PASS NCLEX and NP BOARDS-3

A hospitalized client experiences a fall after climbing over the bed's side rails. Upon reviewing the client's medical record, the nurse discovers that restraints had been prescribed but were not in place at the time of the fall. What information should the nurse include in the follow-up incident report? 1 A statement that the nursing staff was not at fault because the client initiated the accident. 2 A listing of facts related to the incident as witnessed by the nurse. 3 The name of the nurse who was responsible for implementing the restraints. 4 The potential reasons why the restraints were not in place at the time of the fall.

2: We must stick to the facts and state the objective information in the fall incident report.

While assessing an immobilized client, the nurse notes that the client has shortened muscles over a joint, preventing full extension. This condition is known as: 1 Osteoarthritis 2 Osteoporosis 3 Muscle atrophy 4 Contracture

4: This is a contracture. We try to prevent these. They can occur after strokes, spinal cord injuries, and after amputations. The muscle gets very tight if not prevented and it is difficult to move the muscle normally.

A client is admitted with a diagnosis of depression. Which of the following characteristics is most indicative of depression? A. Grandiose ideation B. Self-destructive thoughts C. Suspiciousness of others D. Negative self-image

Command: Most indicative-depression diagnosis D is correct. It lies in their perception of themselves.

The nurse sees clients in the medical surgical unit. Which client does the nurse see first? 1. The client diagnosed with heart failure and who has received 800 mL of IV fluids in 2 hours. 2. The client diagnosed with lung cancer with a blood calcium level of 10.5 mg/dL (2.6 mmol/L). 3. The client diagnosed with hypertension and who requires the 0900 dose of captopril. 4. The client postoperative after a laminectomy and who requires supervision when ambulating.

Command: PRIORITY PATIENT Clues: medical-surgical unit the best answer here is 1. DO NOT DO THIS. Please. If someone has heart failure, they can't tolerate much fluid, and definitely not fast. We diurese these patients, we restrict fluid intake. We aren't going to give them a liter of fluid fast! That's asking for FLASH PULMONARY EDEMA. We are going to check on that patient and stop those fluids. Maybe give them an extra dose of diuretics. 2 is a normal calcium level so they are pretty stable. 3 is just a routine med, not priority. 4 sounds extremely stable and we could probably go in there at any time, but not priority.

The nurse sees patients in the adolescent psychiatric unit. Which of the following patients should the nurse see FIRST? 1. A 13-year-old who complains of impulsivity and poor attention span. 2. A 14-year-old who frequently loses his temper and argues with his teachers. 3. A 15-year-old who wants to be a model and only drinks water and eats vegetables. 4. A 16-year-old who bullies, threatens, and intimidates others and initiates physical fights.

Command: PRIORITY PATIENT Primers: adolescent psychiatric unit The correct answer here is going to be 3. This is really the only medically concerning patient. Yes 4 sounds a bit scary, but we don't really have enough info to know if he is a danger to others, currently. Now 3, it sounds like they may even need to be hospitalized for anorexia. In this case, (3) the medical took priority over the psychological because we didn't have any info on the current state of both 3 and 4. 1 and 2 are just routine and can be addressed, but not anything emergent.

A nurse arrives for work to find that the medical unit is short-staffed. Nursing administration has called several staffing agencies, but they are unable to send a replacement nurse for three hours. The nursing care coordinator sends a recently oriented patient care assistant to help relieve the burden of care. Which activities should the nurse delegate to the patient care assistant? Select all that apply. 1Making occupied beds 2 Taking routine vital signs 3 Answering clients' call lights 4 Watching a client take oral medications 5 Emptying a closed chest drainage system for intake and output

123: These are all within the nursing assistant scope of practice.

A day after an explanation of the effects of surgery to create an ileostomy, a 68-year-old male client remarks to the nurse, "It will be difficult for my wife to care for a helpless old man." This comment by the client regarding himself is an example of Erikson's conflict of: 1 Initiative versus guilt 2 Integrity versus despair 3 Industry versus inferiority 4 Generativity versus stagnation

2: This is the last Erikson stage when the individual looks back upon their life.

A client with coronary artery disease has a sudden episode of cyanosis and a change in respirations. The nurse starts oxygen administration immediately. Legally, should the nurse have administered the oxygen? 1 The oxygen had not been prescribed and therefore should not have been administered. 2 The symptoms were too vague for the nurse to determine a need for administering oxygen. 3 The nurse's observations were sufficient, and therefore oxygen should have been administered. 4 The health care provider should have been called for a prescription before the nurse administered the oxygen.

3: In an emergency situation, the hospital will have protocols for things such as administering oxygen to a deteriorating patient. Legally, oxygen must be administered.

a client has a "prayer cloth" pinned to the hospital gown. The cloth is soiled from being touched frequently. What should the nurse do when changing the client's gown? 1 Make a new prayer cloth. 2 Discard the soiled prayer cloth. 3 Pin the prayer cloth to the clean gown. 4 Wash the prayer cloth with a detergent.

3: Pin the prayer cloth to the clean gown! In cultural competence, it is important to make sure that their traditions and spiritual/religious rituals are acknowledged and encouraged.

A nurse receives abnormal results of diagnostic testing. What action should the nurse take first? 1 Inform the client of the results. 2 Ensure that the results are placed in the client's medical record. 3 Notify the client's health care provider of the results. 4 Obtain results of the other lab tests that were performed.

3: The most important action after observing some abnormal results are notifying the physician! For instance, an abnormal potassium. This one is pretty straightforward.

A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions? 1 Postural drainage 2 Cupping the chest 3 Nasotracheal suctioning 4 Frequent changes of position

4: Frequent changes of position can be helpful in this scenario. We want them to move as much as possible in order to facilitate the movement of these secretions so that they don't consolidate/accumulate in one area and progress to some sort of obstruction/infection.

The HIV-infected patient is taught health promotion activities including good nutrition; avoiding alcohol, tobacco, drug use, and exposure to infectious agents; keeping up to date with vaccines; getting adequate rest; and stress management. What is the rationale behind these interventions that the nurse knows? A. Delaying disease progression B. Preventing disease transmission C. Helping to cure the HIV infection D. Enabling an increase in self-care activities

A is the correct answer here. We can't cure it and we can't entirely prevent it. This is more conceptual.

The ED physician has completed an assessment. Gail is sitting at the bedside while the ED nurse continues to assess Nancy every 15 minutes. Which assessment finding warrants immediate intervention by the nurse? A. Nancy has a negative Babinski's reflex bilaterally B. Nancy only responds to a painful stimuli C. Nancy's Glasgow Coma Scale (GCS) score increases D. Nancy's bilateral grip strength is unequal

B is correct. This shows a decline in LOC. If her GCS increases, this is a good thing. D may need to be further assessed, but A is normal for an adult. B is the best answer because she is definitely in a coma-like state.

The nurse plans to teach blood glucose self-monitoring to a client who is newly diagnosed with diabetes mellitus type 1, and the health care provider has given the client a schedule for testing. In addition to the prescribed schedule, the nurse should also instruct the client to check the blood glucose level in which circumstance? A.Any time the client awakens during the night B.Whenever the client has feelings of dizziness C.Right after meals if insulin is not administered 30 minutes before the meal D.Only at scheduled times; additional testing harmful to fingertips

B is the correct answer. BG checks can be at meals and at bedtime, PRN as needed for S/S hypoglycemia. Dizziness I think would fall into this category. Command: IMPORTANT TO CHECK SUGAR- PRIMER: BLOOD GLUCOSE SELF-MONITORING, DM TYPE I, TESTING SCHEDULE

Due to her deteriorating condition, Nancy is immediately referred to the neurologist. The ED nurse realizes that Nancy has probably suffered a left-sided brain attack. Which clinical manifestation further supports this assessment? A. Spatial-perceptual deficits. B. Visual field deficit on the left side C. Paresthesia of the left side D. Global aphasia

Brain-Left=language Heart-Left=lungs Primers: Left-sided brain attack/CVA, deteriorating condition, neurologist Command: clinical manifestation further supporting left-side stroke Our answer here is D, global aphasia. We know the left side of the brain is associated with language and its development.

The woman is afraid she may get HIV from her bisexual husband. What should the nurse include when teaching her about preexposure prophylaxis (select all that apply)? A. Take fluconazole (Diflucan). B. Take amphotericin B (Fungizone). C. Use condoms for risk-reducing sexual relations. D. Take emtricitabine and tenofovir (Truvada) regularly. E. Have regular HIV testing for herself and her husband.

C, D, E. A is for yeast infections, not necessarily indicated. B is an anti-fungal, not necessarily indicated unless S/S present. C is correct. D is also correct, you can take this prophylactically. E is correct just to keep up on it.

The nurse prepares to administer digoxin, 0.125 mg IV, to an adult client with atrial fibrillation. Which client datum requires the nurse to withhold the medication? A.The apical heart rate is 64 beats/min. B.The serum digoxin level is 1.5 ng/mL. C.The client reports seeing yellow-green halos. D.The potassium level is 4.0 mEq/L.

COMMAND: CLIENT DATA PROMPTING NURSE TO WITHOLD Primer: digoxin, atrial fibrillation A is fine, it is above 60. B is in the correct range. C IS SCARY! THIS MAY MEAN TOXICITY. This is correct. This is a visual disturbance you would see with toxicity. D potassium is healthy, not a bad potassium to have.

The nurse is caring for a hospitalized client with myasthenia gravis. Which finding requires the most immediate action by the nurse? A.O2 saturation, 89% B.Reports diplopia C.Ptosis to left eye D.Difficulty speaking

COMMAND: MOST IMMEDIATE FINDING Primer: MG, action by nurse needed! A is the correct answer. MG can be respiratory-compromising because of the drive to breathe and exhaustion they experience! O2 saturation is fine to be low with COPD patients, but not MG patients. They are struggling to breathe right now. We must act, we might have to intubate them. The other findings are expected.

When caring for a client hospitalized with Guillain-Barré syndrome, which information is most important for the nurse to report to the primary health care provider? A.Ascending numbness from the feet to the knees B.Decrease in cognitive status of the client C.Blurred vision and sensation changes D.Persistent unilateral headache

COMMAND: MOST IMPORTANT INFO TO REPORT PRIMER: GB (GUILLAN BARRE SYNDROME) B is the correct answer, this would indicate hypoxia. Cognitive changes are typically d/t low levels of oxygen here. The ascending paralysis eventually can reach the abdominal and respiratory muscles, which indicates need for intubation for these patients, so we have to monitor this. If they have strange cognitive changes, it could indicate hypoxia.

Nancy had her first symptoms at midnight. She went to the Emergency room around 7am for her S/S. As the nurse initially assesses Nancy, Gail asks, "Why isn't my mother a candidate for thrombolytic therapy?" A. "Since your mother was alert on admission, she is not a candidate to receive this medication. B. "I think that is something you should discuss with your mother's healthcare provider." C. "tPA is usually not administered to anyone older than 65 years." D. "She is not a candidate because of therapeutic time constraints related to this medication."

COMMAND: MOTHER NOT CANDIDATE RATIONALE Primer: thrombolytic therapy, last known well was seven hours ago D is correct, it has been too long since her LKW (last known well to receive TPA).

Gail starts to cry and states, "Mom was just fine last week when we went out to eat and to a show. I love my mom so much, and I am so scared. She is all I have." How should the nurse respond? A. "I am sure everything will be alright." B. "I will notify the chaplain to come and sit with you so you won't be alone." C. "I know this is scary for you. Would you like to sit and talk?" C. "I am sure your mother knows you are here. Just keep talking to her."

COMMAND: NURSE RESPONSE Primer: Crying, scared, sudden change C is the correct answer. Remember with therapeutic communication it must be accurate AND therapeutic! That is our checklist.

The nurse receives report on the medical/surgical unit. Which of the following clients should the nurse see FIRST? 1. A client with an IV of normal saline infusing at 125 ml per hour complaining of slight swelling at the IV insertion site. 2. A client 3 days post right knee replacement complaining of right calf pain with movement. 3. A client with a respiratory rate of 24 and an oxygen saturation of 94% on room air. 4. A client 12 hours after a hysterectomy complaining of nausea.

COMMAND: PRIORITY PATIENT CLUES: MED SURGE UNIT, REPORT The answer here is going to be 2. This is red flag for DVT! Remember this!! DVT is very priority to NCLEX. 1 sounds important, but not DVT-important. The thing with DVT is that it can progress to Pulmonary Embolism which is very scary. This can kill you. The thing with 1 is that it's just normal saline, it's not a vesicant medication it won't hurt your skin. 2 takes priority, even though we may see 1 next. 3 sounds stable, and 4 is just pretty expected after a hysterectomy. We will go there and treat it, but the DVT patient needs to take priority initially.

The nurse cares for patients in the pediatric clinic. Which of the following patients should the nurse see FIRST? 1. A 5-year-old diagnosed with autistic disorder demonstrating finger flapping. 2. A 6-year-old with enuresis who often urinates in his underwear. 3. A 7-year-old who is shy and has difficulty reading. 4. A 9-year-old who has used a weapon toward his mother and caused physical harm to others.

COMMAND: PRIORITY PATIENT Clues: Pediatric clinic 1 is routine, outpatient issue. 2 is also something to be treated outpatient, no urgency here. 3 is very very outpatient! (not critical at all). 4 sounds very scary. He is a danger to himself AND others. We have to act. This is our priority patient.

The nurse cares for clients in a gynecological clinic. Which of the following clients should the nurse see FIRST? 1. A 60-year-old complaining of dry vaginal walls and painful intercourse. 2. A 35-year-old who had a hysterosalpingogram is experiencing tachycardia, and has a generalized rash. 3. A 30-year-old who requires preparation for a cervical biopsy. 4. A 25-year-old scheduled for a Pap smear.

COMMAND: PRIORITY PATIENT Clues: gynecological clinic The answer here is 2, it sounds like an allergic/anaphylactic (potentially) reaction! We have to act. The others sound very routine and occurrences that can be addressed without any urgency. Anything with "gram" usually involves IV contrast. So we know this is a scan. They are likely having a reaction to the contrast, so it is always important to assess allergies, especially to shellfish! Pap Smear is routine and cervical biopsy is considered a routine procedure compared to this acute systemic reaction to the contrast which could cause airway obstruction or anaphylactic shock.

The nurse cares for clients on the pain management unit. Which of the following clients should the nurse see FIRST? 1. A client receiving intraspinal anesthesia for pain control with a heart rate of 76 bpm and a respiratory rate of 8. 2. A client receiving patient-controlled analgesia (PCA) with a heart rate of 112 bpm and a respiratory rate of 24. 3. A client requesting PRN IV medication for severe chronic back pain. 4. A client requesting PRN IV medication for acute abdominal pain.

COMMAND: PRIORITY PATIENT PRIMERS: PAIN MANAGEMENT The first patient sounds very critical! I am worried about this patinet! A respiratory rate of 8 is considered too low and hypoventilation/respiratory-depressed. This patient will likely have to be intubated. 2 sounds like they are in pain with that increased heart rate, but no immediate distress or potential for deterioration. 3 and 4 are important to address but not necessarily priorities compared to number 1. This patient has the potential to code because of hypoventilation, we need to get in that room and potentially give them the antidote or intubate them, as soon as possible!

The triage nurse prioritizes patients to be evaluated in the ER. Which of the following patients will the nurse see FIRST? 1. A young adult complaining of nausea and vomiting for the past several hours. 2. A young adult at 8 weeks' gestation complaining of vaginal spotting. 3. A toddler with a temperature of 101°F (39°C). 4. An infant with vomiting and diarrhea.

Command: PRIORITY PATIENT Primer: EVALUATION IN ER The correct answer here is 4. Infants are much more sensitive than we are. They are much more at risk for these fluid deficits and electrolyte disturbances. This is scary. They are also much more at risk for metabolic acidosis. We have to correct this before it gets dangerous. Infants typically take priority with NCLEX, as we know. 3 is important two, but to be seen second. 1 and 2 are not as much a priority, but still need to be addressed. 4 could deteriorate the quickest!

Which behavior indicates to the nurse that a client with paranoid ideas is improving? A. Arrives on time for all activities B. Talks more openly about plans to protect his possessions C. Aggressively uses the punching bag in the gym D. Discusses his feelings of anxiety with the nurse

Command: Behavior indicating patient improving Clue: paranoid ideas. The answer here is D, it is good if they are verbalizing the anxieties rather than keeping private and continuing the cycles of the delusions without any help.

Which clinical manifestation in the client with hyperthyroidism is most important to report to the health care provider? A.Nervousness B.Increased appetite C.Apical heart rate of 130 beats/min D.Insomnia

Command: Clinical manifestation to report to health care provider Primer: Hyperthyroidism This one is pretty obvious because C seems a bit concerning. 130 is too high for a heart rate, especially at rest! If a patient has hyperthyroidism, we know that they can be at risk for thyroid crisis or thyrotoxicosis. Remember that it is the extreme of the thyroid issues. The other extreme, on the other end of the spectrum is severe hypothyroidism and associated myxedema coma. At baseline, ideally, our thyroids should be "euthyroid." Anything with "Eu" in front of it means normal. Our normal thyroid function translates to a normal metabolism. The thyroid is the regulator of our metabolism. That impacts everything. So we have too much circulating thyroid hormone? Then we are running on overdrive. Not enough? Well then we are much slower. So the thyroid raises things, speeds things up. Think of it as turning up the rate of a conveyor belt or something. So nervousness can certainly occur. And so can increased appetite. But those are mostly expected with hyper-thyroidism. That heart rate is dangerous and we would worry, there could be cardiac complications of that. Insomnia is kind of expected,unfortunately. These are important manifestations, but not nearly as important as that fast heart rate. Our concern would be that the heart tires out and lead to more drastic complications.

After assessing a 26-year-old client with type 1 diabetes mellitus, which data may indicate that the client is experiencing chronic complications of diabetes? A.Blood pressure, 159/98 mm Hg B.Hemoglobin A1c (HbA1c), 6% C.Creatinine level, 1.0 mg/dL D.Chronic sciatica

Command: Complication of diabetes-chronic primer: 26, diabetes mellitus The correct answer here is the BP! That is too high. They prime us with chronic, so we know that it isn't something too concerning, but concerning enough. The other results are roughly normal values. So the only thing here that we are really worried about is the BP. This is something that can occur with DM, the associated complication, hypertension. This is micro/macro -vascular damage that occurs. Diabetes predisposes us to not only micro and macro-vascular damage, but target organ damage as well. Our kidneys and eyes are at risk. Diabetes is certainly associated with DKA and HHS, but those are acute conditions. Don't forget about the long-term complications and insidious impact of chronic hyperglycemia! Please don't confuse hyperglycemia with hypoglycemia. Hypoglycemia is a complication of diabetic treatment. The blood sugar drops. That is an acute condition, and it is dangerous as well. But don't confuse that with diabetes-high blood sugars, that is only a complication of us trying to treat diabetes. Just to be thorough, that creatinine level is normal, and chronic sciatica is not necessarily a complication of diabetes, more musculoskeletal. That hgba1c I think is pretty normal and well-regulated, especially for a diabetic. I want you to know that hgba1c is a good value for us to determine blood sugar over the course of 3 months. This is actually a really good way to test patient compliance with diabetic medications.

A 68-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right-sided hemiplegia.

Command: HOLD MEDICATION RATIONALE PRIMER: dysphasia, possible stroke, severe headache, aspirin The correct answer will be C. ICH or SAH. That headache preceding is ominous and could be a S/S an intracranial bleed (intracranial hemorrhage versus subarachnoid hemorrhage). We don't want them to get aspirin, it would worsen the bleeding.

A psychiatric nurse is presented with a group of patients in the emergency department (ED). Which of the following patients requires IMMEDIATE attention? 1. A young adult who failed medical school and verbalizes, "My pain will be over soon." 2. A young adult who complains of hyperventilation and palpitations at the beginning of a presentation. 3. A middle-aged adult who hears voices to harm others. 4. A middle-aged adult who is fearful after witnessing a murder.

Command: Immediate attention patient Primer: ED 1 takes priority here. This sounds like they are planning suicide. This is definitely a red-flag test tip. 2,3, and 4 are priority as well, but still not as priority as this patient who presents as a "danger to himself." Watch out for this on the exam, it's something they like to test on.

The neurologist writes a diagnosis of "Suspected brain attack" and prescribes a non contrast computed tomography (CT) scan STAT. Which nursing intervention should the nurse implement when preparing Nancy and her daughter for this procedure? A. Explain to the daughter that her mother will have to remain still throughout the CT scan B. Determine if the client has any allergies to iodine C. Provide an explanation of relaxation exercises prior to the procedure D. Premedicate the client to decrease pain prior to having the procedure

Command: NURSE INTERVENTION Primer: Suspected CVA, neurologist, non-contrast CT STAT B is not necessary, it is non-contrast. C is not a priority. D is not necessary. A is the best answer

While in group therapy, a client who is diagnosed with posttraumatic stress disorder (PTSD) is processing an experience from the war in Iraq when another client tips over a chair. What action should the nurse take when the client with PTSD falls to the floor in a fetal position? A. Confront the client who tipped over the chair about the inconsiderate behavior B. Dismiss the other clients from the group therapy session for a 10- minute break. C. Reinforce reality to the client on the floor and remove him to a quiet space. D. Call a security code and medicate both clients with an antianxiety drug.

Command: Nurse action Primer: PTSD, group therapy, processing experience-war C is correct here. They are having a flashback. We must re-orient this patient. A is not acknowledging the fears, B is too interruptive during group therapy, and D is not necessary.

After receiving report from the night shift, the nurse plans assignments for the day on the endocrinology unit. Which client does the nurse see first? 1. The client who requires a fasting blood glucose test in the morning before breakfast. 2. The client who requires a urine test for ketone bodies. 3. The client who will be discharged this afternoon. 4. The client with a fasting blood glucose of 517 mg/dL (28.7 mmol/L).

Command: PRIORITY PATIENT CLUES: Night shift, endocrinology The correct answer here is 4, this patient is extremely hyperglycemic! This is scary. Depending on the type of DM (I or II) they could have DKA or HHS respectively. We must address this urgently! Now 1-3, they are important, but more outpatient and routine procedures/issues. 3 is low priority because of the discharging status. We aren't as worried about any those. We have to get to room 4 so that we can get the blood sugar down.

Children from a school-bus accident are transferred to the hospital. The nurse performs triage in the emergency department (ED). Which of the following patients should the nurse see FIRST? 1. An 8-year-old with a superficial burn to the arm. 2. A 7-year-old with burns on the face. 3. A 6-year-old with small lacerations to the arms and legs. 4. A 5-year-old complaining of elbow pain.

Command: PRIORITY PATIENT CLUES: School-bus accident, transferred, triage, ED The best answer here is 2 because we know that it's so important to check airway when a patient has been exposed to smoke. Burns on the face could indicate excess smoke inhalation. This patient may be at risk for an acute inflammatory response, closing the airway d/t the smoke inhalation. Sometimes we must do this with even moderate smoke inhalation, prophylactically or preventatively. It's scary! Airway is our priority here. 4 is silly, and 3 is treatable but not urgently. 1 is important to address but 2 is still taking priority.

The nurse receives report about the clients on the medicine unit. Which client does the nurse see first? 1. The client who just arrived as a transfer from the emergency department (ED) with an oxygen saturation of 93% and is receiving 2 liters of oxygen per nasal cannula. 2. The client who reports nausea while drinking contrast in preparation for a CT scan. 3. The client who just arrived from the health care provider's office as a direct admission with a hemoglobin of 6.9 g/dL (69 g/L). 4. The client who reports abdominal pain and is requesting pain medication.

Command: PRIORITY PATIENT Clues: Medicine unit, report The correct answer here is 3. This is an extremely low hgb. It's dangerous. We must transfuse. We need to make this patient our priority. 1 is stable, entirely. We aren't worried about them. 2-this is just normal. CT scan contrast is gross. 4 is important, but just not as much of a priority as 3. People who are losing blood can code, and they code FAST. I have seen it happen with a GI bleed, maybe twice.

The nurse cares for clients in the emergency department. Four clients present complaining of side effects from prescribed medication. Which of the following clients should the nurse see FIRST? 1. A client receiving clozapine (Clozaril) and experiencing flu-like symptoms, fever, sore throat, and lethargy. 2. A client receiving valproic acid (Depakene) and experiencing tremors. 3. A client receiving lorazepam (Ativan) and experiencing abdominal discomfort. 4. A client receiving methylphenidate hydrochloride (Ritalin) who lost 5 lb in 4 weeks.

Command: PRIORITY PATIENT PRIMERS: EMERGENCY ROOM, SIDE EFFECTS, NEW PRESCRIPTION MEDICATION Here, we are most concerned for 1. This is an anti-psychotic and we have concern for agranulocytosis and consequential immunocompromise for this patient. This patient may not be able to fight this off, we must assess them! Tremors can indicate depakene toxicity sometimes so we will look into that patient, but next, because 1 is a bit more concerning with that acute infection. I think ativan typically can cause some GI distress, and ritalin has weight loss as a side effect, but typically this levels off after the initial few months of taking the medication.

The community health nurse plans visits for the day. Which of the following clients should the nurse see FIRST? 1. A client diagnosed with type 2 diabetes who is complaining of GI upset after taking chlorpropamide (Diabinese). 2. A client who is complaining of vomiting after chemotherapy. 3. A client with a tonometer reading of 21 mm Hg. 4. A client with a laryngectomy who is complaining of a greenish-yellow discharge.

Command: PRIORITY PATIENT Primer: community health nurse The correct answer here is 4. Those are clear S/S infection. 1 is pretty common. 2 is expected as well. 3 is actually a normal IOP reading, it's not considered glaucoma at 21 mmHg. 4 sounds like a textbook infection post-procedure. So we must see them first.

The nurse cares for patients in the psychiatric ER. Which of the following patients should the nurse see FIRST? 1. A patient receiving haloperidol (Haldol) experiencing an oculogyric crisis. 2. A patient receiving thioridazine (Mellaril) experiencing akathisia. 3. A patient receiving risperidone (Risperdal) experiencing blurred vision. 4. A patient receiving fluphenazine (Prolixin) experiencing sedation.

Command: PRIORITY PATIENT Primer: psych ER The correct answer here is 1. It helps that they put "crisis," they certainly "up-played" this answer. Anything that says "crisis" should be prioritized. B is kind of expected and could be addressed soon, but not necessarily an emergency. 3 means the dose may need to be decreased, but still not priority. 4 is a pretty common side effect in the early administration of the medication. The correct answer is 1. This is an acute dystonic reaction where the eyes lock upward, this can be somewhat life-threatening so we must administer an anti-cholinergic medication ASAP like cogentin. I think they really gave us a hint with the word "crisis."

The nurse obtains histories from four clients preparing for CT scan with oral and IV contrast. Which of the following client statements requires an IMMEDIATE follow-up by the nurse? 1. "I am feeling nauseated." 2. "My face gets red when I eat shrimp." 3. "I get claustrophobic when I am in a small space." 4. "I am having joint pain."

Command: PRIORITY PATIENT STATEMENT CLUES: CT oral and IV, histories, four clients The best answer here is 2. This indicates that this patient may have an allergy to shellfish which has a direct correlation with contrast dye. This would be concerning. The doc should be notified immediately. 1 is normal, 3 is not really an issue since CTs are pretty big (MRIs are much smaller and may require sedation), and 4 may be the whole rationale for why they re getting the test, so it would be expected. 2 is the scariest, we may have to pre-medicate them.

The home care nurse visits a client in a large apartment complex. During the visit, the area experiences a major earthquake. Which of the following clients should the nurse see FIRST? 1. A restless client with a rigid abdomen and absent bowel sounds. 2. An unconscious client with left-sided tracheal shift from midline. 3. A client complaining of excruciating pain with an obvious deformity of the left leg. 4. A client clutching her chest and complaining of severe chest pain.

Command: Priority patient Primers: large apartment complex, major earthquake in area 1 sounds very priority, but 2 even worse. Wow. 2 sounds like a tension pneumothorax. This can be treated, but fast, because they are also unconscious! Probably from hypoxia. 3 is bad, but not as priority as 2 like 1. 4 could be bad, but still not as critical as unconscious and left-sided tracheally-deviated 2. We have to act fast.

The nurse receives report about clients on the medical/surgical unit. Which of the following clients should the nurse see FIRST? 1. A client who is scheduled to receive verapamil (Calan). 2. A client who is scheduled to receive the prescribed metered dose inhaler (MDI). 3. Family members of a client who threaten to sue the hospital if the nurse doesn't talk to them immediately. 4. A client who is verbally abusive to staff and becomes increasingly more agitated.

Command: Priority patient. Primers: med/surge unit. 4 sounds as if he/she could be escalating, this is dangerous. We have to act fast and see this patient first. 2 and 1 are just scheduled orders, and 3 seems urgent, but not quite as urgent as 4. It sounds like employees could be in danger here.

The nurse learns that patients from a motor vehicle accident are being transferred to the emergency department (ED). The nurse performs triage in the ED. Which of the following patients should the nurse see FIRST? 1. A patient with ecchymosis and lacerations to the facial area. 2. A patient complaining of shortness of breath and pressure in the chest. 3. A patient with blood pressure of 90/60 and apical pulse of 120 bpm. 4. A patient complaining of dizziness and nervousness.

Command: priority patient Clues: MVA, ED, triage The best answer here is 3. I know this one is counter-intuitive, so I want you to think of the BP as 80/60 instead of 90/60 for us who live at a 90/60 BP haha. So the tachycardia and lower BP is suspicious for hypovolemic shock, it appears as if they are bleeding out. This is also objective data, AND we have context, the MVA. A lot of people want to pick 2, and I totally get that. However, 2 is subjective data, and could be 2/2 anxiety. It's not as ominous as that impending shock. As we know, sometimes ABC switches to CAB with triage (ex. AAA rupture), and this isn't sounding good. 4 sounds okay just anxiety and 1 sounds important but not as urgent as 2 and 3. We battled this in some of my classes but I really want you to understand that those signs of shock are a BIG DEAL. Even with SOB and CP, that objective critical data overrides the complaints voiced. We will see them next. Shock is a CIRCULATORY issue.

A triage nurse in a busy urgent care center is prioritizing patients for evaluation. Which of the following patients should the nurse see FIRST? 1. A 2-month-old infant. The mother states that the child is very sleepy and has refused to nurse for 8 hours. 2. A crying 2-year-old. The father states that the toddler fell against the fireplace and continuously touches the right elbow. 3. A 5-year-old who is flushed. The grandmother states that the child has a temperature of 101.9°F (39°C). 4. A 6-year-old who complains of a sore throat. The caretaker reports the child has had two episodes of vomiting.

Command: priority patient Clues: busy urgent care center, triage nurse The correct answer here is 1, this baby is very at risk for dehydration! this is scary. It almost seems as if they are lethargic, we should definitely see this patient first.

The nurse cares for clients in the outpatient clinic. Each of the following clients has asked to see the nurse due to complaints of pain. Which of the following clients should the nurse see FIRST? 1. A client with a history of a herniated lumbar disc who complains of severe pain radiating down the left leg. 2. A client with a history of migraine headaches who complains of a headache and light sensitivity. 3. A client with a history of kidney stones who tearfully complains of severe right flank pain. 4. A client with a history of coronary artery disease (CAD) who complains of midepigastric pain radiating to the neck.

Command: priority patient Clues: complaints of pain 4 is the most concerning and it is mostly because of their history. They have a history of CAD, another episode of chest pain/related S/S is probably serious. We need to rule out MI in this patient, right away. Plus this is an outpatient clinic, we really need to get them to the ED!

A nurse working in an emergency department performs a yearly ride-along with a local ambulance service. Responding to the scene of a motor vehicle collision (MVC), which of the following clients should the nurse see FIRST? 1. A client with an obvious deformity of the right humerus with neurovascular systems intact distal to the site. 2. An unconscious client with a crushing chest wound. 3. An unconscious client with a regular heart rhythm at 64 bpm with even and unlabored respirations. 4. An alert client with multiple scalp lacerations.

Command: priority patient Primer: motor vehicle collision, ED, ambulance ride along This one is very obvious to me, the priority patient. the word crushing, mixed with unconscious, that sounds really scary. We need to get on that. However, we know we black tag patients (ethically neglect them) if they have a poor chance/prognosis. But here we are assuming we may be able to help crushing chest wound patient, maybe they are in cardiac tamponade and need decompression.

The triage nurse at an urgent care center notes that four clients have signed in, each complaining of a sore throat. Which of the following clients should the nurse see FIRST? 1. A 7-year-old whose sibling was recently treated for "strep throat." 2. A 10-year-old with a history of chronic allergies. 3. A 21-year-old with a history of chronic sinus infections. 4. A 55-year-old receiving 5-fluorouracil (5-FU).

Command: priority patient Primers/clues: urgent care center, sore throat 4 here is the most urgent. That is a chemo medication and any sort of immunosuppressant, if a patient develops symptoms, that will be a bit ominous. They likely cannot fight off this infection, so we must prioritize them. 2 and 3 they deem "chronic." Chronic is not typically considered priority, relatively speaking. 1 sounds stable enough, but we would probably see them second to treat that infection.

The home health nurse is planning client visits for the day. Which client should the nurse see first? 1. A 70-year-old diabetic with fasting blood glucose readings of 240-260 mg/dL for 1 week. 2. A 65-year-old discharged from the hospital 2 days ago following coronary artery bypass graft surgery (CABG). 3. A 55-year-old with congestive heart failure who gained 3 lbs in the last 24 hours. 4. A 40-year-old with metastatic breast cancer reporting pain unrelieved by pain medication.

Command: priority patient Primers: home health nurse, planning This one is kind of tricky because there really is only one priority patient, and they are only relatively priority. 3 is the correct answer because of the weight gain. It seems as if they are having a heart failure exacerbation, gaining so much weight so quickly. 1, 2, and 4, those patients seem pretty stable. We still want to address/see these patients, but the heart failure patient may need more rapid assessment because of breathing difficulties. This can be urgent and scary. They are the most medically at risk at this time.

The nurse cares for clients on the medical/surgical unit. After receiving report, which of the following clients should the nurse see FIRST? 1. An elderly client 2 days postop after a total hip replacement who slipped out of bed when trying to stand. 2. An elderly client with a history of cardiomyopathy who aspirated cooked cereal at breakfast. 3. An elderly client diagnosed with a right-sided CVA who requires assistance going to the bathroom. 4. An elderly client diagnosed with heart failure (HF) who has been vomiting for 3 days.

Command: priority patient Primers: medical/surgical unit, receiving report The answer here is 2. Aspiration pneumonitis is acute risk for airway obstruction. A lot of people overlook this answer, but this is the most ominous answer and the priority here. 4 sounds sick, but not as much of a priority, no ABC with 4. 3 sounds pretty stable, honestly. 1 sounds as stable 3. 2 is the one I would see first.

A nurse working in an emergency department performs a yearly ride-along with a local ambulance service. Upon responding to the scene of a motor vehicle collision (MVC), which of the following clients should the nurse see FIRST? 1. An infant who is strapped in a car seat and crying uncontrollably. 2. A child who is crying that her leg is broken. 3. A restless client with pale, cool, clammy skin and a rigid abdomen with absent bowel sounds. 4. An alert but mildly disoriented client with a scalp laceration with well-controlled bleeding.

Command: priority patient Primers: motor vehicle collision, ambulance ride along The correct answer is 3. Restless is never good. Plus it sounds like they are hemorrhaging, possibly in hemorrhagic shock. We need to do something, and quickly!

After receiving report from the night shift, the nurse plans assignments for the day on the pediatric unit. Which of the following patients should the nurse see FIRST? 1. A patient diagnosed with leukemia complaining of fatigue. 2. A patient diagnosed with Wilms tumor complaining of thirst. 3. A patient diagnosed with hemophilia complaining of joint pain. 4. A patient diagnosed with gastroesophageal reflux complaining of abdominal pain.

PRIORITY PATIENT=COMMAND CLUES: NIGHT SHIFT, ASSIGNMENTS, PEDIATRIC UNIT The most concerning patient here is 3, the hemophiliac with joint pain. They are likely actively bleeding. This joint pain is a sign. We must see what is going on. 1 is expected. 2 is also pretty expected based on the type of kidney tumor. and 4 is expected too, GERD is essentially heartburn. We must rush to hemophiliac patient and make sure they are getting RICE, (rest, ice, compressio, elevation).

The nurse sees patients in the gastrointestinal clinic. Which of the following patients should the nurse see FIRST? 1. A middle-aged adult diagnosed with irritable bowel syndrome and complaining of cramping and loose stools. 2. A young adult complaining of not having a bowel movement in 2 days. 3. A child diagnosed with gastroenteritis with five diarrheal stools in the last 3 days. 4. A newborn experiencing projectile vomiting and irritability.

Primer: priority patient Clues: GI This newborn experiencing vomiting and irritability, something must be going on. This is scary. As you know, they do tend to prioritize babies, and mostly because we don't really know what is going on, they can't exactly tell us. So that irritability is not a good sign and we should take

The nurse cares for patients in the pediatric clinic. Which of the following patients should the nurse see FIRST? 1. A 9-month-old infant with failure to gain weight and a lead level of 70 g/dL. 2. A 4-year-old child scheduled for surgery who fears body mutilation. 3. A 6-year-old who has repeated, involuntary urination at night. 4. A 7-year-old with a persistent fear of attending school.

Priority patient primers: pediatric That lead level is very high! It is extremely concerning. The other patients are not so much a priority. We just wouldn't be as worried about them. Lead poisoning is extremely dangerous.

After receiving report from the night shift, the nurse plans assignments for the day. Which of the following patients should the nurse see FIRST? 1. A patient who took 10 methylphenidate (Ritalin) and has a blood pressure of 160/100. 2. A patient who requires a metered-dose inhaler. 3. A patient with a short arm cast on the left arm. 4. A patient diagnosed with hypothyroidism requiring TSH level.

Priority patient (command) Primers: Night shift, assignments, nurse priority (nothing else really we can pull out of it) The priority patient here is A. That's an extremely high BP and way too much ritalin. This is a central nervous system stimulant, and probably has a similar impact to the body as cocaine. This is very dangerous! We don't want them to stroke out or have an MI. That diastolic BP is very high. We don't like to see things 100 or over, better yet, in the 90s which can be dangerous as well. 2 is pretty routine. 3 is routine as well, and they don't really have anything ordered. 4 is routine and lab-involved. We don't have to see them even though the lab has been ordered. TSH really tests a chronic state rather than anything acute.

The community health nurse plans visits for the day. Which of the following clients should the nurse see FIRST? 1. A 5-year-old male who experiences hyperactivity and impulsivity for 2 weeks. 2. A 13-year-old female who has been truant from school for 3 days. 3. A 13-year-old female who has vomited every day for the last 3 months because she wants to lose weight for the summer. 4. A 25-year-old male who drinks alcohol every day and is unable to control the amount of alcohol he ingests.

Priority patient is command. Primer is community health nurse. The correct answer here is the vomiting patient. She is at high risk for electrolyte disturbance. This can cause cardiac arrest, very scary. She is also at risk for dehydration. These medical issues or risks are always going to take priority with psych patients. I'm pretty sure anorexics and bulimics have the highest mortality rate. Remember that bulimia includes the binging and purging, while anorexia can include vomiting, but mostly addresses the dieting and use of laxatives. Bulimics are more likely to be normal body weight because of this.

31 Kaplan questions available on Quizlet: Please see quizlet or kaplan for more :) The nurse cares for clients in the outpatient clinic. The nurse returns to the desk to find four phone messages. Which of the following messages should the nurse respond to FIRST? 1. The mother of a 15-year-old reports her son is threatening to jump off a bridge and has access to a gun. 2. A 20-year-old female reports she has lost 2 lb this week and eats only two meals a day. 3. A 45-year-old male with a history of depression who is out of Prozac. 4. A 75-year-old male complains of insomnia and irritability after the death of his wife.

Since we are beginning the priority questions, priority patient (phone message here) will always be the command! Haha. So primer here: outpatient clinic. The correct answer is 1. This patient is suicidal and they have a plan. Suicidal patients with a plan are typically the priority in a group of psych patients.

A client with type 2 diabetes has a plantar foot ulcer. When developing a teaching plan regarding foot care, what information should the nurse obtain first from the client? A.How the client examines her feet B.Which hypoglycemic medication she takes C.Who lives in the home with her D.How long she has had diabetes mellitus

The best answer here is A, demonstration is always preferred with NCLEX. We want to see what she does before we teach her anything knew. It's kind of like analyzing testing strengths before content and testing strategies are given! Assessment prior to implementation is a good pattern to know, but nothing to take too seriously.

After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about a. cerebral aneurysm clipping. b. heparin intravenous infusion. c. oral low-dose aspirin therapy. d. tissue plasminogen activator (tPA).

The correct answer here is C. It sounds like the patient had a mini-stroke or TIA. We will put them on an anti-platelet. They have no residual deficits which is consistent with TIA.

The nurse in the emergency department is caring for a client with type 1 diabetes mellitus in diabetic ketoacidosis (DKA). Which action should the nurse take first? A.Administer regular insulin IV. B.Start an IV infusion of normal saline. C.Check serum electrolyte levels. D.Give a potassium supplement.

The first thing we do here is start that IV infusion, it is so important to hydrate first with DKA/HHS! We may do everything else too, but first we hydrate!

A middle-aged client tells the clinic nurse, "I'm again starting to feel overwhelmed and anxious with all my responsibilities. I don't know what to do." What is the best response for the nurse to make? A. "Describe in more detail your feelings about being overwhelmed." B. "Why don't you give up some of your commitments?" C. "What has worked for you in the past?" D. "I know, but it is important to take time for yourself."

This one is a bit difficult, but it is a good one. Here we are primed with someone who is anxious and tells us her rationale. So next we must come up with a plan, C would be the best answer in this scenario, since it seems that the patient is grounded and understands her emotions and the source of her situational anxiety.