Prioritizing Care

The nurse is caring for four different clients in an emergency department. In which order should the nurse care for the clients according to priority for receiving care?

Client reporting shortness of breath Client reporting severe abdominal pain Client reporting a simple hip fracture Client reporting a neck sprain

Which action should the nurse take when caring for clients through a Community-Based Care Transition Program (CCTP)?

Contacting the client and physician through a conference call line to discuss medication issues

Which client would the nurse treat first according to a three-tiered triage system?

Correct1 Client with respiratory distress

A nurse receives a shift report on four adult clients who are between the ages of 25 and 55. Which client should the nurse assess first?

Female client on warfarin (Coumadin) with an international normalized ratio (INR) of 7.5

The nurse is performing a secondary survey systematically for a group of clients during an emergency situation. What is the proper order of this assessment process?

Full set of vital signs Focused adjuncts Facilitating family presence Comfort measures Inspecting posterior surfaces

What is the immediate nursing intervention for a client experiencing autonomic dysreflexia?

Placing the client in a sitting position

Which of the following assessment findings would the nurse state are common integumentary manifestations in clients with acquired immunodeficiency syndrome (AIDS)?

Poor wound healing

A client is receiving a unit of packed red blood cells (PRBC). The client experiences tingling in the fingers and headache. What is the nurse's priority action?

Stop the transfusion.

How soon should a client with multiple traumas receive treatment according to the five-level emergency severity index (ESI)?

Within 10 minutes

The nurse is assisting a client out of bed. Which is the priority nursing action?

Assisting the client from a supine to an upright position

What is the order of steps in which the nurse prioritizes care for a client injured with frostbite?

Observing for signs of frostbite and preventing further tissue damage Rewarming in a water bath at a temperature of 106° F Elevating the injured areas above the heart level Rewarming in a water bath at a temperature of 106° F Assessing for the development of compartment syndrome

A client is admitted to the emergency department with acute abdominal pain due to pelvic inflammatory disease. Which initial nursing intervention is most suitable in this condition?

Obtain a urinalysis.

The nurse is caring for four clients on a medical unit. Which client should the nurse see first?

Client with chest pain

The healthcare team is caring for four clients in an emergency department. The nurse has been delegated the task to assign tags to the clients. Which client is issued the appropriate tag?

Client with major injuries- yellow tag

What aspect of total client care needs to be taken into consideration if used on a 24-bed care area?

Cost of nurses

The nurse is performing resuscitation interventions for airway, breathing, and circulation as part of a primary survey in a client. Which order of actions should the nurse follow for this client?

Establish airway by positioning, suctioning, and oxygen as needed. Assess breath sounds and respiratory effort. Prepare for chest decompression if needed. Maintain vascular access using a large-bore catheter. Use direct pressure for external bleeding.

Who is responsible for client outcomes in the functional model of care?

Nurse manager

What does the A of the mnemonic "ABCDE" of primary nursing survey stand for?

Airway

The nurse is caring for different clients in a mass casualty event. Which client is assigned the lowest priority for care?

Client with black tag

The client was admitted to the emergency department due to blunt abdominal trauma. Which action should be the nurse initiate first?

Ensuring a patent airway

Which task involves setting up priorities for care?

Managing

The registered nurse is teaching a client who underwent a myringotomy about the care to be taken after surgery. Which statement made by the client indicates the need for further teaching?

"I can wash my hair after 2 days."

Which color tag is used for a client who is expected to die after a disaster with mass casualties?

Black tag

The nurse is assessing a client with hemorrhagic stroke due to a motor bike accident. Which condition of the client requires immediate attention?

Body temperature of 81.2°F

What type of delivery method is used when the nurse provides care to the same client for the entire work period?

Case method

The nurse is assessing a client with severe burn wounds. What are the nursing interventions performed by the nurse in the order of priority?

Checking for a patent airway Maintaining effective circulation Performing adequate fluid replacement Caring for the burn wound

According to Gardner's Tasks of Leading and Managing, within the managing task, which position assists the patient and family with priority setting?

Clinical

Which are considered as nurse competencies within the synergy model of care delivery? Select all that apply.

Collaboration Clinical judgment Cultural competency

Which type of clients are often referred to as the "walking wounded" in a mass casualty scene?

Green tagged clients

A client climbing a mountain experiences symptoms of acute mountain sickness. What is the priority nursing action performed by the nurse as prehospital care?

Having the client descend to lower altitude

The nurse is providing care to a client with a neck and spinal cord injury. Which is the priority when moving this client during the assessment process?

Implementing the logrolling technique

Which order should the nurse follow to detect paradoxical blood pressure in clients with pericarditis?

Palpate the blood pressure. Inflate the cuff above the systolic pressure. Deflate the cuff. Note when sounds are first audible on expiration. Identify when sounds are audible on inspiration. Subtract the inspiratory pressure from expiratory pressure.

The nurse is seeking a position as a clinical nurse leader in a major city hospital. What should the nurse prepare to do in order to secure this type of nursing role? Select all that apply.

Pass the certification exam. Complete a master's degree in nursing.

Which nursing intervention for opening the airway should be performed in an unconscious client with a spinal injury?

Performing a jaw thrust maneuver

What is the priority nursing intervention for a client injured by lightning?

Performing cardiopulmonary resuscitation

The body temperature of a heat stroke client is above 104° F (40° C). What is the priority order the nurse would use for cooling the client so that breathing and circulation are not impaired?

The nurse will take off the client's clothing. The nurse should place ice packs on the neck, axillae, chest, and groin. The nurse should immerse the victim in cold water. The nurse should fan the client rapidly to aid in cooling by evaporation.

The nurse is advising a client to carry a prescription of epinephrine autoinjector. Which insect bite or sting is responsible for the nurse providing this advice?

Wasp

The registered nurse is teaching a student nurse about identifying the different tags in mass causality events to prioritize client care. Which statement made by the student nurse indicates the need for further teaching?

"Clients with a yellow tag should be given highest priority."

Which charge-nurse remark would be expected in a care area that is using team nursing as a care delivery method?

"Have you discussed this client care issue with your team leader?"

Which statement indicates that a nurse is functioning in the role of case manager?

"Outpatient physical therapy at the time you need it is available in the facility across town."

Which factor is known to threaten the nurse's ability to triage and prioritize client care accurately?

A biased approach to care

Which clients are provided with cold compresses as priority nursing interventions? Select all that apply.

A client stung by scorpion A client bitten by black widow spider A client bitten by brown recluse spider

The nurse is preparing to educate a group of clients about health promotion to prevent head and neck cancer. Which clients are of highest priority for education? Select all that apply.

A client who chews tobacco A client who has multiple sex partners A client with a history of alcohol abuse for 5 years

Which client requires nonurgent treatment after a mass casualty incident?

A middle-aged man with skin rash from shaving

The client was admitted to the hospital with low dose amitriptyline poisoning. Which nursing intervention should be provided based on priority?

Administering activated charcoal

What would be the first step in advanced prehospital emergency care for a client stung by a bee? The client has a history of allergic reactions to bee stings.

Administering epinephrine

After assessing a client's reports, the nurse confirms that the client has moderate hypothermia. What should be the nurse's immediate intervention? Select all that apply.

Administering heated oxygen gas Positioning the client in supine position Applying external heat with heating blankets

What are the priority nursing interventions for a grieving client? Select all that apply.

Allowing the client to express feelings Respecting the feelings of the client and creating a comfortable environment

Which primary step should be followed by the nurse when prioritizing care for a hypertensive client?

Assess for a severe headache.

Which is the priority nursing action when providing care to a trauma client?

Assessing respiratory effort

What should be the priority action of the nurse who is caring for a client with a leg in traction?

Assessing the skin integrity

A staff nurse is next in line to be assigned a primary client; however, the nurse is scheduled to be off for the next four work days. What should the nurse manager do?

Assign the client to the nurse who comes after the one leaving for a long weekend.

The registered nurse teaches the student nurse regarding the priority of care provided to clients with chest pain. Which activity performed by the student nurse indicates effective learning?

Correct4 Assessing airway, breathing, and circulation (ABC)

When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the low-Fowler position with the knees slightly bent and encourages the client to lie still. What is the next nursing action?

Cover the wound with a sterile towel moistened with normal saline.

What is the priority nursing care for a client with delirium?

Creating a calm and safe environment

Which assessment data related to the client's airway would indicate the need for priority intervention by the nurse? Select all that apply.

Dyspnea Agonal breaths Inability to speak

A client with multiple injuries due to an accident is admitted into the emergency department. Which is the priority nursing intervention in this situation?

Establishing a patent airway in the client

The emergency department (ED) nurse is providing care to a burn trauma client. Which is the priority for the nurse to monitor for after removing the client's clothing?

Hypothermia

The nurse has accepted a position as a navigator. What should the nurse expect to learn during training for this role? Select all that apply.

Learning ways to work through the health systems Strategies to teach clients about disease, including prevention and treatment Assessing barriers that clients have encountered while attempting to receive care Helping clients cope with delays in receiving treatment until barriers are overcome

A client who was in a motor bike accident has a severe neck injury. Which priority nursing care is most needed?

Maintaining a patent airway

Which health care provider would best help a homeless client receive needed medication for a communicable disease?

Navigator

Which nurse would be the best to create clinical pathways for joint replacement surgeries in an environment that supports differentiated nursing practice?

Nurse with a master's degree who case managed clients in an orthopedic care center

According to the emergency assessment protocol, which are the nursing actions for a client with a chest injury? Select all that apply.

Palpating for bony crepitus Assessing for external signs of injury Observing the rate, depth, and effort of breathing

A client who was in a traffic accident is choking. The nurse suspects that the client may have a spinal cord injury. Which procedure may benefit the client?

Performing jaw-thrust maneuver

Which team member is responsible for 24-hour client care when using an adapted case method?

Primary nurse

Which tag is suitable for a client with high priority during a disaster with mass casualties?

Red

Which tag color according to the disaster triage tag system is assigned to a client who has an immediate threat to life?

Red tag

A nurse in the postanesthesia care unit (PACU) is providing care to a client who had an abdominal cholecystectomy and observes serosanguineous drainage on the abdominal dressing. What is the next nursing action?

Reinforce the dressing.

Which is a theme in the design of "Transforming Care at the Bedside"?

Reliability

The client, who takes part in mountaineering, shows signs of bradycardia along with severe hypotension and a decreased respiratory rate. For which condition is the nurse treating the client?

Severe hypothermia

The nurse is caring for clients who are admitted with injuries due to a bus accident. Which conditions of the clients are prioritized under the emergent classification? Select all that apply.

Shock Airway Obstruction

A client with severe abdominal pain is on meperidine treatment and later develops seizures. Which intervention is given highest priority?

Stop administration of meperidine.

The nurse observes that a client who is on intravenous medication is experiencing an anaphylactic reaction. What is the priority nursing intervention in this situation?

Stop intravenous medication and administer epinephrine (adrenaline).

A client's serum potassium level has increased to 5.8 mEq/L (5.8 mmol/L). What action should the nurse implement first?

Take vital signs and notify the healthcare provider.

What is a high priority assignment in an emergency department when a nurse is providing care for clients during a mass casualty?

Taking inventory and restocking supplies

What is the priority nursing care for a client who is prescribed hydroxychloroquine (Plaquenil)?

Teaching the client to report blurred vision

Which delivery system was developed to provide care through others as an adaptation to functional nursing?

Team

Which member of the healthcare team, when using the team nursing approach, is responsible for prioritizing client care?

Team leader

Which organism would the nurse explain is consistent with a protozoal infection in clients with acquired immunodeficiency syndrome (AIDS)?

Toxoplasmosis

A client with tongue occlusion has loss of gag reflex and alterations in level of consciousness. The blood gas test shows oxygen saturation as 40mm Hg and carbon dioxide saturation as 75 mm Hg. Which type of support provides immediate relief to the client?

Tracheotomy

Which triage classification of clients requires an urgent nursing priority in case of a mass casualty?

Class II

What is the priority nursing intervention for a client bitten by a snake?

Immobilizing the effected extremity using a splint

What term began to be used in the 1960s to describe case management?

Utilization management

Which actions should be completed by the manager of a group of nursing case managers? Select all that apply.

Analyze status of clients' movement through clinical pathways. Match clinical pathway actions with expected diagnostic-related grouping activities. Coordinating communication among all departments in the organization.

A client with severe burns and injuries from a bomb blast is admitted in the emergency unit. Which triaging priority is preferable for the client?

Class I

Which is the priority nursing action when admitting a client to the emergency department during cardiac arrest from ventricular fibrillation?

Initiating defibrillation

Which key feature would the nurse explain indicates malignancy in an acute immunodeficiency syndrome (AIDS) client?

Kaposi sarcoma

A client with a diagnosis of uncontrolled diabetes began receiving furosemide 2 days ago. The nurse reviews the morning lab results and discovers that the client's potassium level is 2.8 mEq/L (Canada: 2.8 mmol/L). What is the most appropriate action for the nurse to take?

Notify the primary healthcare provider of the critically low result.

A health care organization is planning to implement differentiated nursing practice. What should be prepared prior to implementing this care delivery system? Select all that apply.

Salary ranges Position descriptions Expected competencies Degree of participation in decision-making

The nurse is reviewing the amount of drainage on the dressing of a client after discharge from the postanesthesia care unit (PACU). On which area should the nurse focus for this assessment?

Surgical incision site

A client comes to the clinic complaining of a productive cough with copious yellow sputum, fever, and chills for the past 2 days. What is the first thing the nurse should do when caring for this client?

Take the temperature.

Which statement best describes the navigator?

A person who removes barriers to receiving health care

The emergency department (ED) nurse is triaging clients. Which client should be prioritized?

A school-age client with asthma presenting with dyspnea

The registered nurse is teaching a student nurse about caring for clients in emergency conditions. Which client if selected by the student nurse for immediate care would indicate effective learning? Select all that apply.

Client with an active hemorrhage Client with a substernal chest pain

The nurse is caring for four clients who have survived burn injuries from a chemical plant explosion. Which client requires immediate surgical intervention based on priority?

Client with visible thrombosed vessels

There has been a fire in a healthcare facility. How should the nurse respond to the situation? Select all that apply.

The nurse should move bedridden clients from the affected area. The nurse should direct ambulatory clients to walk to a safe location. The nurse should seek to contain the fire by closing the doors and the windows.