EAQ Prioritization (Week 3)

Which action is the priority for a client who is admitted to the hospital with a severe head injury? 1 Maintain ventilation. 2 Prevent contractures. 3 Preserve skin integrity. 4 Monitor blood pressure.

1 Maintain ventilation.

A client is diagnosed with acute gastritis secondary to alcoholism and cirrhosis. The client reports frequent nausea, pain that increases after meals, and black, tarry stools. The client recently joined Alcoholics Anonymous. The nurse would give priority to which client history item? 1 Black, tarry stools 2 Frequent nausea 3 Joining Alcoholics Anonymous 4 Pain that increases after meals

1 Black, tarry stools

The nurse is reviewing a plan of care for a client who experienced a traumatic amputation of a leg the previous day. Which intervention listed on the plan is of lowest priority? 1 Teaching residual limb care 2 Monitoring hemoglobin levels 3 Maintaining the compression dressing 4 Using therapeutic interviewing techniques

1 Teaching residual limb care

The nurse is admitting an 8-month-old infant with suspected bacterial meningitis to the hospital. List in order of priority the nursing actions that would be taken. 1.Institute respiratory isolation. 2.Insert an intravenous access device. 3.Assist with a lumbar puncture. 4.Administer the prescribed antibiotics. 5.Monitor for signs of increased intracranial pressure (ICP).

1.Institute respiratory isolation. 2.Insert an intravenous access device. 3.Assist with a lumbar puncture. 4.Administer the prescribed antibiotics. 5.Monitor for signs of increased intracranial pressure (ICP).

After a client with multiple fractures of the left femur is admitted to the hospital for surgery, the client experiences a sudden onset of cyanosis, tachycardia, dyspnea, restlessness, and petechiae on the chest. Which is the priority nursing action? 1 Obtain vital signs. 2 Administer oxygen. 3 Notify the health care provider. 4 Auscultate the client's lung sounds.

2 Administer oxygen.

Which is the priority nursing action for a client admitted to the hospital in a coma after having a stroke? 1 Monitor vital signs. 2 Maintain an open airway. 3 Maintain Fluids and Electrolytes. 4 Monitor pupil size and response.

2 Maintain an open airway.

Which goal is a priority for a client who is unconscious after a cerebrovascular accident? 1 Promoting elimination 2 Maintaining the airway 3 Optimizing fluid volume 4 Preserving skin integrity

2 Maintaining the airway

A 15-year-old with cystic fibrosis (CF) is admitted with a respiratory infection. The nurse determines that the adolescent is cyanotic, has a barrel-shaped chest, and is in the 10th percentile for both height and weight. Which is the priority nursing intervention? 1 Increasing physical activities 2 Performing postural drainage 3 Maintaining dietary restrictions 4 Administering prescribed pancreatic enzymes

2 Performing postural drainage

A client is admitted to the emergency department with a stab wound of the chest. Which is a priority nursing assessment? 1 Level of pain 2 Quality and depth of respirations 3 Amount of serosanguinous drainage 4 Blood pressure and pupillary response

2 Quality and depth of respirations

Which complication is the nurse's main priority during the early postoperative period after a subtotal thyroidectomy? 1 Hemorrhage 2 Thyrotoxic crisis 3 Airway obstruction 4 Hypocalcemic tetany

3 Airway obstruction

Based on the information in the chart of this client who came to the emergency department reporting pink-tinged urine, which nursing action is a priority? 1 Monitor the intake and output. 2 Take apical pulse for a full minute. 3 Institute measures to prevent physical injury. 4 Obtain stool specimen to test for occult blood.

3 Institute measures to prevent physical injury.

During a client's immediate postoperative period after a laryngectomy, which is a nursing priority? 1 Provide emotional support 2 Observe for signs of infection 3 Keep the trachea free of secretions 4 Promote a means of communication

3 Keep the trachea free of secretions

The nurse on the pediatric unit is admitting an adolescent child with acute glomerulonephritis (AGN). Which is the priority nursing intervention? 1 Assessing the child for dysuria 2 Inspecting the child for jaundice 3 Monitoring the child for hypertension 4 Testing the child's vomitus for occult blood

3 Monitoring the child for hypertension

The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral crackles. Which is the priority nursing intervention? 1 Obtain chest x-ray film immediately. 2 Notify the primary health care provider. 3 Place client in a high-Fowler position. 4 Assess the client's oxygen saturation level.

3 Place client in a high-Fowler position.

The nurse is caring for a child who has an external fixation device on the leg. Which is the nurse's priority goal when providing pin care? 1 Easing pain 2 Minimizing scarring 3 Preventing infection 4 Preventing skin breakdown

3 Preventing infection

A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. What are the priority nursing assessments? 1 Level of consciousness and pupil size 2 Characteristics of pain and blood pressure 3 Quality of respirations and presence of pulses 4 Observation of abdominal contusions and other wounds

3 Quality of respirations and presence of pulses

Which is the priority nursing intervention for a client admitted to the hospital with a brain attack (cerebrovascular accident)? 1 Changing position every 2 hours 2 Keeping a serial record of the pulse 3 Performing range-of-motion exercises 4 Monitoring for increased intracranial pressure

4 Monitoring for increased intracranial pressure

The nurse is providing postoperative care to a client who is being weaned from mechanical ventilation. Which is a priority nursing action? 1 Assessing lung sounds every 15 minutes 2 Remaining with the client to assess responses 3 Monitoring the oxygen saturation levels frequently 4 Teaching the family members about ways to keep the client calm

2 Remaining with the client to assess responses

A client receiving chemotherapy develops a temperature of 102.2°F (39°C). The temperature 6 hours ago was 99.2°F (37.3°C). Which nursing intervention is the priority in this case? 1 Assess the amount and color of urine; obtain a specimen for a urinalysis and culture. 2 Administer the prescribed antipyretic and notify the primary health care provider of this change. 3 Note the consistency of respiratory secretions and obtain a specimen for culture and sensitivity. 4 Obtain the respirations, pulse, and blood pressure when rechecking the temperature in 1 hour.

2 Administer the prescribed antipyretic and notify the primary health care provider of this change.

Which is the priority assessment for the client who has Guillain-Barré syndrome with rapidly ascending paralysis? 1 Monitoring urinary output 2 Assessing nutritional status 3 Monitoring respiratory status 4 Assessing communication needs

3 Monitoring respiratory status