PRIORITIZATION NCLEX style
During a class discussion, the 50-year-old professor suddenly feels left-sided chest pain, dizziness, and diaphoresis. What is the priority action when he arrives in the ED triage area? a) Supply oxygen via nasal cannula b) Place intravenous (IV) access c) Notify the ED physician d) Set the client on continuous electrocardiographic monitoring
A. Supply oxygen via nasal cannula ·Option A: Prioritization. Increasing myocardial oxygenation is the priority goal. ·Options B, C, and D: The other actions are also appropriate and should be done immediately.
Nurse Skye is on the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first? a) A client scheduled for cardiac ultrasound this morning b) A client with syncope being discharged today c) A client with chronic bronchitis on nasal oxygen d) A client with diabetic foot ulcer that needs a dressing change
A. client with chronic bronchitis on nasal oxygen. A client with airway problems should be attended first
A nurse is formulating a plan of care for a client receiving enteral feedings. The nurse identifies which nursing diagnosis as the highest priority for this client? a) diarrhea b) risk for aspiration c) risk for deficient fluid volume d) imbalanced nutrition, less than body requirements
B- Risk for Aspiration Any condition in which gastrointestinal motility is slowed or esophageal reflux is possible places a client at risk for aspiration. Although options 1, 3, and 4 may be a concern, these are not the priority.
Nurse Channing is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first? a) A client with diabetes being discharged today. b) A 35-year-old male with tracheostomy and copious secretions c) A teenager scheduled for physical therapy this morning d) A 78-year-old female client with pressure ulcer that needs dressing change.
B. A 35-year-old male with tracheostomy and copious secretions. The patient with problem of the airway should be given highest priority. Remember Airway, Breathing, and Circulation (ABC) is a priority
Prior to oral defense, a 21-year-old nursing student goes straight to the clinic due to tingling sensations, palpitations, and chest tightness. Deep, rapid breathing and carpal spasms are also observed. What is the nursing priority action for this situation? a) Give supplemental oxygen b) Allow the student to breathe into a paper bag c) Report to the physician immediately d) Get an order for an anxiolytic medication
B. Allow the student to breathe into a paper bag ·Option B: Prioritization. The student is hyperventilating secondary to anxiety, and breathing into paper bag will provide rebreathing of carbon dioxide. Encouraging slow breathing will also help. ·Options A and D: Other options such as oxygen and drug administration may be needed if other causes are known.
What is regarded as one of the priority actions that must be accomplished when a primary assessment of a trauma client is conveyed? a) Taking a full set of vital sign measurements b) Completing a brief neurologic assessment c) Monitoring pulse oximetry reading d) Palpating and auscultating the abdomen
B. Completing a brief neurological assessment ·Option B: Prioritization. A brief neurologic assessment to ascertain level of consciousness and pupil reaction is part of the primary survey. Options A, C, and D: Vital sign measurements, monitoring pulse oximetry readings, and assessment of abdomen are basically part of the secondary survey
A high school student comes in the triage area alert and ambulatory, and his uniform is soaked with blood. He and his classmates are sounding, "We were running around outside the school and he got hit in the abdomen with a stick!" Which statement should be a priority? ·a) "The stick was absolutely filthy and muddy." b) "He has a family history of diabetes, so he requires attention right now." c) "He pulled the stick out because it was too painful for him." d) "There was plenty of blood so we used three gauzes."
C. "He pulled the stick out because it was too painful for him." · Option C: Prioritization. An impaled object may be giving a tamponade effect, and removal can result in abrupt hemodynamic decompensation. · Options A and B: Information such as the dirt on the stick or history of diabetes, is significant in the overall treatment plan but can be addressed next. · Option D: Additional history including a more precise extent of blood loss, depth of penetration, and medical history should be collected.
A client with multiple injuries is rushed to the ED after a head-on car collision. Which assessment finding takes priority? a) Irregular apical pulse b) Ecchymosis in the flank area c) A deviated trachea d) Unequal pupils
C. A deviated trachea · Option C: Prioritization. A deviated trachea is a symptom of tension pneumothorax, which will result in respiratory arrest if not managed. · Options A, B, and D: The remaining options are of lower priority but still need to be addressed.
A client presents to the emergency room with dyspnea, chest pain, and syncope. The nurse assesses the client and notes that the following assessment cues: pale, diaphoretic, blood pressure of 90/60, respirations of 33. The client is also anxious and fearing death. Which action should the nurse take first? a) Administer pain medications b) Administer IV fluids c) Administer dopamine d) Administer oxygen via nasal cannula.
D. Administer oxygen via nasal cannula. Promotion of adequate oxygenation is the most vital to life and therefore should be given highest priority by the nurse.
Nurse Vivian is reviewing immunizations with the caregiver of a 72-year-old client with a history of cerebrovascular disease. The caregiver learns that which immunization is a priority for the client? a) Hepatitis A vaccine b) Lyme's disease vaccine c) Hepatitis B vaccine d) Pneumococcal vaccine
D. Pneumococcal vaccine Pneumococcal vaccine is a priority immunization amongst elderly especially those with chronic illnesses.
A client arrives at the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. The priority nursing action is to: a) obtain vital signs b) ask the client about the precipitating events c) complete an abdominal physical assessment d) insert a nasogastric (NG) tube and Hematest the emesis
A- The priority action is to obtain vital signs to determine whether the client is in shock from blood loss and to obtain a baseline by which to monitor the progress of treatment. The client may not be able to provide subjective data until the immediate physical needs are met. Insertion of an NG tube may be prescribed but is not the priority action. A complete abdominal physical assessment needs to be performed but is not the priority.
A nurse enters a room and finds a patient lying face down on the floor and bleeding from a gash in the head. Which action should the nurse perform first? a) Determine the level of consciousness. b) Push the call button for help c) Turn the client face up to assess d) Go out in the hall to get the nursing assistant to stay with the client while the nurse calls the physician.
A. Determine the level of consciousness. Assessing the level of consciousness should be the first action when dealing with clients that might have fell over.
The nurse plans care for a client in the post anesthesia care unit. The nurse should assess first the client's: a) respiratory status b) level of consciousness c) level of pain d) reflexes and movement of extremities
A. respiratory status. Assessing respiratory status is the first priority. Remember ABC
After exposure to hot weather and sun, clients with signs and symptoms of heat-related ailment rush to the Emergency Department (ED). Sort clients into those who need critical attention to those with less serious condition. 1. An abandoned person who is a teacher; has altered mental state, weak muscle movement, hot, dry, pale skin; and whose duration of heat exposure is unknown 2. An elderly traffic enforcer who complains of dizziness and syncope after standing under the heat of the sun for several hours to perform his job 3. A comparatively healthy housewife who states that the air conditioner has been down for 5 days and who exhibits hypotension, tachypnea, profuse diaphoresis, and fatigue 4. A sportsman who complains of severe leg cramps and nausea, and displays paleness, tachycardia, weakness, and diaphoresis. A. 4, 3, 2, 1 B. 1, 2, 4, 3 C. 1, 4, 2, 3 D. 4, 1, 3, 2
Answer: B. 1, 2, 4, 3 Option B: Prioritization. (1) The abandoned person has symptoms of heat stroke, a medical emergency, which heightens the risk of brain damage. (2) The elderly traffic enforcer is at risk for heat syncope and should be instructed to relax in a cool environment and withdraw from approaching related circumstances. (4) The sportsman is experiencing heat cramps, which can be treated with rest and fluids. (3) The homemaker is having heat exhaustion and management includes IV or oral fluids and settle in a cool area.
Several clients arrive in the ED with the same complaint of abdominal pain. Designate them for care in order of the severity of their condition. · 1. A 12-year-old girl with a low-grade fever, anorexia, nausea, and right lower quadrant tenderness for the past 2 days2. A 25-year-old woman complaining of dizziness and severe left lower quadrant pain who states she is probably pregnant3. A 38-year-old man complaining of severe occasional cramps with three episodes of watery diarrhea hours after meal4. A 42-year-old woman with moderate right upper quadrant pain who has vomited little amounts of yellow bile and whose symptoms have worsened over the past week5. A 53-year-old man who experiences discomforting mid-epigastric pain that is worse between meals and during the night6. A 68-year-old man with a pulsating abdominal mass and sudden onset of "tearing" pain in the abdomen and flank within the past hour a) 2, 6, 4, 1, 5, 3 b) 6, 2, 4, 1, 3, 5 c) 2, 6, 1, 4, 5, 3 d) 6, 2, 1, 4, 3, 5
Option D: Prioritization. (6) The 68-year-old man with pulsating mass is experiencing abdominal aneurysm that may rupture, and he may abruptly deteriorate. (2) The 25-year-old woman with lower left quadrant pain is at risk for ectopic pregnancy, which is a life-threatening condition. (1) The 12-year-old girl needs evaluation to rule out appendicitis. (4) The 42-year-old woman with vomiting needs evaluation for gallbladder problem, which seems to be worsening. (3) The 38-year-old man has food poisoning, which is usually self-limiting. (5) The 53-year-old man with mid-epigastric pain may have ulcer, but followup diagnostic testing and educating lifestyle modification can be scheduled with the primary health care provider.
