Priority questions
Tension pneumothorax
-trachael deviation -absent breath sounds on affected side -respiratory distress -assymetrical chest movement, chest pain
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 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.
1. pt took 10 methylphenidate and has BP 160/100 -assess for seizures, coma, tachycardia, tachypnea -maintain airway, give characol -inhaler is potentional problem BUT NOT CURRENT
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.
4. 9 yr old who used a weapon toward his mother and caused physical harm to others -priority safety
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."
2. my face gets red when i eat shrimp -possible allergy
calcium
8.5-10.5
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.
1.hf who received 800 ml in two hours -fluid overload -circulatory
methylphenidate
ritalin -stimulant
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.
1. 2 month infant who is very sleep and refused to nurse for 8 hours -think about dehydration and acidosis -infant more acute than children
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.
1. client taking clozapine experiencing flu-like sx, fever sore throat, and lethargy -antipsychotic -may have agranulocytosis
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.
1. client w/ anesthesia for pian w/ HR of 76 and RR of 8 -monitor for CNS depression
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.
1. pt receiving haloperidol experiencing oculogyric crisis -eyes locked upward-painful -will need anticholinergic (benzotropine, atropine)
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.
2.client post knee replacement complaining of right calf pain w/ movement -possible DVT think immobility r/t knee replacement
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.
2.unconscious client w/ crushing chest wound -compromised breathing
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.
2.unconscious client w/ left sided tracheal shift from midline -tension pneumothorax (right lung)
which client to see first? 1. 1 day post op after an appendectomy 2.detached retina surgically repaired 4 hours ago 3.client diagnosed w/ esophagel varices receiving nadolol 4. 2 days post op after laminectomy w/ spinal fusiob
3. client diagnosed w/ esophagel varices receiving nadolol -nadolol is a BB- decreases HR and BP Need to assess for bleeding and shock
see first 1. postop client received morphine 15 mg 2 hours ealier and reports a 7/10 pain 2.client who had an appendectomy 1 day ago and WBC is 17.8 3. newly admitted from ED and reported SOB 4.client eating breakfast after reciving 15 units lispro 30 minutes ago
3. client w/ SOB -airway and breathing -elevated WBC to be expected after appendectomy 2nd client to assess is postop pt w/ severe pain
community nurse obtains lab values who should she see first 1.urine culture and sensitvity indicates E. coli 2.urinalysis reveals leukocytes 3.antistreptolysin O (ASO) titer is elevated 4.cystourethrogram reveals vesicouretel reflex
3. indicates glomerulonephritis
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.
3. only drinks water and eats veggies -electrolyte imbalance unstable -other two answers are basically the same
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.
3.client w/ hemoglobin of 6.9 -anemia or bleeding--need respiratory assessment, 02 needed hemoglobin males 14-18, women 12-16
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.
3.restless client w/ pale, cool, clammy skin and rigid abdomen w/ absent bowel sound Circulatory -possible hemorrhage, shock
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.
4. newborn experiencing projectile vomitting and irritability -pyloric stenosis ===risk for dehydration, hypovolemia
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).
4. pt receiving 5-fluorouracil 5-fluorouracil= chemotherapy drug SE neutropenia more suscpetible to infection
nurse receives 4 phone calls which message should she return first 1. client diagnosed w/ headache for 3 days unrelieved by narotics 2.client reports ankle pain and swelling after twisting it 3.the parent of a preschooler call and reports "my child has a rash and sore throat" 4.the toddler parents reports "my child swallowed a dime"
4. toddler swallowed a dime -need to evaluate if respiratory difficulty present -is it occluding the airway
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.
4.infant w/ vomitting and diarrhea -fluid imbalance
chlorpropamide
diabetes med SE diarrhea, GI upset, and hypoglycemia
ASO titer
high levels could indicate glomerulonephritis -bacterial endocarditis, rheumatic fever, strep
most chemotherapy drugs result in what SE
neutropenia SUSCEPTIBLE TO INFECTION -need to report fever, sore throat
Tension pneumothorx
thoracentesis if hemothorax -monitor respiratory status -admin oxygen -high fowelers -chest tube -encourage deep breathing, coughing
tonometer
used to diagnose glaucoma- IOP reading should be 10-21
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.
1. 9 month with failure to gain wt and lead level of 70 -need immediate chelation therapy -at 4 level need yearly screening
nurse on oncology floor who to assess first 1. client w/ breast cancer with extensive bone metastasis is irritable and confused 2.client reporting vomitting 6 hours after chemo 3. client w/ lung cancer reporting fatigue and mild SOB w/ ambultation 4.client w WBC count of 1,600 reporting burning on urination
1. client w/ breast cancer w/ extensive bone metastis who is irritable and confused -think bone destruciton =more calcium hypercalcemia (Groans, Moans, Bones, Stones, Overtones) groans-constipation r/t dehydration moans-joint pain, NV Bones-deep bone pain, factures stones-kidney stones overtones-confusion, irritability, dysrhytmias
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.
1.mother of 15 yr old reports threatening to jump off a bridge -priority r/t safety
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.
1.young adult who says my pain will soon be over -PICK SUICIDAL OVER COMMAND HALLUCINATIONS hearing voices should be next
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.
2. 35 yr old hystersalpingogram experiencing tachycardia and generlized rash -xray of uterus and fallopian tubes involving contrast ALLERGIC REACTION
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.
2. burns on the face -airway/breahting issue complications-shock, hypovolemia
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.
4. client w/ laryngectomy who is complaining of greenish-yellowish discharge -indicates infection
see first 1. client w/ IV going at 125ml/hr and has an ordered antibiotic 2.requests pain med and pain is 4/10 3.client reports bubbles in belly after abdominal surgery 4. client w/ temp elevation 2 hours earlier and received an antipyretic 1 hr ago
4. client w/ temp elevation 2 hours earlier and received an antipyretic 1 hr ago -need to reassess after giving med -bubbles in stomach is expected after abdominal surgery-return of peristalsis
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.
3. pt w/ BP of 90/60 and apical pulse of 120 -pt in shock -dont pick pressure in chest because POTENTIAL problem
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.
3. pt w/ hemophilia complaining of joint pain JOINT PAIN INDICATES BLEEDING -need factor VIII and RICE
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.
3.vomitted every day for last 3 months -electrolye imbalance -possible cardiac issues
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.
4. elderly client w/ hx of cardiomyopathy and aspirated -would look at heart failure and vomitting next for possible dig poisoning
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).
4. fasting blood glucose of 517 -should be 60-110 needs regular insulin
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.
4. hx of CAD who complains of midepigastric pain radiating to the neck -possible MI -pain that starts at abdomen or chest that radiates to neck or shoulder needs to be evaluated
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.
4. verbally abusive and increasingly more agitated
