Prioritization Practice Test
The nurse is giving a bed bath to an assigned client. An assistive personnel (AP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. The nurse would do which? Finish the bed bath and then administer the pain medication to the other client. Ask the AP to find out when the last pain medication was given to the client. Ask the AP to tell the client in pain that medication will be administered as soon as the bed bath is complete. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.
The nurse is responsible for the care provided to the assigned clients. The appropriate action is to provide safety to the client that is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not a responsibility of the AP.
A nurse working in a long-term care facility is assigned to care for four clients on the hospice unit. In planning client rounds, which client would the nurse collect data on first? A client who is bed bound and needs to be turned and repositioned every 2 hours A client who was complaining of severe back pain on the previous shift A client who needs assistance dressing before transport to the dining room for breakfast A client who is being moved to a different room and will need assistance packing
The nurse is working on a hospice unit, which means that the nurse is caring for terminally ill clients. The client who is terminally ill needs to be comforted, and the nurse must maintain a satisfactory lifestyle through the phase of dying. Although all of these clients need the nurse's attention, the client who needs to be seen first would be the client who was in severe pain on the previous shift. The nurse should evaluate this client to see if further pain medication is needed. Alleviating suffering is a priority nursing responsibility. Because pain is often an element of suffering, promoting optimal pain relief is a primary goal.
A licensed practical nurse (LPN) has received the assignment for the day shift. After making rounds and checking all of the assigned clients, which client will the LPN plan to care for first? A client scheduled for physical therapy at 1:00 pm A client with a fever who is diaphoretic and restless A client who is ambulatory A postoperative client who has just received pain medication
The LPN would plan to care for the client who has a fever and is diaphoretic and restless first because this client's needs are the priority. It is best to wait for pain medication to take effect before providing care to the postoperative client. The client who is ambulatory and the client scheduled for physical therapy later in the day do not have priority needs related to care.
The nurse is assisting in caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. When collecting data on the client, the nurse checks which first? Respiratory status Blood pressure Temperature Urine output
Morphine sulfate depresses respirations. The nurse monitors the client's respiratory status closely. Although the incorrect options may be a component of the data collection process, option 4 identifies the priority nursing action.
The nurse is assigned to care for four clients. When planning client rounds, which client would the nurse collect data from first? A client requiring daily dressing changes A client receiving oxygen who is having difficulty breathing A postoperative client preparing for discharge A client scheduled for a chest x-ray
The airway is always a priority, and the nurse would attend to the client who has been experiencing an airway problem first. The clients described in options 1, 2, and 3 would have intermediate priority.
The nurse just finished receiving the client assignment for the day. Which client would the nurse see first? The client requesting to speak to the charge nurse The client slumped down in bed with an oxygen saturation of 94% The client requesting medications before breakfast The client who is agitated following surgery
Agitation is a hyperactive state ranging from restlessness to aggression. Common causes of agitation can be pain, anxiety, hypoxia, sleep deprivation, sepsis, medication reaction, and many others. The client who is agitated following surgery should have immediate follow-up to assess what the agitation could be caused from to ensure it is not one of the more serious causes.
After receiving a client assignment for the day, which client would the nurse see first? A client awaiting discharge instructions and intravenous line removal A client with pneumonia who complains about using the incentive spirometer A client admitted for a gastrointestinal (GI) bleed with stable hemoglobin and hematocrit A client who needs help with bathing
GI bleeding can become a medical emergency if not treated and managed promptly. Hemodynamic stability, correction of hypercoagulability, fluid resuscitation, and determining and treating the cause are imperative for this potential life-threatening condition. The nurse would need to assess this client and then consult with the registered nurse. In the context of the other client situations, the client with the GI bleed is the priority.
The nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department. The nurse should assign priority to which client? A client with a minor laceration on the index finger sustained while cutting an eggplant A client who twisted their ankle when they fell in-line skating A client with chest pain who states that they just ate pizza that was made with a very spicy sauce A client complaining of muscle ache, headache, and malaise
In an emergency department, triage involves classifying clients according to their need for care, and it includes establishing priorities of care, the type of illness, the severity of the problem, and the resources available to govern the process. Clients with trauma, chest pain, severe respiratory distress, cardiac arrest, limb amputation, or acute neurological deficits, and those who sustained a chemical splash to the eyes are classified as emergent, and these clients are the number 1 priority. Clients with conditions such as simple fractures, asthma without respiratory distress, fever, hypertension, abdominal pain, or renal stones have urgent needs, and these clients are classified as the number 2 priority. Clients with conditions such as minor lacerations, sprains, or cold symptoms are classified as nonurgent, and they are the number 3 priority.
The nurse is assigned to care for four clients. When planning client rounds, which client would the nurse check first? A client admitted during the previous shift with a diagnosis of gastroenteritis A client in skeletal traction A postoperative client preparing for discharge A client who is dependent on a ventilator
The airway is always a priority, and the nurse first checks the client on a ventilator. The clients described in options 1, 3, and 4 have needs that would be identified as intermediate priorities.
The nurse on the day shift receives client assignments for the day. Which assigned client would the nurse check first? A client with a diagnosis of ulcerative colitis who is scheduled to be discharged today A client who was admitted during the night because of a severe exacerbation of asthma A client who had a pulmonary wedge resection 2 days ago and is attached to a closed chest tube drainage system A client scheduled for a kidney, ureter, and bladder (KUB) x-ray to determine the location of a kidney stone
The nurse would first check the client who was admitted during the night because of a severe exacerbation of asthma. This client's problem directly relates to airway, and the nurse would need to determine that the interventions administered on admission and during the night were effective. The nurse would next check the client who had a pulmonary wedge resection 2 days ago and is attached to a closed chest tube drainage system. This client's problem also relates to airway; however, there is no indication that this client is experiencing any severe problems. The nurse would next assess the client scheduled for a KUB. The nurse would want to ensure that this client understands the reason for the x-ray. Additionally, the nurse needs to determine whether the client is experiencing any pain as a result of the kidney stone. The nurse would next assess the client preparing for discharge to determine the need for reinforcement of home care instructions.
