Unit 6- Prioritization and Delegation

The nurse is making assignments for the next shift. Which client can be assigned to a licensed practical nurse/licensed vocational nurse (LPN/LVN)? Select all that apply.

A client who needs assistance with colostomy irrigation A client who is receiving glargine subcutaneously An LPN/LVN can perform colostomy irrigation and administer subcutaneous injections. A client who just had CABG is unstable and needs to be monitored by an RN. The initial admission assessment should also be performed by an RN. C3 to C5 injury may cause respiratory compromise. Possible paralysis of diaphragm due to phrenic nerve involvement may occur. This client is unstable and should be assigned to an RN.

The nurse is preparing to feed an infant diagnosed with pyloric stenosis prior to surgical repair. What is the nurse's most important intervention?

Burp the infant frequently. These infants usually swallow a lot of air from sucking on their hands and fingers because of their intense hunger. Burping frequently will reduce gastric distention, and increase the likelihood that the infant will retain the feeding. Feedings should be given slowly with the infant lying in a semi-upright position. Parental participation should be encouraged to the extent possible, but this will not increase the likelihood that the feeding will be retained. Record the type, amount, and character of the vomit, as well as its relation to the feeding. The amount of feeding volume lost is usually refed to the infant.

While assessing a 2-hour-old neonate, a nurse observes the neonate to have acrocyanosis. Which nursing action should be performed first?

Do nothing different because acrocyanosis is normal in the early neonatal period. Acrocyanosis, or bluish discoloration of the hands and feet in the early neonatal period is a normal finding and should not last more than 24 hours after birth. The other choices are inappropriate for this condition.

An alert and oriented client comes to the emergency department after hitting his head in a motor vehicle accident. What should the nurse do first?

Immobilize the client's head and neck All clients with a head injury are treated as if a cervical spine injury is present until an X-ray confirms otherwise. ROM would be contraindicated at this time. There is no indication that the client needs an immediate chest X-ray, although one may be done after stabilizing the spine. The airway doesn't need to be opened since the client appears alert and not in respiratory distress. The head-tilt, chin-lift maneuver wouldn't be used until cervical spine injury is ruled out.

A client has received an infusion of antibiotics and is now experiencing an anaphylactic reaction. What is the most important intervention by the nurse?

Maintain a patent airway The first priority is to maintain a patent airway. The client will then require an epinephrine injection. If hypotension develops, a saline bolus may be given. The client's vital signs should be monitored, but not as the first action.

A nurse caring for an infant with neonatal bronchopulmonary dysplasia (chronic lung disease) administers furosemide. What is the priority intervention following the administration of this medication?

Monitor electrolyte status. Furosemide is a potent diuretic. If given in excessive amounts it can lead to a profound diuresis of water and electrolyte depletion that could lead to life-threatening arrhythmias. Input and output should be monitored along with vital signs. Furosemide can be ototoxic; therefore, hearing should be evaluated.

A multiparous client who has been in labor for 2 hours states that she feels the urge to move her bowels. What would the nurse do first?

Perform a pelvic examination. A report of rectal pressure usually indicates a low presenting fetal part, and imminent birth. The nurse should perform a pelvic examination to assess the dilation of the cervix and station of the presenting fetal part. Do not let the client use the toilet or a bedpan before she's examined because she could birth on the toilet or in the bedpan. Checking the FHR is important but comes after the nurse evaluates the client's report.

Which nursing intervention is a priority for a pregnant adolescent during her first trimester?

Refer the client to a dietitian for nutritional counseling. Adolescents are at risk for delivering low-birth-weight neonates. Nutritional counseling should be a priority for these clients to ensure proper fetal development. A pregnant adolescent is not likely to deliver a macrosomic neonate. The final head size of the fetus is unknown at this time. Adolescents are not at increased risk for developing gestational diabetes or placenta previa.

A nurse finds a client crying after being told by the health care provider that the client is to start hemodialysis to treat acute renal failure. What is the nurse's most important intervention?

Sit quietly with the client. Sitting with the client shows compassion and concern and may help the nurse establish therapeutic communication. Making a referral doesn't allow the client to explore feelings with the nurse. The nurse can't guarantee the acute renal failure is temporary. Discussing the client's other abilities diverts the emphasis from the client's primary issue.

The nurse is developing a plan of care for a hospitalized client who is at risk for suicide. What is the most important intervention for the nurse to include?

Use a caring approach to maintain close observation of the client Close observation, using a caring and therapeutic approach, is essential in order to decide the level of suicide precautions needed. Merely developing a strong relationship with the client isn't addressing the client's potential for self harm. Although antianxiety medication is sometimes used, the efficacy of antianxiety medications in lowering suicide risk is limited. Encouraging the client to stay away from group activities could cause isolation that would be detrimental to the client's well-being.

A nurse is caring for a client with pheochromocytoma. What is the most important intervention by the nurse?

promoting an environment free from emotional distress The child experiencing hyperfunctioning of the adrenal gland or pheochromocytoma has excessive epinephrine resulting in an accelerated metabolism. Symptoms include hypertension, headaches, hyperglycemia with weight loss, diaphoresis, and hyperventilation. Through provision of a low-stress environment, analgesia as needed, a high-calorie diet, and supportive parents, the child will be able to prepare for surgery to eliminate the tumor causing the hypersecretion of epinephrine.

Which client does the nurse evaluate as having the highest risk of developing a postoperative wound infection?

The client who had a perineal prostatectomy The incision in a perineal prostatectomy is close to the rectum, which normally contains gram-negative organisms that can cause infection if introduced into other areas of the body. Therefore, a perineal incision can become contaminated more easily than those of the other procedures.

The nurse is planning care for an infant with bronchiolitis. What is the nurse's priority intervention for this child?

Assess respiratory status frequently. Infants with bronchiolitis will have impaired gas exchange related to bronchiolar obstruction, atelectasis, and hyperinflation. Changes in respiratory status may occur quickly as energy reserves are depleted; therefore, close monitoring is essential. Positioning the infant, monitoring fluid status, and including parents in care plan are necessary, but not the priority.

The nurse is examining charts to identify clients at risk for developing multiple myeloma. Which client is most at risk?

a 60-year-old Black man Multiple myeloma is more common in middle-aged and older adult clients. The median age at diagnosis is 60 years. It is twice as common in Black clients as it is in White clients, and it occurs most often in Black men.

A client experiencing alcohol withdrawal reports being upset about going through detoxification. Which goal is the priority for this client?

working with the nurse to remain safe The priority goal is for client safety. Although drinking enough fluids, identifying personal strengths, and committing to a drug-free lifestyle are important goals, the nurse's first priority must be to promote client safety.

A client is admitted with an eating disorder. Which client response should the nurse address first?

"I feel dizzy and light-headed when I get up." The priority intervention, by the nurse, would be to assess the client's vital signs to note any alterations. A client stating "My life is over if I gain weight" is an example of catastrophizing. Dental erosion and caries are commonly found in a client with an eating disorder. Muscle weakness is also commonly found in a client with an eating disorder.

Which client is most at risk for developing acute lymphocytic leukemia?

A 4-year-old white female Acute lymphocytic leukemia is most common in young children and in adults age 65 and older. It's also more common in whites than in blacks or Asians.

A client with type 1 diabetes mellitus is conscious but confused, weak, diaphoretic, and having heart palpitations. What is the nurse's priority action?

Provide 15 to 20 grams of a fast-acting oral carbohydrate. The client is exhibiting signs of hypoglycemia. Since the client is conscious, the first intervention is to give a fast-acting oral carbohydrate, such as orange juice, hard candy, or honey. If the client becomes unconscious, the nurse would administer IM or subQ glucagon or dextrose 50% I.V. if access is available. Administering insulin wouldn't be appropriate because the client is experiencing hypoglycemia.

Which client, diagnosed with pneumonia, is most likely to have community-acquired pneumonia?

A client newly admitted to a long-term care facility The client who is a new resident in a long term care facility is at high risk for community-acquired infections. Traveling is not likely to cause community-acquired pneumonia. Legionnaires' disease is a risk if traveling on a confined cruise ship. Receiving family visits and the death of a spouse are not typically causative factors associated with developing community-acquired pneumonia.

A client ingested a large amount of acetaminophen at 1:00 am. Two hours later, the client comes to the emergency department, and is diagnosed with acetaminophen poisoning. What is the priority intervention for this client?

Administer acetylcysteine. If the client is seen within 1 hour of ingestion, activated charcoal can be given to prevent absorption, or gastric lavage can be used. Blood work would be obtained but wouldn't be the first priority. Intravenous fluids would also be administered, but administering ?-acetylcysteine, the specific antidote for acetaminophen poisoning, is the priority.

The nurse is caring for a client who has just undergone electroconvulsive therapy (ECT) for the treatment of severe depression that is unresponsive to medication. What is the nurse's most important intervention immediately postprocedure?

Assess vital signs. ECT is performed under sedation, so vital signs are monitored carefully for approximately one hour after the procedure or until the client is stable. The client should not have anything by mouth and will take time to awaken enough to require orientation to the environment. Analgesia should not be needed immediately postprocedure, because the client will not yet be conscious.

Which nursing intervention is a priority for an infant during the first 24 hours following surgery for cleft lip repair?

Carefully clean the suture line after feedings to reduce the risk of infection. The suture line must be carefully cleaned with a sterile solution after each feeding to reduce the risk of infection, which could adversely affect the healing and cosmetic results. The infant shouldn't be placed in the prone position, because this puts pressure on the incision and may affect healing. Anticipatory care should be provided to reduce the risk of the infant crying, which puts strain on the incision. Pacifiers and other firm objects should not be placed in the infant's mouth because they can disrupt the suture line.

What is the most important intervention for the nurse to implement while caring for a neonate with an omphalocele?

Carefully position and handle the omphalocele. Careful positioning and handling prevents infection and rupture of the omphalocele. The omphalocele should be kept moist until the neonate is taken to the operating room. The parents can see the defect if they so choose. Palpation of the omphalocele increases the risk of rupture and infection.

A 72-year-old client with cirrhosis is admitted to the hospital in a hepatic coma. What is the nurse's most important intervention?

Check airway, breathing, and circulation. Priorities include airway, breathing, and circulation. Once these are ensured, a neurological check is needed to determine status. General orientation and completing the admission may require the help and affirmation of family members. Depending on the client's alertness, orientation to the environment may need to be kept simple.

A client is 2 days postoperative from a femoral popliteal bypass. During assessment, the nurse finds the client's left leg is cold and pale. What is the nurse's initial action?

Check distal pulses. The nurse must assess the client for postsurgical complications. Before the health care provider is notified, the nurse must assess circulation by checking for distal pulses that could be altered by a clot. Elevating the foot of the bed would promote venous return but decrease arterial blood flow and should be avoided. The leg should be lightly covered after circulation is assessed.

A postpartum mother is concerned about a noted decrease in her breast milk production. Which response by the nurse best addresses this mother's concern?

Decrease supplemental feedings with formula. Routine formula supplementation may interfere with establishing an adequate milk volume because suckling the breast stimulates prolactin production. Prolactin is the hormone responsible for milk production. Vitamin C levels haven't been shown to influence milk volume. One alcoholic beverage generally tends to relax the mother, and facilitate the milk let-down reflex. Excessive consumption of alcohol may block milk let-down, though supply isn't necessarily affected. Frequent feedings are likely to increase milk production.

A 10-hour-old newborn female presents to the nursery with the following: axillary temperature 97.1° F (36.2° C); apical pulse 132; respirations irregular at 40/min; blood glucose 58 mg/dl; wet diaper with a pink-tinged discoloration. What is the priority nursing action?

Double wrap the infant and apply a cap to the head. The infant's axillary temperature indicates hypothermia and measures to increase the infant's temperature should be taken. There is no need to call the health care provider since pink or rust tinged discharge is normal in female infants. There is no need to feed the infant or place the infant under an oxygen hood because the blood glucose level and the respiratory rate are within normal limits.

The nurse is caring for a client with functional neurologic symptom disorder who has experienced pseudoseizures. What intervention is appropriate for the nurse to perform?

Encourage the client to discuss feelings about the pseudoseizures. Pseudoseizures or psychogenic nonepileptic seizures are considered a psychological symptom and are not related to electrical disturbance in the central nervous system as epileptic seizures are. However, they are a serious disorder and should not be minimized to the client by the nurse. Cognitive behavioral therapy is a primary intervention and requires open dialogue between the client and nurse so the client should be encouraged to verbalize feelings. Placebo administration is unethical, and the nurse should not participate in this intervention. While the nurse should remain calm and not draw excessive attention to the client during a pseudoseizure, the nurse should not ignore the client outright.

A married male client is admitted to the psychiatric unit. During the nurse's interview the client states, "I cannot live this lie anymore. I wish I were a woman. I cannot live one more day feeling this way." What is the nurse's priority intervention?

Encourage the client to talk about his feelings. This client reveals that he is under severe stress with potential suicidal ideation that needs to be further explored. The nurse should establish if the client has a plan for self-harm that would warrant suicide precautions prior to initating these precautions. Discussions should not focus on gender conflict issues, because these are more long term and cannot be quickly assessed or resolved. The primary health care provider should not be notified until an assessment is completed. The client should not speak to his partner until he has processed his feelings and is ready to face the associated challenges.

The nurse has just admitted a client with sickle cell crisis. What is the nurse's priority intervention?

Increasing fluid intake and giving analgesics The primary therapy for sickle cell crisis is to increase fluid intake according to age and to give analgesics. Blood transfusions are given conservatively to avoid iron overload. Antibiotics are given to clients with fever. Routine splenectomy is controversial, and not recommended.

A client reports an inability to sleep while on the medical unit. Which intervention should the nurse perform first?

Inquire about the client's sleeping habits. Assessing the client's sleeping habits may provide information about the causes of the inability to sleep. Sedatives should be given as a last option. A backrub may promote sleep but may not address this client's problem. Moving the client may not address the client's specific problem.

While performing a cervical examination on a client in labor, a nurse's fingertips feel pulsating tissue. What is the most appropriate nursing intervention?

Leave the fingers in place and press the nurse call light. When the umbilical cord precedes the fetal presenting part, it's known as a prolapsed cord. Leaving the fingers in place and calling for assistance is the safest intervention for the fetus. The nurse will need to keep the fetus off the cord to reduce cord compression. The nursing staff will contact the provider, and the client will probably require a cesarean birth to decrease the risk of fetal demise during birth. Placing the client in the semi-Fowler's position would increase the pressure of the fetus on the umbilical cord. Asking the client to push with the next contraction would force the presenting part against the cord, causing severe bradycardia and possible fetal demise.

A primiparous client arrives for her first prenatal visit at 10 weeks' gestation. The client seems nervous and has many questions. What is the most important intervention by the nurse?

Reassure the client that all her questions will be answered during the visit. The nurse has made the observation that the client requires reassurance and should attempt to establish a positive nurse-client relationship. Providing initial reassurance helps set the client's mind at ease. Offering reading materials will not help develop this relationship. Asking this client to immediately disrobe does not address her concerns and could make the client more nervous. Telling a client "not to worry" is dismissive. The client should be treated as a partner in her care rather than being told that her health care provider will take care of everything.

A nurse on a maternity unit witnesses a parent slapping the face of a crying neonate. What is the nurse's priority action?

Take the neonate to the nursery, inform the health care provider of what was witnessed, and notify social services. The neonate's safety and protection are the nurse's first priority. The nurse should immediately take the neonate to the nursery and inform the health care provider of the abuse. As an advocate for the neonate, the nurse provides the health care provider with an opportunity to examine the child for injuries. The nurse should not confront the client. Observing the mother for further incidents may be part of the revised care plan; however, this incident requires immediate intervention.

A registered nurse (RN) is supervising an unlicensed assistive personnel (UAP). Which principle would the nurse follow when delegating tasks?

The RN delegates a task based on the UAP's skill set. The RN must delegate tasks that are within the scope of practice of the unlicensed personnel. The RN need not directly supervise all delegated tasks, as this would negate the benefits of delegation. When a task is delegated, the RN retains responsibility for the successful completion of the task. The RN must always follow up with the UAP to ensure the task was completed appropriately.

A nurse is teaching a group of parents about urinary tract infections (UTIs) in children. What is the priority educational topic for this group of parents?

interventions to prevent UTIs Prevention is the most important goal of teaching about a preventable condition such as UTIs. The most preventive measures are simple hygienic practices that should be a routine part of daily care. While some of the teaching about prevention will overlap with risk factor discussion, some risk factors, such as female gender, are not something that can be targeted for prevention. Teaching about treatment, detection, and testing is important, but this is not the priority and will not be relevant if the UTI is successfully prevented.

A client with pneumonia has developed dyspnea, has a respiratory rate of 32 breaths/min, and is having difficulty expelling secretions. The nurse auscultates the lung fields and hears bronchial sounds in the lower left lobe. Which action should the nurse take first?

Apply oxygen The client is having difficulty breathing, and is probably becoming hypoxic. As an emergency measure, the nurse should provide oxygen without waiting for a health care provider's order. Antibiotics may be warranted, but would require a provider's order. This client should be maintained on bed rest if he's dyspneic to minimize his oxygen demands, but providing additional oxygen will more immediately address his problem. The client will require nutritional support, but while dyspneic, the priority is oxygenation.

During assessment, a client verbally rates pain as 9 out of 10 on a 0-10 pain scale. There is no indication of pain relief, even though the previous nurse signed for an opioid for this client one hour prior. The client denies receiving anything for pain since the previous night. Which action should the nurse take next?

Approach the nurse who signed for the opioid to seek clarification about the missing drug. The nurse should not assume the client is confused but should instead investigate why the pain is poorly controlled. Given the scenario, the nurse needs to rule out the possibility that the other nurse has signed for a medication that was not administered. This requires asking the other nurse directly about the situation. Neither the supervisor nor pharmacist should be involved until after the situation is investigated with the nurse in question.

An order has been written to discontinue an infusion of total parenteral nutrition (TPN) for a child. What is the priority nursing action?

Gradually reduce the rate of the TPN per health care provider order. Gradually reducing the rate will avoid a sudden loss of the highly concentrated solution of amino acids, glucose, and other nutrients, and allow the child's body to adapt. Infusing a glucose solution after discontinuing TPN is not necessary when the infusion rate has been tapered. A glucose solution may need to be infused if discontinuation was sudden to avoid an abrupt drop in blood glucose. Administering insulin after discontinuing TPN would result in hypoglycemia. The pharmacy should be notified so that additional TPN is not prepared, but that is not a priority nursing action.

A client in early labor tells the nurse that she has a thick, yellow discharge from both of her breasts. What is the nurse's most appropriate intervention?

Inform the client that the discharge is colostrum, and a normal finding. After the fourth month, colostrum may be expressed. The breasts normally produce colostrum for the first few days after birth. Milk production begins one to three days postpartum. A clinical breast examination isn't usually indicated in the intrapartum setting. Although a culture may be indicated, it requires advanced assessment as well as a medical order.

While performing an assessment of a 75-year-old client in the emergency department, a nurse notes several areas of ecchymosis in various stages of healing on the client's body. What is the nurse's priority action?

Inquire how these bruises occurred. The nurse should obtain more information from the client first, in order to complete the initial assessment. The nurse should not assume that the bruises are a result of abuse, and she should not notify the nursing supervisor until additional facts are obtained. The nurse should inform the provider so an examination can be completed. She should follow the facility's policy and procedure for reporting abuse and document the findings.

The nurse is assessing a child with type 1 diabetes mellitus who recently came to the emergency department with signs and symptoms consistent with diabetic ketoacidosis. What is the nurse's priority when planning care for this child?

Prepare to administer intravenous fluids and insulin per order. Diabetic ketoacidosis, the most complete state of insulin deficiency, is a life-threatening condition. The child should be admitted to an intensive care unit for management. Treatment would consist of rapid assessment, adequate insulin to reduce the elevated blood glucose level, fluids to overcome dehydration, and electrolyte replacement. Education would be a priority after the child has stabilized.

The nurse is caring for a recently circumcised newborn. Based on the progress note, what would be the most appropriate nursing intervention?2/10 0800Progress Note TabThree day old male, two days post-circumcision by Mogen clamp. Small amount of yellow-white exudate noted around glans. No bleeding or swelling noted. Axillary temp 36.4 C (97.5 F). Nursing eagerly, latching on well. Voided x1 post-circ.

Provide routine care to the circumcised area. The yellow-white exudate is part of the granulation process and is a normal finding for a healing penis following circumcision. Routine vital signs and normal layering would be recommended for this neonate as this temperature is normal in a newborn. It is not necessary to increase monitoring or covering of the neonate. Pacifiers do soothe pain in the neonate; however, there is no indication in this progress note that the neonate is in pain.

A nurse is caring for a 3-year-old child following the removal of a Wilms' tumor. The parent states that the child is in pain, and requests pain medication. What is the nurse's priority in regard to this parent's request?

Use the Faces Pain Scale to assess the child's degree of pain. The nurse should assess the client's pain level using the age-appropriate Faces Pain Scale. After the pain assessment, the nurse should determine the time previous pain medications were administered and medicate accordingly.

The nursing team consists of one RN, one LPN, and one unlicensed assistive personnel (UAP). Which assignment should the RN delegate to the LPN?

administering daily am medications LPNs should be assigned higher level skills in stable, predictable situations. Lower level custodial skills should be assigned to UAP. A new tracheostomy may be unstable. The task of suctioning should be retained by the RN.

A child has ingested a bottle of over-the-counter medication and is brought into the emergency department by the parents. The nurse expedites rapid first aid for poisoning by immediately accessing what resource?

contacting the Poison Control Center by phone Despite having directions on the bottle or in the CPS about what to do in the event of overdose of medications, best practice dictates the nurse contact the Poison Control Center for directions. Often, medication labels are outdated and should not be followed. Written hospital guidelines may also be out of date. Although making the call takes time, it guarantees the best treatment for the poisoning.

What is the most important intervention for the nurse to include in the care plan for a male infant following surgical repair of hypospadias?

frequent assessment of the tip of the penis Following hypospadias repair, a pressure dressing is applied to the penis to reduce bleeding and tissue swelling. The tip of the penis should then be assessed frequently for signs of circulatory impairment. The dressing around the penis is initially changed by the surgeon, and shouldn't be changed every 4 hours thereafter. The provider will determine when the suprapubic catheter will be removed. Urethral catheterization should be avoided after repair of hypospadias to prevent trauma to the repaired urethra.

The nurse in the emergency department is caring for a 12-year-old child with full-thickness, circumferential burns to the chest who has difficulty breathing. What is the priority intervention?

intubation Intubation is performed to maintain a patent airway. Escharotomy is a surgical incision used to relieve pressure from edema. It's needed with circumferential burns that prevent chest expansion or cause circulatory compromise. Insertion of a chest tube and needle thoracocentesis are performed to relieve a pneumothorax.

A client is brought to the emergency department after a house fire. What is the priority assessment by the nurse?

Assess oxygen saturation and the client's ability to speak. The nurse's priority is to make sure the airway is open and that the client is breathing, which would be best accomplished by seeing if the client can speak and what the oxygen saturation is. Vital signs, degree of burns, and the client's pain can all be assessed once the nurse establishes that the client has a patent airway.

A nurse is assigned to four clients. Which client should the nurse see first?

A client who is being prepared for a major surgery receiving clopidogrel Clopidrogel is an anti-platelet drug that should be stopped seven days prior to surgery because it can increase the risk of bleeding. All the other options are correct. Fondaparinux can be given to a client who had ORIF to prevent blood clot formation. Pegfilgastrim is given to a client with low white blood cell (WBC). Emtricitabine is a nucleoside-nucleotide reverse transcriptase inhibitor (NNRTI) drug used for clients with HIV/AIDS.

The nurse is concerned that a client admitted with major depressive disorder may be suicidal. What is the most important action by the nurse?

Ask a direct question such as, "Do you ever think about killing yourself?" The best approach is to ask about thoughts of suicide in a direct and caring manner. Assessing for attention-seeking behaviors doesn't deal directly with the problem. The client should be assessed directly, not through family members. Assessment must be performed before determining whether suicide precautions are necessary.

While performing the morning postpartum assessment, the nurse notices that a client's perineal pad is completely saturated with lochia rubra. What is the nurse's best action?

Ask the client when she last changed her perineal pad. If the morning assessment is done relatively early, it's possible that the client hasn't yet been to the bathroom, and the perineal pad may have been in place all night. In addition, her lochia may have pooled during the night, resulting in a heavy flow in the morning. Vigorous massage of the fundus isn't recommended if heavy bleeding or hemorrhage is present. If the nurse were uncertain, and wanted a second opinion, it would be appropriate to call the health care provider or ask another qualified nurse after doing a complete assessment of the client's status.

The parent of a 2-year-old with epiglottitis states a need to pick up the older child from school. The 2-year-old child begins to cry and appears more stridorous. What is the nurse's priority action?

Ask the parent if there's anyone else who can meet the older child. Increased anxiety and agitation should be avoided to prevent airway obstruction. A 2-year-old child fears separation from parents, and the parent should be encouraged to stay. Other means of picking up the older child should be found. Telling the child that everything will be all right may not decrease agitation. The parent is the primary caregiver and important to the child for emotional and security reasons.

A nurse is instructing an unlicensed assistive personnel (UAP) on the proper care of a client in Buck's extension traction following a fracture of the left fibula. Which observation would indicate that teaching has been effective?

The weights are allowed to hang freely over the end of the bed. In Buck's traction, the weights should hang freely without touching the bed or floor. Lifting the weights would break the traction. The client should be moved up in bed, allowing the weight to move freely along with the client. The leg should be kept in straight alignment. Performing ankle rotation exercises could cause the leg to go out of alignment.

A nurse is working on a pediatric floor with a five-client assignment. In which order should the nurse see the assigned clients, starting with the client the nurse should see first? All options must be used.

a 15-year-old client waiting for transport to the operating room a 2-month-old client with respiratory syncytial virus in an oxygen tent a 4-year-old client with nausea and vomited one hour ago a 3-day-old client with hyperbilrubinemia waiting for discharge a 5-year-old client admitted with asthma at the radiology department The nurse will prioritize the 15-year-old client waiting for transport to the operating room to be sure the client is ready for surgery. Then, the 2-month-old client with respiratory syncytial virus in an oxygen tent should be assessed to be sure that oxygenation is safe. The 4-year-old client with nausea and who vomited one hour ago can be assessed third since the nausea and vomiting occurred 1 hour ago. The 3-day-old client with hyperbilrubinemia waiting for discharge is stable and can be seen next. Lastly, the 5 year old client admitted with asthma is at radiology department so the assessment can be done when the client returns to the unit.

A staff nurse receives a phone call and is told there is a bomb in a client's room. What is the nurse's priority action?

Ask the caller for details about the bomb placement. With imminent danger, it is important to determine as much information as possible, as quickly as possible. Transferring the call, or placing the caller on hold could result in a disconnection and loss of information. Clients may need to be evacuated.

Parents bring a preschool-age client to the emergency department with suspected ingestion of an unknown toxic substance. What intervention should the nurse perform first?

Assess the child's vital signs and neurological status. The nurse must assess the child to determine if life-saving intervention such as cardiopulmonary resuscitation is needed. This assessment will direct all the subsequent actions, such as the application of oxygen and intravenous fluids. The parents have indicated the source of suspected poisoning is unknown, so although interviewing them to try to determine the possible source and the initial symptoms should be done, the nurse must first assess and stabilize the child.

An older adult client has developed pneumonia. What initial assessment finding would most concern the nurse?

Confusion or delirium The major sign of pneumonia in older adults may be a change in how clearly they think, or when an existing lung disease gets worse. Other common symptoms of pneumonia are fever, severe chills, hemoptysis, dyspnea, pleuritic chest pain and a productive cough. These symptoms tend to manifest later in elderly clients.

A client is admitted with intervertebral disk prolapse, and shows new symptoms of urinary incontinence and paralysis of both legs. What is the priority action by the nurse?

Notify the provider immediately Cauda equina syndrome occurs when there is compression on the nerve roots. It affects areas below the level of these nerve roots. It is an emergency that requires surgical intervention. If not treated, it may lead to permanent loss of bladder and bowel control and paralysis of the legs. Inserting a urinary drainage device, increasing the frequency of vital signs, and administering anti-inflammatory medication may be interventions that are needed; however, they are not the priority.

Which client would be considered to be at the highest risk for respiratory failure?

A client with Guillain-Barré syndrome Guillain-Barré syndrome is a progressive neuromuscular disorder that can affect the respiratory muscles and cause respiratory failure. The other conditions don't typically affect the respiratory system.

A hospitalized client, with a productive cough, chills, and night sweats is suspected of having active tuberculosis (TB). What is the nurse's most important intervention?

Maintain the client on respiratory isolation This client is showing signs and symptoms of active TB and, because of the productive cough, is highly contagious. He should be admitted to the hospital and placed in respiratory isolation. Three sputum cultures should be obtained to confirm the diagnosis.

A 49-year-old client is admitted to the emergency department frightened and reporting hearing voices telling the client to do bad things. Which intervention should be the nurse's priority?

Assess the nature of the commands by asking what the voices are saying. Safety is the priority. The nurse should ask the client directly about the nature of the auditory commands to ensure the safety of the client and staff. The nurse should never make promises to the client that the nurse may not be able to fulfill. The provider may order a neuroleptic, but the nurse's priority is to address safety.

A 40-year-old client with schizophrenia lives in a rooming house. The client scratches vigorously and reports creatures eating at the skin. Which intervention should be done first?

Assess the physical problems. Clients with schizophrenia generally have poor visceral recognition because they live so fully in their fantasy world. They need to have an in-depth assessment of physical complaints that may spill over into their delusional symptoms. Talking with the client won't provide an assessment of the itching, and itching isn't an adverse reaction of antipsychotic drugs. The client's provider should be called if the assessment warrants.

A school-age client with a diagnosis of epilepsy is admitted to the pediatric unit of a local hospital for evaluation of anticonvulsant medications. As the nurse enters the client's room, the client begins to have a seizure. What is the priority nursing action?

Loosen any restrictive clothing. The primary nursing goal during a seizure is to protect the client from physical injury and maintain a patent airway. Loosening clothing will allow free movement and aid in keeping the airway open. After making sure the client is safe from injury, the nurse should push the call light if further assistance is needed. The nurse should never forcibly hold a client down, and shouldn't force the jaw open.

A nurse is examining a client in active labor, who has had spontaneous rupture of the amniotic membrane, and notes a protruding umbilical cord. What is the priority nursing action?

Place the client in knee-chest position. A Trendelenburg or knee-chest position takes the weight of the fetus off the umbilical cord, allowing blood to flow. The cord should never be pushed back into the uterus, as this could damage the cord, obstruct the flow of blood through the cord to the fetus, or introduce infection into the uterus. The client should not be instructed to push, as she is only in active labor, and emergency surgery may be necessary. The cord should be wrapped in a sterile saline-soaked gauze.

What is the nurse's most important intervention for a client having a tonic-clonic seizure?

Protect the client from further injury The priority during and after a seizure is to protect the person from injury by keeping them from falling to the floor. Furniture or other objects that be a source of injury during the seizure should be moved out of the client's way. Timing the seizure, and noting the origin of the seizure are important, but are not the priority. Nothing should be placed in the client's mouth during a seizure because teeth may be dislodged or the tongue pushed back, further obstructing the airway.

A nurse walks into the room of a client diagnosed with congestive heart failure (CHF). The client is lying supine and is diaphoretic, anxious, and dyspneic. What is the nurse's priority action?

Raise the head of the bed to 45°. Raising the head of the bed will help the client's lungs expand and allow for deeper breaths. The nurse would need a provider's order for oxygen, and it may not be most beneficial if the head of the bed is not elevated. Lorazepam may decrease the client's anxiety, but it may also diminish respirations and increase dyspnea. Arterial blood gases are not a priority.

A charge nurse is developing the client care assignments for the shift. Which client is most appropriately assigned to a licensed practical nurse (LPN)?

a client who experienced a cerebral vascular accident and has a do-not-resuscitate (DNR) status The most appropriate client to assign to the LPN is the newly admitted client with DNR status. Typically, a newly admitted client is assigned to a registered nurse (RN) because the client requires frequent assessments. The client who recently underwent cerebral arteriography, and the client who recently underwent carotid endarterectomy will require frequent assessments by an RN. The client just transferred from the ICU has the potential for becoming unstable, and should be assigned to an RN.

An older adult client with pneumonia is admitted with prescriptions for intravenous antibiotics, supplemental oxygen as needed, and antipyretics. The nurse should immediately notify the health care provider for which assessment finding?

acute onset delirium The acute change in client cognition (i.e., delirium) is considered a medical emergency and should be investigated immediately. This acute change could be evidence of sepsis, electrolyte imbalances, or other organic causes that should be diagnosed and treated as soon as possible. The nurse should assess for the common symptoms of pneumonia such as fever, chills, dyspnea, pleuritic chest pain, and a productive cough. These symptoms should be monitored, but the nurse has treatments prescribed by the health care provider to address these findings.

A nurse is caring for a 2-year-old client, who weighs 25 lb (11.3 kg), and has a fractured femur. What is the nurse's priority assessment for this client?

affected leg distal to the fracture The nurse should focus the assessment on the area distal to the fracture. This area is most at risk for neurovascular compromise. If a fracture severs or obstructs blood vessels or nerves, blood flow is disrupted distal to the site, and may lead to nerve or tissue damage. The unaffected leg should be used for baseline comparison. This client should be assessed for the five "Ps:" pulse, pallor, parathesia, pain, and paralysis.

A 30-year-old multiparous client in active labor is admitted to the labor and delivery unit. She has received no prenatal care for this pregnancy. Which data would the nurse obtain first?

date of last menstrual period (LMP) The date of the LMP is essential to estimate the date of birth, and should be obtained first. The nursing history would also include subjective information, such as personal history of STIs, gravidity, and parity. Although beneficial to the hospital for financial reimbursement, the insurance provider has no bearing on the nursing history. The number of siblings is not pertinent to the assessment.

A two-month-old infant arrives with a heart rate of 180 bpm and a temperature of 103.1° F (39.5° C) rectally. What is the most appropriate initial nursing intervention?

give acetaminophen Acetaminophen should be given to decrease the temperature. A heart rate of 180/bpm is normal in an infant with a fever. A tepid sponge bath may be given to help decrease the temperature and calm the infant. Carotid massage, and placing the infant's hands in cold water are attempts to decrease the heart rate through vagal maneuvers. This will not work because the source of the increased heart rate is fever. Fluid intake is encouraged after the acetaminophen is given to help replace insensible fluid losses.

What is the priority nursing assessment of a client with an eating disorder?

level of danger to self The priority assessment should be to determine if the client is a danger to self. Cultural needs, substance abuse history, and academic performance are an important part of assessment, but not the priority.

A 10-month-old child is found choking and becomes unconscious. What is the nurse's priority intervention after opening the child's airway?

look inside the child's mouth for a foreign object As soon as the infant is found choking, the nurse should give five back blows and five chest thrusts in an attempt to dislodge the object and open the airway. After the airway is open, the nurse should check for a foreign object and remove it with a finger sweep if it can be seen. After the object is removed, 30 quick compressions should be given before rescue breathing is attempted. Blind finger sweeps should never be performed because this may push the object further into the airway.

What is the nurse's priority when caring for a 10-month-old infant with meningitis?

maintaining an adequate airway Maintaining an adequate airway is always a top priority. Maintaining fluid and electrolyte balance and controlling seizures and hyperthermia are all important, but not as important as an adequate airway.

The nurse is planning interventions for a client who is having an acute gout attack. What is the priority nursing intervention for this client?

Administer prescribed analgesics Administering prescribed analgesics to relieve pain would be the priority. The other actions are appropriate measures, but aren't the priority.

The nurse is assessing a client who has been experiencing black stools for the past month. The client suddenly reports chest and stomach pain. What is the most important action by the nurse?

Assess the client's vital signs Assessing vital signs would determine this client's hemodynamic stability. Monitoring the heart rhythm may be indicated based on assessment findings. Administering oxygen and drawing blood require a health care provider's order, and would not be part of a screening evaluation.

The nurse is reviewing the interventions listed in the plan of care for a child in vaso-occlusive crisis. Which intervention should the nurse implement first?

administering analgesics Pain management is a priority intervention when a client is in crisis. Analgesics are used to control pain. Hydration is essential to promote hemodilution and maintain electrolyte balance. Bed rest should be promoted to reduce oxygen utilization. Antibiotics will not be effective in resolving the vaso-occlusive crisis.

A nurse is planning preoperative care for a child diagnosed with Wilms' tumor. What is the nurse's most important intervention?

Avoid abdominal palpation or manipulation. After a diagnosis of Wilms' tumor, the abdomen should not be palpated. Palpation of the tumor could lead to rupture, which would spread cancerous cells throughout the abdomen. If surgery is successful, long-term radiation and chemotherapy would not be required. Enteral feedings and total parenteral nutrition are not part of the preoperative treatment of Wilms' tumor. Radiation and chemotherapy are not started preoperatively.

A client at term arrives in the labor and delivery unit experiencing contractions every 4 minutes. After a brief assessment, the client is admitted, and an electronic fetal monitor is applied. Which assessment finding would be most concerning to the nurse?

blood pressure of 146/90 mm Hg A blood pressure of 146/90 mm Hg may indicate gestational hypertension. Over time, gestational hypertension reduces blood flow to the placenta and can cause intrauterine growth restriction, and other problems that reduce the fetus's ability to tolerate the stress of labor. A weight gain of 30 lb (13.6 kg) is within expected parameters for a healthy pregnancy. A woman over age 30 doesn't have a greater risk of complications if her general condition is healthy before pregnancy. Syphilis that has been treated does not pose an additional risk.

A child with Wilms' tumor has had a kidney removed, and is now receiving chemotherapy. What priority information should the nurse share with this child's family at the time of discharge?

Avoid contact sports. Because the child has only one kidney, certain precautions are recommended to prevent injury to the remaining kidney. Fluid intake is essential for renal function, and should not be decreased. The child's sodium intake shouldn't be reduced. Avoiding other children is unnecessary, may make the child feel self-conscious, and may lead to regressive behavior.