Prioritization and Delegation
A nurse suspects that the laboring client may have been physically abused by her partner. What is the most appropriate intervention by the nurse? A - Collaborate with the interprofessional team to make a referral to social services B - Contact hospital security to monitor the partner C - Confront the partner D - Question the client in front of her partner
A Collaborating with others in the health care team, and the provider to make a referral to social services will create a plan, and provide support for the client. Additionally, by law, the nurse or nursing supervisor must report the suspected abuse to the police, and follow up with a written report. Confrontation will most likely provoke anger in the suspected abuser. Questioning the woman in front of her partner doesn't allow her the privacy required to address this issue, and may place her in greater danger. If the woman is not in imminent danger, there is no need to call hospital security.
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? A - Apply carotid massage B - Give acetaminophen C - Encourage fluid intake D - Place the infant's hands in cold water
B 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.
The nurse is caring for an eight-year-old child who arrived at the emergency department with chemical burns to both legs. What is the priority intervention for this child? A - Debriding and grafting the burns B - Diluting the chemicals C - Applying topical antibiotics D - Applying sterile dressings
B Diluting the chemical is the priority. It will help remove the chemical and stop the burning process. The remaining treatments are initiated after dilution.
Which client would be considered to be at the highest risk for respiratory failure? A - A client with breast cancer B - A client with Guillain-Barré syndrome C - A client with a fractured hip D - A client with cervical sprains
B 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 woman arrives at the emergency department with a fractured arm. Her husband is constantly present, and the woman appears anxious. What is the nurse's priority action? A - Provide the woman with a written pamphlet about domestic abuse B - Clearly state that all clients are asked about abuse prior to any treatment C - Privately ask the woman if she is being abused D - During triage inquire if the woman is in a safe environment
C It is a priority to privately ask the client if she is being abused. Counseling, or printed resources should be given privately. Clarifying that all clients are asked about abuse prior to any treatment allows for the client to understand why these questions are being asked.
The nurse has just admitted a client to the emergency department for evaluation of a possible myocardial infarction (MI). Which diagnostic intervention, by the nurse, would be priority? A - Echocardiogram B - Cardiac catheterization C - Cardiac enzymes D - Electrocardiogram (ECG)
D An ECG is the quickest, most accurate, and most widely used tool to determine the location of MI. Cardiac catheterization is an invasive study used to determine coronary artery disease. While it may also indicate the location of myocardial damage, the study may not be performed initially. Cardiac enzymes are used to diagnose MI but do not determine the location. An echocardiogram is used to view myocardial wall function after an MI has been diagnosed.
A mother calls the health clinic and tells the nurse that she found her toddler with an open and empty bottle of acetaminophen. The mother asks the nurse what she should do. What is the nurse's priority intervention? A - Have the mother give the child syrup of ipecac B - Determine whether the mother knows cardiopulmonary resuscitation (CPR) C - Tell the mother to get the child to drink a glass of milk D - Give the mother instructions on how to call poison control
D The mother should call poison control and ask what immediate steps she should take to treat this ingestion. Home administration of syrup of ipecac is no longer recommended. Milk is not an antidote for acetaminophen toxicity. Asking about CPR is not appropriate since it would distract from the immediate interventions needed.
A nurse is assessing the fundus of a client who is 12 hours postpartum, and finds that the fundus is boggy. Which action should the nurse take first? A - Administer blood replacement products B - Prepare the client for surgery C - Administer methylergonovine, as ordered D - Massage the fundus
D The nurse should first massage the boggy uterus to stimulate it to contract. The client may need surgery but only if other measures fail to cause the uterus to contract and control bleeding. Blood replacement products may be given if the client has a significant blood loss. Methylergonovine may be ordered if massage fails to firm the uterus.
The nurse is caring for a client with terminal lung cancer. What is the priority nursing intervention for this client? A - Provide pain control. B - Provide nutritional support. C - Prepare the client's will. D - Provide emotional support.
A A client, with terminal lung cancer, may have extreme pleuritic pain and should be treated to reduce his discomfort. Preparing the client and their family for impending death and providing emotional support are also important, but shouldn't be the primary focus until the pain is under control. Nutritional support may be provided, but as the terminal phase advances, the client's nutritional needs greatly decrease. Nursing care doesn't focus on helping the client prepare a will.
A mother reports that her school-age child has been reprimanded for daydreaming during class. The mother is concerned because her other child has been diagnosed with absence seizures. This behavior is new, and the child's grades are dropping. What is the most appropriate action by the nurse? A - Refer the child to the primary health care provider to assess for absence seizures B - Refer the child to an audiologist for a hearing assessment C - Refer the child to the primary care provider to assess for attention deficit hyperactivity disorder (ADHD) D - Refer the child to the special education department to assess for a learning disability
A Absence seizures are commonly misinterpreted as daydreaming. The child loses awareness, but no alteration in motor activity is exhibited. A mild hearing problem usually presents as leaning forward, talking loudly, increasing the volume of the TV and radio, and continually asking, "What?" There isn't enough information to indicate a learning disability. ADHD isn't characterized by episodes of daydreaming.
Which nursing intervention is priority for a pregnant adolescent during her first trimester? A - Refer the client to a dietitian for nutritional counseling B - Tell the client that she will most likely need a cesarean birth due to the head size of the fetus C - Assess the client for signs and symptoms of placenta previa D - Schedule the client for a screening glucose tolerance test
A 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 child with hemophilia is hospitalized with bleeding into the knee. Which action should the nurse take first? A - Elevate the affected part B - Prepare to administer a plasma transfusion C - Prepare to administer a whole blood transfusion D - Perform active range-of-motion (ROM) exercise on the affected part
A Bleeding into the joint is the most common type of bleeding episode in the more severe forms of hemophilia. Elevating the affected part and applying pressure and cold are indicated. The nurse should anticipate transfusing the missing clotting factor rather than whole blood or plasma, which won't stop the bleeding promptly, and may pose a risk of fluid overload. Active ROM exercises are contraindicated because they may cause more bleeding, injury, and pain.
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 - A client who needs assistance with colostomy irrigation B - A client who has C3 to C5 spine injury C - A client who just had coronary artery bypass graft (CABG) D - A client who is receiving glargine subcutaneously E - A client who needs initial admission assessment
A D 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 caring for a neonate diagnosed with diabetes insipidus. Which assessment finding would warrant an immediate intervention? A - Weight loss B - Increased head circumference C - Increased feeding D - Edema
A Diabetes insipidus has a slow progression. Weight loss can occur when there is a large loss of fluid. Edema isn't evident in the neonate with diabetes insipidus. There should be an increase in head circumference with treatment. A normal neonate should gain weight as he grows. Increased feeding is a positive finding.
Which client would benefit most from information explaining the importance of receiving an annual Papanicolaou (PAP) test? A - A client infected with the human papillomavirus (HPV) B - A client who has used oral contraceptives for 27 years C - A client with a history of recurrent candidiasis D - A client who had her first pregnancy before the age of 20
A HPV causes genital warts, which are associated with an increased incidence of cervical cancer. Recurrent candidiasis, pregnancy before age 20, and the use of oral contraceptives have not been shown to increase the risk of cervical cancer.
A client is admitted to the labor and delivery unit in labor with blood flowing down her legs. What would be the priority nursing intervention? A - Monitor fetal heart tones B - Place an indwelling catheter C - Perform a cervical examination D - Prepare the client for cesarean birth
A Monitoring fetal heart tones would be the priority, due to a possible placenta previa or abruptio placentae. Although an indwelling catheter may be placed, it is not a priority intervention. Performing a cervical examination would be contraindicated because any agitation of the cervix with a previa can result in hemorrhage and death for the mother or fetus. Preparing the client for a cesarean birth may not be indicated. A sonogram will need to be performed to determine the cause of bleeding. If the diagnosis is a partial placenta previa, the client may still be able to deliver vaginally.
The nurse is ambulating a client. The client experiences chest pain after ambulating 50 feet. What is the nurse's priority intervention? A - Sit the client down B - Get the client back to bed C - Administer the ordered sublingual nitroglycerin D - Obtain an electrocardiogram (ECG)
A The priority is to decrease oxygen consumption by sitting this client down. When the client's condition is stabilized, he can be returned to bed. An ECG can be obtained after the client is sitting down, and the ordered sublingual nitroglycerin could be administered.
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? A - Maintain the client on respiratory isolation B - Prepare the client to be discharged on bed rest C - Administer the tuberculin test ordered by the health care provider D - Administer the isoniazid ordered by the health care provider immediately before discharge
A 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.
The nurse is planning care for an infant with bronchiolitis. What is the nurse's priority intervention for this child? A - Position the infant with the head elevated B - Assess respiratory status frequently C - Incorporate parents into the child's care D - Monitor intake and output
B 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.
A 49-year-old client is admitted to the emergency department frightened and reporting that he hears voices telling him to do bad things. Which intervention should be the nurse's priority? A - Reassure the client that he is safe and that the voices are not real B - Assess the nature of the commands by asking what the voices are saying C - Administer a neuroleptic medication before speaking with the client D - Tell the client he is safe now and promise the staff will protect him
B 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 she may not be able to fulfill. The provider may order a neuroleptic, but the nurse's priority is to address safety.
A nurse finds a client crying after she was told by the health care provider that she is to start hemodialysis to treat her acute renal failure. What is the nurse's most important intervention? A - Refer the client to the hemodialysis team B - Sit quietly with the client C - Discuss with the client the other abilities she has D - Remind the client this is a temporary situation
B 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 assessing a client 22 hours after a cesarean birth. Which assessment finding would require immediate action by the nurse? A - A gush of blood from the vagina when the client stands up B - Heart rate of 132 beats/min and blood pressure of 84/60 mmHg C - Oral temperature of 100.2° F (37.9º C) D - Reports of abdominal pain and cramping SUBMIT ANSWER
B Tachycardia and hypotension may be signs of hemorrhage. An oral temperature of 100.2° F (37.9º C) may be due to dehydration, if it occurs on the first postpartum day. A gush of blood from the vagina when a client stands is a normal finding on the first postpartum day. Reports of abdominal pain and cramping are expected following cesarean birth.
A client is undergoing peritoneal dialysis. The dialysate dwell time is completed, and the clamp is opened to allow the dialysate to drain. The nurse notes 1,500 ml was instilled, but only 500 ml has drained. Which intervention should be done first? A - Clamp the catheter and instill more dialysate at the next exchange time B - Assess the catheter for kinks or obstruction C - Change the client's position D - Call the health care provider
B The first intervention should be to check for kinks and obstructions because that could be preventing drainage. After checking for kinks, the client should change position to promote drainage. Don't give the next scheduled exchange until the dialysate is drained because abdominal distention will occur, unless the output is within the parameters set by the health care provider. If unable to get more output despite checking for kinks and changing the client's position, the nurse should then call the health care provider to determine another intervention.
A client has received an infusion of antibiotics and is now experiencing an anaphylactic reaction. What is the most important intervention by the nurse? A - Administer epinephrine B - Maintain a patent airway C - Monitor vital signs D - Administer a bolus of normal saline solution
B 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.
The nurse is assigned to care for four clients. Which client should the nurse see first? A - A client with paranoid personality disorder client who refuses to attend the community morning meeting B - A client with borderline personality disorder who continues to talk about wanting to cut her arms C - A divorced client with a dependent personality disorder who is seeking care from another client D - A client with an avoidant personality disorder who refuses to go to groups on the unit
B The nurse has to address the physical safety of the borderline personality disorder client first. The behaviors of the other three clients with personality disorders affect the milieu of the unit and can be addressed later.
The nurse is assessing a client during a home health visit. The client reports a severe burning on urination. What is the most important action by the nurse? A - Have the client drink 2,500 to 3,000 ml of water per day B - Obtain a urine specimen from the client C - Have the client drink cranberry juice D - Have the client take a sitz bath twice daily
B Though it is suspected that the client has a urinary tract infection (UTI), a urine specimen is needed to determine specific treatment. After obtaining the specimen, comfort measures can be provided pending the results which may take 24 to 72 hours. Drinking large amounts of water will help flush bacteria from the urinary tract, but it is not bacteria specific. Cranberry juice increases the acidity of urine and helps to prevent UTIs; however, it does little to treat a UTI. A sitz bath may provide comfort but does not address the priority need.
A nurse is caring for a client exhibiting mild contractions and a cervical dilation of 4 cm. Using an external fetal monitor, the nurse observes variable decelerations. Which action should the nurse take first? A - Prepare for imminent birth B - Place the client on her left side C - Increase the IV rate D - Administer oxygen by face mask
B Variable decelerations in fetal heart rate are caused by compression of the umbilical cord. Typically, variable decelerations are corrected by placing the client in a left lateral position to alleviate cord pressure. Since variable decelerations are usually transient and correctable, the nurse would not prepare for an imminent birth. Increasing the IV rate is not needed or ordered. If other measures have been ineffective in correcting the variable deceleration, oxygen may be administered.
A nurse is planning preoperative care for a child diagnosed with Wilms' tumor. What is the nurse's most important intervention? A - Prepare the family for the initiation of chemotherapy and radiation B - Insert a nasogastric tube for enteral feedings C - Avoid abdominal palpation or manipulation D - Begin IV therapy of hyperalimentation and lipids
C 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 reports an inability to sleep while on the medical unit. Which intervention should the nurse perform first? A - Give the client a backrub before bedtime B - Move the client to a bed farthest from the nurses' station C - Inquire about the client's sleeping habits D - Offer a sedative routinely at bedtime
C 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.
The nurse is caring for a client with type 1 diabetes mellitus. At 3:00 AM, the nurse finds the client disoriented to time and place, diaphoretic, and complaining of palpitations. What is the nurse's priority intervention? A - Call the healthcare provider for additional insulin order B - Give 10 to15 g of carbohydrate orally C - Check blood glucose level D - Administer 1 mg of glucagon subcutaneously
C Check the blood glucose level first when symptoms arise, then proceed with treatment according to the results. If the client is hypoglycemic, administration of a simple carbohydrate is appropriate. If the client is conscious, the carbohydrate may be given orally. If consciousness is altered, subcutaneous or intramuscular glucagon is appropriate. This client is showing symptoms of hypoglycemia, additional insulin would further lower the blood glucose.
Which client would be considered to be at the highest risk for respiratory failure? A - A client with a fractured hip B - A client with breast cancer C - A client with Guillain-Barré syndrome D - A client with cervical sprains
C 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.
Which client would benefit most from information explaining the importance of receiving an annual Papanicolaou (PAP) test? A - A client who had her first pregnancy before the age of 20 B - A client with a history of recurrent candidiasis C - A client infected with the human papillomavirus (HPV) D - A client who has used oral contraceptives for 27 years
C HPV causes genital warts, which are associated with an increased incidence of cervical cancer. Recurrent candidiasis, pregnancy before age 20, and the use of oral contraceptives have not been shown to increase the risk of cervical cancer.
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? A - Call the health care provider immediately B - Have the charge nurse review the assessment C - Ask the client when she last changed her perineal pad D - Vigorously massage the fundus
C 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.
What is the nurse's priority action when a neighbor frantically rushes over and states, "My child has just been bitten by a dog!" A - Immediately administer antibiotics B - Nothing; bites from dogs have a low incidence of infection C - Clean and irrigate the wounds D - Administer a rabies vaccine
C Not every dog bite requires antibiotic therapy, but cleaning the wound is necessary for all injuries involving a break in the skin. Rabies vaccine is used if there is suspicion that the dog has rabies. The infection rate for dog bites has been reported to be as high as 50%.
A nurse, working in the triage area of an emergency department, sees several pediatric clients arrive simultaneously. Which client should be treated first? A - A two-year-old child with stridorous breath sounds, sitting up and drooling B - A crying four-year-old child with a laceration on his scalp C - A three-year-old child with Down syndrome who's pale and asleep D - A three-year-old child with a barking cough and flushed appearance
C The child with the airway emergency should be treated first because of the risk of epiglottitis. The three-year-old with the barking cough and fever should be suspected of having croup and should be seen promptly, as should the child with the laceration. The nurse would need to gather information about the child with Down syndrome to determine the priority of care.
Which client, diagnosed with pneumonia, is most likely to have community-acquired pneumonia? A - A client who has had multiple family visitors B - A client who recently traveled on a cruise ship C - A client newly admitted to a long-term care facility D - A client whose spouse recently died
C 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 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? A - Family history of sexually transmitted infection (STIs) B - Name of insurance provider C - Date of last menstrual period (LMP) D - Number of and ages of previous children
C 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 seven-year-old child who ingested several leaves of a poisonous plant has arrived in the emergency department. What is the priority nursing intervention? A - Provide emotional support to the child B - Begin teaching accident prevention C - Be prepared for immediate intervention D - Provide emotional support to the parents
C Time and speed are critical factors in stabilizing the child. The remaining three answers are important nursing functions but don't require the immediate.
A client with an uncomplicated, term pregnancy arrives at the labor-and-delivery unit in early labor saying that she thinks her water has broken. What is the nurse's best action? A - Collect a sample of the fluid for microbial analysis B - Prepare the woman for birth C - Immediately contact the provider D - Ask what time this happened and note the color, amount, and odor of the fluid
D Gather more information. Noting the color, amount, and odor of the fluid, as well as the time of rupture, will help guide the nurse in her next action. There's no need to immediately call the client's provider or prepare this client for birth if the fluid is clear and birth isn't imminent. Rupture of membranes isn't unusual in the early stages of labor. Fluid collection for microbial analysis is not routine if there's no concern for infection.
The nurse is caring for a client in the post anesthesia care unit (PACU) following an adrenalectomy. What is the nurse's priority action? A - Assessing serum potassium B - Administering opioids C - Administering dextrose in water D - Assessing blood pressure
D Removing a major source of adrenal hormones may cause a state of temporary adrenal insufficiency. After an adrenalectomy, the patient is usually sent to a critical care unit. Immediately after surgery, the patient should be assessed every 15 minutes for shock due to possible insufficient glucocorticoid replacement. Assessment is a priority over interventions. Assess the blood pressure, then electrolytes, and finally assess the client for fluid replacement and pain management needs.
The nurse is preparing to discharge a client with asthma. Which intervention is most important for the nurse to perform prior to discharge? A - Arrange for a thorough, deep cleaning of the home B - Counsel the family in making arrangements to remove the family pet C - Discuss appropriate sports activities that the child can be involved in D - Obtain additional equipment and medication that can be provided at the school
D The child needs to have equipment and medication available at school to treat and prevent asthma attacks. A discussion should be held with the child and family to motivate the child to be involved in as many normal childhood activities as possible. The house should be kept as clean as possible to prevent exacerbations due to dust and pet dander. If the child is allergic to the family pet, the nurse should provide counseling on ways to minimize the risks.
The nurse is providing community education to a group of clients about the prevention of type 2 diabetes mellitus. Which client would be at highest risk for the development of diabetes mellitus? A - A middle-age woman who delivers mail B - A young adult who plays basketball regularly C - A middle-age man with a basal metabolic rate within normal limits D - An elderly woman who is sedentary
D The risk for developing type 2 diabetes mellitus is increased in clients over 65 years of age. Maintaining a normal weight and basal metabolic rate, along with exercise decrease the risk. The risk is increased with a lack of exercise.
