated - 14, Feb 2022

The emergency department (ED) nurse cares for a client who presents with irritability, nuchal rigidity, and a fever. Which of the following actions should the nurse take first? A. Administer prescribed ibuprofen. B. Place the client on droplet precautions. C. Notify the public health department. D. Obtain prescribed blood cultures.

Explanation Choice B is correct. Initiating droplet precautions is a high priority for this client. The classic bacterial meningitis triad is fever, neck stiffness, and altered mental status. Protecting the other clients and staff from disease transmission is essential for the nurse. Thus, the nurse should initiate droplet precautions by placing the client in a room with all visitors and staff wearing a surgical mask in the client's presence. Choices A, C, and D are incorrect. Medications to lower fever, such as acetaminophen or ibuprofen, would be helpful for a client with bacterial meningitis. If bacterial meningitis is confirmed, the public health department must be notified to initiate contact tracing. However, these do not prioritize the safety and infection control of the clients and staff within the ED. Additional Info Source : Archer Review Neisseria meningitidis is a common cause of bacterial meningitis in children and adolescents. Symptoms classically have an abrupt onset and include headache, fever, nuchal rigidity, photophobia, and myalgias. The nurse's immediate concern is to protect the safety of the staff and the other clients by placing the client in isolation with droplet precautions. The other actions do not reflect an immediate priority. Treatment for N. meningitidis includes prompt initiation of antibiotics such as ceftriaxone. Last Updated - 19, Dec 2022

The nurse in the gynecology ward has just finished receiving the report from the previous shift. Which patient should the nurse see first? A. A client who is complaining of perineal pain while voiding. B. A client who had multiple saturated perineal pads changed during the night. C. A client who is refusing her newborn to be roomed in with her. D. A client who is upset because her baby will not latch. Submit Answer

Explanation Choice B is correct. Multiple peri-pads being saturated overnight indicates heavy bleeding, which may signify a hemorrhage. The nurse should see and examine this patient first. Choice A is incorrect. The pain may be related to an episiotomy or a perineal tear during delivery, but this patient should not be prioritized over a client who may be hemorrhaging. Choice C is incorrect. The patient needs to be assessed for bonding problems; however, this is a psychosocial issue. Clients with physiological issues need to be evaluated first such as a possible hemorrhaging patient. Choice D is incorrect. The patient needs coaching and instructions from the nurse regarding breastfeeding and latching. However, this should not be prioritized over a possible hemorrhaging client. Last Updated - 18, Jan 2022

While caring for a client who requires a mechanical ventilator for breathing, the high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform? A. Disconnect the client from the ventilator and use a manual resuscitation bag. B. Perform a quick assessment of the client's condition. C. Call the respiratory therapist for help. D. Press the alarm reset button on the ventilator. Submit Answer

Explanation Choice B is correct. Several situations can cause the high-pressure alarm to sound. An assessment of the client will tell the nurse whether the alert was triggered by something simple, such as the patient coughing, or by a more difficult situation that might require using a manual resuscitation bag and calling the respiratory therapist. Several things can trigger pressure alarms on mechanical ventilators. Some of the most common causes of high-pressure alarm triggers include water in the ventilator circuit, increased or thicker mucus or other secretions blocking the airway (caused by not enough humidity), bronchospasm, coughing, gagging, or "fighting" the ventilator breath. Regardless of the cause of the triggered alarm, the priority for nurses is to evaluate the patient's status first. Choice A is incorrect. If the patient is struggling for air, the nurse should disconnect the ventilator and use a manual resuscitation bag. This will be evident when the patient is assessed, which is the first nursing action that should be taken. Choice C is incorrect. Although the respiratory therapist may need to be called, this should not be the nurse's first response. Choice D is incorrect. The reset button may need to be engaged. However, the patient's status should be the nurse's priority. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential Last Updated - 28, Oct 2021

A patient who is 2-days postoperative from right femoral popliteal bypass surgery complains of worsening right leg pain. Upon assessment, the RN notes swelling and ecchymosis at the incision sites. Which action would be the nurse's initial priority? A. Apply pressure to sites with sandbag B. Palpate pedal pulses C. Assess for signs of claudication D. Apply warm compress to incision sites Submit Answer

Explanation Choice B is correct. The most significant complications this patient is at risk for after the revascularization procedure are thrombus, hemorrhage, infection, and arrhythmias. Mild to moderate swelling, bruising, and pain at the surgical site are expected and typically resolve over time as the leaked blood is reabsorbed. The most important action would be to assess the patient's pedal pulses (distal to incisions). If pulses are intact, the nurse would then address the patient's complaint of worsening pain. Choice A is incorrect. These symptoms are expected following this type of surgery. Manual pressure would be appropriate if the patient was actively bleeding. Choice C is incorrect. Intermittent claudication is a cramp-like pain in the leg or buttock during activity due to poor blood supply. This is a sign of arterial disease, but not of postoperative complication, and would not be a priority for this patient. Choice D is incorrect. The RN should perform a focused assessment to rule out potential complications before implementing any interventions. Applying a warm compress may be helpful for reducing the patient's pain, but will also result in vasodilation which may increase swelling. NCSBN Client need: Topic: Physiological Integrity, Sub-topic: Reduction of Risk Potential Last Updated - 16, Feb 2022

Which of the following clients should the nurse assess first when preparing to do initial rounds? A. The client with diabetes who is being discharged today. B. A 32-year-old female with a tracheostomy experiencing copious secretions. C. A 16-year-old scheduled for physical therapy this morning. D. An 80-year-old male with a decubitus ulcer that needs a dressing change. Submit Answer

Explanation Choice B is correct. The patient with airway compromise should always be given the highest priority. Remember ABC (Airway, Breathing, Circulation). Choices A, C, and D are incorrect. None of the patients in these answer options indicate a priority for the initial assessment. NCSBN Client Need Topic: Safe and Effective Care Environment - Coordinated Care, Subtopic: Prioritizing Patient Care Last Updated - 15, Feb 2022

The nurse is about to lift a 350-pound patient using an electric lift attached to the bed and transfer him to a stretcher. What should be the priority nursing action? A. Call for assistance from two staff members. B. Make sure the client is correctly positioned in the lift prior to operating the lift. C. Slowly lift the client off the bed. D. Make sure the stretcher is locked.

Explanation Choice B is correct. The safety of the client should take priority. The nurse must ensure that the client is safely secured and adequately attached to the lift. Incorrect positioning of the client in the lift's sleeves might put the client at risk for falls. Choice A is incorrect. The lift can be handled by two people, the nurse plus one other staff; there is no need to call for two additional staff members. Moreover, the priority action is to ensure safety by securing the patient on the lift and ensuring proper positioning. Choices C and D are incorrect. The nurse should ensure that the stretcher is locked and then slowly lift the client. However, the priority action is to make sure the client is correctly positioned. Last Updated - 15, Feb 2022

The RN is caring for clients on a med-surg unit. Which result would warrant immediate intervention by the nurse? A. A blood glucose level of 250 in a type 2 diabetic being treated for pneumonia. B. A patient on a heparin drip with a 50% decrease in platelets over the past week. C. A type 2 diabetic client with A1C 10.5 complaining of tingling and numbness in the toes. D. An acute post-streptococcal glomerulonephritis client with a BP of 140/88 mmHg, proteinuria, and rust-colored urine. Submit Answer

Explanation Choice B is correct. This client is showing signs of heparin-induced thrombocytopenia (HIT): 50% decrease in platelets 5-10 days after heparin therapy was initiated. This is a thrombotic emergency and the nurse should assess the client, notify the physician, and discontinue the heparin drip. Choice A is incorrect. This client is being treated for pneumonia and is likely on antibiotics and corticosteroids. Both of these medications are known to increase blood glucose levels. This blood glucose result is high and the client may require a change in the insulin dose, but this would not be an emergency or the nurse's top priority. Choice C is incorrect. This client has an elevated A1C level (the ideal range is less than 7.0%). Hemoglobin A1C reflects blood sugar control over the past three months, so this would not be the highest priority. The patient complaining of tingling and numbness in the toes indicates peripheral neuropathy, a common problem in diabetic clients, mainly when blood sugars are poorly controlled. The nurse should determine what teaching/interventions the client needs to achieve better control of blood sugars and manage symptoms of neuropathy. Choice D is incorrect. This client is presenting with symptoms typical of acute post-streptococcal glomerulonephritis (APSGN): hypertension due to fluid retention, rust-colored hematuria due to upper urinary tract bleeding, and proteinuria due to decreased filtration. The symptoms that are expected are not the highest priority. Most clients with APSGN recover fully with conservative treatment and rest. NCSBN Client Need Topic: Prioritization, Subtopic: Establishing priorities, diagnostic tests, the potential for alterations in body systems, changes/abnormalities in vital signs Additional Info Last Updated - 08, Dec 2022

The nurse on the medical floor receives a report on four patients. Which patient should the nurse see first? A. A client with a pulmonary embolism that has dyspnea and a pCO2 of 30 mmHg, who is on anticoagulation. B. A client with atrial fibrillation on Warfarin with a history of prior rectal bleeding and an INR of 6.0. C. A client with congestive heart failure and brain natriuretic peptide of 640 pg/mL. D. A client with acute pancreatitis and serum calcium of 8.9 mg/dL. Submit Answer

Explanation Choice B is correct. While answering prioritization questions, it is essential to determine which findings are unexpected and which pose an immediate risk of complications to the client. The target international normalized ratio (INR) for atrial fibrillation is 2.0-3.0. A supra-therapeutic INR of 6.0 is too high for this patient and puts the patient at high risk for bleeding. Additionally, given his prior history of gastrointestinal bleeding, he is more prone to recurrent bleeding in the setting of coagulopathy. The nurse should hold warfarin, assess the patient for signs of bleeding and notify the physician of abnormal results to determine if vitamin K should be administered to counter the effects of warfarin. Choice A is incorrect. The client has an established diagnosis of Pulmonary Embolism (PE) and is on therapeutic anticoagulation. Dyspnea and elevated D-dimer are expected results in patients with known PE. D-dimer reflects thrombin and plasmin activity; it is usually positive in hospitalized patients with thrombotic events. Low pO2 (Hypoxia) and low pCO2 (Respiratory alkalosis) are expected findings in patients with PE. Normal PCO2 is 35-45 mmHg, so 30 mmHg is small but not critical (<20 mmHg). Choice C is incorrect. Brain natriuretic peptide is a marker for congestive heart failure (CHF) because it correlates with left ventricular pressure. High left ventricular pressures and high BNP levels are expected findings in patients with heart failure. A BNP of more than 100 pg/mL is abnormal. The client has an established diagnosis of CHF and a report of BNP at 640 pg/mL does not require immediate action. Choice D is incorrect. Acute pancreatitis can cause decreased calcium levels (hypocalcemia). Severe hypocalcemia may be seen in acute pancreatitis and can present with neurological as well as cardiovascu

You are the nurse manager of the surgical acute care unit. You have noticed that several clients have almost been sent to the preoperative suite when they are not scheduled for a planned surgical procedure. Fortunately, no clients have gotten a "wrong surgery" because this possible error was caught in time. What is your priority action as the nurse manager? A. Praise the staff for catching these near misses before a surgical error occurs. B. Investigate and explore this near miss. C. Investigate and explore this medical error. D. Report the nature and frequency of these medical errors to the State Department of Health. Submit Answer

Explanation Choice B is correct. You, as the nurse manager of this surgical unit, should investigate and explore this near miss to prevent further medical errors in the future. This is your priority action. It's important to conduct near-miss investigations within 24 to 48 hours of the incident while memories are fresh about what happened and how the incident could have been prevented. Know these definitions: Near miss: A near miss is defined as "any event that could have had adverse consequences but did not and was indistinguishable from fully-fledged adverse events in all but outcome." In a near miss, an error was committed, but the patient did not experience clinical harm, either through early detection or sheer luck. In the above question, the clients have not undergone the wrong surgery and therefore, it's a near miss. Sentinel event: An unexpected occurrence involving death or serious physical/psychological injury. These events are called "sentinel" because they signal the need for immediate investigation and response. In the above question, the harm has not occurred. Therefore, it's not a sentinel event. Note that the terms "sentinel event" and "error" are not synonymous. Not all sentinel events occur because of an error and not all errors result in sentinel events. Choice A is incorrect. Although you should praise the staff for catching these near misses before a surgical error occurs, the priority is to investigate what led to the near miss. Choice C is incorrect. These near misses are not an actual medical error. Choice D is incorrect. These near misses are not an actual medical error, so it does not have to be reported to the State Department of Health. Last Updated - 22, Jan 2022

The RN is caring for a patient with suspected meningitis. Which action would the nurse recognize as the highest priority immediately following a lumbar puncture procedure? A. Test for gag reflex return B. Elevate the head of the bed to 30 degrees C. Encourage oral fluid intake D. Assess patient for Brudzinski sign Submit Answer

Explanation Choice C is correct. A lumbar puncture (or spinal tap) procedure is used to obtain cerebrospinal fluid (CSF) to diagnose meningitis and identify the cause. The nurse would encourage oral fluid intake following this procedure to replace CSF volume and reduce the risk of spinal headaches. Choice A is incorrect. A lumbar puncture procedure would involve local anesthetic at the site of the lower spine but would not involve sedation that would affect the gag reflex. Choice B is incorrect. The patient should be positioned lying flat for several hours following the lumbar puncture procedure to reduce the risk of spinal fluid leakage and spinal headache. Choice D is incorrect. A positive Brudzinski sign indicates meningeal irritation and may be used to screen for meningitis, but would not be appropriate to perform after the lumbar puncture procedure. NCSBN Client need: Topic: Physiological Integrity, Sub-topic: Reduction of Risk Potential Last Updated - 03, Feb 2022

The nurse is caring for a patient with a percutaneous endoscopic gastrostomy tube. Prior to starting the scheduled bolus feeding, the nurse is unable to auscultate the patient's bowel sounds and notes 80 mL gastric residual volume. Of the following, which action would be the nurse's priority? A. Notify physician B. Hold bolus and recheck residual volume in 1 hour C. Check for abdominal distension D. Reposition the patient in semi-Fowler's position Submit Answer

Explanation Choice C is correct. According to current American Society for Parenteral and Enteral Nutrition ( ASPEN) guidelines for nutrition support, enteral nutrition should not be stopped for a gastric residual volume (GRV) of less than 500 mL unless there are other signs of feeding intolerance. Signs/symptoms of feeding intolerance include nausea, vomiting, abdominal distention, constipation, and abdominal pain. If no bowel sounds are present, the nurse should assess the patient's abdomen for changes from the baseline, such as tenderness or distension. If no changes from the baseline, the feeding bolus may be administered as ordered Choice A is incorrect. Assessment data of the absence of bowel sounds and a gastric residual volume less than 200 mL would not warrant immediately notifying the physician. The nurse should first assess the signs of feeding intolerance. In the absence of signs of feeding intolerance, the feeding can be continued as long as the GRV is less than 500 mL. However, the providers should implement methods to reduce aspiration risk for the GRVs ranging from 200 to 500 mLs. Such measures include administering prokinetic agents such as metoclopramide and erythromycin ( to stimulate gastric motility), optimizing glucose control (hyperglycemia can delay gastric emptying), and using continuous rather than bolus feeding for high-risk patients. Choice B is incorrect. The absence of bowel sounds and a gastric residual volume less than 500 mL would not be a contraindication for administering scheduled feedings, but an additional assessment of the abdomen should first be performed and compared to the patient's baseline. In patients who are not critically ill, GRV should be checked every four hours during the first 48 hours of gastric feeding and, after that, every six to eight hours. Choice D is incorrec

The nurse is caring for a client with diabetic ketoacidosis and is prescribed a regular insulin protocol. The nurse administers 1 unit/kg of regular insulin to the client instead of the 0.1 unit/kg bolus. The nurse should take which initial action? A. Notify the primary healthcare provider (PHCP) B. Complete an incident report C. Assess the client for hypoglycemia D. Withhold the client's regular insulin infusion Submit Answer

Explanation Choice C is correct. All of these actions are correct, but the nurse needs to assess the client for hypoglycemia. Regular insulin, when given intravenously, peaks within 15-30 minutes, and the client given this much insulin could develop hypoglycemic shock. When a client has been prescribed a continuous regular insulin infusion, they usually receive a bolus dose of 0.1 unit/kg first, then the continuous infusion is started. Choices A, B, and D are incorrect. All of these actions are appropriate following a medication error of this magnitude. The PHCP should be contacted once the client's glucose is obtained to receive orders on treatment which may range from parenteral glucagon or modifying the intravenous fluids. Additional Info Regular insulin is a high-risk medication, requiring a second nurse verification because of the high risk of injury associated with this medication. When given intravenously, regular insulin peaks within fifteen to thirty minutes. When given subcutaneously, regular insulin peaks within two to four hours. Last Updated - 08, Jul 2022

A 25-year-old is found unconscious with a fever and a noticeable rash. Which of the following ordered tests is essential for the nurse to obtain right away? A. Blood sugar check B. Basic Metabolic Panel (BMP) C. Blood cultures D. Arterial blood gases Submit Answer

Explanation Choice C is correct. Blood cultures would be ordered to investigate the source of fever and rash. Blood cultures should be obtained as quickly as possible. As soon as the blood cultures have been obtained the client will likely be placed on broad-spectrum antibiotics to start to kill the offending pathogen in the client's blood circulation. Choice A is incorrect. Abnormal blood sugar levels may result in a client who is confused or unconscious. Low blood sugar values will not cause a fever and will not cause a skin rash. Other interventions will be the priority at this time based on those additional accompanying symptoms of fever and rash. Fever and rash are indicative of an infection. Choice B is incorrect. A Basic Metabolic Panel (BMP) will likely be ordered to show this client's electrolytes, renal, and liver function- but it will not be the priority. The nurse should be most concerned about an acute infection given the client's presentation: febrile, with a noticeable rash, and found unconscious. The concern is that this client has an infection that has travelled to their bloodstream; causing sepsis. This has likely progressed to septic shock causing the client's blood vessels to vasodilate, and decreasing their blood pressure so low that perfusion to the brain is inadequate. This is an emergency. The nurse should immediately obtain blood cultures to determine the source of the client's infection. Choice D is incorrect. ABGs are not indicated to test the source of fever or rash. An ABG would be obtained to check the pH of a client's blood along with their CO2 and HCO3- levels if respiratory failure was suspected. An ABG is a lab that is often obtained to check how well a client is tolerating their ventilator settings or if a client has been on BiPAP for respiratory failure. In this patient presenting w

A nurse receives laboratory results for several clients under her care. Which client result would the nurse report to the health care provider (HCP) immediately? A. An elevated amylase result in a client diagnosed with acute pancreatitis B. An elevated white blood cell (WBC) count in a client with a septic leg wound C. A urinalysis positive for leukocytes and nitrites in a chemotherapy client D. A serum glucose of 235 mg/dL in a client with type 1 diabetes mellitus Submit Answer

Explanation Choice C is correct. Chemotherapy agents place clients at increased risk of infection due to immune suppression of the medication(s), specifically by decreasing neutrophils. Neutropenia, a reduction in the blood neutrophil count, is common in chemotherapy clients. As the neutropenia increases, so does the client's risk (and severity of) bacterial and fungal infections. If a bacterial or fungal infection does occur, the likelihood of the infection spreading to other parts of the body increases. In a urinalysis, the presence of leukocytes and nitrites is indicative of a urinary tract infection. This result should indicate to the nurse that a urinary tract infection is present in this immunocompromised client, warranting the nurse to notify the HCP of the result so antibiotic therapy may be initiated immediately. Choice A is incorrect. An elevated amylase result in a client diagnosed with acute pancreatitis is an anticipated finding and would not warrant reporting the result to the HCP. Choice B is incorrect. In a client diagnosed with a septic leg wound, an elevated white blood cell count (also known as leukocytosis) is an anticipated finding. Leukocytosis usually occurs in response to infection, trauma, or inflammation. Since this client is known to be septic, the leukocytosis is an anticipated finding and, therefore, does not warrant the nurse immediately reporting this lab result to the HCP. Choice D is incorrect. The client's serum glucose level of 235 mg/dL is above the normal range of 70-110 mg/dL, but this is a relatively common finding in clients with type I diabetes mellitus and does not necessitate immediate reporting to the HCP. Learning Objective Identify the chemotherapy client's urinalysis as the result which requires reporting to the health care provider due to the immunocompromised state of

Which color codes are the highest priority for medical and nursing care? See exhibit. A. The yellow color code B. The green color code C. The red color code D. The black color code Submit Answer

Explanation Choice C is correct. Clients designated with a red triage color code have been deemed to possess one or more serious, life-threatening injuries. Therefore, this group of clients is the highest priority for medical and nursing care. Choice A is incorrect. Clients designated with a yellow triage color code have been deemed to possess injuries that are not life-threatening. This group of clients is not the highest priority for medical or nursing care. Choice B is incorrect. Clients designated with a green triage color code have been deemed to possess only minor injuries. This group of clients is not a high priority for medical or nursing care. Choice D is incorrect. Clients designated with a black triage color code have been deemed to have suffered significant injuries to the point that death is inevitable and will occur shortly. Here, staff will provide palliative pain medication as the only intervention until expiration. No other resources are provided. Learning Objective Recognize that in a mass casualty situation, you have limited resources and cannot utilize those resources on clients whose expiration is impending. Additional Info This color coding is similar to a triage you would see in a mass casualty situation. Last Updated - 06, May 2021

The nurse has received the following prescriptions for newly admitted clients. The nurse should first A. irrigate a wound for a client with a stage III pressure ulcer. B. complete pin care for a client with a halo fixation device. C. administer diazepam for a client with delirium tremens (DTs). D. insert an indwelling urinary catheter for a client with retention. Submit Answer

Explanation Choice C is correct. Delirium tremens (DTs) is a severe form of alcohol withdrawal. This prescription should be implemented immediately as the risk of seizure activity is quite significant. Choices A, B, and D are incorrect. These prescriptions require quite a bit of time and are low priority compared to the client experiencing an acute threat of a seizure. The nurse must prioritize actions based on acuity and time necessary to complete each task. Activities related to discharge are low priority and any dressing changes are also a low priority. Additional Info Delirium tremens (DTs) is the most severe form of alcohol withdrawal. Manifestations of DTs include disorientation, hyperthermia, psychomotor agitation, hypovolemia, hallucinations, hypertension, and seizure activity. To prevent seizure activity and mitigate agitation, benzodiazepines are commonly used. Maintenance dosing of benzodiazepines may be used along with PRN dosing for additional mitigation of symptoms. DTs occur within 48 to 96 hours following the last alcoholic drink. Last Updated - 27, Jul 2022

The nurse is preparing to discharge clients from the nursing unit. Which client has the greatest need to be referred for outpatient community services? A. A client newly diagnosed with skin cancer that lives with family. B. A client recovering from a stroke and is discharged to inpatient rehab. C. A client who is homeless and has a substance use disorder. D. A client leaving against medical advice for the treatment of cellulitis. Submit Answer

Explanation Choice C is correct. Individuals with difficulty obtaining and sustaining housing have high rates of treatment non-adherence. Lack of adequate housing poses a serious threat to treatment adherence because of the lack of privacy, storage of medications, and a sense of detachment from the community. This client should be referred for outpatient services because they are homeless and have a substance use disorder. Both are issues that may be mitigated with community services. Choices A, B, and D are incorrect. Cancer support groups are essential for a client coping with the illness. This would be an appropriate referral, but not the greatest need of a referral considering the client lives with family, which can be viewed as a support system. A client recovering from a stroke requires many interdisciplinary resources and would not need a referral for community services because they are going to inpatient rehab. A client leaving AMA would not require a referral; the serious cellulitis diagnosis is acute and will resolve with antibiotics. Additional Info An RN may initiate referrals. The nurse should identify clients with the most significant need for community services. Examples of clients needing community services include: Homelessness Complex conditions (HIV, cancer) Insufficient support systems Financial instability Last Updated - 11, Feb 2022

The nurse is planning client assignments for a licensed practical/vocational nurse (LPN/VN). Which client assignment would be appropriate? A client A. in an arm cast who is suspected to have compartment syndrome. B. immediately post-operative from a prostate reseaction reporting bladder spasms. C. with a paralytic ileus requiring the insertion of a nasogastric tube. D. newly diagnosed with Hepatitis A and requires discharge teaching. Submit Answer

Explanation Choice C is correct. LPNs may insert and manage a nasogastric tube. This is within the scope of practice and can be safely delegated to this nurse. Choices A, B, and D are incorrect. Compartment syndrome is a medical emergency requiring RN care because the client is unstable and is at risk for neurovascular compromise. A client immediately post-operative should not be delegated to an LPN until stability has been established. Following a prostate resection, the client is at risk for hemorrhage and must be assessed for this potential complication. Therefore, such a potentially unstable scenario is not an appropriate assignment for the LPN. The client requiring discharge teaching will need the RN, as the "initial" teaching is not within the LPN's scope of practice. Learning Objective While delegating, recognize the LPN/LVN scope of practice which often involves the care of stable and predictable clients. Additional Info Last Updated - 31, Dec 2022

The RN is training a new nurse on a medical-surgical floor. Which action would warrant intervention by the experienced RN? A. The nurse administers ceftriaxone via IV 30 minutes early for a pneumonia client. [20%] B. The nurse places a surgical mask on a patient with influenza before transport. [4%] C. The nurse obtains green drainage from a nasogastric tube for culture. [33%] D. The nurse secures a Jackson-Pratt drain to the patient's gown with a safety pin.

Explanation Choice C is correct. Nasogastric tubes drain gastric contents, which are typically yellow/green in color due to the presence of bile. Sending these contents for culture may cause unnecessary worry for the patient and would not be appropriate since this is an expected assessment. All other actions listed are appropriate. Choice A is incorrect. Non-time-critical scheduled medications are those where early or delayed administration within 1-hour window would not result in harm or substantial sub-optimal therapeutic response. Scheduled IV antibiotics may be given within a 1-hour window unless they are precisely timed. The nurse may administer the IV ceftriaxone up to 30 minutes before the scheduled time. Choice B is incorrect. A diagnosis of influenza requires droplet precautions, which include the patient wearing a surgical mask when transported outside of the room. Choice D is incorrect. Jackson-Pratt drainage systems can be pinned to a patient's gown and should be secured below the exit site to prevent tension on the tubing. NCSBN Client need: Topic: Physiological Integrity, Sub-topic: Reduction of Risk Potential Last Updated - 09, Feb 2022

ich potential nursing problem is the highest priority for a patient who is in the immediate postoperative stage? A. Risk for infection B. Risk for fluid volume deficit C. Risk for hemorrhage D. Risk for altered body image Submit Answer

Explanation Choice C is correct. Patients are at risk of illness during the post-operative stage. Of the answer choices listed, this potential problem would be the highest priority and would result in the most severe complications. Choice A is incorrect. This patient would be at risk for infection due to new surgical procedures, but this would not be as high of a priority as the risk for bleeding. Choice B is incorrect. This patient would be at risk for dehydration and fluid volume deficit due to blood loss and decreased oral intake, but this would not be as high of a priority as the risk for illness. Choice D is incorrect. This patient may be at risk for altered body image due to this surgical procedure. Still, this psychosocial problem would not be as high of a priority as the physiological problem of risk for illness. NCSBN Client Need Topic: Prioritization, Subtopic: Potential for complications from surgical procedures Last Updated - 25, Jan 2022

The emergency department (ED) nurse is caring for a group of clients following an industrial accident. It would be a priority for the nurse to follow up on the client who A. has a fracture to the lower extremity and increasing pain. B. is crying because they cannot locate their child. C. has singed eyebrows and a hoarse voice. D. is diabetic, and their insulin pump has been lost. Submit Answer

Explanation Choice C is correct. Singed eyebrows and a hoarse voice are suggestive of a smoke inhalation injury. Considering this is an airway concern, this client should be prioritized. Choices A, B, and D are incorrect. Pain is associated with a fracture and would be expected. This client will not be prioritized over a client who has sustained an insult to their airway. Additionally, the other two client situations of not being able to locate a child or insulin pump are not of immediate physiological concern. Additional Info The emergent triage category implies that a condition exists that poses an immediate threat to life or limb. Conditions that should be triaged as emergent include: active hemorrhage, unstable vital signs, significant trauma, chest pain, and manifestations of a stroke. The urgent triage category indicates that the client should be treated quickly but that an immediate threat to life does not exist at the moment. Conditions that typically fall into the urgent category are those with a new onset of pneumonia (as long as respiratory failure does not appear imminent), renal colic, abdominal pain, complex lacerations not associated with major hemorrhage, displaced fractures or dislocations, and temperature higher than 101°F (38.3°C). Those triaged as non-urgent can generally tolerate waiting several hours for health care services without a significant risk for clinical deterioration. Conditions within this classification include clients with sprains and strains, simple fractures, general skin rashes, and uncomplicated urinary tract infections. Last Updated - 15, Aug 2022

The nurse is caring for a 13-year-old male child in the pediatric unit with a left-side below the knee cast. The boy reports pain and numbness of the foot. The nurse notes that the toes of the left foot are cold. Which of the following actions should the nurse take first? A. Remove the cast. B. Have the child ambulate. C. Notify the physician. D. Elevate the leg on two pillows. Submit Answer

Explanation Choice C is correct. The client is already showing the signs of compartment syndrome. The client has pain, numbness, and cold feet (low perfusion). Pain, pulselessness, pallor, paresthesias, and paralysis are the "5 Ps" associated with compartment syndrome. Compartment syndrome is an emergency. The nurse should be able to recognize signs and symptoms of compartment syndrome and notify the physician STAT. Compartment syndrome often results after trauma and is more common in the anterior compartment of the leg. Following a trauma, there may be decreased intra-compartmental space or increased intra-compartmental fluid volume (due to fracture, hematoma, etc). Because the surrounding fascia is noncompliant, the compartment pressure increases. In normal circumstances, there is a balance between venous outflow and arterial inflow. But increasing compartmental pressure results in a reduction of venous outflow. Consequently, venous pressure increases, further fueling an increase in compartmental pressure. Once compartmental pressure increases more than arterial pressure, arterial blood flow gets affected, and ischemia ensues. If ischemia lasts longer, irreversible necrosis/death of the tissue occurs. Choice A is incorrect. The child is displaying signs of neurovascular compromise due to compartment syndrome. The cast should be removed to relieve pressure; however, it is not the first action to be taken by the nurse. Cast removal should be arranged after informing the physician. Fasciotomy may be needed, and the physician needs to know immediately. Choice B is incorrect. The child should not ambulate as this will increase the child's risk of further injury. Choice D is incorrect. After notifying the physician, the affected limb should be placed at the level of the heart, not above the heart level. While elevation ab

The client has just been given an IV dose of morphine 6 mg for neuropathic pain. A few minutes later, the nurse notes that the client's respirations are now 8, and his blood pressure has dropped from 122/83 mmHg to 88/67 mmHg. Which nursing action is the most appropriate? A. Prepare for intubation. B. Prepare to administer a dopamine infusion. C. Administer naloxone. D. Start an IV infusion of normal saline. Submit Answer

Explanation Choice C is correct. The client is suffering from morphine toxicity. The nurse needs to administer the antidote, which is naloxone (Narcan). Choice A is incorrect. The client is in morphine toxicity. The nurse needs to administer an antidote to reverse the symptoms of respiratory depression. Preparing for intubation should not be the nurse's initial action. Choice B is incorrect. The drop in blood pressure is a result of morphine toxicity. Dopamine infusion is not yet necessary as of the moment. Choice D is incorrect. Starting an IV infusion may be necessary; however, in this case, the first action of the nurse would be to administer an antidote to morphine. Last Updated - 03, Feb 2022

The nurse is caring for the following assigned clients. The nurse should initially follow-up with the client who A. is repeatedly washing their hands. B. talking over others during group therapy. C. yelling and shouting at others. D. is voluntarily admitted and requesting discharge. Submit Answer

Explanation Choice C is correct. The client yelling and shouting at other clients requires immediate intervention because this situation is hostile and warrants the nurse to de-escalate the situation before it intensifies. Choices A, B, and D are incorrect. A client repeatedly washing their hands is a feature of obsessive-compulsive disorder, and the nurse should not intervene unless the act threatens the client or others. Further, a client talking over others in therapy will require intervention, but this is not the immediate need as it is not a hostile situation. Finally, voluntarily admitted clients might request discharge, but this is a low-priority item compared to the client yelling at others. Additional Info When prioritizing client needs, focus on ensuring that physiological, safety and security needs are met first. In this question, the client's safety and security needs are prioritized over the other needs. Last Updated - 07, Dec 2022

The nurse is reassessing her female patient diagnosed with appendicitis. At her last assessment, the patient expressed 8/10 pain but now states that she has no pain. The nurse did not administer any pain medication. What is the priority nursing action? A. Document the pain score and continue monitoring B. Check the WBC count C. Notify the healthcare provider D. Palpate McBurney's point Submit Answer

Explanation Choice C is correct. The nurse should immediately notify the healthcare provider of this change in the patient's status. A sudden change of 8/10 pain to 0/10 pain in a patient diagnosed with appendicitis could indicate rupture, so the healthcare provider needs to be immediately notified. This sudden pain relief is usually followed by a gradual increase in pain once again and guarding in the right lower quadrant. A ruptured appendix may result in infection, peritonitis, and abscess. Tachycardia, tachypnea, fever, restlessness, and irritability may follow. Choice A is incorrect. When a patient with appendicitis has sudden pain relief, it is a sign of a possible appendix rupture. Appendiceal rupture is a surgical emergency, and the patient must be taken to the operating room quickly. Without taking further action, it is inappropriate for the nurse to document just the pain score. Choice B is incorrect. WBC count can be checked to look for signs of infection, such as leukocytosis; however, this is not the priority action. Sudden relief of pain is concerning for rupture of the appendix. The physician must be notified right away. Choice D is incorrect. The patient with appendicitis will likely have tenderness at McBurney's point, but this patient is already expressing a sudden relief of pain. She needs to be evaluated for possible rupture, so the nurse should immediately notify the healthcare provider. The provider may order CT imaging to confirm the diagnosis. Learning Objective Understand that sudden pain relief in a patient with acute appendicitis may suggest an appendiceal rupture. Additional Info Last Updated - 11, Feb 2022

The nurse is taking care of a client receiving a D5LR intravenous infusion. Suddenly, the client complains of chest pain and difficulty breathing. On exam, there is cyanosis and tachycardia. The nurse also notices an empty IV bottle. What is the initial intervention of the nurse? A. Replace the empty IV bottle with a new one. B. Replace the IV line and attach a new IV bottle. C. Stop the IV infusion and turn the client on his left side with the head of the bed lowered. D. Stop the IV infusion and notify the physician. Submit Answer

Explanation Choice C is correct. The nurse should suspect an air embolism because the patient is presenting with characteristic symptoms in a setting where the fluid infusion is complete and the IV drip set is still open. An empty IV "bottle" offers this clue. Manifestations of an air embolism include tachycardia, hypotension, chest pain, difficulty breathing, and cyanosis. Air embolism may cause blockage of small pulmonary vessels compromising the gas exchange, obstruction of ventricular pumping, and arrhythmias. In practice, the replacement of IV infusion bottles with collapsible airbags has largely minimized the risk of air embolism during IV infusions. The nurse's initial action would be to turn off the infusion system, place the client on his left side with the head lowered (left Trendelenburg position), and then notify the physician. The left-sided Trendelenburg position will help the air bubble float in the right ventricle/right atrium and prevents it from causing right ventricular outlet obstruction. Choice A is incorrect. Replacing the IV bottle is not an appropriate intervention in this situation since the client is already presenting with signs and symptoms of air embolism. To prevent air embolism, the nurse should have replaced the IV bottle before it is empty. At this time, the nurse should turn off the infusion system and place the client in the left-Trendelenburg position. Choice B is incorrect. Replacing the IV line and hooking up a new IV bottle does not address the air embolism. Choice D is incorrect. A nurse should never delay a life-saving intervention that is within the scope of his/her practice. After stopping the infusion, the next immediate action for the nurse would be to place the client on his left side with the head lowered to trap the air in the right atrium. After this, the nurse must not

The UAP reports to the nurse that the patient who is on oxygen is presenting with a profusely bloody nose. The patient has been on warfarin for atrial fibrillation. Which action would be the highest priority? A. Instruct the UAP to offer oral and nasal care to help with dryness. B. Notify the physician so the scheduled warfarin can be held. C. Assess the client and look for bruising, bloody stools, and bleeding gums. D. Obtain a bubbler to humidify the oxygen. Submit Answer

Explanation Choice C is correct. The nurse's priority action should be to assess the patient and determine if there are any other sources of bleeding. For a patient on anticoagulation, assuming that a dry nose is the only reason for profuse nasal bleeding before assessing the patient is unacceptable. Choice A is incorrect. The nurse should assess this patient, not re-send the UAP. The nurse cannot assume that the bleeding is due to nasal passage dryness alone, so the patient needs to have an assessment completed to determine the reason. If the evaluation reveals no other sites of bleeding, and if the INR returns within the therapeutic range, it can be presumed that the nasal dryness alone is the cause of such localized bleeding. Choice B is incorrect. The nurse should not call the physician until completing at least a focused assessment of the patient and current problems. If the INR is supratherapeutic and warfarin is suspected to be causing the bleeding, holding warfarin may be appropriate but would not be the highest priority at this time. Assessing for other bleeding sites and clarifying the etiology is the most crucial next intervention. Choice D is incorrect. A bubbler helps to humidify the dry air and oxygen delivered via a nasal cannula or face mask. The nurse cannot assume that the bleeding is due to nasal passage dryness, so the patient needs to have an assessment completed to determine the reason. Last Updated - 01, Nov 2021

The emergency department (ED) triage nurse is assigned to see the following clients. Which of the following clients requires the most rapid action in the ED? A. A travel blogger who needs tuberculosis testing after exposure to a person with TB during his trip. B. An elderly woman who has a history of a methicillin-resistant Staphylococcus aureus (MRSA) leg wound infection. C. A pregnant woman with a blister-like rash on the face who possibly has varicella. D. An infant with a runny nose and whose older brother has pertussis. Submit Answer

Explanation Choice C is correct. The primary responsibility of the triage nurse is to perform an initial nursing assessment and determine which patient(s) require immediate care or isolation. The triage nurse should be able to identify patients who pose a potential risk to others by being familiar with commonly occurring illnesses/infections. Emergency department nurses and triage nurses must be adept at prioritization. Prioritization refers to the concept of deciding which duties/clients require immediate attention and which ones could be delayed until later. None of the clients in the options above show any signs of unstable vitals. Therefore, the safety of the client and other clients takes priority. Chickenpox (Varicella) is transmitted airborne and can be easily transferred to other clients in the emergency unit. The pregnant woman with suspected Varicella rash (Choice C) should be isolated right away from other clients through placement in a negative-pressure room. Choice A is incorrect. The client who has been exposed to Tuberculosis (TB) does not place the other clients at risk for infection because he/she has no symptoms of active TB. Latent tuberculosis is not infectious by itself. Pulmonary/Cavitary disease can manifest with a productive cough and carries the highest risk of infection. Only such symptomatic TB patients should be placed in a negative-pressure room with airborne isolation precautions. Choices B and D are incorrect. Droplet precautions should be instituted for the client with possible pertussis. Contact isolation should be implemented for the client with a history of MRSA infection. But these two patients should be attended to after isolating the pregnant client with possible varicella because the risk of infectivity with the airborne transmission is much higher. Last Updated - 14, Jan 2022

The nurse is caring for a 2-year-old client who is intubated and mechanically ventilated. Two hours into the shift, the hospital receives a tornado warning. What is the priority action the nurse should take? A. Clock out, her shift is over, and she is not responsible. B. Remove the child from the ventilator and carry her to a tornado shelter. C. Move the patient as close to the interior of the room as possible. D. Close all of the doors. Submit Answer

Explanation Choice C is correct. The priority action for the nurse is always to "best protect her patient." During a tornado warning, the appropriate nursing action is to move patients away from windows and as close to the room's interior as they can safely be moved. This action best protects them in the event of a tornado. Choice A is incorrect. It is not appropriate to clock out because her shift is over. The nurse is always responsible for her patients' safety, so clocking out does not best protect her patient. Choice B is incorrect. It is inappropriate to remove the child from the ventilator because it could result in serious harm and even death if the child is dependent on mechanical ventilation. Choice D is incorrect. Closing all of the doors will not protect the patient during a tornado. This is an appropriate action in some fire events depending on the fire's location, but never for a tornado. NCSBN Client Need Topic: Effective, safe care environment; Subtopic: Infection control and safety Last Updated - 15, Feb 2022

The nurse has arrived at a bus accident. The nurse plans to triage which client with a red tag? A client with A. a simple fracture in the forearm and painful swelling. B. profuse bleeding from a chest laceration and is experiencing apnea. C. a crushed leg who reports no sensation in the extremity. D. severe anxiety and abrasions on both arms. Submit Answer

Explanation Choice C is correct. This client would be red-tagged by using the emergency triage tagging system (red, yellow, green, and black) because of their compromised circulation. Red tags require emergent care because of an immediate threat to their life. Choices A, B, and D are incorrect. The client who is experiencing apnea would be a black tag. This is when death has occurred or is imminent. The nurse should prioritize red tags, not black tags. The client experiencing severe anxiety and abrasions to the arms would be classified as a green tag, along with the client with a simple fracture. Additional Info Emergent (red tags) include life-threatening injuries, including obstruction to the airway, severe hemorrhage, or shock. Immediate treatment is necessary. Urgent (yellow tags) include alterations in blood glucose (hypoglycemia), disorientation, and large wounds that need treatment within 30 minutes to 2 hours. Nonurgent (green tags) include minor injuries such as strains, sprains, simple fractures, or abrasions. Treatment may be delayed up to four hours. Last Updated - 23, Nov 2022

The emergency department (ED) nurse is caring for a client admitted with diabetic ketoacidosis (DKA). Which clinical data requires immediate follow-up? A. Respiratory rate (RR) 23/minute B. Capillary blood glucose 319 mg/dL C. Mean arterial pressure (MAP) 51 mm Hg D. PaO2 90 mm Hg Submit Answer

Explanation Choice C is correct. This client's mean arterial pressure (MAP) is critically low. The MAP for an adult should be at least 60 mm Hg (this will ensure adequate perfusion to critical organs), with the ideal MAP being 70 mm Hg. This client's MAP requires immediate correction because of the end-organ damage the client is likely experiencing. Choices A, B, and D are incorrect. Tachypnea associated with respiratory alkalosis is expected in a client with DKA. A RR of 22/minute is concerning but not critical. Further, the client's PaO2 shows no concern for hypoxia; therefore, this is not an immediate priority. The client's CBG is elevated but expected for a client experiencing DKA. A PaO2 of 90 mm Hg is normal for an adult (the normal range being 80 - 100 mm Hg). Additional Info ✓ DKA is a medical emergency that requires emergent treatment. ✓ This complication is exclusive to those with type I diabetes mellitus. ✓ Manifestations of DKA include hyperglycemia, fluid volume deficit, lethargy, tachypnea, and metabolic acidosis. ✓ The treatment goals for a client with DKA include repleting critically lost volume and normalizing the blood glucose. ✓ Achieving both would help correct the underlying metabolic acidosis. ✓ Isotonic saline replacement is utilized initially, and then once the blood glucose approaches 250 mg/dL to 300 mg/dL, the fluids change to 5% dextrose and 0.45 saline with potassium additive. ✓ Monitoring parameters include hourly blood glucose and the client's potassium. Last Updated - 06, Jan 2023

The nursing student inserts an indwelling urinary catheter for a female patient prior to surgery. Which of the following would require immediate intervention by the RN? A. The patient states she feels the need to urinate. B. Patient reports a pinching sensation as the catheter is advanced. C. The student nurse notes resistance when inflating the balloon. D. The student separates the labia majora and labia minora with non-dominant hand. Submit Answer

Explanation Choice C is correct. This may indicate the balloon is within the urethra, not the bladder. If inflated within the urethra, the balloon may cause significant damage. Any complaints or nonverbal signs of discomfort or resistance is noted by the nurse during balloon inflation, are indications to stop this procedure immediately. Choice A is incorrect. The patient may feel the urge to void as the catheter is advanced through the internal urethral sphincter, this would not be a reason to stop the procedure. Choice B is incorrect. The student nurse should explain to the patient that she may feel pressure upon catheter insertion. A brief pinching sensation indicates the catheter is passing through the internal urethral sphincter and would not be a reason to stop the procedure. Choice D is incorrect. This action is appropriate. The student should use the non-dominant hand to position the patient and the dominant hand should remain sterile for insertion. NCSBN Client need: Topic: Physiological Integrity, Sub-topic: Reduction of Risk Potential Last Updated - 24, Jan 2022

The nurse receives a report on four patients at the start of shift change. Which patient should the nurse see first? A. A patient with a right femur fracture who complains of right leg pain. B. A patient being treated for pneumonia with scheduled IV antibiotics due. C. A patient with a history of T6 spinal injury 6 months ago, now presents with a headache. D. A patient that is 1-day postoperative open cholecystectomy with green drainage. Submit Answer

Explanation Choice C is correct. This patient may be developing autonomic dysreflexia, a medical emergency. One of the first signs/symptoms of autonomic dysreflexia is a severe, throbbing headache following spinal cord injury (most common in T6 and above). Patients usually develop autonomic dysreflexia one month to one year after their injury. However, it has also been described in the first days or weeks after the original trauma. Objectively, an episode is defined as an increase in systolic blood pressure of 25 mmHg. Patients with this condition will develop dangerously high blood pressure that can result in severe, fatal diseases such as seizures, pulmonary edema, and myocardial infarction. Assessing this patient would be the nurse's highest priority. Choice A is incorrect. Right leg pain is expected in a patient with an acute right femur fracture. The nurse needs to address this patient's pain, but expected outcomes would not be the highest priority. Choice B is incorrect. Scheduled medications would not be a higher priority than the patient showing symptoms of a life-threatening complication. Choice D is incorrect. Green drainage is expected in a patient with an open cholecystectomy due to the green color of bile in the common bile duct. The nurse should assess this patient's drainage and progression of healing, but it would not be the highest priority. NCSBN Client Need Topic: Establishing priorities, medical emergencies, Subtopic: Priorities Last Updated - 02, Dec 2021

The nurse is preparing medications for the shift. Which of the following clients should be prioritized for immediate medication administration? A. Digoxin to a client with an apical pulse of 50 B. Furosemide to a client with a serum potassium level of 3.0 mEq/L C. Magnesium sulfate to a client with Torsades de pointes D. Verapamil to a client with blood pressure of 100/60 mmHg Submit Answer

Explanation Choice C is correct. Torsades de pointes, a form of ventricular tachycardia, is a life-threatening condition. The nurse should immediately administer the medication to the client to prevent the disease from progressing into ventricular fibrillation. Choice B is incorrect. Furosemide is a loop diuretic used to treat congestive heart failure and edema. The drug predisposes the client to hypokalemia. In this case, the client already has a low serum potassium level. Therefore, the nurse needs to notify and question the prescribing physician whether he/she should still proceed with administering the medication. Choice A is incorrect. When the nurse is administering digoxin, she should check the patient's apical pulse and withhold the dose if the pulse falls below 60 beats per minute. Choice D is incorrect. The blood pressure of the client is at 100/60 mmHg. Verapamil is a calcium channel blocker and is often used to treat high blood pressure and angina. It can be administered as ordered. Typically, physicians order blood pressure medications to be held at a systolic blood pressure of 90 mmHg or below. However, in this case, the nurse should prioritize administering magnesium to the client with Torsades de pointes. Last Updated - 04, Jan 2022

The nurse has become aware of the following client situations. The nurse should first follow up with which client? A. A client with an irregular pulse that is receiving treatment for atrial fibrillation. B. A client with pneumonia who had an increase in temperature to 102.3° F. C. A client receiving nebulizer treatments for asthma that suddenly stops wheezing. D. A client that has active pulmonary tuberculosis (TB) and refuses prescribed medications. Submit Answer

Explanation Choice C is correct. Wheezing, tachypnea, and dyspnea are all expected findings during an acute asthma exacerbation. The sudden cessation of wheezing highly concerns the nurse, indicating that the client is no longer oxygenating because they are not moving air. This warrants immediate follow-up as it is a sudden change. A gradual improvement in symptoms is expected. Choices A, B, and D are incorrect. An irregular pulse is an expected finding associated with atrial fibrillation as this is an irregular arrhythmia. Pyrexia, a productive cough, and chest discomfort are common features of pneumonia and do not require follow-up. A client refusing medications is concerning but does not override a physical threat to a client's breathing. Additional Info Clinical features of an asthma exacerbation include the following: Tachypnea Dyspnea Persistent cough Use of accessory muscles for breathing Tachycardia Wheezing in the lung fields The priority treatment is administering oxygen followed by prescribed albuterol via nebulizer. A client may be prescribed adjunctive agents such as systemic glucocorticoids or magnesium sulfate. The nurse should avoid the administration of beta-adrenergic blockers as this may worsen or induce an exacerbation. Last Updated - 03, Feb 2022

You are the Registered Nurse working a night shift with a Certified Nursing Assistant. It is your first night back after a vacation, so you are not familiar with the patients. The CNA reports that Mrs. Smith has a headache, Mrs. Jones cannot stop coughing, Mr. Peters has an oxygen saturation of 88%, and Mr. White's IV is beeping. The patient you should see first is: A. Mrs. Smith B. Mrs. Jones C. Mr. Peters D. Mr. White

Explanation Choice C is correct. You should see Mr. Peters first since his oxygen saturation is below 94%. The prioritization for patient care should first be based on the "ABCs - Airway, Breathing, Circulation". An oxygen saturation reading below 94% should be investigated since this would indicate that the patient may have an airway or breathing problem. You should ask the CNA to sit with Mrs. Jones until you can get in to evaluate her coughing. Mrs. Smith's headache should be assessed third. Finally, you should look at Mr. White's IV to determine why it is beeping. NCSBN Client Need Topic: Management of Care, Sub-Topic: Establishing Priorities, Prioritization Last Updated - 28, May 2021

The nurse working on the medical-surgical unit is assigned as a preceptor to work with a newly hired nurse. Which of the following, if performed first by the newly hired nurse, would indicate the ability to prioritize appropriately? A. Initiates a referral for a client needing home health care. [6%] B. Performs a central line dressing change on a client receiving 0.9% saline infusion. [10%] C. Collects a urine specimen from a client's indwelling urinary catheter. [6%] D. Obtains capillary blood glucose for a client receiving continuous regular insulin.

Explanation Choice D is correct. A client receiving continuous regular insulin infusion requires hourly capillary blood glucose checks because of the high risk of hypoglycemia. Regular insulin via intravenous infusion peaks within fifteen to thirty minutes. Thus, the nurse must watch for hypoglycemia signs, including tachycardia, palpitations, and diaphoresis. Choices A, B, and C are incorrect. Initiating a client referral, performing a central line dressing change, and obtaining a urine specimen are low-priority items compared to a client receiving a high-risk medication, especially via a route that allows for a rapid peak. Additional Info A continuous infusion of regular insulin is the mainstay treatment for diabetic ketoacidosis (DKA). When regular insulin is given intravenously, it peaks much sooner than when it is given subcutaneously. Thus, the nurse needs to check the glucose hourly. Finally, monitoring the client's serum potassium is essential because regular insulin will lower potassium levels. Last Updated - 07, Dec 2022

Based on the following choices and accompanying rationales, which of the following clients would be the highest priority? A. The need to develop trust versus mistrust since this is the most basic of all needs. B. The need to be free of fear and anxiety, as these feelings inhibit coping. C. The need for adequate cardiovascular functioning because without this, life is unsustainable. D. The need for a patent airway as life cannot be sustained without this. Submit Answer

Explanation Choice D is correct. According to Maslow's Hierarchy of Needs, a patent airway is one of the most basic needs and would fall under the "Physiological Needs" level of the pyramid. While cardiovascular functioning (Choice C) also falls under the same level of Maslow's Hierarchy of Needs, one would then default to the standard ABC mnemonic survey and assessment (i.e., airway/cervical spine (A); breathing (B); circulation (C)), therefore rendering a patent airway a higher priority than adequate cardiovascular functioning. Choice A is incorrect. Under Erikson's theory of psychosocial development, the trust versus mistrust stage is the first developmental milestone of infants. Although important, physical needs are always prioritized over psychological needs. This is also reflected in Maslow's Hierarchy of Needs. Choice B is incorrect. The need to be free of fear and anxiety is a psychological need, and, based on Maslow's Hierarchy of Needs, physical needs are a higher priority than psychological needs. Choice C is incorrect. Although the need for adequate cardiovascular functioning does fall under the "Physiological Needs" level of Maslow's Hierarchy of Needs and is, therefore, a high priority, it is not the highest priority listed in the answer choices provided. Source : Archer Review Learning Objective Using Maslow's Hierarchy of Needs, determine which client should be prioritized. Additional Info Always utilize Maslow's Hierarchy of Needs when prioritizing interventions. The Airway Breathing Circulation (ABC) framework identifies, in order, the three basic needs for sustaining life. An open airway is necessary for breathing, so it is the highest priority. Breathing is necessary for oxygenation of the blood to occur. Circulation is necessary for oxygenated blood to reach the body's tissues. The severity o

A patient tells the nurse that she is ashamed of how her hair looks and wants to wash her hair before her daily tests and appointments are performed. How should the nurse prioritize the patient's care? A. The nurse should explain to the patient that there is not enough time to wash her hair today because she has too many critical medical tests and appointments. B. The nurse should schedule the testing and meal planning first and complete hygiene as time permits. C. Perform the dressing changes first, schedule testing, counsel, and complete hygiene last. D. Arrange to wash the patient's hair first, perform hygiene, and then schedule diagnostic testing and counseling. Submit Answer

Explanation Choice D is correct. As long as time constraints permit, the most immediate priorities when scheduling nursing care are the priorities identified by the patient as being the most important. Choices A, B, and C are incorrect. In this case, washing the patient's hair and assisting with hygiene puts the patient first and sets the tone for a productive nurse-patient relationship. Diagnostic tests and dressing changes in a stable patient can certainly wait until after the patient-identified priorities are addressed. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Basic Care and Comfort Last Updated - 15, Feb 2022

The nurse is developing the care plan for an 86-year-old patient with a diagnosis of cor pulmonale. Which nursing intervention would be most important to include in regards to monitoring this patient's peripheral edema? A. Assess for skin tenting over the sternum [5%] B. Weigh patient at same time daily [52%] C. Obtain baseline BNP level [3%] D. Record calf circumference daily

Explanation Choice D is correct. Cor pulmonale describes right ventricular enlargement due to pulmonary hypertension. The accumulation of fluid in the interstitial spaces results in dependent edema, jugular vein distension, shortness of breath, and weight gain. Measuring and recording the circumference of the extremity at the same location daily is the best way to monitor for changes in the patient's peripheral edema. Choice A is incorrect. Checking for tenting is a technique to assess skin turgor for dehydration, not to monitor peripheral/dependent edema. Additionally, assessing for the turgor does not provide an accurate measure of dehydration in older patients due to loss of skin elasticity with age. Choice B is incorrect. Weighing the patient daily would be an appropriate method of monitoring for alternations in overall fluid status, but does not specifically address peripheral edema. Choice C is incorrect. BNP (B-type natriuretic peptide) reflects left ventricular presence/severity of heart failure. This value may be abnormal due to cor pulmonale, but would not specifically reflect the patient's level of edema. NCSBN Client need: Topic: Physiological Integrity, Sub-topic: Reduction of Risk Potential Last Updated - 14, Feb 2022

The nurse has become aware of the following client situations. The nurse should first follow up with which client? A client A. that had a myocardial infarction two days ago and the troponin is elevated. B. with infective endocarditis that wants to leave against medical advice (AMA). C. that has arterial insufficiency and is reporting leg pain after walking in the hall. D. recovering from cardiac catheterization that has developed atrial fibrillation. Submit Answer

Explanation Choice D is correct. Following a cardiac catheterization, the nurse should assess the client closely for any arrhythmias, including atrial fibrillation. This is a significant finding as the client will have an increased risk of thrombosis, which may migrate and cause a cerebrovascular accident (CVA). Choices A, B, and C are incorrect. Following a myocardial infarction, the troponin level may be elevated for up to two weeks. Thus, the troponin would be expected to be elevated for two days following an insult to the myocardium. A client requesting to leave AMA is a priority for the nurse, but it does not prioritize over a physical need such as a condition change of a client. A classic feature of arterial insufficiency is intermittent claudication, pain induced by the exertion of the leg and relieved by rest. This is an expected finding and not a priority. Additional Info Following a cardiac catheterization, the nurse should assess the client closely for: Decreased or absent pulse in the distal extremity on the affected side Cardiac arrhythmias Signs of shock Bleeding from the catheter insertion site Acute kidney injury Stroke The client will be given head-of-the-bed and activity restrictions immediately following this procedure. The nurse should report any abnormalities in vital signs and retroperitoneal bleeding (bruising in the flank area). Last Updated - 06, Dec 2022

The nurse is caring for the following assigned clients. It would be a priority to follow up with a client who A. is being treated with acute glomerulonephritis (AGN) and has periorbital edema. B. discarded their first urine sample upon starting a 24-urine collection. C. is receiving continuous bladder irrigation and reports the need to void. D. just returned from a hemodialysis session and reports dizziness. Submit Answer

Explanation Choice D is correct. Hypotension is a complication associated with hemodialysis. Dizziness may explain this finding, and the nurse should immediately intervene because the client risks falling. The hypotension may be caused by too much fluid removed during the dialysis. This is a safety issue, and the nurse should prioritize this client's needs. Choices A, B, and C are incorrect. AGN has a clinical feature of periorbital edema often present in the morning. This is an expected finding and does not require follow-up. During a 24-hour urine collection, it is appropriate for the first urine to be discarded, which marks the start of the 24-hour collection. During continuous bladder irrigation, a large catheter is utilized and the client reporting that they need to urinate despite having an indwelling catheter is a normal finding not requiring follow-up. Additional Info Hypotension is a common occurrence after hemodialysis and needs to be recognized because the client is at risk for falls and injuries. The most common reason an individual develops hypotension after dialysis is that too much fluid was removed. The nurse should ensure client safety by establishing fall precautions and notifying the provider. Last Updated - 13, May 2022

The nurse witnessed a patient fall in the bathroom who is now on the floor, conscious. The nurse takes a look at the patient and immediately suspects that her hip is fractured. Which of the following nursing interventions should the nurse initiate first? A. Helping the patient back to bed. B. Notifying the family of the fall. C. Arranging for an x-ray. D. Immobilizing the patient's leg before moving the patient. Submit Answer

Explanation Choice D is correct. Immobilizing the patient's leg before moving her minimizes bleeding, edema, pain and prevents further injury to the tissues and structures surrounding the fracture. This also decreases the patient's risk for the development of other complications such as fat embolism and shock. Choice A is incorrect. Helping the patient back to bed produces more damage to the surrounding area of the fracture, causing more pain, and increasing the patient's risk for embolism. Choice B is incorrect. The nurse can notify the family of the situation after the patient has been stabilized. Choice C is incorrect. The nurse can arrange the x-ray to assess further damage of the fall after the patient has been stabilized. Additional Info Last Updated - 13, Oct 2021

The charge nurse is observing a newly hired nurse care for a patient who sustained a closed head injury, is receiving mechanical ventilation, and is at risk for developing increased intracranial pressure (ICP). Which of the following actions, if performed by the newly hired nurse, would require intervention by the charge nurse? A. Suctioning the patient when the high-pressure alarm sounds. B. Hyperventilating with 100% FiO2 prior to suctioning. C. Performs oral care with a chlorhexidine solution. D. Maintaining the head of the patient's bed more than 90 degrees. Submit Answer

Explanation Choice D is correct. Maintaining a patient's head of the bed more than 90 degrees is detrimental for a patient with a traumatic brain injury ( TBI). The patient should avoid hip and neck flexion as this raises intracranial pressure ( ICP). While elevating the head end of the bed beyond 30 degrees may drop the ICP further, it can also cause an unwanted drop in the mean arterial pressure ( MAP). A decrease in MAP reduces cerebral perfusion pressure ( CPP). A fall in CPP is detrimental to the patient with a TBI. Therefore, the head of the bed recommendation for a patient with a risk for increased ICP is 30 to 45 degrees. Such an angle decreases the ICP while maintaining adequate CPP around 70 to 80 mm Hg. Such head of the bed elevation is also necessary to prevent the patient from developing ventilator-acquired pneumonia. Choices A, B, and C are incorrect. Suctioning is a necessary procedure for patients with artificial airways. Suctioning the patient when the high-pressure alarm sounds is an appropriate intervention. A high-pressure alarm is triggered when an obstruction is evident in the tubing. Not intervening immediately may cause airway compromise and put the client at risk of death. While suctioning may cause an increase in the ICP, one should use the ABC prioritization method and address the airway first. There is no absolute contraindication to suctioning when clinical indicators indicate the need for it. When clinically warranted, a patient should be hyperventilated with 100% oxygen before suctioning. Oral care with chlorhexidine or hydrogen peroxide is recommended to prevent ventilator-acquired pneumonia. Learning Objective When considering head elevation in patients with increased ICP, one should also ensure adequate CPP is maintained. A 30-45 degree elevation decreases ICP while also maintaining

The nurse has become aware of the following client situations. The nurse should first follow up with which client? A. A client with a chest tube that has tidaling in the water seal chamber. B. A client that is receiving mechanical ventilation and is occasionally biting on the tube. C. A client that is receiving albuterol via a nebulizer and reports headache and nervousness. D. A client with pneumonia that has become restless and confused. Submit Answer

Explanation Choice D is correct. One of the dreaded complications of pneumonia is acute respiratory distress syndrome (ARDS) which is manifested by hypoxia. The client demonstrating confusion and restlessness is quite concerning for hypoxia. The nurse should quickly assess the client and intervene by calling a rapid response if this should occur in the acute care setting. Choices A, B, and C are incorrect. Tidaling in the water seal chamber is a normal finding when a client has a chest tube. Biting on an endotracheal tube is a common finding and does require follow-up as the client could be in pain. Headache and nervousness are common effects associated with albuterol treatments. Additional Info For a client with pneumonia, the nurse must constantly monitor for ARDS since this syndrome is characterized by an inflammatory injury to the lungs. Classic findings include hypoxemia, progressive dyspnea, and adventitious lung sounds. Medical treatment includes positive airway pressure with oxygen, prone position, glucocorticoids, glucose control, and antimicrobials or antivirals. The prone position is preferred because this position improves ventilation in the dorsal region of the lung, therefore improving oxygenation. Last Updated - 14, Feb 2022

The nurse is assessing a patient who reports intermittent tingling and numbness in bilateral lower extremities. Which intervention by the nurse would be most important to prevent injury for this patient? A. Perform Semmes-Weinstein monofilament test B. Refer the patient for a diabetic diet consult C. Obtain an order for Gabapentin D. Teach the patient about appropriate footwear Submit Answer

Explanation Choice D is correct. Peripheral neuropathy puts the patient at increased risk for traumatic injury and tissue breakdown since the patient may not notice early skin damage due to altered sensation. Of the options provided, educating the patient on proper footwear is the only action that aims to prevent injury related to the patient's altered sensation in the feet. Choice A is incorrect. The Semmes-Weinstein monofilament test is an appropriate way to test for sensation in the feet and is used to identify risk for neuropathic ulceration, but this assessment tool is not a preventative action. Choice B is incorrect. Diabetes is a common cause of peripheral neuropathy, but the question does not provide any information that indicates this patient is diabetic, and would not specifically address promoting the patient's safety. Choice C is incorrect. Gabapentin is used to improve neuropathic pain and may be appropriate for this patient, but would not directly prevent injury. NCSBN Client need: Topic: Safe and Effective Care Environment, Sub-topic: Safety and Infection Control Last Updated - 13, Jan 2022

The nurse is caring for a patient recovering from cardiac catheterization via the right femoral artery. The nurse notes stable vitals one hour after the procedure but cannot palpate the patient's right pedal pulse. Which action would be the nurse's highest priority? A. Assess bilateral lower extremity capillary refill B. Notify the physician C. Place bed in Trendelenburg D. Recheck pedal pulse with doppler Submit Answer

Explanation Choice D is correct. Peripheral pulses may be diminished following cardiac catheterization, but the complete absence of a pulse indicates a serious complication. If unable to palpate the patient's pulse, the nurse's priority action should be to attempt to locate it with a doppler. Choice A is incorrect. This assessment data would not be a priority for treatment/intervention. If the pulse remains absent upon doppler examination, the nurse can expect the patient's circulation will be compromised. Choice B is incorrect. Pulses may be diminished following this procedure, but non-palpable pulses may be heard with the doppler. In the absence of any patient distress, the nurse should first evaluate the pulse distal to the incision site with a doppler before notifying the physician. Choice C is incorrect. This position (supine with both feet elevated 15-30 degrees above head) is appropriate for patients with a low pulse due to vagal nerve stimulation. This action would not address this patient's problem of a non-palpable pulse. Last Updated - 12, Feb 2022

The nurse is triaging clients in the emergency department (ED). Which client should the nurse triage as emergent? A client A. reporting pleuritic chest pain with a productive cough. B. who is pregnant and reporting intermittent nausea and vomiting. C. who has an isolated area of reddened vesicles and malaise. D. with sudden onset of ataxia and dysarthria. Submit Answer

Explanation Choice D is correct. Sudden onset of dysarthria and ataxia concerns for stroke. These manifestations require emergent prioritization because treatment is necessary to prevent further tissue damage. Choices A, B, and C are incorrect. Pleuritic chest pain would not be categorized as urgent because coughing indicates airway patency. Intermittent nausea and vomiting, without abdominal pain and cramping, would be triaged as nonurgent as this could be a normal part of pregnancy. An area of vesicles and the client reporting malaise would also be categorized as nonurgent. Additional Info The emergent triage category implies that a condition exists that poses an immediate threat to life or limb. Conditions that should be triaged as emergent include: active hemorrhage, unstable vital signs, significant trauma, chest pain, and manifestations of a stroke. The urgent triage category indicates that the client should be treated quickly but that an immediate threat to life does not exist at the moment. Conditions that typically fall into the urgent category are those with a new onset of pneumonia (as long as respiratory failure does not appear imminent), renal colic, abdominal pain, complex lacerations not associated with major hemorrhage, displaced fractures or dislocations, and temperature higher than 101°F (38.3°C). Those triaged as non-urgent can generally tolerate waiting several hours for health care services without a significant risk for clinical deterioration. Conditions within this classification include clients with sprains and strains, simple fractures, general skin rashes, and uncomplicated urinary tract infections. Last Updated - 10, Jul 2022

The nurse has received an assignment of four patients on the Medical-Surgical floor. Which patient should she/he check on first? A. A 61-year-old male patient who is one day post-op from hernia repair with complaints of pain at the incision site. B. A 68-year-old female patient with type II diabetes who is complaining of stomach discomfort. C. A 72-year-old male patient with emphysema and a history of uncontrolled hypertension who is complaining of a headache. D. A 70-year-old female patient who is two days post-op from ankle surgery who complains of feeling some shortness of breath. Submit Answer

Explanation Choice D is correct. The ABCs identify the patient's airway, breathing, and cardiovascular status as the highest of all priorities in that sequential order. Maslow's Hierarchy of Needs identifies the physiological or biological needs, including the ABCs, the safety/psychological/emotional needs, the need for love and belonging, the requirements for self-esteem and esteem by others, and the self-actualization needs in that order of priority. Examples of each of these needs, according to Abraham Maslow's Hierarchy of Needs, include: Physical and Biological Needs: Some physical needs include the need for the ABCs of the airway, breathing and cardiovascular function, nutrition, sleep, fluids, hygiene, and elimination. Safety and Psychological Needs: Psychological or emotional, safety and security needs include needs like low-level stress and anxiety, emotional support, comfort, environmental and medical protection, and emotional and physical security. Love and Belonging: The love and belonging needs reflect the person's innate need for love, belonging and the acceptance of others. Self-Esteem and Esteem by Others: All people need to be recognized and respected as valued people by themselves and by others. People need self-worth, self-esteem, and the esteem of others. Self Actualization: Self-actualization needs to motivate the person to reach their highest level of ability and potential. In addition to prioritizing and reprioritizing, the nurse should also have a plan of action to manage their time effectively; they should avoid unnecessary interruptions, time-wasters, and helping others when this could potentially jeopardize their priorities of care. Choice A is incorrect. Incision site pain is not uncommon, especially one-day post-op. Choice B is incorrect. Stomach discomfort is not an immediate cause of con

The nurse walks into the room and finds her client complaining of severe shortness of breath and chest pain. She suspects a pulmonary embolism. After notifying the rapid response team, the nurse's priority action is which of the following? A. Obtain vital signs and place the client in left-sided, Trendelenburg position. B. Administer heparin. C. Check lung sounds. D. Elevate the head of the bed. Submit Answer

Explanation Choice D is correct. The first action following the notification of the rapid response team when a pulmonary embolism is suspected is "elevating the head of the bed" to about 30 degrees. This is a quick action that does not require a doctor's order. A pulmonary embolism causes ventilation and perfusion mismatch. In a position with the head of the bed elevated, gravity pulls the diaphragm downward, allowing for lung expansion and improved ventilation. Please note that an embolus may refer to a blood clot (pulmonary embolism, arterial thromboembolism), air bubble (air embolism), or a piece of fatty deposit (fat embolism) that can be carried into the bloodstream to lodge in a vessel and cause an embolism. Many students make a knee-jerk selection of Trendelenburg's position the moment they see the word embolism in the question. Please note that the Trendelenburg's position or left lateral position is used in patients with "air" embolism. This is because air is a gas and it will float in the upper part of the right ventricle/right atrium when patients are placed in such a position. Pulmonary embolism (PE) is a blood clot. Often, it travels from the lower extremities to the lungs. You do not want to keep a patient with acute PE in Trendelenburg's position because that may facilitate further embolism in an acute thromboembolism scenario. Choice A is incorrect. The patient is short of breath and is clearly in distress. Vital signs should be taken after the patient's head of the bed is elevated and oxygen has been initiated. Choice B is incorrect. While this patient may receive heparin, a doctor's order will be needed to initiate heparin. Choice C is incorrect. The patient is in distress. The rapid response team needs to be notified and the head end of the bed needs to be elevated prior to proceeding with further a

The nurse is caring for a patient with a jejunostomy tube receiving intermittent enteral feedings. Which intervention would be the highest priority to reduce the risk of aspiration for this patient? A. Flush tubing with 20 mL water after feeding is completed. B. Position patient in left-lying position after feedings. C. Assess blood glucose every 6 hours. D. Place the patient in semi-Fowler's following feedings. Submit Answer

Explanation Choice D is correct. The nurse should assist this patient to position in semi-Fowler's or to lay on the right side following feedings, as these positions will reduce the risk of leakage, gastric reflux, and aspiration. Choice A is incorrect. This action would not reduce the patient's risk of aspiration. The nurse should use 50-60mL to flush the remaining formula, maintain patency, and reduce the risk of bacterial growth from any formula still remaining in the tubing. Choice B is incorrect. Laying on the right side (not left) would support digestion/gastric emptying and reduce the risk of reflux and aspiration. Choice C is incorrect. The nurse should assess and record blood glucose levels every 6 hours during the initiation of continuous feedings until levels are maintained within the ordered range for a 24-hour period at the maximum flow rate. However, this patient is receiving intermittent feedings, and this action would not reduce the patient's risk of aspiration. NCSBN Client need: Topic: Physiological Integrity, Sub-topic: Pharmacological and Parenteral Therapies Last Updated - 15, Feb 2022

The client is admitted to the surgical ward after being treated initially in the ER for a femur fracture due to a motor vehicle accident. The client is being interviewed by the nurse for his surgery when he suddenly reports a sharp pain in his chest, displays difficulty breathing, and becomes restless. The nurse suspects a fat embolism; which action of the nurse should take priority? A. Prepare for intubation and mechanical ventilation B. Administer IV fluids C. Check vital signs and respiratory status D. Notify the physician Submit Answer

Explanation Choice D is correct. The nurse suspects a fat embolism. The question provides enough information regarding the client's distress and sudden change in his clinical status. The mortality rate from a fat embolism is about 10%. Early recognition and treatment are crucial. The nurse should immediately inform the physician to initiate medical interventions. Fat embolism is a potentially life-threatening complication that occurs from long bone fractures that result in the dislodging of fat emboli and then travel into the bloodstream, up into the pulmonary circulation. Symptoms mimic that of a pulmonary embolism. The client may report chest pain, respiratory distress (dyspnea), and may have mental status changes (confusion). Other signs include tachypnea, low oxygen saturation, fever, tachycardia, and low blood pressure. Petechiae (axillary or subconjunctival petechiae) are characteristic of a fat embolism and help differentiate it from other etiologies. Treatment includes intravenous hydration, oxygenation, immobilization, and fixation of the fractured limb. In severe cases of hypoxia and neurological deterioration, intubation and ventilation may be required. Choice A is incorrect. The client may eventually need intubation and mechanical ventilation, depending on the respiratory and neurological condition. However, this is not the initial action of the nurse. Choice B is incorrect. IV fluids may be necessary to prevent hypovolemic shock in the client, but this should be done after informing the physician. Choice C is incorrect. There is sufficient information in the question to indicate the client's distress. The client may need his vital signs checked and monitored; however, this does not take priority over informing the physician and starting emergency interventions. Last Updated - 04, Feb 2022

A 30-year old patient presents to the Emergency Department with alcohol withdrawal seizures. The psychiatry nurse understands that the patient will soon be admitted to the non-medical psychiatric care unit. To keep this patient safe, the nurse must perform which priority nursing action? A. Ask the physician for a clonazepam prescription, an anxiolytic that may help with the withdrawal symptoms. B. Ensure that a working IV pump is set up at the patient's bedside. C. Order a STAT arterial blood gas (ABG). D. Pad the side rails of the patient's assigned bed. Submit Answer

Explanation Choice D is correct. The patient presented with alcohol withdrawal seizures. The priority nursing action is to pad the patient's bed's side rails to prevent injury since the patient is at high risk of a recurrent seizure. In an acute care setting, side rails are often used as a medical assistive device and not a restraint. Side rails are considered a restraint only if the intent is to prevent the patient's free access and keep them in bed. In the setting of seizure precautions, side rails are raised, and the bumper pads are used as a medical assistive device. Choice A is incorrect. While clonazepam may help with the anxiety associated with alcohol withdrawal, it is not the drug of choice in managing alcohol withdrawal. Instead, diazepam, lorazepam, and chlordiazepoxide are used most frequently to treat or prevent alcohol withdrawal. Furthermore, providing the patient with this medication is not the priority action in patient safety. Choice B is incorrect. Since the patient will be admitted to a non-medical psychiatry floor, continuous intravenous infusion is not permitted while on that unit. However, necessary injections, oral medications, or other non-invasive procedures are performed while on the non-medical unit. Choice C is incorrect. Ordering a STAT arterial blood gas is not necessary when the patient arrives at the psychiatry unit. Before the patients are sent to the non-medical psychiatry floor, they are already deemed clinically stable and medically cleared. NCSBN client need Topic: Safety and Infection Control, Injury Prevention Last Updated - 23, Dec 2021

After receiving client reports on the medical-surgical floor. Which of the following clients should the nurse see first? A. A client with a respiratory rate of 24 and an oxygen saturation of 92%. B. A client who is scheduled for gastric surgery related to peptic ulcer disease in two hours. C. A client who is six hours post-op from a hysterectomy and is complaining of nausea. D. A client who had a cast applied two hours ago and now has complaints of her arm feeling like it is "sleeping". Submit Answer

Explanation Choice D is correct. The patient with a cast who describes her arm as feeling like it's asleep is likely experiencing impaired circulation. This patient should be assessed first and the physician should be notified. Prioritizing patient care related to the status of each patient in the nurse's care is a critical skill. While all patients are important and must be monitored, the ability to recognize a potential complication before it gets out of hand and causes more damage is crucial. Choice A is incorrect. Although the increased respiratory rate and lower O2 saturation may cause concern, there is nothing in this scenario that suggests the patient is in distress. Choice B is incorrect. This patient has no complaints and can be evaluated after the patient that is experiencing compromised circulation. Choice C is incorrect. Complaining of nausea after a hysterectomy is a potential problem that is often expected. It is not, however, of immediate concern. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort Last Updated - 09, Jan 2022

A client in the post-anesthesia care unit is semiconscious and dyspneic. He exhibits retraction of the intercostal muscles and his oxygen saturation is 88%. What is the nurse's priority action at this time? A. Place a pillow under the client's head B. Insert an oropharyngeal airway C. Administer oxygen by mask D. Reposition the client in a side-lying position Submit Answer

Explanation Choice D is correct. The priority action in the care of a post-anesthesia client is to secure a patent airway. The most common cause of airway obstruction in a semiconscious or unconscious patient is the tongue. The anesthetic agents and muscle relaxants used during surgery may cause relaxation of tongue and jaw muscles, causing posterior movement of the language and epiglottis, which leads to the obstruction of the airway. The client is dyspneic, using intercostal muscles, and manifesting symptoms of airway obstruction. Repositioning in the side-lying position with the face slightly down is a simple initial nursing action that can prevent occlusion of the pharynx and allow the drainage of mucus from the mouth. If repositioning fails to improve the condition, other airway positioning maneuvers (for example, head-tilt-chin lift, jaw-thrust) should be attempted. Supplemental oxygen (Choice C) can be administered once the airway patency is established. If these initial interventions fail to maintain a patent airway, then an airway adjunct (oropharyngeal or nasopharyngeal airway) should be used (Choice B). Choice A is incorrect. A pillow under the head increases the risk of aspiration or airway obstruction. Choice B is incorrect. Since the issue is airway obstruction, efforts to promote an open airway are most appropriate. The first step, however, is to open the airway via non-invasive measures. A simple initial intervention, such as repositioning, may help by making the tongue move forward. If those initial non-invasive measures fail, move it to insert an airway adjunct. Additionally, because this client is semiconscious, a nasopharyngeal airway would be appropriate if the initial interventions failed. If the patient is semi-conscious and can cough, they still have a gag reflex, so an oral airway is contrain

The nurse enters the room of a 5-year-old client and finds the client lying on the floor. The fall was unwitnessed. What is the priority nursing action? A. File an incident report B. Assist the child back to bed C. Call for help D. Assess the child for any injuries Submit Answer

Explanation Choice D is correct. The priority nursing action is to assess the client. The nurse should assess the child for any injury and/or loss of consciousness. Following the assessment, the nurse can determine a further course of action. Choice C is incorrect. While it is likely that the nurse will need to call for help, this is not the priority nursing action. The nurse should first assess the fallen child. Choice A is incorrect. Following any fall event, the nurse must file an incident report. Incident reports help evaluate the cause of falls and help take steps to prevent future unwanted incidents. However, the patient is the utmost priority, and the nurse must assess the patient first before proceeding to other actions. Choice B is incorrect. Before assisting the child back to the bed, the nurse must complete her assessment. This includes assessing for an injury (fractured bones, etc). If the child is injured, the nurse should take appropriate actions to move them safely. Inappropriate handling of an injured limb (example: hip fracture) may inflict further distress to the child and/or aggravate the injury. NCSBN Client Need: Topic: Effective, safe care environment; Subtopic: Infection control and safety Last Updated - 12, Dec 2021

An 82-year-old man presents to the emergency department after a ground-level fall. The paramedics tell you that the left pupil was fixed and dilated. Upon arrival, the patient's elbows, wrists, and fingers are flexed, and legs extended and rotated inward. What is the most important intervention for this patient? A. Obtain IV access immediately B. Turn patient on his side C. Obtain accurate history from the family D. Take him straight to the CT scan

Explanation Choice D is correct. This patient's left pupil is fixed and dilated, which means it is not reactive to light and stays the same size. When this happens, it can be clinically inferred that there is a lesion or hemorrhage on the opposite (contralateral) side of the brain. The patient also exhibits decorticate (flexor) posturing, with elbows, wrists, and fingers flexed, while the legs are extended and rotated inward. Often, such abnormal posturing indicates severe brain damage. The patient sustained a fall and these symptoms likely represent raised intracranial pressure due to intracranial hemorrhage. This patient needs to be taken straight to the CT department to obtain a CT scan of the brain. This will allow the physician to diagnose the patient and initiate early treatment. Choice A is incorrect. Even though obtaining IV access is an important intervention, it is not the priority at this time. A non-contrast CT scan is usually the first intervention to detect a hemorrhage. Intravenous contrast is not necessary. The nurse can obtain IV access after the urgent CT scan is performed. Early diagnosis and appropriate treatment are critical in these settings. Choice B is incorrect. If the patient started having a seizure, then he would need to be turned onto his side. However, he is posturing, which is not a seizure. There are two different types of posturing; decorticate and decerebrate. Decorticate looks as if the patient is turning his or her arms into the core of the body. Decerebrate looks like the patient's arms are facing outwards, away from the body. Choice C is incorrect. This intervention is important, especially to understand any events before arriving at the hospital, medications taken, and recent procedures completed. NCSBN Client Need Topic: Physiological Adaptation; Sub-topic: Alterations in Body S

While working in the PICU, you are assigned to a 12-year-old male who is 1-hour post-op from transsphenoidal hypophysectomy. He has 2 PIV's, is on room air, has an NG tube, and a foley catheter. You complete your assessment and note the following: HR: 141 RR: 24 Temp: 37.1 O2: 99% PIV's: Patent and saline locked NG: No drainage, clamped Foley: 400 mL of clear urine Which of the following actions are appropriate given your assessment? Select all that apply. A. Notify the health care provider of the urine output. B. Request an order for IV fluids. C. Document your findings. D. Initiate NC 2L O2 at 100%. Submit Answer

Explanation Choices A, B, and C are correct. A is correct. This is an excessive amount of urine output for 1 hour and is concerning for diabetes insipidus given the procedure the patient recently underwent. Any urine output greater than 300 mL is alarming and the healthcare provider should be notified immediately. Diabetes insipidus is a severe complication from neurosurgery that occurs around the pituitary. This amount of urinary output can lead to shock if not treated promptly. B is correct. Requesting an order for IV fluids is an appropriate nursing action given your assessment. You are concerned about the possibility of DI considering the excessive urine output and there is no fluid replacement currently ordered for this patient. This is concerning for shock, and IVF should be initiated to rehydrate and adequately replace losses from the urinary output. C is correct. These findings should be accurately documented to ensure proper follow-up and orders for this patient. Choice D is incorrect. No oxygen therapy is indicated for this patient at this time. His O2 saturation is adequate on room air, he is not tachypneic, and the question stem gave you no other information to indicate that there was an increased work of breathing or oxygen requirement. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation, Fluid & Electrolytes Last Updated - 07, Nov 2021

While ambulating a patient who has an infusion running through their peripherally inserted central catheter (PICC) in the right arm, they suddenly complain of dyspnea and chest pain. You immediately sit them down in the closest chair and assess them. Their BP is 72/38 mmHg and their heart rate is 186. What is the priority nursing action? Select all that apply. A. Clamp the catheter B. Notify the health care provider C. Lay the patient flat D. Administer oxygen Submit Answer

Explanation Choices A, B, and D are correct. The nurse suspects that the patient has an air embolism related to their PICC line. This is a potential complication of central venous catheters and the nurse is expected to monitor for it. Signs and symptoms include tachycardia, hypotension, chest pain, dyspnea, tachypnea, and hypoxia. Since the nurse suspects an air embolism, she should clamp the catheter immediately to prevent any further air entry. This is a medical emergency, and the health care provider should be notified promptly. Hypoxia is a symptom of an air embolism; therefore the patient should immediately begin receiving oxygen to prevent tissue ischemia and further complications. Choice C is incorrect. Laying the client supine could cause air embolism to exit the right atrium of the heart and travel to the brain or lungs, causing complications such as a stroke or pulmonary embolism (PE). The patient should be positioned on their left side with their head lower than their feet. This will trap the embolism in the right atrium of the heart and prevent further complications. Additional Info Last Updated - 19, Dec 2022

The emergency department (ED) nurse is triaging clients in the ED. It would be appropriate for the nurse to triage which client as nonurgent? A client Select all that apply. A. with a localized abscess on the right leg. B. reporting that they have chest pressure. C. with nausea, vomiting, and painful urination. D. requesting a refill of their prescribed antidepressant. E. with a single laceration to the left hand. Submit Answer

Explanation Choices A, D, and E are correct. These client situations require a triage of non-urgent. The non-urgent triage category signifies that the client can be placed in the waiting area for a set of times without risking clinical deterioration. Choices B and C are incorrect. A client reporting chest pressure should be triaged as emergent as they need to be evaluated by a primary healthcare provider (PHCP) immediately. Nausea, vomiting, and pain with urination are suggestive of renal colic, which should be triaged as urgent. Additional Info The emergent triage category implies that a condition exists that poses an immediate threat to life or limb. Conditions that should be triaged as emergent include: active hemorrhage, unstable vital signs, significant trauma, chest pain, and manifestations of a stroke. The urgent triage category indicates that the client should be treated quickly but that an immediate threat to life does not exist at the moment. Conditions that typically fall into the urgent category are those with a new onset of pneumonia (as long as respiratory failure does not appear imminent), renal colic, abdominal pain, complex lacerations not associated with major hemorrhage, displaced fractures or dislocations, and temperature higher than 101°F (38.3°C). Those triaged as non-urgent can generally tolerate waiting several hours for health care services without a significant risk for clinical deterioration. Conditions within this classification include clients with sprains and strains, simple fractures, general skin rashes, and uncomplicated urinary tract infections. Last Updated - 10, Jul 2022

While volunteering at a summer camp as the RN on duty, a child playing soccer falls and breaks their arm. It appears to be a compound fracture. Place the following actions in order of nursing priority when dealing with this injury: Apply ice around the injured site Assess the injury while calling for help Cover the open wound with a clean dressing Elevate the arm Submit Answer

Explanation Compound fracture (open fracture) is a fracture with bone fragments protruding through the skin. Because there's an open wound or skin breach near the fracture site, bacteria from the contaminants can enter the wound and lead to infection. It is essential to treat the open fracture early to prevent infection. The infection can progress to osteomyelitis ( bone infection) if not addressed. The following are the steps in addressing an open fracture:- Assess: As always, the priority nursing action is to assess the injury. While assessing the injury, the nurse should also assess for any neurovascular compromise. Protect: The nurse should cover the open wound with a clean dressing to prevent infection. Apply pressure over the surrounding wound, not over the protruding bone. Apply an ice pack to the site above and around the fracture. Avoid applying ice directly to the skin because it may cause skin damage. Also, care should be taken not to contaminate the open wound. Elevate: Elevate the arm to reduce the swelling; however, this may have to be done carefully in an open fracture setting without greatly mobilizing fracture fragments. These nonpharmacological interventions will reduce swelling and pain while waiting for help. The child will need to go to the hospital for possible surgery and casting of the extremity. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological Adaptation Learning Objective Recognize the complications of an open fracture and understand that the most critical risk is infection. Protect the site by covering it with a clean dressing until surgical help arrives.

You are a nurse working in a medical unit with a trained aide. You have admitted a new patient and have received the following orders. Place the answer choices in the correct sequential order based on the prioritization for performing these tasks. Vital signs every 4 hours. CBC, electrolytes, urinalysis, and 2 sets of blood cultures. Amoxicillin 250 mg by mouth first dose now and then every 6 hours. Insulin 2 units Humulin subcutaneous now. Submit Answer

Explanation Correct ordered sequence: Insulin - 2 units Humulin subcutaneous now CBC, Electrolytes, urinalysis, and 2 sets of blood cultures Amoxicillin 250 mg by mouth first dose now and then every 6 hours Vital signs every 4 hours While prioritizing the orders from the physician, the nurse should look for the orders that specify urgency - such as "STAT" or "as soon as possible" or "now." A "now" prescription for insulin should be done as soon as possible after the patient arrives on the floor. The nurse should understand that insulin lowers the patient's blood sugar and can help to prevent sequelae associated with high blood sugar. Since the patient is being initiated on antibiotics, it appears there is a suspicion of infection. In patients with suspected infection, glycemic control is helpful in achieving good outcomes. Collecting the labs is the second task that should be completed since blood cultures have been ordered. Blood cultures must always be collected BEFORE the administration of an antibiotic so that the antibiotic does not interfere with the results. Obtaining cultures after antibiotics may give false-negative results. As soon as the blood cultures are drawn, the nurse should administer the amoxicillin since it is ordered for "now" and then every 6 hours. In almost any infection including sepsis, guidelines allow a 1 to 2 hour window from the time of patient arrival before which antibiotics can be administered. Blood cultures must be obtained before antibiotics. Finally, vital signs are the lowest priority for the nurse since this is a task that can be delegated to the aide following an initial assessment. It can be executed after the above orders are completed. NCSBN Client Need Topic: Management of Care; Sub-Topic: Establishing Priorities

A 4-year-old girl presents to your ED with 20% of her body surface area burned. The child is stable. The burns appear to be chemical, and the child is covered in an unknown substance. Upon her arrival to your trauma room, place the following priority nursing actions in the order they should be completed. Cover the wound with a clean cloth Stop the burning process Assess airway, breathing, and circulation Remove the burned clothing and jewelry Submit Answer

Explanation The correct sequence is as follows: The nurse should first stop the burning process. In this scenario, that would require removing the unknown substance from the child by decontamination. Before any other nursing intervention, this must be done to prevent the burn from worsening. Next, the nurse should remove the burned clothing and jewelry. These are not actively burning but are already burnt. Therefore, this step should be preceded by more critical interventions in the sequence. Metals from silver and on clothes such as buttons and zippers can become very hot and continue cooking the client if not removed. Also, there is significant swelling after a burn, so if the nurse does not remove clothing and jewelry, they can become constrictive and cut off circulation. Subsequently, the nurse should assess the airway, breathing, and circulation. The patient has no airway-related symptoms. The airway, however, should be assessed because internal burns can occur and may eventually cause airway swelling and compromise. Intravenous fluids should be initiated as necessary. If the nurse proceeded to assess the airway directly without stopping the burning process, precious time would be lost, and the offending chemical will continue to burn the patient. If there are any apparent symptoms and signs of airway compromise and the patient is unstable, the nurse can follow the ABC prioritization sequence and assess the airway first. However, in this patient, no such symptoms or signs of airway compromise were mentioned in the question stem. Therefore, the airway should be assessed for hidden ( occult) damage following decontamination steps. Next, the nurse should cover the wound with a clean cloth to prevent infection, and lastly, the nurse should keep the child warm. Last Updated - 14, Sep 2022

The nurse is caring for a group of clients. Which client should the nurse see first? Drag and drop each client in order of priority starting with the first client to be seen. A 65-year-old newly admitted client with an acute coronary syndrome (ACS) who is receiving a heparin infusion. A 51-year-old client who has a discharge prescription following a heart failure exacerbation. A 46-year-old client two days post-operative from a vaginal hysterectomy reporting burning at the indwelling catheter site. A 31-year-old client three days post-operative who requires a sterile dressing change. Submit Answer

Explanation The nurse initially should see the client with ACS because of the instability that coincides with this condition. The client who is two days post-operative complaining of burning at the urinary catheter site should be assessed next. After that, the client requiring a sterile dressing change who is three days post-operative should be evaluated. Finally, the client requesting discharge teaching should be seen last because this would be considered low priority. Last Updated - 26, Oct 2021

You are taking care of an 80-year-old patient who is post-op day one from abdominal surgery. Upon assessment, you notice bowel protruding through her incision and quickly determine that evisceration has occurred. Place the following actions in order of priority: Prepare the patient for immediate surgery. Take vital signs and monitor for signs of shock. Call for help and stay with the patient. Document the incident. Cover the wound with a sterile normal saline dressing. Submit Answer

Explanation The priority of nursing action is to call for help but stay with the patient. The nurse should tell the person who responds to notify the surgeon immediately. This is a surgical emergency, therefore the surgeon must be notified STAT. After help has been called, the nurse needs to cover the wound with a sterile 0.9% sodium chloride dressing. This helps prevent infection and keep the protruding organ moist and hydrated before surgery. The nurse should instruct the patient not to strain or cough, and keep the client in low Fowler's position (no more than 20 degrees of bed elevation) with his/her knees flexed. This position relaxes abdominal muscles and reduces abdominal muscle tension. After this, the next nursing action is to check the patient's vital signs and monitor for shock while waiting for the health care providers. If signs of shock such as tachycardia and hypotension are noted, this is a medical emergency, and the health care provider/rapid response team needs to be called to the bedside immediately. After taking vital signs, the nurse should begin preparing the patient for immediate surgery. Lastly, after the patient has been taken to surgery, the nurse needs to document the incident. Last Updated - 25, Oct 2021