NUR 436 Prioritizing Care

A nurse is assigned to take care of a group of clients. Which client should the nurse see first?

A 2-year-old client with diarrhea

What are the priority nursing interventions for a grieving client? Select all that apply.

-Allowing the client to express feelings -Respecting the feelings of the client and creating a comfortable environment

A client has a severe, unilateral throbbing headache that has lasted for 2 days. What should be the priority nursing care?

Administering sumatriptan

A nurse is preparing to administer an intravenous piggyback medication to a client who is receiving a continuous infusion of intravenous (IV) fluids. What is the priority nursing intervention?

Check the compatibility of the medication and the continuous IV solution

What is a nursing priority to prevent complications in clients with respiratory acidosis?

Monitoring breathing status

What does the A of the mnemonic "ABCDE" of primary nursing survey stand for?

Airway

The nurse is caring for four different clients in a healthcare facility. Which client should be provided with immediate care?

Client with 85% oxygen saturation

Which is a theme in the design of "Transforming Care at the Bedside"?

Reliability

The nurse is teaching a group of student nurses about caring for the client with sealed implants of radioactive sources. Which comments by the student nurse indicate the need for the further teaching? Select all that apply

"I should keep visitors at least 3 feet from the source of radiation." "I should keep the door to the room of the client open as a nursing priority." "I should save all dressings and bed linens in the client's room until after the radioactive source is removed."

A nurse is teaching a group of healthcare workers about the prevention of human immunodeficiency virus (HIV) transmission by healthcare workers. Which statements made by a healthcare worker indicate the need for the further teaching? Select all that apply.

"I should never re-use equipment used in invasive procedures." "If I perform exposure-prone procedures, I should know my HIV antibody status." "If I am infected with HIV, I am restricted from practice of non-exposure-prone procedures."

The nurse plans to provide a back massage to a client. What should the nurse do first in this situation?

Assess the client's preference for touch and massage.

Which is the priority action by the nurse when discharging a client with limited English proficiency?

Assessing the need for medical interpreter for client teaching

Which type of clients are often referred to as the "walking wounded" in a mass casualty scene?

Green Tagged

The client receives dosages of sedative and opioid drugs during the postoperative period following surgical correction of a small bowel obstruction. What is the most critical assessment to be performed as a nursing safety priority?

Respiratory assessment

The nurse is advising a client to carry a prescription of epinephrine autoinjector. Which insect bite or sting is responsible for the nurse providing this advice?

Wasp

Which member of the healthcare team, when using the team nursing approach, is responsible for prioritizing client care?

Team Leader

The client who has a history of allergy to bee stings is brought to the emergency department following a bee sting. What are the interventions to be followed in correct order?

1. Inject epinephrine through the intramuscular route in the mid-portion of the outer thigh. 2. Remove the stinger gently by scraping with a needle. 3. Administer oral liquid diphenhydramine. 4. Establish an intravenous infusion with normal saline

The nurse is caring for different clients in a mass casualty event. Which client is assigned the lowest priority for care?

Black Tag

The healthcare team is caring for clients who sustained injuries in an accidental fire. Which client should be provided with immediate care based on priority?

Client with burns to the head

Which client should be treated first according to the National Institutes of Health Stroke Scale (NIHSS)?

Client with score of 3 for facial palsy

The nurse is providing emergency care to a client suffering from heat stroke. What should be the order of nursing interventions in this scenario?

Emergency care should be provided to the client with heat stroke to restore thermoregulation. First the nurse should ensure a patent airway. Then the nurse should remove the client from the hot environment into air conditioning or shade and remove his or her clothing. Then the nurse should pour or spray cold water on the client's body and scalp. The client should be fanned with newspapers or whatever is available. This should be followed by placing ice in cloth or bags and positioning the packs on the client's scalp.

The client presents to the emergency department with increasing incoherence and periods of stupor. According to the EMS, the client was found wandering outside in the cold without a coat. Which condition would the nurse consider to be responsible for the client's signs and symptoms?

Moderate hypothermia

The nurse is caring for victims of a bomb blast in the emergency department who are receiving different pain medications. Which client must be placed on electrocardiogram equipment?

Naproxen

The nurse is caring for a client with hypothermia. What should be the nurse's priority of care?

Removing the client from cold environment

The client, who takes part in mountaineering, shows signs of bradycardia along with severe hypotension and a decreased respiratory rate. For which condition is the nurse treating the client?

Severe hypothermia