silvestri study set alt format proiity order 02/14/23
The nurse is triaging clients in the waiting room of the emergency department. In what order would the nurse triage the clients from highest priority to lowest? 12341.A client with a history of hypertension who is complaining of dizziness2.A client who fell off a ladder who has a superficial wound on the forehead3.A client who is complaining of paresthesia and of having difficulty when swallowing4.A client who ran out of medication and is requesting to see a primary health care provider
Triage systems help identify and prioritize who needs to be treated first. Those clients or diagnoses that require immediate care are prioritized first, including life-threatening situations. Client 3 is complaining of paresthesia, or a "pins and needles" feeling, and of difficulty in swallowing. This is potentially an airway emergency and needs to be treated immediately as an anaphylactic reaction can progress to shock if left untreated. Client 1 may be having a hypertensive episode and needs to be seen next. Client 2 has a superficial wound and would be treated next. Finally, client 4 is seeking a PHCP to help get a prescription refilled and does not require immediate attention.
The nurse has determined that a postpartum client has uterine atony. The nurse would take actions in which priority order? Arrange the actions in the priority order that they would be done. All options must be used. 1.Monitor vital signs.2.Contact the primary health care provider.3.Check the amount of drainage on the peripad.4.Massage the uterus attempting to achieve firmness.
When uterine atony occurs, the first nursing action would be to massage the uterus until firm. If this does not assist in controlling blood loss, the primary health care provider is notified. In addition, once bleeding is under control, the nurse needs to monitor the vital signs and then estimate the amount of blood loss
A client is brought into the emergency department for suspected tricyclic antidepressant overdose. Place the actions that the nurse would take in order of priority. All options must be used. 1.Administer oxygen.2.Check and monitor vital signs.3.Obtain an electrocardiogram.4.Check airway and maintain patency.5.Prepare gastric lavage with activated charcoal.6.Prepare to administer prescribed medications.
A tricyclic antidepressant overdose can be life threatening. Signs and symptoms include dysrhythmias, including tachycardia, intraventricular blocks, complete atrioventricular block, and ventricular fibrillation; hypothermia; flushing; dry mouth; dilation of the pupils; confusion, agitation, and hallucinations; and seizures followed by coma. The immediate action is to check the airway and institute measures such as oxygen to maintain an adequate oxygenation level. Vital signs are checked and monitored, and an electrocardiogram is obtained to check for dysrhythmias. Gastric lavage with activated charcoal is done to prevent further absorption of the medication. Medications to counteract anticholinergic effects may be prescribed, as well as antidysrhythmics. The nurse documents the event, actions taken, and the client's response.
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, what actions would the nurse take? Arrange the actions in the order that they would be performed. All options must be used. 1.Administer oxygen.2.Document the occurrence.3.Take the client's vital signs.4.Clamp the intravenous (IV) catheter.5.Contact the primary health care provider (PHCP).6.Position the client in a left Trendelenburg's position.
Air embolism occurs when air enters the catheter system during IV tubing changes or when the IV tubing disconnects. Air embolism is a critical situation. If air embolism is suspected, the nurse would first clamp the IV catheter to prevent further introduction of air and the air embolism from traveling through the heart to the pulmonary system. The nurse would next place the client in a left side-lying position with the head lower than the feet (to trap air in the right side of the heart). The nurse would notify the PHCP and administer oxygen as prescribed. The nurse would monitor the client closely and take the client's vital signs. Finally, the nurse documents the occurrence.
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 would the nurse plan the actions to take? Arrange the actions in the order that they would be performed. All options must be used. 1.Reposition the client.2.Stop the oxytocin infusion.3.Perform a vaginal examination.4.Check the client's blood pressure.5.Administer oxygen by face mask at 8 to 10 L/min.6.Administer medication as prescribed to reduce uterine activity.
If uterine hypertonicity occurs, the nurse would immediately intervene to reduce uterine activity and increase fetal oxygenation. The nurse would stop the oxytocin infusion and increase the rate of the no additive solution, position the client in a side-lying position, and administer oxygen by face mask at 8 to 10 L/min. The nurse then would attempt to determine the cause of the uterine hypertonicity and perform a vaginal examination to check for a prolapsed cord. The nurse would then check the blood pressure for the presence of hypertension or hypotension. The nurse stays with the client and contacts the primary health care provider (PHCP) as soon as possible (or asks another nurse to contact the PHCP) and then implements the PHCP's prescriptions, including the administration of medications to reduce uterine activity.
The nurse is assigned to the following clients. The nurse would assess the clients in which order of priority? Place the client in the order of priority for assessment. All options must be used. 1.A client who is undergoing surgery for a hysterectomy on the following day2.A client admitted to the hospital for observation who has absent bowel sounds3.A client with heart failure who has a 4-lb weight gain since yesterday and is experiencing shortness of breath4.A 24-hour postoperative client who had a wedge resection of the lung and has a closed chest tube drainage system
The nurse determines the order of priority by considering the needs of the client. The clients with problems related to the cardiac system or respiratory system are the high priorities. However, the client with heart failure is the first priority because this client is experiencing shortness of breath (life threatening). There is no indication that the client with a closed chest tube drainage system is experiencing any difficulty, so this client would be the second priority. Because absent bowel sounds could be an indication of a bowel obstruction (intermediate priority), this client would be the nurse's third priority. The client who is undergoing surgery for a hysterectomy on the following day would be the last priority (low priority), and the nurse would assess this client and prepare this client for surgery after other clients are assessed.
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 would the nurse take to perform this procedure? Arrange the actions in the order that they would be performed. All options must be used. 1.Hyperoxygenate the client.2.Place the client in a semi-Fowler's position.3.Attach the suction tubing to the suction catheter.4.Turn on the suction device and set the regulator at 80 mm Hg.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 positions the client first and then prepares the necessary equipment before donning gloves. The nurse hyperoxygenates the client both before and after suctioning. Next, the nurse inserts the catheter into the tracheostomy until resistance is met and then pulls it back 1 cm, applies intermittent suction, and slowly withdraws the catheter while rotating it back and forth. The catheter is then rinsed, and the nurse performs oropharyngeal suctioning to clear the upper airways; the catheter is contaminated after the oropharyngeal area is suctioned.
In order by priority, place the nursing actions that would be taken for a pediatric client in the event of poison ingestion. All options must be used. 1.Administer the antidote prescribed.2.Assess the ABCs—airway, breathing, and circulation.3.Begin cardiopulmonary resuscitation if necessary.4.Empty mouth of pills, if present, or flush skin or body part exposed.5.Identify the poison by asking parents or witnesses to the ingestion.
In the event of a poisoning, the nurse treats the child first, not the poison. The ABCs—airway, breathing, and circulation—and vital signs are assessed. Cardiopulmonary resuscitation is initiated immediately if necessary. Exposure to the poison is terminated next, such as emptying the mouth of pills or other materials or flushing the skin or other body area. Then the poison is identified by questioning the parents or witnesses of the event to determine the appropriate treatment. The nurse administers the antidote or takes other measures as prescribed by the primary health care provider, such as administering activated charcoal. The nurse documents the occurrence, assessment findings, poison ingested, treatment measures, and the child's response.
The nurse is caring for a pediatric client who is recovering from abuse and neglect. Place in order of priority the interventions that the nurse performs. All options must be used. Clean and dress wounds2.Provide emotional support3.Administer pain medications4.Ensure environmental safety
nterventions that may be performed by the nurse when caring for a client who is a victim of abuse or neglect include administering pain medications, providing wound care, using assistive devices to support sprains or fractures, and educating the client and family about self-care, as well as education on support programs that provide awareness and emotional support. Also, ensuring that the victim is in a safe environment both in the hospital and when the victim is discharged is a priority. Administering pain medications and cleaning and dressing wounds need to be done first, followed by ensuring environmental safety and providing emotional support.
A confrontation test is prescribed for a client seen in the eye and ear clinic. How would the nurse perform this test? Arrange the actions in the order that they would be performed. All options must be used. 1.Asks the client to cover one eye2.Examiner covers eye opposite to the eye covered by the client3.Asks the client to report when object is first noted4.Stands 2 to 3 ft (60 to 90 cm) in front of client and faces the client5.The examiner brings in an object gradually from periphery
The confrontation test is a gross measure of peripheral vision. It compares the person's peripheral vision with the examiner's, whose vision is assumed to be normal. If the client does not see the object at the same time as the nurse, peripheral field loss is expected. The client needs to be referred to an eye care specialist. The procedure is conducted in the following order: stand 2 to 3 ft (60 to 90 cm) in front of the client and face the client; client covers one eye on request; nurse covers the eye opposite the one covered by the client; an object is gradually brought inward from the periphery; and the client reports when the object is first noted.
The nurse is caring for a client receiving hemodialysis. The client begins to experience dyspnea, tachypnea, chest pain, low oxygen saturation, and hypotension. The nurse suspects an air embolism. Place the actions that the nurse would take in order of priority. All options must be used. 1.Assess vital signs.2.Administer oxygen.3.Stop the hemodialysis.4.Document the event and the client's response.5.Notify the primary health care provider.6.Turn the client on the left side, with the head down.
Air embolism occurs when air enters the catheter system and is a complication of hemodialysis. The signs of air embolism include dyspnea, tachypnea, chest pain, hypotension, reduced oxygen saturation, cyanosis, anxiety, and changes in sensorium. Air embolism is a critical situation and if it is suspected, hemodialysis is stopped immediately, and the client would be placed in a left side-lying position with the head lower than the feet. This position is used to try to prevent the air from traveling as a bolus to the lungs by trapping it in the right side of the heart. The primary health care provider is notified immediately, and oxygen is administered. Vital signs, including pulse oximetry, are assessed, and other prescribed interventions are done. The event, actions taken, and the client's response are documented.
After correctly completing the rights of medication administration, performing hand hygiene, and ensuring the correct position of the client, which steps would the nurse take to administer medication via a volume control container? Arrange the actions in the order that they would be performed. All options must be used. 1.Clean injection port on top of volume control container with an antiseptic swab.2.Close the clamp and check to be sure that clamp on air vent volume control container is open.3.Regulate intravenous (IV) infusion rate to allow medication to infuse in the time recommended by institutional policies.4.Dispose of the syringe in puncture-proof and leak-proof container. Discard supplies and perform hand hygiene.5.Fill volume control container with desired amount of IV fluid by opening clamp between volume control container and main IV bag.
An organized procedure is used to administer medication via a volume control container. Institutional procedures are always followed. This procedure is as follows: (1) Fill the volume control container with desired amount of IV fluid by opening the clamp between the volume control container and main IV bag. (2) Close the clamp, and check to be sure that the clamp on the air vent volume control container is open. (3) Clean injection port on top of volume control container with an antiseptic swab. (4) Remove needle cap, insert needleless syringe tip through the port, and then inject the medication. Label the volume control container with the name of the medication, dosage, total volume including diluents, and time of administration. (5) Regulate the IV infusion rate to allow medication to infuse in the time recommended by institutional policies. (6) Dispose of the syringe in a puncture-proof and leak-proof container. Discard supplies and perform hand hygiene.
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 would be performed. All options must be used. 1.Raise the head of the bed.2.Check for bladder distention.3.Contact the primary health care provider (PHCP).4.Loosen tight clothing on the client.5.Administer an antihypertensive medication.6.Document the occurrence, treatment, and response.
Autonomic dysreflexia is characterized by severe hypertension, bradycardia, severe headache, nasal stuffiness, and flushing. The cause is a noxious stimulus, most often a distended bladder or constipation. Autonomic dysreflexia is a neurological emergency and must be treated promptly to prevent a hypertensive stroke. Immediate nursing actions are to sit the client up in bed in a high-Fowler's position and to remove the noxious stimulus. The nurse would loosen any tight clothing and then check for bladder distention. If the client has a Foley catheter, the nurse would check for kinks in the tubing. The nurse also would check for a fecal impaction and would disimpact the client, if necessary. The PHCP is then contacted, especially if these actions do not relieve the signs and symptoms. Antihypertensive medication may be prescribed by the PHCP to minimize cerebral hypertension. Finally, the nurse documents the occurrence, treatment, and client response.
A client involved in a head-on automobile crash has awakened from a coma and asks for the spouse,, who was killed in the same accident. The family does not want the client to know at this time that the spouse has died. The family wants all nursing staff to tell the client that the spouse 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 would the nurse take to systematically process this ethical dilemma? Arrange in order the steps for systematic processing of the ethical dilemma. All options must be used. 1.Evaluate the action.2.Verbalize the problem.3.Negotiate the outcome.4.Consider possible courses of action.5.Gather all information relevant to the case.6.Examine and determine one's own values on the issues.
Ethical reasoning is the process of thinking through what one ought to do in an orderly and systematic manner to provide justification for actions based on principles. First, the nurse determines whether the issue involves an ethical dilemma and gathers information that is relevant to the case. Second, the nurse undertakes personal value clarification and identifies their own values regarding the issue. Third, the nurse verbalizes the problem in a simple sentence. Fourth, the nurse considers possible courses of action. In this case, the nurse may choose to seek the counsel of the agency's ethicist regarding the issue. Fifth, the nurse negotiates the outcome by developing confidence in their own point of view with deep respect for the opinions of others. In this case, the nurse may negotiate with the family to determine a course of action that would allow the nurse to preserve integrity yet allow the family to determine when the client would be informed of the tragic loss. Finally, the nurse evaluates the action.
In order of priority, how would the nurse perform abdominal thrusts on an unconscious adult? Arrange the actions in the order that they would be performed. All options must be used. 1.Open the airway.2.Attempt ventilation.3.Assess unconsciousness.4.Perform abdominal thrusts.5.Look in the mouth and remove the object blocking the airway, if seen.
For health care providers, the sequence for removing a foreign body airway obstruction in an adult is as follows. After determining unconsciousness, the airway is opened and the rescuer looks into the mouth of the victim and removes the object blocking the airway, if it is seen. Next, the rescuer attempts to ventilate the victim. If unsuccessful, the victim's head is repositioned and ventilation is reattempted. Five abdominal thrusts are then delivered. The sequence is repeated until successful.
The nurse is caring for a client who is scheduled for a liver biopsy. What is the priority order of actions for the nurse to take for the procedure? All options must be used. 1.Position the client supine, with the right side of the upper abdomen exposed; the client's right arm is raised and extended behind the head.2.Remain with the client throughout the procedure.3.Ensure that informed consent has been obtained.4.Assist the client into a right lateral (side-lying) position, and place a small pillow under the puncture site.5.Monitor vital signs closely and monitor for signs of bleeding.6.Explain the procedure to the client.
For the client undergoing liver biopsy (or any invasive procedure), the procedure is explained to the client and informed consent is obtained by the primary health care provider performing the procedure. Since the liver is located on the right side of the upper abdomen, the client is positioned supine, with the right side of the upper abdomen exposed. In addition, the right arm is raised and extended behind the head and over the left shoulder. This position provides for maximal exposure of the right intercostal spaces. The nurse remains with the client during the procedure to provide emotional support and comfort. After the procedure, the client is assisted into a right lateral (side-lying) position, and a small pillow or folded towel is placed under the puncture site for at least 3 hours, or as prescribed, to provide pressure to the site and prevent bleeding. Vital signs are monitored closely after the procedure, and the client is monitored for signs of bleeding. The nurse documents appropriate information about the procedure, the client's tolerance, and postprocedure assessment findings.
The nurse is caring for an infant client with tetralogy of Fallot who is experiencing a hypercyanotic spell. Place the actions the nurse would take in order of priority. All options must be used. 1.Administer 100% oxygen.2.Place the infant in a knee-chest position.3.Administer morphine sulfate as prescribed.4.Document the occurrence, actions taken, and the infant's response.5.Administer fluids intravenously.
Hypercyanotic spells are also known as tet spells or blue spells and occur in infants or children with certain types of heart defects. The infant or child becomes acutely cyanotic and hyperpneic because of the sudden infundibular spasm. These spells may occur as a result of stressful procedures or from feeding, crying, or defecation. If a spell occurs, the nurse needs to provide a calm and comforting approach while immediately placing the infant in the knee-chest position; this assists breathing and increases oxygenation to body tissues. Oxygen is administered by face mask or blow-by. Morphine sulfate is administered as prescribed subcutaneously or through an existing intravenous line (morphine sulfate helps to reduce the infundibular spasm). Intravenous fluids are administered to replace fluids and to keep the infant well hydrated and to keep the hematocrit and blood viscosity within acceptable limits. Depending on the infant's response, a repeated dose of morphine sulfate may be prescribed. Finally, the nurse documents the occurrence, actions taken, and the infant's response.
List in order of priority the actions the nurse would take when a client in labor is experiencing eclampsia? 1.Remain with the client.2.Monitor fetal heart rate patterns.3.Administer medications to control seizure.4.Document the occurrence, client's response, and outcome.5.Insert an oral airway after the seizure ends and suction the client's mouth.6.Ensure that the client's airway is open, turn the client to the side, and provide 8 to 10 L/min of oxygen.
If eclampsia occurs, the nurse remains with the client and calls for help. The nurse ensures an open airway. If the client is not on the side already, the nurse attempts to turn the client on the side. The side-lying position permits greater circulation through the placenta and may help to prevent aspiration. The nurse administers oxygen by face mask at 8 to 10 L/min to ensure adequate placental oxygenation. The nurse also notes the time the seizure began and the duration of the seizure and protects the client from injury during the event. The nurse monitors fetal heart rate patterns closely and administers medications as prescribed (magnesium sulfate may be prescribed). After the seizure has ended, the nurse inserts an oral airway to maintain airway patency and suctions the client's mouth as needed. If warranted, the nurse prepares for the delivery of the fetus after stabilization of the client. The nurse documents the occurrence, the client's response, and the outcome.
The nurse is caring for a client in labor when a prolapsed umbilical cord is noted. In order of priority, which actions would the nurse take? All options must be used. 1.Prepare for immediate birth.2.Monitor fetal heart rate and tones.3.Elevate the fetal presenting part that is lying on the cord by applying gloved finger pressure.4.Administer oxygen 8 to 10 L/min via face mask.5.Place the client in Trendelenburg or knee-chest position.
If umbilical cord prolapse occurs, the cord is lying alongside or below the presenting part of the fetus and can be seen or felt in or protruding from the vagina. The nurse stays with the client and asks another nurse to call the primary health care provider immediately. The nurse must relieve cord pressure immediately so that the fetus receives adequate oxygenation. The nurse can relieve cord pressure by elevating the fetal presenting part that is lying on the cord; the nurse does this by quickly gloving the hand and inserting two fingers into the vagina to the cervix and exerting upward pressure on the presenting part. The nurse also relieves cord pressure by placing the client into an extreme Trendelenburg or modified left lateral position or a knee-chest position (a rolled towel is placed under the client's hip). The nurse administers oxygen, 8 to 10 L/min, by face mask to the client, monitors the fetal heart rate and fetal heart rate patterns, and assesses the fetus for hypoxia. The client is prepared for immediate birth (vaginal or cesarean). The nurse documents the event, actions taken, the client's response, and any additional pertinent information. The nurse never attempts to push the cord into the uterus. If the umbilical cord is protruding from the vagina, the cord is wrapped loosely in a sterile towel saturated with warm sterile normal saline.
The nurse working in the hospital hears a client call out that there is a fire in the hospital room. What actions would the nurse take? Arrange the actions in the order that they would be performed. All options must be used. 1.Extinguish the fire.2.Activate the fire alarm.3.Rescue the client from injury.4.Pull the pin on the fire extinguisher.5.Close the doors to the other clients' rooms.
In the event of a fire, the first priority is to rescue the client and protect the client from injury. The next priority is to activate the fire alarm and report the exact location of the fire to emergency workers to aid in the rescue process. Next, the nurse would contain the fire by closing doors and placing towels under the doorways to prevent the spread of smoke. The nurse then obtains the fire extinguisher, pulls the pin, and extinguishes the fire.
A parent brings their 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 primary health care provider's prescriptions, in which order of priority would the nurse implement the actions? Arrange the actions in the order that they would be performed. All options must be used. 1.Maintain a patent airway.2.Administer an antipyretic.3.Obtain an axillary temperature.4.Assess breath sounds by auscultation.5.Insert an intravenous line for fluid administration.6.Obtain an oxygen saturation level using pulse oximetry.
Maintenance of a patent airway is essential. Emergency intubation equipment needs to be readily available. Once a patent airway is determined or established and maintained, the breath sounds would be auscultated. This action is followed by checking the pulse oximetry. All of these interventions relate to the respiratory status and are the priority. Following this, fluid needs would be considered because their administration relates to maintaining circulatory status. Then the temperature is taken, and an antipyretic is administered (usually by the rectal route) if needed.
The nurse is caring for a client undergoing a paracentesis. Place the preprocedure, during the procedure, and postprocedure nursing actions in order of priority. All options must be used. 1.Position the client upright.2.Monitor blood pressure and pulse and maintain client on bed rest.3.Obtain informed consent.4.Obtain vital signs and weight, and have client empty bladder.5.Document the event and the client's response.6.Document amount of fluid removed.
Paracentesis is the transabdominal removal of fluid from the peritoneal cavity. The nurse first ensures that the client understands the procedure and that informed consent has been obtained because the procedure is invasive. The nurse next obtains preprocedure vital signs, including weight, so that a baseline is obtained. Weight is taken before and after the procedure to provide an indication of the effectiveness of the procedure in fluid removal. The client is assisted to void to empty the bladder and to move the bladder out of the way of the paracentesis needle. The client is positioned upright on the edge of a bed with the back supported and the feet resting on a stool or in a Fowler's position in bed. The nurse assists the primary health care provider (PHCP), monitors vital signs per protocol, and provides comfort and support to the client during the procedure. Once the procedure is complete, the nurse applies a dressing to the site of puncture and monitors for leakage or bleeding. The client is placed in a position of comfort, bed rest is maintained as prescribed, and vital signs are monitored to assess for complications. The fluid removed from the client is measured, labeled, and sent to the laboratory for analysis. The nurse documents the event, the client's response, the appearance and amount of fluid removed, and any additional pertinent data.
After receiving report at the beginning of the 0700 shift, the nurse must decide in what order the clients would be assessed. How would the nurse plan assessments? Arrange the clients in the order that they would be assessed. All options must be used. 1.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).2.A 12-hour post-cesarean section delivery gravida 3, para 3 who reports a return of feeling in the lower extremities as well as a sensation of wetness underneath the buttocks.3.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 softener4.A 24-hour post-vaginal delivery gravida 4, para 4 who is complaining of abdominal cramping after nursing the baby and requesting ibuprofen
The 12-hour post-cesarean section delivery client would be assessed first because of reporting a sensation of wetness; this could be excessive bleeding. The 24-hour post-vaginal delivery client is complaining of pain, which can be treated easily with oral medications; therefore, this client needs to be assessed next. The 8-hour post-vaginal delivery client who is scheduled for a bilateral tubal ligation has an IV infusion. A baseline assessment must be conducted preoperatively for a bilateral tubal ligation; however, the scheduled operative time is 5 hours away. The client who had a cesarean section delivery 48 hours ago is assessed last, as this client is the farthest out from delivery and the effectiveness of a stool softener will be achieved over time with continued administration.
The nurse is preparing to obtain an arterial blood gas specimen from a client and plans to perform the Allen's test on the client. The nurse would perform the steps in which order to conduct an Allen's test? Arrange the actions in the order that they would be performed. All options must be used. 1.Document the findings.2.Explain the procedure to the client.3.Release pressure from the ulnar artery.4.Apply pressure over the ulnar and radial arteries.5.Ask the client to open and close the hand repeatedly.6.Assess the color of the extremity distal to the pressure point.
The Allen's test is performed before an arterial blood gas specimen is obtained from the radial artery to determine the presence of collateral circulation and the adequacy of the ulnar artery. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. The nurse would first explain the procedure to the client. To perform the test, the nurse applies direct pressure over the client's ulnar and radial arteries simultaneously. While applying pressure, the nurse asks the client to open and close the hand repeatedly; the hand should blanch. The nurse then releases pressure from the ulnar artery while continuing to compress the radial artery and then assesses the color of the extremity distal to the pressure point. If pinkness fails to return within 6 seconds, the ulnar artery is insufficient, indicating that the radial artery would not be used for obtaining a blood specimen. Finally, the nurse documents the findings.
The nurse has a prescription to obtain an arterial blood sample from a client. Prior to the procedure the nurse assesses the adequacy of the client's radial artery by performing the Allen's test. In which order would the Allen's test be performed? Place in correct order of priority. All options must be used. 1.Apply pressure over the ulnar and radial arteries simultaneously.2.Release pressure from the ulnar artery while compressing the radial artery.3.Ask the client to open and close the hand repeatedly.4.Assess the color of the extremity distal to the pressure point.5.Explain the procedure to the client.6.Document the findings.
The Allen's test is performed before obtaining an arterial blood specimen from the radial artery to determine the presence of collateral circulation and the adequacy of the ulnar artery. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. The nurse first would explain the procedure to the client. To perform the test, the nurse applies direct pressure over the client's ulnar and radial arteries simultaneously. While applying pressure, the nurse asks the client to open and close the hand repeatedly; the hand would blanch. The nurse then releases pressure from the ulnar artery while compressing the radial artery and assesses the color of the extremity distal to the pressure point. If pinkness fails to return within 6 to 7 seconds, the ulnar artery is insufficient, indicating that the radial artery would not be used for obtaining a blood specimen. Finally, the nurse documents the findings. Other sites, such as the brachial or femoral artery, can be used if the radial artery is deemed inadequate.
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 the client reports feeling light-headed. In which priority order would the nurse perform these interventions? Arrange the actions in the order they would be performed. All options must be used. .Apply oxygen.2.Check the client's blood pressure.3.Ensure that two large-bore intravenous lines are present with an isotonic solution infusing.4.Ask the client about taking any nonsteroidal anti-inflammatory medications.
The client has an upper gastrointestinal (GI) bleed. Upper GI bleeding is an emergency because it can lead to hypovolemic shock. The first intervention of those listed would be to apply oxygen in an attempt to maximize the amount of oxygen being delivered by the decreased number of red blood cells due to the bleeding. The next action would be to ensure that two large-bore intravenous (IV) lines are present and begin replacement of the intravascular fluid volume with an isotonic IV fluid. The nurse would then check the blood pressure. These are all actions to stabilize and assess the client's current condition. The last intervention is to ask the client about nonsteroidal anti-inflammatory medications. Although it is important to identify the cause of the bleeding and obtain a complete history of events leading up to the bleeding episode, this needs to be deferred until emergency care is initiated.
A client who is a gravida 3, para 3 had a cesarean section 1 day ago and is being treated prophylactically for endometritis. The client is complaining of abdominal cramping at a pain level of 6 on a scale of 1 to 10 (with 10 being the greatest amount of pain) and fears having a first bowel movement. These medications are prescribed and due to be administered now. Based on priority, in which order would the nurse administer the medications? Arrange the medications in the order that they would be administered. All options must be used. 1.Prenatal vitamin 1 tablet orally daily2.Docusate sodium 100 mg orally daily3.Ampicillin sodium 1 g IV piggyback over 60 minutes4.Ketorolac 30 mg by intravenous (IV) push over 3 minutes
The client is complaining of abdominal cramping, which is the priority and would be treated first; an IV route (ketorolac) is used because it will alleviate the pain rapidly. The risk of infection is greater than the need for a stool softener or a multivitamin; therefore, the IV antibiotic is administered next. The client who has not had a first bowel movement and is afraid to do so is the next priority; therefore, the docusate sodium would be administered next. The multivitamin requires daily administration and works over time to assist in replenishing the nutrients lost during blood loss associated with the surgery; this would be administered last.
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 is feeling hungry, shaky, and weak. The client ate breakfast at 8:00 a.m. and is due to eat lunch at noon. Arrange the actions that the nurse will take in the order that they would be performed. All options must be used. 1.Take the client's vital signs.2.Retest the blood glucose level.3.Check the client's blood glucose level.4.Give the client ½ cup (118 mL) of fruit juice to drink.5.Give the client a small snack of carbohydrate and protein.6.Document the client's complaints, actions taken, and outcome
The client is experiencing symptoms of mild hypoglycemia. If symptoms such as hunger, irritability, shakiness, or weakness occur, the nurse first will check the client's blood glucose level to verify that the client is experiencing hypoglycemia. Once this is verified, the nurse will give the client 10 to 15 g of carbohydrates, such as ½ cup (118 mL) of fruit juice. The nurse will retest the blood glucose level after 15 minutes. While waiting the 15 minutes, the nurse will check the client's vital signs. The nurse will give the client another 10- to 15-g carbohydrate food item if the client's symptoms do not resolve. Otherwise, the nurse will provide a small snack of carbohydrates and protein if the client's next scheduled meal is more than 1 hour away from the time of the occurrence. After treatment and resolution of the hypoglycemic event, the nurse will document the occurrence, actions taken, and outcome.
A pediatric client with major burn injuries arrives at the emergency department. Place the actions that the nurse would take in order of priority. All options must be used. 1.Remove burned clothing and jewelry.2.Keep the child warm.3.Begin resuscitation measures if necessary.4.Cover the wound(s) with a clean cloth.5.Assess the ABCs—airway, breathing, and circulation.
The initial management of the burn injury begins at the scene of the injury. The first priority is to stop the burning process; this must be done before other interventions. To stop the burning process, flames need to be smothered. The child needs to be placed in a horizontal position because a vertical position may cause the hair to ignite or the inhalation of flames, heat, or smoke. The child would be rolled in a blanket or other article, taking care not to cover the face and head because of the danger of inhaling smoke and fumes. As soon as the flames are extinguished, the child is assessed for adequate airway, breathing, and circulation. Measures are taken immediately if resuscitation is necessary. Burned clothing and jewelry are removed to prevent further burning of the skin and disruption of skin integrity, and then the burn is covered with a clean cloth, which prevents contamination of the wound, reduces pain by eliminating air contact, and prevents hypothermia. The child is then kept warm to prevent hypothermia and is immediately transported to the nearest emergency facility.
The nurse has a prescription to insert a peripheral intravenous catheter. Place the steps to perform this procedure in correct order of priority. All options must be used. 1.Tape and secure the site with a transparent dressing.2.Check the primary health care provider (PHCP) prescription.3.Explain the procedure to the client.4.Clean the skin with an antimicrobial solution, as specified by the Centers for Disease Control and Prevention (CDC).5.Stabilize the vein below the insertion site, puncture the skin and vein, and insert the catheter.6.Remove the tourniquet
The nurse checks the PHCP's prescription for the intravenous (IV) line and then determines the type and size of infusion device. The type and size are important to ensure adequate flow of the prescribed solution. For example, if a blood product is prescribed, the nurse would need to insert an appropriate catheter gauge size for blood delivery. The nurse also considers the client's size, age, mobility, and other factors in selecting the type and size of the infusion device. The nurse prepares the appropriate IV tubing or extension set and primes the IV tubing or extension set to remove air from the system. The appropriate vein is selected, the tourniquet is applied, and the vein is checked and palpated for resilience. Strict surgical asepsis is employed, and the skin is cleaned with an antimicrobial solution (as specified by agency policy), using an inner to outer circular motion. The vein is stabilized to prevent its movement, and the skin is punctured. Blood in the flashback chamber indicates that the device is in the vein, and when noted the catheter is carefully advanced to avoid puncture of the back wall of the vein. The tourniquet is removed, the stylet is removed from the catheter device, the IV tubing or extension set is connected, and the IV flow is started. Following assessment of the client and site, the nurse tapes and secures the site and labels the tubing, dressing, and solution bag appropriately and according to agency policy. The nurse checks the site and ensures that the solution is flowing. Finally, the nurse documents the specifics about the procedure.
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 would be performed. All options must be used. 1.Uncap the distal end of the tubing.2.Close the roller clamp on the IV tubing.3.Open the roller clamp and fill the tubing.4.Attach the distal end of the tubing to the client.5.Spike the IV bag and half-fill the drip chamber.
The nurse would close the roller clamp on the IV tubing to prevent the solution from running freely through the tubing once it is attached to the IV bag. The nurse would next uncap the proximal (spike) end of the tubing, attach it to the IV bag, and then squeeze the drip chamber to half-fill it. Next, the roller clamp is opened slowly, and the fluid is allowed to flow through the tubing in a controlled fashion to prevent air from remaining in parts of the tubing. Finally, the distal end of the tubing is uncapped and attached to the client.
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 would be performed. All options must be used. .Inject the medication.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.Check the compatibility of phenytoin with the IV solution.6.Document that the medication was administered.
The nurse would first check the compatibility of the medication with the ingredients in the IV solution. The nurse then draws up the medication, checks the ID bracelet to verify client identity, pinches off the tubing above the injection port, and injects the medication at the recommended rate through the port nearest to the IV insertion site. The nurse then documents that the medication was administered.
A unit of packed red blood cells has been ordered for a client with low hemoglobin and hematocrit, and typing and crossmatching has been done. 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 would the nurse plan the actions to take? Arrange the actions in the order that they would be performed. All options must be used. 1.Hang the bag of blood.2.Obtain the unit of blood from the blood bank.3.Ensure that an informed consent has been signed.4.Insert an 18- or 19-gauge intravenous catheter into the client.5.Verify the primary health care provider's (PHCP's) prescription for the blood transfusion.6.Ask a licensed nurse to assist in confirming blood compatibility and verifying client identity.
The nurse would first verify the PHCP's prescription for the blood transfusion and ensure that the client has been informed about the procedure and has signed an informed consent. Once this has been done, the nurse would ensure that at least an 18- or 19-gauge intravenous needle is inserted into the client. Blood has a thicker and stickier consistency than intravenous solutions, and using an 18- or 19-gauge catheter ensures that the bore of the catheter is large enough to prevent damage to the blood cells. Next, the blood is obtained from the blood bank once the nurse is sure that the client has been informed and has an adequate access for administering the blood. Once the blood has been obtained, two registered nurses or one registered nurse and one licensed practical nurse (depending on agency policy) must together check the label on the blood product against the client's identification number, blood group, and complete name. This minimizes the risk of error in checking information on the blood bag and thereby minimizes the risk of harm or injury to the client. The nurse would measure vital signs and assess lung sounds and then hang the transfusion.
The nurse is caring for a pediatric client who is going to receive a vaccination. Place the nursing actions for performing this procedure in order of priority. All options must be used. 1.Assess for allergies.2.Verify the prescription.3.Check the lot number and expiration.4.Obtain parental consent.5.Provide a vaccination record to the parents.6.Select appropriate site and administer the vaccine.
The nurse would first verify the prescription and then obtain an immunization history from the parents to ensure that the immunizations are up to date. The nurse would also question the parents about the presence of any allergies in the child because some vaccines contain components to which the child may be allergic. The nurse next provides information to the parents about the vaccine and obtains consent. The expiration date and the lot number (located on the medication vial) of the vaccine need to be checked before preparing the vaccine for administration. When the vaccine is prepared, the nurse prepares the child for the procedure, selects an appropriate site, and administers the vaccine. The nurse documents that the vaccination has been administered and provides an updated immunization record to the parents.
A home health care nurse is planning client visits and nursing activities for the day. The nurse begins the visits at 9:00 a.m. All clients live within a 5-mile radius. In order of priority, how would the nurse plan the assignments for the day? Arrange the actions in the order that they would be performed. All options must be used. 1.A client requiring supervision of a dressing change2.A client being visited by the home health aide at 10:30 a.m.3.A client requiring an admission assessment to home health care4.The first dressing change for a client requiring twice-daily dressing changes5.A client with diabetes mellitus who needs a fasting blood glucose level drawn6.The second dressing change for a client requiring twice-daily dressing changes
The nurse would plan to visit the client with diabetes mellitus first and draw the fasting blood glucose level because this client needs to remain NPO (nothing by mouth) until the blood is drawn. This client also would be unable to take any medication, such as insulin, until the blood is drawn. The nurse would plan to see the client requiring twice-daily dressing changes next because the dressing changes would be spaced as far apart as possible. The nurse then would plan to see the client being visited by the home health aide and provide instructions and directions to the home health aide regarding care of the client. The nurse then would visit the client requiring supervision of the dressing change and would perform the admission assessment next because that may take more time than the other clients. The nurse then would return to the client requiring the second twice-daily dressing change; dressing changes would be spaced as far apart as possible.
An adult client with a burn injury just arrived at the emergency department. Place the nursing actions in the care of this client in order of priority. All options must be used. 1.Assess for airway patency.2.Obtain vital signs.3.Administer oxygen as prescribed.4.Elevate the extremities.5.Keep the client warm.6.Initiate an intravenous (IV) line and begin fluid replacement as prescribed.
The primary goals for a burn injury are to maintain a patent airway, administer IV fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore, the priority actions are to assess for airway patency and to maintain a patent airway. The nurse then prepares to administer oxygen. The type of oxygen delivery system is prescribed by the primary health care provider. Oxygen is necessary to perfuse tissues and organs. Vital signs should be assessed so that a baseline is obtained, which is needed for comparison of subsequent vital signs once fluid resuscitation is initiated. The nurse then initiates an IV line and begins fluid replacement as prescribed. The extremities are elevated (if no obvious fractures are present) to assist in preventing shock. The client is kept warm (using sterile linens) and is placed on NPO status because of the altered gastrointestinal function that occurs as a result of the burn injury. A Foley catheter may be inserted so that the response to the fluid resuscitation can be carefully monitored. Once these actions are taken, the nurse performs a complete assessment, stays with the client, and monitors the client closely. In addition, tetanus toxoid may be prescribed for prophylaxis.
The nurse is triaging pediatric clients as they arrive to the emergency department after a school bus accident. In what order would the nurse triage the victims from highest priority to lowest? All options must be used. 1.Child with a closed head wound and multiple compound fractures of the arms and legs2.Sobbing child with several minor lacerations on the face, arms, and legs3.Confused child with bright red blood pulsating from a leg wound4.Child with a simple fracture of the arm complaining of arm pain
Triage systems identify which victims are the priority and need to be treated first. Rankings are based on immediacy of needs, including victims with immediate threat to life requiring immediate treatment (emergent), victims whose injuries are not life threatening provided that they are treated within 30 minutes to 2 hours (urgent), and victims with sustained local injuries who do not have immediate complications and can wait at least 2 hours for medical treatment (nonurgent). The confused child with bright red blood pulsating from a leg wound indicates arterial puncture. The child is also confused, which indicates the presence of hypoxia and shock (emergent). The child with a closed head wound and multiple compound fractures of the arms and legs has sustained multiple traumas, so this victim is also classified as emergent and would require immediate treatment; however, the confused child with bright red blood pulsating from a leg wound is the higher priority because of the arterial puncture. The child with a simple fracture of the arm complaining of arm pain has sustained injuries that are not life threatening provided that the injuries can be treated in 30 minutes to 2 hours (urgent). The sobbing child with several minor lacerations on the face, arms, and legs has sustained minor injuries that can wait at least 2 hours for treatment (nonurgent).
