Prioritize Hypotheses

The nurse is preparing to give a full bed bath to a client. Which question is most important for the nurse to ask the client before beginning the bed bath?

"Do you have any allergies?"

The nurse is collecting data on a child with a diagnosis of rheumatic fever. Which question should the nurse initially ask the parent of the child?

"Has the child complained of a sore throat within the past few months?"

The nurse is collecting data on a client in crisis. Which question would the nurse ask to determine the client's perception of the precipitating event that led to the crisis?

"What leads you to seek help now?"

A client is recovering following a cardiac arrest. Which findings would the nurse act on first?

The client's respiratory rate is 28 breaths per minute.

The nurse is collecting data on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain. During the admission, the client reports chest pain. The nurse immediately asks the client which question?

"Where is the pain located?"

An older client with a history of hyperparathyroidism and severe osteoporosis is hospitalized. The nurse caring for the client plans to address which problem first?

The possibility of injury

After receiving a client assignment for the day, which client would the nurse see first?

A client admitted for a gastrointestinal (GI) bleed with stable hemoglobin and hematocrit

The nurse on a medical unit is instructing the unlicensed assistive personnel (UAP) regarding toileting needs of the assigned clients. The nurse would instruct the UAP to prepare to assist which client first?

A client who was admitted 2 days ago with a pelvic fracture

The nurse employed in an emergency department is assigned to assist in triaging clients coming to the emergency department for treatment on the evening shift. The nurse would suggest assigning priority to which client?

A client with chest pain who states that they just ate pizza that was made with a very spicy sauce

An explosion occurred at an industrial plant, involving injury to 50 victims. The nurse at the scene determines that which victim would be transported to the hospital first?

A victim with singed nasal and facial hair and difficulty breathing

The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and numerous casualties have occurred. The victims will be brought to the emergency department. Which would be the initial nursing action?

Activate the agency's emergency response plan.

The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. Which assessment is the nursing priority?

Activation status and settings of the device

A client has just been admitted with a diagnosis of myxedema coma. If all of the following interventions were prescribed, the nurse would place highest priority on completing which action first?

Administering oxygen

The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority?

Airway patency

The nurse is caring for a client diagnosed with abruptio placentae. During labor, the priority nursing action is to monitor which criteria?

All vital signs, especially heart rate and blood pressure

A lethargic yet easily aroused 6-year-old child is brought to the emergency department with a diagnosis of an overdose with diazepam. During the initial data collection, the nurse determines that the child's blood pressure and respirations are below normal for their age. The Glasgow Coma Scale is performed and reveals a score of 10. Based on this information the nurse determines that which problem would have the highest priority?

Altered respiratory status

The nurse is working on a medical-surgical unit. Which client would the nurse see first, based on their risk for experiencing delirium?

An client being treated for a urinary tract infection (UTI)

A female client complains of an "odd, left-sided, twinge-like pain" along the anterior axillary line and states they have had this feeling for the past 3 days. Which is the initial action?

Determine whether the pain is cardiac in origin.

A 2-year-old child is admitted to the hospital with a diagnosis of nephrotic syndrome. In planning care for this child, which nursing intervention would be of highest priority?

Dipstick the urine for protein every 4 hours.

A 5-year-old child has been transferred to the pediatric unit after a cardiac catheterization. Which intervention has the highest priority in the care of this child immediately following the procedure?

Assess for any bleeding on the dressing.

The nurse is performing a postpartum fundal assessment on a client 6 hours after delivery. The nurse finds the fundus above the umbilicus and displaced to the right. Which intervention would the nurse do first?

Assist the client to the bathroom to void and then reassess the fundus.

A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client?

Audible stridor

A client is scheduled for discharge and will be taking phenobarbital for an extended period. The nurse would place the highest priority on informing the client regarding which point that directly relates to client safety?

Avoid drinking alcohol while taking this medication.

The nurse is caring for a client with a wound culture positive for methicillin-resistant Staphylococcus aureus (MRSA). Which client data would be the priority to immediately report to the registered nurse (RN)?

Blood cultures are positive for gram-positive cocci in clusters.

A client is having frequent premature ventricular contractions. The nurse would place priority on assessment of which information?

Blood pressure and oxygen saturation

The nurse is caring for a client who underwent a total knee replacement. Postoperatively, the nurse monitors for which highest priority assessment?

Calf pain

The nurse is assigned to care for a client being admitted to the mental health unit following a suicide attempt. The client attempted the suicide by lacerating both wrists. Which is the initial nursing action upon admission of the client?

Check the wound sites.

When a client progresses from preeclampsia to eclampsia, which is the nurse's first action?

Clear and maintain an open airway.

A client has sustained full-thickness circumferential burns of the trunk. Which would be the priority concern of the nurse?

Client's ability to adequately ventilate

The nurse is volunteering with an outreach program to provide basic health care for unhoused people. Which finding, if noted, must be addressed first? Laboratory Results Tests and Results Blood glucose 206 mg/dL Reference Range 70-99 mg/dL - Fasting

Complaints of pain associated with numbness and tingling in both feet

The RN in a neonatal intensive care unit (NICU) receives a telephone call to prepare for the admission of a newborn with Apgar scores of 1 and 4, born at 41 weeks' gestation. The LPN, who is assisting with admission plans, determines that what is the highest priority for this newborn?

Connect the resuscitation bag to the oxygen outlet.

The nurse is caring for a client experiencing acute lower gastrointestinal bleeding. In developing the plan of care, which priority problem would the nurse assign to this client?

Deficient fluid volume related to acute blood loss

The nurse is assigned to care for a pregnant client with a diagnosis of sickle cell anemia. The nurse plans care, knowing that which problem would receive highest priority?

Dehydration

The nurse is monitoring a client in labor whose membranes rupture spontaneously. Which is the initial nursing action?

Determine the fetal heart rate.

The nurse in the emergency department has just assumed care from emergency medical services for a client who has a large penetrating stab wound. A chest x-ray has determined the diagnosis of hemothorax. Which initial action would the nurse take?

Ensure a patent airway.

A client has just had skeletal traction applied following insertion of pins. The nurse would place highest priority on performing which action?

Ensuring that the weights on the traction setup are hanging free

A client is at risk for complications of heart failure. Which is the nurse's priority for early detection of the most likely cause of complications with this client?

Evaluating total body fluid

A client is scheduled to have electroconvulsive therapy (ECT). Which problem would the nurse include in the plan as a priority?

Fear

A client with Crohn's disease has just had surgery to create an ileostomy. The nurse assesses the client in the postoperative period for which most frequent complication of this type of surgery?

Fluid and electrolyte imbalance

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa?

Hemorrhage

A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain?

Impaired tissue perfusion

The LPN is collaborating with the RN in preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places priority on which client problem?

Inadequate fluid volume

The nurse is caring for a client diagnosed with anal fistula and is monitoring for complications of this problem. Which priority complication would the nurse monitor for while managing care for this client?

Infection

The nurse is preparing to care for a child who received an allogeneic bone marrow transplant (BMT). The nurse understands that which is the priority concern?

Infection

A client arrives in the emergency department with an eye injury resulting from metal fragments that hit the eye while the client was drilling into metal. The nurse checks the eye and notes small pieces of metal floating on the eyeball. Which action would the nurse take first?

Irrigate the eye with sterile saline.

The nurse is discussing the care needs with an unlicensed assistive personnel (UAP) who is preparing to bathe a client who has mild dementia and requires minimal help with hygiene. The nurse identifies which client need as the highest priority when giving the instructions?

Maintain client safety.

The nurse is caring for a client within the first 24 hours following a total gastrectomy for gastric cancer. During this time frame, the nurse would focus on which priority intervention?

Maintaining a patent nasogastric (NG) tube

The nurse reinforces instructions to the client prescribed to take cyclosporine oral solution. Which instruction would the nurse primarily include?

Mix the concentration with chocolate milk.

The nurse is caring for a client in preterm labor when their membranes rupture. Which is the initial nursing action?

Monitor the fetal heart rate.

The nurse is preparing a plan of care to monitor for complications in a client who will be returning from the operating room following transsphenoidal resection of a pituitary adenoma. Which nursing intervention does the nurse document in the plan as a priority for this client?

Monitor urine output.

The nurse has assisted in developing a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan and selects which nursing intervention as the highest priority?

Monitoring fetal status

The nurse reviews the nursing care plan of an older client with diabetic neuropathy of the lower extremities as a result of type 2 diabetes mellitus. The nurse plans care, knowing that which problem has the highest priority for this client?

The possibility of injury as a result of decreased sensation in the legs and feet

The nurse is setting up the bedside unit for a client being admitted to the nursing unit from the emergency department with a diagnosis of coronary artery disease (CAD). The nurse would place highest priority on making sure that which is available at the bedside?

Oxygen tubing and flowmeter

In planning care for a child with contact dermatitis, which concern is the highest priority for the child?

Pain

A client newly admitted to the labor unit reports to the nurse feeling a large gush of fluid before arriving at the hospital. The nurse checks the client and notes that the umbilical cord is protruding from the vagina. Which action would the nurse take first?

Place the client in Trendelenburg's position.

The nurse is assisting in caring for a client diagnosed with multiple organ dysfunction syndrome (MODS). Which client problem would the nurse assign as the highest priority for this client?

Risk for ineffective coping

The nurse is assisting in preparing a teaching plan for a client with Ménière's disease. The nurse places highest priority on teaching the client information related to which information?

Safety

A client experiencing delusions of being poisoned is admitted to the hospital after not eating or drinking for several days. On data collection, the nurse notes no evidence of dehydration and malnutrition at this time. The nurse would immediately plan to address which client need?

Safety and security

A client with diabetes mellitus has had a right below-knee amputation. Given the client's history of diabetes mellitus, which complication is the client at most risk for after surgery?

Separation of the wound edges

The nurse is caring for a client with type 1 diabetes mellitus who is hyperglycemic. Which problem would the nurse consider first when planning care for this client?

Signs of dehydration

A client has just been treated with cardioversion. The nurse would check which measure first?

Status of airway

The nurse is caring for a client who has undergone spinal fusion with insertion of hardware. The nurse would be most concerned with which assessment finding?

Temperature of 101.6° F (38.7° C) orally

A client arrives in the emergency department following an eye injury from a chemical solution. Which is the initial nursing action?

Test the eye pH with litmus paper.

The nurse is preparing a client for an emergency cesarean delivery. Which information regarding the client has priority?

When was the last time the client ate or drank?