Nurs 465 Practice Questions on Setting Priorities

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 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 type 2 diabetes mellitus and has a blood glucose of 68 mg/Dl

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 child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough

A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level.

A self-report pain rating scale

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

Assess orthostatic blood pressure

A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first?

Auscultate for wheezing

A nurse is caring for a client who is in active labor and notes late deceleration in the FHR. Which of the following actions should the nurse take first?

Change the client's position

While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first?

Discontinue the existing IV line

A nurse in the emergency department is performing an assessment on a client who reports being sexually assaulted. Which of the following actions should the nurse take first?

Document the client's verbatim statements

A nurse finds radioactive pellets on the floor of the surgical unit. Which of the following actions should the nurse take first?

Follow safety data sheet (SDS) instructions

A charge nurse is working with an assistive personnel who provides excellent care to clients and is an effective team member. Which of the following actions should the nurse take first to recognize the AP's contributions to client care?

Give positive feedback directly to the AP

A nurse is removing PPE after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first?

Gloves

A nurse is admitting a client who has experienced a weight loss of 11 kg (25lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for the client?

Identify the client's nutritional status

A nurse is assessing a client's abdomen who reports stomach pain. Which of the following actions should the nurse take first?

Inspect

A nurse is caring for a client who is 4 hours postpartum following a vaginal birth. The client has saturated a perineal pad within 10 minutes. Which of the following actions should the nurse take first?

Massage the client's fundus

A nurse enters a client's room and sees that ashes from a cigarette are beginning to ignite trash in the waste basket. Which of the following actions should the nurse take first?

Rescue the client from immediate danger

A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first?

Review the clients electrolyte values

A nurse is caring for a client who attacked one of her friends and is administered to the psychiatric unit. Which of the following actions should the nurse take first?

Set behavioral limits for the client

A nurse in an acute mental health facility is caring for a client who jumps out of her chair and begins to shout angrily at the clients around her. Which of the following actions should the nurse take first?

Speak to the client calmly, giving simple directions

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 enters an adult client's room and finds him unresponsive. After determining that the client is not breathing and does not have a pulse, which of the following actions should the nurse take first?

Summon the code team

A nurse is caring for a client who has dementia. The client is agitated and is having difficulty staying in his chair. Which of the following actions should the nurse take first?

place a seat alarm in the client's chair

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

A 10-year-old child 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 assess first?

A client admitted 1 hour ago for an ectopic pregnancy

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

A client experiencing a tension pneumothorax

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 catheter removed 5 hours ago and has not voided

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

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

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 of 5.8/mEq/L, and is prescribed sodium polystyrene sulfonate

A nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first?

A client who has severe respiratory stridor and a deviated trachea

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 gestation and reports painless vaginal bleeding

A nurse is prioritizing client care after receiving change of shift report. Which of the following clients should the nurse plan to see first?

A client who told an assistive personnel he is short of breath

A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first?

Administer IV fluids

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?

Administer oxygen therapy

A nurse is caring for a client who develops an airway obstruction from a foreign body but remains conscious. Which of the following actions should the nurse take first?

Administer the abdominal thrust maneuver

A nurse in an emergency department is caring for a client who is bleeding profusely from a deep laceration on his left lower forearm. After observing standard precautions, which of the following actions should the nurse perform first?

Apply direct pressure over the wound

A nurse in an emergency department is caring for a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound. Which of the following interventions should the nurse perform first?

Apply pressure directly to the wound

A nurse manager observes an unknown man in a laboratory coat making copies of a client's medical record. Which of the following actions should the nurse plan to take first?

Approach the man and ask why he is making copies

A nurse is caring for a client who is 1 day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first?

Ask the client to rate her pain on a scale of 0 to 10

A nurse is bathing a toddler and notices that she has several bruises. Which of the following actions should the nurse take first?

Ask the parents what caused the bruises

A nurse has been reassigned from her regular area of work to a unit that is short staffed. Which of the following actions should the nurse take first?

Ask what she will be assigned to do

A nurse is planning care for a client who is receiving enteral feedings through an NG tube. Which of the following actions should the nurse plan to take first?

Aspirate the client's stomach contents

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 preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first?

Auscultate lung fields

A nurse is caring for four clients. After administering morning medications, she realizes that the nifedipine prescribed for one client was inadvertently administered to another client. Which of the following actions should the nurse take first?

Check the client's vital signs

A nurse is caring for a client who is receiving hydromorphone HCL via PCA pump and reports continuous pain of 6 on a scale of 0 to 10. Which of the following actions should the nurse take first?

Check the display on the PCA pump

A nurse if caring for a client who has an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?

Check the oximeter

A nurse is assessing a client who has a cast in place for a fractured tibia. Which of the following actions should the nurse take first?

Checking capillary refill

A nurse is among the first responders to a mass casualty accident and does not know what type of PPE is needed. Which of the following actions should the nurse take?

Choose the highest level of protection equipment available

A nurse is caring for a client who has a central venous catheter and develops acute shortness of breath. Which of the following actions should the nurse take first?

Clamp the catheter

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 receiving change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?

Collect and analyze client data

A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor. Which of the following assessment findings should the nurse report to the provider first?

Continuous contraction lasting 2 minutes

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, which of the following actions should the nurse take first?

Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation

A nurse is caring for a client in the emergency department who, 2 hr earlier, severed the tip of a finger in an accident. During the assessment, the nurse detects a strong smell of alcohol from the client's breath. For which of the following findings should the nurse assess first?

Date of the client's last tetanus immunization

A nurse is preparing to transfer a client from a bed to a chair. Which of the following actions should the nurse take first?

Determine if the client can bear weight

A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following actions should the nurse administer first?

Epinephrine

The nurse in a trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

Evaluate chest expansion

A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?

Evaluate the firmness of the uterus

A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of PPE should the nurse remove first?

Gloves

A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following pieces of PPE should the nurse remove first?

Gloves

A nurse is preparing to care for a client who has suspected exposure to plague as a result of bioterrorism. Which of the following actions should the nurse plan to take first?

Initiate contact precautions

A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse take first?

Initiate oxygen therapy

A nurse is preparing to administer 10 units of regular insulin and 20 units of NPH insulin to a client who has diabetes mellitus. When mixing the two types of insulin, which of the following actions should the nurse take first?

Inject 20 units of air into the NPH insulin vial

A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?

Insert a gloved hand into the vagina to relieve pressure on the cord

A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse take first?

Inspect the cuts for debris

A nurse is providing teaching to the parent of an infant about introducing solid foods. The nurse should recommend that which of the following foods be introduced first?

Iron-fortified cereal

A nurse in a clinic is collecting a history from a client who reports that a member of his family just received a diagnosis of pulmonary tuberculosis. The nurse should expect that the provider will prescribe which of the following diagnostic tests first?

Nucleic acid amplification test (NAAT)

A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parental nutrition administration, and reports a pain level of 6 on a scale 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 nursing actions should the nurse plan to complete first?

Obtain vital signs for both clients

A nurse is providing care to a mother immediately following a stillbirth delivery. Which of the following actions should the nurse take first?

Offer mother private time with the newborn

A nurse witnesses a motor vehicle crash and finds a client who is not breathing. The nurse suspects the client has a cervical vertebrae fracture. Which of the following actions should the nurse take first?

Open the client's airway using the jaw-thrust maneuver

A nurse is assessing a client following the application of a leg cast for the treatment of a fracture. If the cast is too tight, which of the following finding should the nurse expect to observe first?

Pallor of the toes

A nurse in an emergency department is caring for a client who is experiencing acute alcohol withdrawal. Which of the following actions should the nurse take first?

Perform a neurological exam

An assistive personnel contacts a nurse manager and reports that on the last shift a nurse seemed distracted and that a client reported that the nurse smelled of alcohol. The AP alleged that the nurse was drinking alcohol during the shift. Which of the following actions should the nurse manager take first?

Perform an investigation into the facts surrounding the incident

A nurse is receiving change of shift report and is delegating tasks to the assistive personnel. 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 is admitting a child who has suspected epiglottitis. Which of the following actions should the nurse take first?

Place the child on droplet precautions

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

Place the client in a high-fowler's position

A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first?

Place the client in a sitting position

A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first?

Place the client in the lateral position

A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first?

Position the client supine

A nurse is 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 caring for a client who experienced a femur fracture 8 hours ago and now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first?

Provide high-flow oxygen

A nurse sees and assistive personnel (AP) entering the room of a client who requires transmission based precautions without using the appropriate PPE. Which of the following actions should the nurse take first?

Provide the appropriate PPE to the AP

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following action should the nurse take first?

Raise the head of the bed

A nurse is caring for a client who has a fractured right femur and is in balance suspension traction. The client is reporting pain from muscle spasms. Which of the following actions should the nurse take first?

Realign the client's position

A nurse is assessing a client who returned to the unit 4 hours ago after a partial colectomy. Which of the following findings should the nurse attend to first?

Report of severe incisional pain

A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse notices she does not have immunity to rubella. Which of the following times should the nurse understand is recommended for rubella immunization?

Shortly after giving birth

A nurse is administering platelets to a client who reports having lower back pain and feeling chilled and itchy. Which of the following actions should the nurse take first?

Stop the infusion

A nurse is caring for a client who has streptococcal pneumonia and a prescription for penicillin G by intermittent IV bolus. 10 minutes into the infusion of the third dose, the client reports that the IV site itches and that he feels dizzy and short of breath. Which of the following actions should the nurse take first?

Stop the infusion

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

Take an arterial blood gas (ABG) specimen to the laboratory

A staff nurse has applied for a promotion. The hiring manager insinuated that if there was a sexual relationship between the two of them, the nurse's promotion request would get increased consideration. Which of the following actions should the staff nurse take first?

Tell the hiring manager in clear terms that this conduct causes feelings of discomfort and that the behavior should stop immediately

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the clients right nostril. Which of the following actions should the nurse take first?

Test the drainage for glucose

A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first?

Turn the client onto her side

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Turn the client's head to the side

A nurse manager is planning to discipline a nurse after discovering that the nurse was discourteous to a client. Which of the following disciplinary steps should the nurse manager take first?

Verbal admonishment

A nurse is preparing to remove an NG tube from a client. Which of the following actions should the nurse take first?

Verify the provider's prescription to discontinue the tube

A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first?

Wash the area of the puncture thoroughly with soap and water

While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first?

Wash the site of the injury with soap and water

A nurse is caring for a client who has CHF and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?

check the client's vital signs

A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first?

check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate

A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client finding should the nurse intervene first?

stridor