Uworld's Prioritization part 1
50. The nurse is working in a busy emergency department and is assigned 4 clients. Which client should the nurse see first? a. Client receiving cyclophosphamide reporting bloody urine b. Client who reports severe nausea and vomiting after chemotherapy c. Client with an elbow abrasion and a lip laceration possibly requiring sutures d. Homeless client who appears drowsy with a temperature of 95 F (35 C)
d. Homeless client who appears drowsy with a temperature of 95 F (35 C)
41. The nurse on the medical unit finishes receiving the change of shift hand-off report at 7:30 AM. Which assigned client should the nurse see first? a. Client with a gastrointestinal bleed, who is receiving a unit of packed red blood cells b. Client with an ulcerative colitis flare-up has temperature 101 F (38.3 C) and abdominal cramping c. Client with atrial fibrillation, on telemetry, prescribed warfarin, with an International Normalized Ratio (INR) of 3.2 d. Client with chronic kidney disease scheduled for bedside hemodialysis at 8:00 AM, with a serum creatinine of 8.4 mg/dL (743 µmol/L)
a. Client with a gastrointestinal bleed, who is receiving a unit of packed red blood cells
1. nThe nurse performs admission assessments on 4 clients. Which client assessment information is most concerning and needs priority care? a. 17-year-old with suspected meningococcal meningitis who has a fever of 103 F (39.4 C), headache with photophobia, and stiff neck. b. 36-year-old who is an IV drug user with cellulitis of the arm, a fever of 103.2 F (39.6 C), and foul-smelling drainage from self-injection sites. c. 45-year-old with diabetes mellitus and osteomyelitis of the foot who has a fever of 100.9 F (38.3 C) and a serum glucose of 295 mg/dL (16.4 mmol/L) d. 76-year-old with chronic bronchitis who has a fever of 101 F (38.3 C) and a productive cough of thick green mucus
a. 17-year-old with suspected meningococcal meningitis who has a fever of 103 F (39.4 C), headache with photophobia, and stiff neck.
9. The nurse is triaging clients from the waiting room. The care of which client is a priority? a. 2-year-old who ingested a button battery approximately 30 minutes ago and is asymptomatic b. 4-year-old who started crying and suddenly won't use the left arm after being swung by the arms c. Child with cerebral palsy and a baclofen pump who has increased muscular spasms d. Child with osteogenesis imperfecta who walks in reporting being hit on the front of the head with a baseball
a. 2-year-old who ingested a button battery approximately 30 minutes ago and is asymptomatic
11. Which client in the emergency department should the nurse see first? a. 2-year-old with fever and sore throat who is restless and drooling b. 7-year-old with appendicitis who has right lower quadrant pain and vomiting c. 9-year-old with immune thrombocytopenia who has generalized petechiae d d. 17-year-old with cystic fibrosis who is coughing up thick, blood-tinged sputum Submit
a. 2-year-old with fever and sore throat who is restless and drooling
71. The nurse receives report on 4 pediatric clients in the emergency department. Which client should be seen first? a. 3-week-old with fever who is sleeping more than usual and refuses to feed b. 4-month-old who has painless, new-onset, bilateral testicular swelling c. 8-month-old who ingested a bottle of children's bubble soap 30 minutes ago d. 2-year-old with fever, runny nose, cough, and sore throat for the past 2 days
a. 3-week-old with fever who is sleeping more than usual and refuses to feed
64. The nurse is caring for the assigned clients on a pediatric inpatient unit. Which client is the priority? a. 8-year-old with sickle cell crisis who has sudden-onset unilateral arm weakness b. 11-year-old with viral meningitis requesting pain medication for headache c. Male child scheduled for surgery for intussusception who has reddish mucoid stool d. Male child with hemophilia who has hemarthrosis and is receiving desmopressin
a. 8-year-old with sickle cell crisis who has sudden-onset unilateral arm weakness
6. The post-anesthesia care unit nurse is caring for 4 clients during the immediate postoperative period. Which client would be the priority for the nurse to see first? a. A client post cholecystectomy reporting increased nausea b.A client post myomectomy with mild oozing of blood from the surgical site c.A client post spinal surgery requesting additional pain medication d.A client post transurethral resection of the prostate with reddish-pink drainage
a. A client post cholecystectomy reporting increased nausea
65. A blizzard is predicted to hit a large city within a few hours. The home care nurse is prioritizing and revising the schedule and estimates that 3 home visits can be made before the blizzard hits. Which clients should the nurse see? Select all that apply. a. A client who fell and hit the head but refuses to go to the emergency department b.A client who is due for a maintenance dose of cyanocobalamin c. A client who needs pre-filled insulin syringes d. A client who was discharged from the hospital yesterday after heart failure treatment e. A client with a stage 3 pressure injury in need of a dressing change
a. A client who fell and hit the head but refuses to go to the emergency department c. A client who needs pre-filled insulin syringes e. A client with a stage 3 pressure injury in need of a dressing change
54. A nurse working in the office of a health care provider receives 4 telephone messages. Which client call should the nurse return first? a. Client with acute sinusitis prescribed azithromycin 3 days ago now has hives b. Client with chronic low back pain requests an oxycodone medication prescription refill c. Client with fever of 100 F (37.7 C) has aching and itching at site after getting a flu shot yesterday d. Client with newly diagnosed asthma has palpitations after using an albuterol rescue inhaler
a. Client with acute sinusitis prescribed azithromycin 3 days ago now has hives
69. The emergency nurse is triaging clients. Which report is most concerning and would be given priority for definitive diagnosis and care? a. Abrupt, tearing, moving (upper to lower) back pain and epigastric pain b. Severe lower back pain after lifting heavy boxes c. Sharp calf ache with ambulation that improves with rest d. Unilateral leg swelling with 2+ pitting edema after an airplane trip
a. Abrupt, tearing, moving (upper to lower) back pain and epigastric pain
67.After morning report, the nurse must perform which action first when caring for assigned clients? a. Administer IV bumetanide to a client with heart failure who has bilateral crackles and dyspnea b. Hang the second unit of packed red blood cells for a client with a hemoglobin of 6 g/dL (60 g/L) c. Replace the empty IV opioid medication syringe in a patient-controlled analgesia pump d.Replace the heparin infusion bag that has 100 mL remaining and is infusing at 50 mL/hr
a. Administer IV bumetanide to a client with heart failure who has bilateral crackles and dyspnea
18. The nurse in the emergency department receives 4 clients. Which client should the nurse see first? a. Child who is confused and irritable and whose parent claims 2 glyburide pills are missing b. Child with an abscess on the buttock that is red, swollen, and warm to the touch c. Child with immune thrombocytopenia who fell off a bike and reports shoulder pain d. Child with low-grade fever, barking cough, and runny nose who has mild retractions
a. Child who is confused and irritable and whose parent claims 2 glyburide pills are missing
7. The nurse has received report on the following clients. Which client should the nurse assess first? a. Client 4 hours postoperative colon resection who has a blood pressure of 90/74 mm Hg b. Client receiving palliative care who has Cheyne-Stokes respiration with 20-second periods of apnea c. Client with anemia and hemoglobin level of 7 g/dL (70 g/L) who has a pulse of 110/min after ambulation d. Client with diabetic ketoacidosis who has rapid, deep respirations at a rate of 32/min
a. Client 4 hours postoperative colon resection who has a blood pressure of 90/74 mm Hg
40. The nurse has received report on 4 clients. Which client should the nurse see first? a. Client admitted this morning with acute pyelonephritis whose IV line is infiltrated b. Client scheduled for surgery in 2 hours who has questions about the procedure c. Client who had a colostomy yesterday and now has a leaking colostomy bag d. Client with a total hip replacement 3 days ago who reports no bowel movement in 2 days
a. Client admitted this morning with acute pyelonephritis whose IV line is infiltrated
75. The nurse has received report on four clients at the start of the shift. Which client should the nurse assess first? a. Client in a body cast who reports abdominal pain and bloating b. Client receiving antibiotics who reports new-onset vaginal itching c. Client who reports numbness of the surgical site following mastectomy d. Client who reports shoulder pain following robotic laparoscopic cholecystectomy
a. Client in a body cast who reports abdominal pain and bloating
2. The oncoming nurse is receiving report on 4 clients. Which should be the priority assessment? a. Client who had a carotid endarterectomy that day with a blood pressure of 160/88 mm Hg b. Client who is 1 day post bowel resection with absent bowel sounds c. Client with a pulse of 109/min who has a history of atrial fibrillation d. Client with pancreatitis whose total parenteral nutrition is almost finished
a. Client who had a carotid endarterectomy that day with a blood pressure of 160/88 mm Hg
42. The unit secretary notifies the nurse that 4 clients called the nurses' station reporting pain. Which client should the nurse assess first? a. Client who had a foot amputation today reporting left shoulder pain radiating down the arm b. Client who has acute pancreatitis reporting severe, continuous, penetrating abdominal pain c. Client who has multiple myeloma reporting deep pelvic pain after walking down the hall d. Client who has sickle cell disease reporting severe pain in the arms and upper back
a. Client who had a foot amputation today reporting left shoulder pain radiating down the arm
4. After receiving the hand off nurse to nurse evening shift report, which client should the nurse assess FIRST? a. Client who is 3 days postoperative bowel resection, now reports shortness of breath and chest pain b. Client who is 3 days postoperative right knee surgery, now reports fever, cough and shortness of breath c. Client who was transferred from the post-anesthesia care unit (PACU) 15 minutes ago. d. Client with a kidney stone who is requesting pain medication for severe flank pain.
a. Client who is 3 days postoperative bowel resection, now reports shortness of breath and chest pain
29. Multiple clients present to the emergency department. Which client should the triage nurse prioritize for diagnostic testing and definitive care? a. 26-year-old IV drug user reporting fever and right arm redness and swelling b. 32-year-old kidney transplant client reporting low-grade fever and generalized body pains c. 69-year-old with diverticulosis reporting left lower quadrant pain and fever d. 74-year-old with right knee replacement reporting fever and right knee swelling Submit
b. 32-year-old kidney transplant client reporting low-grade fever and generalized body pains
20. The nurse reviews the laboratory results for 4 assigned clients. Which result is most important for the nurse to report to the primary health care provider? a. Client with atrial fibrillation receiving warfarin for 7 days with an International Normalized Ratio (INR) of 1.3 b. Client with chronic bronchitis who has a hematocrit of 56% [0.56] and hemoglobin of 19 g/dL (190 g/L) c. Client with Clostridium difficile infection who has a white blood cell count of 15,000/mm3 (15 × 109/L) d. Client with sepsis receiving gentamycin who has a creatinine of 0.6 mg/dL (53 µmol/L)
a. Client with atrial fibrillation receiving warfarin for 7 days with an International Normalized Ratio (INR) of 1.3
39. Four clients were involved in a major highway motor vehicle accident. Which client requires priority care? a. Client with blood pressure of 90/70 mm Hg and deviated trachea b. Client with concussion who was unconscious for 5 minutes c. Client with grossly swollen upper thigh and blood pressure of 80/60 mm Hg d. Client with pain at the thoracic spine and complete paralysis of both legs
a. Client with blood pressure of 90/70 mm Hg and deviated trachea
44. The nurse is managing assigned clients on the evening shift. Which client presentation is a priority? a.Blunt head trauma with projectile vomiting b .History of Alzheimer disease with agitation c. History of carpal tunnel syndrome with hand numbness d. History of third cranial nerve pathology with double vision
a.Blunt head trauma with projectile vomiting
19. Four clients with different skin alterations come to the emergency department. Which client should the nurse advise that the health care provider (HCP) see first? a. 8-year-old client who uses corticosteroid inhaler and has white patches on the tongue b. 50-year-old client who developed a smooth, red, pinpoint rash after taking sulfa c. 60-year-old client with pain and crusted blisters along the back d. 70-year-old client who has erythema with a small pustule at the hair follicle Submit
b. 50-year-old client who developed a smooth, red, pinpoint rash after taking sulfa
16. The primary care provider's office nurse must return telephone calls concerning 4 clients. Which client has the most emergent situation and requires an immediate call back? a. 28-year-old woman is requesting antibiotic to be called to pharmacy due to another bladder infection b. 55-year-old man who takes trazodone is reporting a painful erection of 3 hours duration c. 78-year-old man with sinusitis who takes pseudoephedrine is having difficulty voiding d. 84-year-old man with prostate cancer and spine metastasis is requesting increased pain medication
b. 55-year-old man who takes trazodone is reporting a painful erection of 3 hours duration
13. The nurse receives a report on 4 clients. Which client should the nurse assess first? a. A 29-year-old heroin user admitted for arm cellulitis 24 hours ago has abdominal cramps and is restless b. A 34-year-old admitted with femur fracture 24 hours ago is confused and has SpO2 of 91% c. A 65-year-old admitted with serum sodium of 125 mEq/L (125 mmol/L) 8 hours ago is confused d. A 78-year-old admitted for urinary tract infection 6 hours ago is disoriented to time and place
b. A 34-year-old admitted with femur fracture 24 hours ago is confused and has SpO2 of 91%
3. The nurse is caring for pediatric clients in an acute care setting. Which of these clients should the nurse see first? a. A 1-day post tubal myringotomy client with purulent tympanic drainage b. A 4-day post valve replacement client with a temperature of 102 F (38.8 C) and petechiae c. A 10-day-old client with a patent ductus arteriosus who has a continuous murmur d. A 6-year-old client with epiglottitis who is drooling and has a severe sore throat
b. A 4-day post valve replacement client with a temperature of 102 F (38.8 C) and petechiae
14. The pediatric nurse receives report on 4 clients. Which client should the nurse see first? a. A 2-month-old awaiting evaluation for possible hip dislocation; parents are at the bedside b. A 6-year-old just returned from a bronchoscopy; a parent is at the bedside c. A 7-year-old just returned from a noncontrast abdominal CT scan; no parents are at the bedside d. An 11-year-old scheduled for ear surgery today; no parents are at the bedside
b. A 6-year-old just returned from a bronchoscopy; a parent is at the bedside
56. The clinic nurse receives phone calls about the following 4 clients. Which call should the nurse return first? a. A 6-month-old who received the diphtheria, tetanus, acellular pertussis vaccine 18 hours ago and developed fever of 102 F (38.9 C) and injection site redness b. An 11-month-old with inconsolable crying and drawing up of the legs toward the abdomen c. A 4-year-old diagnosed with right lung pneumonia 2 days ago who has chest pain when breathing deeply d. A 15-year-old whose eyes are red and itchy and have a yellow discharge
b. An 11-month-old with inconsolable crying and drawing up of the legs toward the abdomen
8. The nurse has just received shift report. Which client should be seen first? a. Client 1 day post-op abdominal aortic aneurysm (AAA) repair who has hypoactive bowel sounds in all 4 quadrants b. Client 2 days post-op below-the-knee amputation (BKA) who reports same-leg foot pain rated as 7 on the pain scale c. Client with a deep venous thrombosis (DVT) who is up to use the bathroom for the second time d. Client with Raynaud's phenomenon who reports throbbing, tingling, and swelling of fingers in both hands
b. Client 2 days post-op below-the-knee amputation (BKA) who reports same-leg foot pain rated as 7 on the pain scale
31. The nurse receives report on 4 clients. Which client should the nurse see first? a. Client admitted 12 hours ago with acute asthma exacerbation who needs a dose of IV methylprednisolone b. Client admitted 2 days ago with congestive heart failure who is reporting shortness of breath and had an extra dose of furosemide prescribed recently c. Client admitted with intestinal obstruction who is reporting abdominal pain and distention and needs nasogastric tube placement d. Client who had cardiac valve surgery 8 days ago but was readmitted with a sternal wound infection and needs antibiotics and a dressing change
b. Client admitted 2 days ago with congestive heart failure who is reporting shortness of breath and had an extra dose of furosemide prescribed recently
72. The nurse receives the hand-off shift report on assigned clients. Which information is most concerning and prompts the nurse to assess that client first? a. Client 1 day post colon resection who is receiving continual epidural morphine and reports severe itching b. Client admitted 2 hours ago with gastroenteritis who has been vomiting for 36 hours and has muscle cramps and weakness c. Client who has received IV bumetanide for 3 days for heart failure and experiences dizziness when standing up d. Client with acute poststreptococcal glomerulonephritis who is receiving antibiotics and has gross hematuria
b. Client admitted 2 hours ago with gastroenteritis who has been vomiting for 36 hours and has muscle cramps and weakness
57. The new nurse is viewing new laboratory values. Which client would be the priority to report to the health care provider? a. Client 2 days after a hip arthroplasty with a white blood cell count of 12,000/mm3 (12x109/L) b. Client admitted for cocaine overdose with a creatine kinase of 30,000 U/L (30,000 U/L) c. Client admitted for end-stage renal disease with a creatinine of 3.6 mg/dL (274.5 mmol/L) d. Client in heart failure exacerbation with a brain natriuretic peptide of 600 pg/mL (173 pmol/L)
b. Client admitted for cocaine overdose with a creatine kinase of 30,000 U/L (30,000 U/L)
30. A nurse on the medical surgical unit has just received report. Which client should be seen first? a. Client 1 day post femoral-popliteal bypass grafting who has an intravenous (IV) antibiotic due now b. Client diagnosed with deep venous thrombosis (DVT) yesterday who reports some chest discomfort and cough c. Client with hypertension and blood pressure of 180/92 mm Hg who reports a headache d. Client on fall precautions who just called the nurses' station for assistance in using the bathroom immediately Submit
b. Client diagnosed with deep venous thrombosis (DVT) yesterday who reports some chest discomfort and cough
58. The nurse receives handoff of care report on four clients. Which client should the nurse assess first? a. Client 1-day post-thoracotomy wedge resection who has subcutaneous emphysema at the chest tube insertion site b. Client with asthma who reports shortness of breath following an albuterol nebulizer treatment 15 minutes ago c. Client with COPD exacerbation who is receiving bi-level positive airway pressure (BIPAP) therapy and has a pulse oximetry reading of 90% d. Client with leg cellulitis following a spider bite who needs the IV restarted to initiate prescribed antibiotics
b. Client with asthma who reports shortness of breath following an albuterol nebulizer treatment 15 minutes ago
70. Multiple clients arrive at the emergency department. Which client should the triage nurse prioritize for the health care provider to see first? a. Client at 24 weeks gestation, showing no signs of labor, with cough productive of yellow phlegm b. Client with dementia arriving with new-onset restlessness and confusion c. Client with epilepsy who had a seizure earlier but is now alert and oriented d. Client with newly deformed forearm with normal circulation and sensation, pain rated 8/10
b. Client with dementia arriving with new-onset restlessness and confusion
62. An emergency department nurse is assigned to triage. Which client should the nurse assess first? a. Five-year-old with a superficial leg laceration b. Lethargic 3-month-old with diarrhea for the past 12 hours c. Seven-year-old with a elevated temperature of 101 F (38.3 C) and hematuria d. Seventeen-year-old with severe, acute abdominal pain
b. Lethargic 3-month-old with diarrhea for the past 12 hours
46. Unlicensed assistive personnel report 4 situations to the registered nurse. Which situation warrants the nurse's intervention first? a. Room 1: Client on a 24-hour urine collection had a specimen discarded by mistake b. Room 2: Client and family request clergy to administer last rites c .Room 3: Puncture-resistant sharps disposal container on the wall is full d. Room 4: Client with diabetes mellitus has an 8 AM fingerstick glucose of 80 mg/dL (4.4 mmol/L)
c .Room 3: Puncture-resistant sharps disposal container on the wall is full
51. The nurse receives report on 4 clients. Which client conditions require priority assessment? a. 34-year-old with acute pericarditis reporting left-sided chest pain that is worse with inspirations b. 54-year-old post right femoropopliteal bypass surgery reporting sudden-onset severe right foot pain c. 64-year-old post hip replacement reporting sudden-onset right-sided chest pain and dyspnea d. 70-year-old with pneumonia; rapid, irregular pulse of 140/min; and blood pressure of 130/86 mm Hg
c. 64-year-old post hip replacement reporting sudden-onset right-sided chest pain and dyspnea
10. The nurse assistant reports vital signs on 4 clients. Which client should be a priority for the nurse to assess? a. 28-year-old with infective endocarditis and heart rate of 105/min b. 45-year-old with acute pancreatitis and sinus tachycardia of 120/min c. 65-year-old with tachycardia of 110/min after liver biopsy d. 74-year-old on diltiazem drip with atrial fibrillation and heart rate of 115/min
c. 65-year-old with tachycardia of 110/min after liver biopsy
55. The office nurse receives 4 telephone messages from clients. Which client should the nurse call back first? a. 20-year-old college student who reports getting a ringlike, red bull's eye-shaped, itchy leg rash after hiking in the woods 2 days ago b. 65-year-old female with pneumonia taking antibiotics who reports white, curdlike vaginal discharge and itching c. 78-year-old prescribed warfarin who reports increasing headaches and gait disturbance after falling a month ago d. 86-year-old with gout who is prescribed colchicine and reports diarrhea and not feeling well
c. 78-year-old prescribed warfarin who reports increasing headaches and gait disturbance after falling a month ago
5. Four children are brought to the emergency department. Which child should be assessed first? a. A 13-month-old who ingested an unknown quantity of children's multivitamins b. A 15-month-old with a fever of 100.5 F (38.1 C) after being vaccinated c. A 3-year-old with a forehead laceration and colorless nasal drainage d. A 4-year-old with enlarged tonsillar lymph nodes who is crying in pain
c. A 3-year-old with a forehead laceration and colorless nasal drainage
23. The nurse has been assigned to the staging area of a disaster response to an act of terrorism that deployed a caustic chemical agent. A client comes to the triage area with burns to the skin, severe pain, and visible chemical residue. What is the nurse's priority action? a. Assess skin to determine severity of burns and wounds b. Assign client to a cit with other similarly triaged clients c. Assist the client to the designated showering area d. Prepare supplies to establish intravenous access
c. Assist the client to the designated showering area
38. The nurse receives report on 4 assigned clients. Which client should the nurse assess first? a. Client 1 hour post laparoscopic cholecystectomy for gallstones who reports right shoulder pain b. Client 4 hours post tracheostomy who has a small amount of pink drainage on the tracheotomy dressing c. Client 48 hours post abdominal hysterectomy who is ambulatory and reports aching in the right leg d. Client 3 days post open gastric bypass who reports fever and foul-smelling discharge at the surgical site Submit
c. Client 48 hours post abdominal hysterectomy who is ambulatory and reports aching in the right leg
60. A nurse receives information in a change of shift report. Which client is the priority? a. Client prescribed levothyroxine to treat hypothyroidism who reports nervousness, sweating, and insomnia b. Client receiving intravenous antibiotics for bacterial pneumonia who reports cough with blood-tinged sputum c. Client with a femoral external fixator who has a temperature of 100.9 F (38.3 C) and redness and pain around the pin sites d. Client with chronic pancreatitis who reports upper abdominal pain and voluminous, foul-smelling, fatty stools
c. Client with a femoral external fixator who has a temperature of 100.9 F (38.3 C) and redness and pain around the pin sites
34. The nurse receives handoff of care report on four clients. Which client should the nurse assess first? a. Client who had an appendectomy today and reports severe nausea and 8 out of 10 pain b .Client with a diabetic foot ulcer who has current blood glucose level of 301 mg/dL (16.7 mmol/L) c. Client with a fever of unknown origin whose arterial blood gas reveals PaCO2 30 mm Hg (4.0 kPa) d. Client with persistent diarrhea who has continuous lactated Ringer solution IV infusing at 125 mL/hr
c. Client with a fever of unknown origin whose arterial blood gas reveals PaCO2 30 mm Hg (4.0 kPa)
12. The nurse receives morning report on 4 clients who were admitted 24 hours earlier for injuries incurred in motor vehicle collisions. Which client should the nurse assess first? a. Client with a fractured pelvis who has a large area of ecchymosis and bruising over the pelvic region b. Client with a fractured tibia and leg cast who has pink skin under the cast edge and swollen toes c. Client with a lung contusion who has an oxygen saturation of 90% and severe inspiratory chest pain d. Client with a pneumothorax and a chest tube who has intermittent bubbling in the water-seal chamber Submit
c. Client with a lung contusion who has an oxygen saturation of 90% and severe inspiratory chest pain
61. A nurse working in the office of a health care provider must respond to client telephone messages. Which client should the nurse call first? a. Client with a left humerus fracture reporting stiffness and limited range of motion in the left shoulder b. Client with a left shoulder sling due to a fractured clavicle reporting vomiting after taking oxycodone c. Client with a right leg cast applied yesterday for a fractured ankle reporting tingling in the right foot d. Client with fibromyalgia reporting unrelieved burning pain and prescribed amitriptyline 1 week ago
c. Client with a right leg cast applied yesterday for a fractured ankle reporting tingling in the right foot
53. The nurse receives report on 4 clients. Which client should the nurse assess first? a. Client with end-stage renal disease receiving hemodialysis who reports fever with chills and nausea b. Client taking ibuprofen for ankylosing spondylitis who reports black-colored stools c. Client with altered mental status who is not following commands starts vomiting d. .Client with acute diverticulitis receiving antibiotics who reports increasing abdominal pain
c. Client with altered mental status who is not following commands starts vomiting
26. After the nurse receives the change-of-shift report, which client should the nurse assess first? a. Client with asthma who has shortness of breath and high-pitched expiratory wheezing b. Client with diabetes and a stasis leg ulcer dressing saturated with serosanguineous drainage c. Client with heart failure who is short of breath and coughing up pink frothy sputum d. Client with left pleural effusion and absent breath sounds in the left base Submit
c. Client with heart failure who is short of breath and coughing up pink frothy sputum
17. The emergency department nurse receives report on 4 clients. Which client should the nurse assess first? a. Client with acute cholecystitis who reports right shoulder pain b. Client with gastroparesis who reports persistent nausea and vomiting c. Client with intractable lower back pain who reports new urinary incontinence d.Client with Ménière disease who reports increasing tinnitus
c. Client with intractable lower back pain who reports new urinary incontinence
15. The emergency department nurse is assigned to triage. Which client should the nurse assess first? a. Client who smokes who has intermittent leg pain that is worse with walking and eases with rest b. Client with diabetes mellitus who has a temperature of 100.7 F (38.2 C) c. Client with leg swelling and calf pain who was on a 15-hour flight 2 days ago d. Client with pain, edema, and redness in the leg following a dog bite 1 hour ago
c. Client with leg swelling and calf pain who was on a 15-hour flight 2 days ago
21. The nurse receives handoff report on 4 clients. Which client should the nurse assess first? a. Client with chronic anxiety disorder taking buspirone and diphenhydramine who has a dry mouth b. Client with chronic heart failure taking metoprolol and lisinopril who has dizziness when standing up c. Client with major depressive disorder taking phenelzine and pseudoephedrine who has a headache d. Client with type 2 diabetes taking metformin and lovastatin who has stomach upset and nausea
c. Client with major depressive disorder taking phenelzine and pseudoephedrine who has a headache
45. The nurse receives a hand-off report from the night shift nurse. Which client should the nurse assess first? a. Client with anemia who began receiving a unit of packed red blood cells 1 hour ago b. Client with hemoglobin of 7 g/dL (70 g/L) who needs to be started on IV iron therapy c. Client with seizure activity who received lorazepam 20 minutes ago d. Client with suspected leukemia scheduled for a bone marrow biopsy in 1 hour
c. Client with seizure activity who received lorazepam 20 minutes ago
25. The nurse receives handoff of care report on four clients. Which client should the nurse assess first? a. Client with Graves disease who has a heart rate of 110/min and blood pressure of 122/85 mm Hg b. Client with pneumonia and temperature of 101.8 F (38.8 C) who is unable to receive antibiotics due to an occluded IV catheter c. Client with sickle cell disease whose pain rating has increased from 3 to 9 on a scale of 0-10 over the last hour d. Client with type 2 diabetes whose fingerstick glucose level is 220 mg/dL (12.2 mmol/L)
c. Client with sickle cell disease whose pain rating has increased from 3 to 9 on a scale of 0-10 over the last hour
73. The nurse prepares to administer the prescribed 8 AM medications to 4 clients. The nurse should administer medication to which client first? a. Client 2 days postoperative abdominal surgery who is to receive enoxaparin for venous thromboembolism prophylaxis b. Client with hypertension who has a blood pressure of 196/98 mm Hg and is to receive IV hydralazine c. Client with suspected sepsis who has a temperature of 102.3 F (39.1 C) and is to receive an initial dose of IV ceftazidime d. Client with type 2 diabetes mellitus and blood sugar of 500 mg/dL (27.8 mmol/L) who is to receive subcutaneous regular insulin and insulin glargine
c. Client with suspected sepsis who has a temperature of 102.3 F (39.1 C) and is to receive an initial dose of IV ceftazidime
24. The nurse in the emergency department receives report on 4 clients. Which client should be seen first? a. 5-year-old with an accidental epinephrine auto-injector stick and a heart rate of 124/min b. 7-year-old who is crying, has vaginal lacerations and bruising, and has a heart rate of 118/min c. 10-year-old with a large, draining abscess on the left buttock and a temperature of 101.2 F (38.4 C) d. 14-year-old who is lethargic after playing a football game and has a temperature of 104.1 F (40.1 C) Submit
d. 14-year-old who is lethargic after playing a football game and has a temperature of 104.1 F (40.1 C) Submit
36. The nurse receives report on 4 clients. Which client should be seen first? a. 10-month-old with audible congestion and mucus-producing cough b. 10-year-old with an active nose bleed who is applying pressure c. 12-year-old with urinary frequency and burning, and fever d. 15-year-old with painful right hip, fever, and limited range of motion Submit
d. 15-year-old with painful right hip, fever, and limited range of motion Submit
28. The nurse is performing beginning of shift assessments on 4 clients. Which client's assessment findings should the nurse immediately report to the health care provider? a. 36-year-old client with alcohol withdrawal who is receiving IV lorazepam every 3 hours for agitation and has a blood pressure of 190/98 mm Hg b. 56-year-old client with stable angina who has chest and jaw pain relieved with nitroglycerin, blood pressure of 98/70 mm Hg, and dizziness when getting up c. 60-year-old client with chronic kidney disease who has a blood pressure of 168/88 mm Hg, serum creatinine level of 5.0 mg/dL (442 µmol/L), and reports nausea and itching d. 82-year-old client with a pressure injury who has a change in mental status, temperature of 96.4 F (35.8 C), pulse of 110/min, and blood pressure of 96/72 mm Hg
d. 82-year-old client with a pressure injury who has a change in mental status, temperature of 96.4 F (35.8 C), pulse of 110/min, and blood pressure of 96/72 mm Hg
49. The nurse receives report for clients on the neurology floor. Which client is important for the nurse to assess first? a. A 25-year-old client with multiple sclerosis who had bladder incontinence last night b. A 37-year-old client with Guillain-Barré syndrome who has "0" deep tendon patellar reflexes c. A 58-year-old client with Parkinson disease who is drooling d. A 78-year-old client with dementia who has new-onset agitation and confusion
d. A 78-year-old client with dementia who has new-onset agitation and confusion
22. Four clients come to the emergency department simultaneously. Which client should the nurse see first for definitive care? a. 6-month-old with a temperature of 101 F (38 C) who is rubbing the ears and being fussy b. 10-day-old client with a red mark (stork bite) on the neck, the mother is concerned c. A client who took a handful of amitriptyline pills, a tricyclic antidepressant drug d. A client who tripped and hit the head but is alert with no loss of consciousness, currently takes warfarin
d. A client who tripped and hit the head but is alert with no loss of consciousness, currently takes warfarin
27. The registered nurse is performing triage at a pediatric emergency department. Which client should be seen first? a. Child with history of cystic fibrosis (CF) has new yellow sputum and cough today b. Crying infant with fiery redness and moist papules in the diaper region c. Grade-school client with swollen ecchymotic ankle after playing basketball d. Adolescent client with abdominal pain, heart rate 120/min, and respirations 26/min Submit
d. Adolescent client with abdominal pain, heart rate 120/min, and respirations 26/min Submit
68. A nurse receives the following change-of-shift morning report for the assigned clients. Which client should the nurse assess first? a. Client 1 day postoperative with fine inspiratory crackles in the lung bases on auscultation who is to ambulate for the first time this morning b. Client 1 day postoperative with serosanguineous drainage on the abdominal surgical dressing and temperature of 100.4 F (38 C) c. Client 2 days postoperative receiving intermittent epidural bolus analgesia who now reports incisional pain as a 4 on a 0-10 scale d. Client 2 days postoperative receiving fluids infusing at 125 mL/hr, with a Foley catheter and urine output of 100 mL during the last 8 hours
d. Client 2 days postoperative receiving fluids infusing at 125 mL/hr, with a Foley catheter and urine output of 100 mL during the last 8 hours
66. The nurse receives a report on the assigned clients for the shift. Which client should the nurse assess first? a. 1-day postoperative client with lower abdominal pain and no urine output for 6 hours b. An elderly client with blood pressure 190/88 mm Hg who is asymptomatic c. Client with hepatitis C virus who has alanine aminotransferase/aspartate aminotransferase (ALT/AST) values 4 times the normal value d. Client who underwent thyroidectomy yesterday and now has positive Trousseau's sign
d. Client who underwent thyroidectomy yesterday and now has positive Trousseau's sign
32. The nurse is managing an assigned team. The following clients have family members reporting a concern. Which client should the nurse see first? a. Client who has a migraine is reporting 10/10 pain and nausea b. Client who is postictal after a seizure is drowsy and confused c. Client with amyotrophic lateral sclerosis is experiencing dysarthria d. Client with a Glasgow Coma Scale score of 9 is no longer responding when called
d. Client with a Glasgow Coma Scale score of 9 is no longer responding when called
35. The nurse receives report on 4 clients. Which client should the nurse assess first? a. Client 1 day postoperative receiving patient-controlled analgesia with morphine who reports itching and nausea b. Client receiving maintenance IV normal saline solution with labeled tubing indicating that tubing was changed 48 hours ago c. Client with a pulmonary embolus receiving continuous IV heparin infusion and warfarin who has an International Normalized Ratio of 1.9 d. Client with a resistant bacterial infection receiving IV vancomycin who reports discomfort at the peripheral IV site
d. Client with a resistant bacterial infection receiving IV vancomycin who reports discomfort at the peripheral IV site
43. The nurse assesses and reviews the laboratory results for 4 clients. Which client's fever is of highest priority and should be reported to the health care provider immediately? a. Client newly diagnosed with Hodgkin lymphoma scheduled for chemotherapy who has a fever of 100.9 F (38.3 C) and white blood cell count of 6,000/mm3 (6.0 × 109/L) b. Client with acute cholecystitis scheduled for laparoscopic surgery who has a fever of 102 F (38.9 C) and white blood cell count of 13,000/mm3 (13.0 × 109/L) c. Client with Clostridium difficile infection receiving metronidazole who has a fever of 101 F (38.3 C) and white blood cell count of 18,000/mm3 (18.0 × 109/L) d. Client with colon cancer receiving chemotherapy who has a fever of 100.4 F (38 C) and white blood cell count of 1,500/mm3 (1.5 × 109/L)
d. Client with colon cancer receiving chemotherapy who has a fever of 100.4 F (38 C) and white blood cell count of 1,500/mm3 (1.5 × 109/L)
33. The night nurse receives the hand-off report on assigned clients. Which client should the nurse assess first? a. Client with acute kidney injury scheduled for hemodialysis in the morning has a urine output of 200 mL for the past 8 hours b. Client with an indwelling urinary catheter who is 1-day postoperative prostatectomy reports severe bladder spasms c. Client with an ureteral stent placed this morning after laser lithotripsy reports burning on urination and hematuria d. Client with spinal cord injury (above T6) requiring intermittent catheterization reports a throbbing headache and nausea
d. Client with spinal cord injury (above T6) requiring intermittent catheterization reports a throbbing headache and nausea
52. Four clients come to the emergency department and are assessed by the triage nurse. Which client should be prioritized for more definitive care? a. Client with history of gout who has severe pain in the right foot b. Client with history of migraines reporting headache and photophobia c. Client with severe epigastric pain radiating to the back after an alcohol binge d. Client with sudden onset of the "worst headache of my life"
d. Client with sudden onset of the "worst headache of my life"
47. Which client should the nurse assess first? a. Client with atrial fibrillation with a new prescription for warfarin b. Client with chronic obstructive pulmonary disease with an oxygen saturation of 91% c. Client with postoperative pain rated 8 out of 10 d. Client with third-degree heart block with a pulse of 42/min
d. Client with third-degree heart block with a pulse of 42/min
48. At 8 AM, medications are prescribed for assigned clients. Which medication should the nurse administer first? a. Acetylsalicylic acid for a client with a history of coronary artery disease and ischemic stroke b. Metformin for a client with serum glucose of 285 mg/dL (15.8 mmol/L) who is scheduled for a CT scan with contrast c. Morphine sulfate for a client with terminal lung cancer who has chronic bone pain d. Pyridostigmine for a client with myasthenia gravis exacerbation who reports difficulty swallowing
d. Pyridostigmine for a client with myasthenia gravis exacerbation who reports difficulty swallowing
74. The nurse reviews the most current laboratory results for assigned clients. Which finding is the highest priority for the nurse to report to the health care provider? a. CD4+ cell count of 500/mm3 (0.5 × 109/L) in a client with oral candidiasis and HIV who is receiving fluconazole orally b. Hemoglobin A1C of 7.3% in a client with community-acquired pneumonia and type 2 diabetes who is receiving IV levofloxacin c. Platelet count of 148,000/mm3 (148 × 109/L) in a client with a venous thrombosis who is receiving a continuous heparin infusion d. Serum glucose of 68 mg/dL (3.8 mmol/L) in a client with radiation enteritis who is receiving total parenteral nutrition
d. Serum glucose of 68 mg/dL (3.8 mmol/L) in a client with radiation enteritis who is receiving total parenteral nutrition
37. The emergency department nurse is triaging clients. Which client is a priority for diagnostic workup and definitive care? a. Fell, twisting the right knee; heard a "pop" b. History of glomerulonephritis; has "iced tea"-colored urine c. Pain 10/10 in reddened eye; wears contact lens d. Took a handful of amitriptyline tablets after a fight with spouse
d. Took a handful of amitriptyline tablets after a fight with spouse
63. Four clients come to the emergency department (ED). Which client should the triage registered nurse (RN) assign as highest priority for definitive diagnosis and treatment? a. Client with chronic obstructive pulmonary disease (COPD) with yellow expectoration and an oxygen saturation of 91% b. Healthy child with new-onset fiery-red rash on cheeks and the "flu" c. Middle-aged client with vaginal itching and white, curdlike discharge d. Unconscious elderly client who smells of alcohol and has fresh vomit on the face
d. Unconscious elderly client who smells of alcohol and has fresh vomit on the face
