alternate item formats priority order (ordered response)

The nurse is caring for a client diagnosed with cirrhosis of the liver with portal hypertension. The client vomited 500 mL bright red emesis and states that he is feeling lightheaded. In which priority order should the nurse perform these interventions? Arrange the actions in the order they should be performed. All options must be used.

1) Apply oxygen. 2) Ensure that 2 large-bore intravenous lines are present with an isotonic solution infusing. 3) Check the client's blood pressure. 4) Ask the client if he is taking any nonsteroidal antiinflammatory medications.

In order of priority, how should the nurse perform abdominal thrusts on an unconscious adult? Arrange the actions in the order that they should be performed. All options must be used.

1) Assess unconsciousness. 2) Open the airway. 3) Look in the mouth and remove the object blocking the airway, if seen. 4) Attempt ventilation. 5) Perform abdominal thrusts.

A unit of packed red blood cells has been prescribed for a client with low hemoglobin and hematocrit typing and crossmatching. The nurse receives a telephone call from the blood bank and is informed that the unit of blood is ready for administration. In order of priority, how should the nurse plan the actions to take? Arrange the actions in the order that they should be performed. All options must be used.

1) Verify the health care provider's (HCP's) prescription for the blood transfusion. 2) Ensure that an informed consent has been signed. 3) Insert an 18- or 19-gauge intravenous catheter into the client. 4) Obtain the unit of blood from the blood bank. 5) Ask a licensed nurse to assist in confirming vital signs and blood compatibility and verifying client identity. 6) Hang the bag of blood.

A mother brings her child to the emergency department. Based on the child's sitting position, drooling, and apparent respiratory distress, a diagnosis of epiglottitis is suspected. In anticipation of the health care provider's prescriptions, in which order of priority would the nurse implement the actions? Arrange the actions in the order that they should be performed. All options must be used.

1) Maintain a patent airway 2) Assess breath sounds by auscultation. 3) Obtain an oxygen saturation level using pulse oximetry. 4) Insert an intravenous line for fluid administration. 5) Obtain an axillary temperature. 6) Administer an antipyretic.

The nurse has determined that a postpartum client has physical findings consistent with uterine atony. The nurse should take action in which priority order? Arrange the action in the priority order that they should be done.All options must be used.

1) Massage the uterus attempting to achieve firmness. 2) Contact the health care provider. 3) Monitor vital signs. 4) Check the amount of drainage on the peripad

The nurse is preparing to suction the airway of a client who has a tracheostomy tube and gathers the supplies needed for the procedure. In order of priority, which actions should the nurse take to perform this procedure? Arrange the actions in the order that they should be performed. All options must be used.

1) Place the client in a semi Fowler's position. 2) Turn on the suction device and set the regulator at 80 mm Hg. 3) Attach the suction tubing to the suction catheter. 4) Hyperoxygenate the client. 5) Insert the catheter into the tracheostomy until resistance is met, and then pull it back 1 cm 6) Apply intermittent suction and slowly withdraw the catheter while rotating it back and forth.

The nurse working in the hospital hears a client call out that there is a fire in the hospital room. What actions should the nurse take? Arrange the actions in the order that they should be performed. All options must be used.

1) Protect the client from injury. 2) Activate the fire alarm. 3) Close the doors to the other clients' rooms. 4) Pull the pin on the fire extinguisher. 5) Extinguish the fire

After receiving report at the beginning of the 0700 shift, the nurse must decide in what order the clients should be assessed. How should the nurse plan assessments? Arrange the clients in the order that they should be assessed.All options must be used.

1) A 12-hour post-cesarean section delivery gravida 3, para 3 who reports a return of feeling in her lower extremities as well as a sensation of wetness underneath her buttocks. 2) A 24-hour post-vaginal delivery gravida 4, para 4 who is complaining of abdominal cramping after nursing her baby and requesting ibuprofen. 3) An 8-hour post-vaginal delivery gravida 2, para 2 client who is scheduled for a bilateral tubal ligation at 1200 today and has a continuous peripheral intravenous (IV) solution of 5% dextrose in lactated Ringer's solution (D5LR). 4) A 48-hour post-cesarean section delivery gravida 1, para 1 who reports not yet having a bowel movement since delivery and requests a stool softener.

A hospitalized client with type 1 diabetes mellitus received Humulin N and Humulin R insulin 2 hours ago (at 7:30 a.m.). The client calls the nurse and reports that he is feeling hungry, shaky, and weak. The client ate breakfast at 8 a.m. and is due to eat lunch at noon. Arrange the actions that the nurse will take in the order that they should be performed. All options must be used.

1) Check the client's blood glucose level. 2) Give the client ½ cup (118 mL) of fruit juice to drink. 3) Take the client's vital signs. 4) Retest the blood glucose level. 5) Give the client a small snack of carbohydrate and protein. 6) Document the client's complaints, actions taken, and outcome.

After correctly completing the rights of medication administration, performing hand hygiene, and ensuring the correct position of the client, which steps should the nurse take to administer medication via a volume control container? Arrange the actions in the order that they should be performed. All options must be used.

1) Fill volume control container with desired amount of IV fluid by opening clamp between volume control container and main IV bag. 2) Close the clamp and check to be sure that clamp on air vent volume control container is open. 3) Clean injection port on top of volume control container with an antiseptic swab. 4) Remove the needle cap and insert the needleless syringe tip through the port, and then inject the medication and label volume control container with name of medication, dosage, total volume including diluents, and time of administration. 5) Regulate intravenous (IV) infusion rate to allow medication to infuse in the time recommended by institutional policies. 6) Dispose of the syringe in puncture-proof and leak-proof container. Discard supplies and perform hand hygiene.

A client involved in a head-on automobile crash has awakened from a coma and asks for her husband, who was killed in the same accident. The family does not want the client to know at this time that her husband has died. The family wants all nursing staff to tell the client that the husband was taken by helicopter to another hospital, has a head injury, and is in the intensive care unit (ICU). Because the American Nurses Association Code of Ethics requires the nurse to preserve integrity, but the nurse wants to follow the family's instruction, the nurse faces an ethical dilemma. Which steps should the nurse take to systematically process this ethical dilemma? Arrange in order the steps for systematic processing of the ethical dilemma

1) Gather all information relevant to the case. 2) Examine and determine one's own values on the issues. 3) Verbalize the problem 4) Consider possible courses of action. 5) Negotiate the outcome. 6) Evaluate the action.

A client who is a gravida 3, para 3 had a cesarean section 1 day ago. She is being treated prophylactically for endometritis. She is complaining of abdominal cramping at a 6 on a pain level scale of 1 to 10 (with 10 being the greatest amount of pain) and fears having her first bowel movement. These medications are prescribed and due now. Based on priority, in which order should the nurse administer the medications? Arrange the medications in the order that they should be administered. All options must be used.

1) Ketorolac 30 mg by intravenous (IV) push over 3 minutes 2) Ampicillin sodium 1 g IV piggyback over 60 minutes 3) Docusate sodium 100 mg orally daily 4) Prenatal vitamin 1 tablet orally daily

A home health care nurse is planning client visits and nursing activities for the day. The nurse begins the visits at 9 a.m. All clients live within a 5-mile radius. In order of priority, how the nurse should plan the assignments for the day? Arrange the actions in the order that they should be performed. All options must be used.

1) A client with diabetes mellitus who needs a fasting blood glucose level drawn 2) The first dressing change for a client requiring twice-daily dressing changes 3) A client being visited by the home health aide at 1030 4) A client requiring supervision of a dressing change 5) A client requiring an admission assessment to home health care 6) The second dressing change for a client requiring twice-daily dressing changes

The nurse has a prescription to administer phenytoin by intravenous (IV) push through an IV line infusing 1000 mL of 0.9% sodium chloride. Arrange the actions in the order that they should be performed. All options must be used.

1) Check the compatibility of phenytoin with the IV solution. 2) Draw up the medication in a 3-mL syringe 3) Check the client's identification (ID) bracelet. 4) Pinch off the IV tubing above the injection port. 5) Inject the medication. 6) Document that the medication was administered.

The nurse is monitoring a client receiving total parenteral nutrition (TPN). The client suddenly develops respiratory distress, dyspnea, and chest pain, and the nurse suspects air embolism. In order of priority, how should the nurse plan the actions to take? Arrange the actions in the order that they should be performed. All options must be used.

1) Clamp the intravenous (IV) catheter. 2) Position the client in a left Trendelenburg's position. 3) Contact the health care provider (HCP). 4) Administer oxygen. 5) Take the client's vital signs. 6) Document the occurrence.

A client has a prescription to begin an infusion of 1000 mL of 5% dextrose in lactated Ringer's solution. The client has an intravenous (IV) cannula inserted, and the nurse prepares the solution and IV tubing. Arrange the actions in the order that they should be performed.All options must be used.

1) Close the roller clamp on the IV tubing. 2) Spike the IV bag and half-fill the drip chamber. 3) Open the roller clamp and fill the tubing. 4) Uncap the distal end of the tubing. 5) Attach the distal end of the tubing to the client.

The nurse is preparing to obtain an arterial blood gas specimen from a client and plans to perform the Allen test on the client. The nurse would perform the steps in which order to conduct an Allen test? Arrange the actions in the order that they should be performed.All options must be used.

1) Explain the procedure to the client 2) Apply pressure over the ulnar and radial arteries. 3) Ask the client to open and close the hand repeatedly. 4) Release pressure from the ulnar artery. 5) Assess the color of the extremity distal to the pressure point. 6) Document the findings

A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, the nurse takes the following actions. Arrange the actions in the order they should be performed. All options must be used.

1) Raise the head of the bed. 2) Loosen tight clothing on the client. 3) Check for bladder distention. 4) Contact the health care provider (HCP). 5) Administer an antihypertensive medication. 6) Document the occurrence, treatment, and response.

A confrontation test is prescribed for a client seen in the eye and ear clinic. How should the nurse perform this test? Arrange the actions in the order that they should be performed.All options must be used.

1) Stands 2 to 3 feet (60 to 90 cm) in front of and faces the client 2) Asks the client to cover 1 eye 3) Examiner covers eye opposite to the eye covered by the client 4) The examiner brings in an object gradually from periphery 5) Asks the client to report when object is first noted

The nurse is monitoring a client in labor who is receiving oxytocin and notes that the client is experiencing hypertonic uterine contractions. In order of priority, how should the nurse plan the actions to take? Arrange the actions in the order that they should be performed. All options must be used.

1) Stop the oxytocin infusion. 2) Reposition the client. 3) Administer oxygen by face mask at 8 to 10 L/min. 4) Perform a vaginal examination. 5) Check the client's blood pressure. 6) Administer medication as prescribed to reduce uterine activity.