NURS 465 practice questions on priority setting

identify the problem

a nurse manager has recently become aware of a conflict between the pharmacy and the staff nurses regarding sending and receiving medications. Which of the following actions should the nurse take first to resolve the conflict?

verbal admonishment

a nurse manager is planning to discipline a nurse after discovering that the nurse was discourteous to a client. Which of the following steps should the nurse manager take first?

approach the man and ask why he is making copies

a nurse manager observes an unknown man in a laboratory coat making copies of a clients medical record. Which of the following actions should the nurse take first?

provide the appropriate PPE to the AP

a nurse sees an assistive personnel entering the room of a client who requires transmission based precautions without using the appropriate PPE. Which of the following actions should the nurse take first?

gloves

a nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment should the nurse remove first?

gloves

a nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following pieces of ppe should the nurse remove first?

a client who was admitted for chest pain and is reporting a new onset of indigestion

a nurse has received change of shift report on a group of clients and is preparing her assignment. Which of the following clients should the nurse asses first?

nucleic acid amplification test

a nurse in a clinic is collecting a history from a client

perform neurological exam`

a nurse in an emergency department is caring for a client who is experiencing acute alcohol withdrawal. which of the following actions should the nurse take first?

administer IV fluids

a nurse in the emergency department is caring for a client who has a 30%burn injury to her lower extremities. Which of the following interventions should the nurse perform first?

continuous contraction lasting 2 min

a nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor

pallor of the toes

a nurse is assessing a client following the application of a leg cast for the treatment of a fracture. If the cast is too tight, which of the following finds should the nurse expect to observe first?

stridor

a nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media

checking capillary refill

a nurse is assessing a client who has a cast in place for a fractured tibia. Which of the following actions should the nurse take first?

cover the wound with a moist, sterile gauze dressing

a nurse is assessing a client who has had staples removed from an abdominal would postoperatively. The nurse notes separation of the wound edges with copius light-brown serous drainage.Which of the following actions should the nurse take first?

stop the infusion of blood

a nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mmHg. Which of the following action should the nurse take first?

report of severe incisional pain

a nurse is assessing a client who returned to the unit 4 hr ago after a partial colectomy. Which of the following findings should the nurse attend to first?

a client asking about his PCA pump that contains morphine

a nurse is assigned a group of clients at the start of the shift. Which of the following clients should the nurse plan to care for first?

ask the parents what caused the bruises

a nurse is bathing a toddler

check the display on the pca pump

a nurse is caring for a client is recieving hydromorphone hcl via pca pmp

set behavioral limits for the client

a nurse is caring for a client who attacked one of her friends and is admitted to the psychiatric unit. Which of the following actions should the nurse first take?

administer oxygen therapy

a nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?

administer the abdominal thrust maneuver

a nurse is caring for a client who develops an airway obstruction from a foreign body but remains conscious. Which of the following actions should the nurse take first?

an infant who has pertussis and is receiving oxygen via nasal cannula

a nurse on a pediatric unit is reviewing her client assignment following the shift report. Which of the following clients should the nurse plan to assess first?

a client admitted 1 hr ago for ectopic pregnancy

a nurse on an obstetrics gynecology unit is planning care for four clients after receiving change of shift report. Which of the following clients should the nurse assess first?

follow safety data sheet instructions

a nurse find radioactive pellets of the floor of the surgical. Which of the following actions should the nurse take first?

assess the client

a client receives a wrong medication. The nurse who made the medication error should take which of the following actions first?

was the area of the puncture with soap and water

a nurse accidentaly sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first?

check for a carotid pulse

a nurse enters an adult client's room and finds him unresponsive. after notifying the rapid response team, which of the following actions should the nurse take first?

summon the code team

a nurse enters an adult clients room and finds him unresponsive. After determining that the client is not breathing and does not have a pulse, Which of the following actions should the nurse take first?

discontinue the existing IV line

while assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen and painful and that the surrounding tissues are hard.

administer epinephrine subcut

a nurse is caring for a client who received an injection of penicillin G procaine

evaluate the firmness of the uterus

a nurse is caring for aclient who gave birth 2 hr ago. The nurse notes taht the clinets blood pressure is 60/50 mmHg. Which of the following actions should the nurse take first?

prevent the client from aspirating

a nurse is caring for client who is vomiting. Which of the following actions should the nurse take first?

a client who had an indewelling urinary catheter removed 5 hr ago and has not voided

a nurse is caring for four clients on medical-surgical unit

check the clients vital signs

a nurse is caring for four clients. After administering morning medication, she realizes that the nifedipine prescribed for one client was inadvertently administered to another client. Which of the following actions should the nurse take first?

determine what the client knows about managing diabetes

a nurse is developing a teaching plan for a client who has a new diagnosis of type 2 diabetes mellitus

check that the client lifts the walker and then places it down in front of her

a nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. To ensure proper use and the safety of the client, which of the following actions should the nurse take first?

position the client supine

a nurse is preparing to discontinue a clients indwelling urinary catheter. which of the following actions should the nurse take first?

determine if the client can bear weight

a nurse is preparing to transfer a client from a bed to a chair. Which of the following actions should the nurse take first?

obtain vital signs for both clients

a nurse is prioritizing care for two clients

a client who told an assistive personnel he is short of breath

a nurse is prioritizing client care after receiving change of shift report. Which of the following clients should the nurse plan to see first?

offer mother private time with the newborn

a nurse is providing care to a mother immediately following a stillbirth delivery. Which of the following actions should the nurse take first?

iron fortified cereal

a nurse is providing teaching to the parent of an infant about introducing solid foods. The nurse should recommend that which of the following foods be introduced first?

collect and organize client data

a nurse is receiving change of shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?

suction the tracheostomy of a client who has copious secretions

a nurse is receiving shift report about a group of assigned clients. which of the following actions should the nurse plan to take first?

raise the side rails of the bed

a nurse in the emergency department is implementing a plan of care for an older adults client who is experiencing delirium tremens. which of the following actions should the nurse take first?

choose the highest level

a nurse is among the first responders to a mass casualty incident and does not know what type of personal protective equipment (PPE) is needed. Which of the following actions should the nurse take?

a client who is at 28 weeks gestation and reports painless vaginal bleeding

a nurse is an antepartum unit is triaging clients. Which of the following clients should the nurse see first?

check the oximeter

a nurse is caring for a client who had an evacuation of a subdural hematoma. Which of the following actions should the nurse take?

realign the clients position

a nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. The client is reporting pain from muscle spasms.Which of the following actions should the nurse take first?

place the client in a sitting position

a nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. which of the following actions should the nurse take first?

assess the clients airway

a nurse is caring for a client who has an endotracheal tube and is receiving mechanical vent

place a seat alarm on the clients chair

a nurse is caring for a client who has dementia. The client is agitated and is having difficulty staying in his chair. Which of the following actions should the nurse take first.

assess orthostatic blood pressure

a nurse is caring for a client who has gastrointestinal bleeding. Which of the following actions should the nurse take first?

perform a bladder scan

a nurse is caring for a client who has not voided for 8 hr following the removal of an indwelling urinary catheter. Which of the follow actions should the nurse take first?

place the client in a high-fowlers position

a nurse is caring for a client who has quadriplegia form a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mmHg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

"What are the voices telling you?"

a nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following responses should the nurse make first?

stop the infusion

a nurse is caring for a client who has streptococcal pneumonia and a prescription for penicillin G by intermittent IV bolus. 10 minutes into the infusion of the third dose, the client reports that the IV site itches and that he feels dizzy and short of breath. Which of the following actions should the nurse take first?

cover the area with a sterile dressing moistened with 0.9% sodium chloride irrigation

a nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help. Which of the following actions should the nurse first take?

massage the clients fundus

a nurse is caring for a client who is 4 hr postpartum following a vaginal birth

check the tubing for kinks

a nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostat. The nurse notes that the clients indwelling urinary catheter has not drained in the past hour. which of the following actions should the nurse take first?

change the clients position

a nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?

turn the client onto her side

a nurse is caring for a client who is in active labor when the clients membranes

insert a gloved hand into the vagina to relieve pressure on the cord

a nurse is caring for a client who is in the first stage of labor.

clear the respiratory tract

a nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?