NSG 280 Priority

A nurse is reviewing data for four children. Which of the following children should the nurse assess first?

A 10-year old who has sickle cell anemia who reports severe chest pain

A nurse on an obstetrics-gynecology unit is planning care for four clients after receiving change of shift report. Which of the following clients should the nurse see first?

A client admitted 1 hour ago for an ectopic pregnancy

A nurse is preparing to administer medications to four clients. The nurse should administer medications to which of the following clients first?

A client who has renal failure, a serum potassium level of 5.8/mEq/L, and is prescribed sodium polystyrene sulfonate

A nurse has received morning report on the following four clients. Which of the following clients should the nurse assess first?

A client who was administered glipizide for DM2 and has a blood glucose of 68 mg/dL

A nurse has received change of shift report on a group of clients and is preparing her assignment. Which of the following clients should the nurse assess first?

A client who was admitted for chest pain and is reporting a new onset of indigestion

A nurse is caring for four clients who are postoperative from surgery 24 hours ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse's priority?

A client whose BP at 0800 was 136/88 mm Hg and at 1200 is 106/60 mm Hg

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. The client pulls out his endotracheal tube. Which of the following actions should the nurse take first?

Assess the client's airway

A nurse is caring for a client who ingested a poison and is not experiencing a seizure. Which of the following is the priority action the nurse should take?

Check the patency of the client's airway

A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address?

Dysphagia

A nurse caring for a client who is vomiting. Which of the following actions should the nurse take first?

Prevent the client from aspirating

A nurse is planning care for a newly admitted client who has major depressive disorder following the loss of a child. Which of the following goals should the nurse identify as the priority?

The client makes a contract to not harm herself

A nurse is assigned client care activities to an AP. Which of the following statements by the AP indicates a need for assistance in establishing priorities?

"I have my assignment and will start with room 1, then work my way to room 10".

A nurse is assigned a group of clients at the start of the shift. Which of the following clients should the nurse plan to care for first?

A client asking about his PCA pump that contains morphine

A nurse is performing triage for a group of clients following a mass casualty incident. Which of the following clients should the nurse plan to care for first?

A client experiencing a tension pneumothorax

A nurse receives report about assigned clients at the start of the shift. Which of the following clients should the nurse plan to see first?

A client who experienced a cesarean birth 4 hours ago and reports pain

A nurse is caring for four clients on a medical-surgical unit. Which of the following clients should the nurse assess first?

A client who had an indwelling urinary catheter removed 5 hours ago and has not voided

A nurse is assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first?

A client who has a cast on the left leg and reports numbness and paresthesia.

A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the priority for care?

A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site

A nurse in the emergency department is triaging clients following a mass casualty event. The nurse should identify which of the following clients as emergent?

A client who has a punctured femoral artery

A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?

A client who is at 28 weeks of gestation and reports of painless vaginal bleeding

A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately?

A middle adult male who is diaphoretic and reports epigastric pain

A nurse is triaging clients in the emergency department. Which of the following clients should the nurse ask the provider to care for first?

A school-age client who has acute epiglottitis, is drooling, and has an absence of spontaneous cough

Following a tornado, a nurse is determining which of the clients assigned to her care can be discharged to free up beds for injured clients. Which of the following clients should the nurse recommend for discharge?

A young adult client who has Crohn' disease and is 1 day preoperative for an ileostomy

A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care?

Airway protection

A nurse on a pediatric unit is reviewing a client assignment following the shift report. Which of the following clients should the nurse plan to see first?

An infant who has pertussis and is receiving oxygen via nasal cannula

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

Ask the client if she has considered harming her newborn.

A nurse on a surgical unit is caring for a group of clients. Which of the following is the priority action of the nurse?

Assessing a client who experiences unilateral calf pain when ambulating

A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?

Clear the respiratory tract

A nurse is developing a teaching plan for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following actions should the nurse plan to take first?

Determine what the client knows about managing diabetes

A nurse is working with a limited staff because of a severe storm in the area. The facility incident commander has initiated disaster protocols. Which of the following actions should the nurse take?

Focus on proving care that prevents life-threatening emergencies

A nurse is planning care for a client who has anorexia nervosa. The nurse should make which of the following client goals a priority?

Gain 2 pounds of weight per week

A school nurse receives a call that some children and teachers report being exposed to an undetermined noxious gas odor presenting in the classrooms and are experiencing dizziness. Which of the following actions should the nurse take?

Have students evacuated from the school and establish a triage area in the school parking lot

A nurse is caring for a newborn who has macrosomia and whose mother has diabetes mellitus. The nurse should recognize which of the following newborn complications as the priority focus of care?

Hypoglycemia

A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client's vital signs are: BP 98/52 mm Hg, HR 118/min, RR 24/min, and Temp 36.4 C (97.6 F). Which of the following is the priority nursing action?

Initiate IV access

A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day post-op following a partial bowel resection, requires a dressing change, total parental nutrition administration and reports pain level of 6 on a scare from 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires tube feeding, dressing change, and daily weight. Which of the following nurse actions should the nurse plan to complete first?

Obtain vital signs on both clients.

A nurse is assessing a client who is being admitted from the PACU following an abdominal hysterectomy. Which of the following assessments is the nurse's priority?

Oxygen saturation

A nurse has received change of shift report and is delegating tasks to an AP. The nurse should tell the AP to complete which of the following tasks first?

Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast

A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal HR 130/min, maternal HR 128/min, and maternal BP 92/54 mm Hg. Which of the following is the priority action for the nurse to take?

Position the client with one hip elevated

A nurse is receiving shift report about a group of assigned clients. Which of the following actions should the nurse plan to take first?

Suction the tracheostomy of a client who has copious secretions

A nurse has several tasks to delegate to an AP. Which of the following tasks should the nurse ask the AP to perform first?

Take an ABG specimen to the laboratory