36.C Prioritization
The client is diagnosed with an acute exacerbation of IBD. Which priority intervention should the nurse implement first? 1. Weigh the client daily and document in the client's chart 2. Teach coping strategies such as dietary modifications 3. Record the frequency, amount, and color of stools 4. Monitor the client's oral fluid intake every shift
3. Record the frequency, amount, and color of stools
Which action by the nurse can help to avoid pitfalls that can result in client harm? (Select all that apply.) A. Incorporating client preferences as possible when prioritizing care B. Knowing client healthcare concerns C. Following ethical care practices D. Prioritizing client care appropriately E. Delegating care only when absolutely necessary
A, B, C, D Rationale: To avoid common pitfalls when providing care, the nurse should follow ethical care practices, know client healthcare concerns, prioritize care appropriately, and incorporate client preferences as possible when prioritizing client care. Appropriate delegation can be helpful to the nurse when prioritizing care, so it should not be avoided but used appropriately.
The nurse is prioritizing client care as low, medium, or high priority for the current assignment. Which client should the nurse identify as having a high-priority circumstance? (Select all that apply.) A. A client with emphysema and a pulse oximeter reading of 88 B. A client with congestive heart failure and shortness of breath C. A client who is experiencing extreme bouts of diarrhea D. An extremely confused older client E. A client who is receiving warfarin (Coumadin)
A, B, E Rationale: High-priority circumstances include clients with a risk for bleeding, such as a client receiving warfarin (Coumadin), clients with ineffective breathing patterns, and clients with impaired gas exchange. A confused client and a client with diarrhea would have medium-priority circumstances.
The nurse is planning the day on a general medical unit. Which activity should the nurse prioritize as "must do" and not advisable to be delegated to unlicensed assistive personnel (UAP)? A. Health teaching for a client being discharged poststroke B. Assisting clients with hygienic care activities C. Ambulating a stable client to the bathroom D. Collecting vital signs on assigned clients
A. Health teaching for a client being discharged poststroke Rationale: "Must do" activities carry the highest priority for completion and should not be delegated. Health teaching and discharge teaching must be done by the nurse. Collecting vital signs, ambulating a stable client to the bathroom, and assisting clients with hygienic activities can all be safely delegated to unlicensed assistive personnel (UAPs).
The nurse is planning care for a client in sickle cell crisis. The client's pain level is a 9/10, temperature 98.8F, blood pressure 140/90 mmHg, heart rate 100 beats per minute, respirations 28 per minute, and oxygen saturation 88%. Which intervention should the nurse perform first? A. Provide oxygen via nasal cannula. B. Administer opioid analgesic. C. Administer nebulizer treatment. D. Give scheduled antihypertensive medication.
A. Provide oxygen via nasal cannula. Rationale: Good tissue perfusion is extremely important in patients with sickle cell disease. Therefore, the nurse would administer oxygen via nasal cannula due to poor oxygen saturation levels. Then, the nurse would administer pain medication to alleviate the client's pain. There is no evidence the client has pulmonary congestion requiring a nebulizer treatment. The nurse would then administer the scheduled antihypertensive.
The nurse is assessing a 56-year-old male client. The client was admitted to the hospital for treatment of acute exacerbation of sickle cell disease (SCD). When prioritizing nursing care and implementing interventions, which complaint by the client is most appropriate for the nurse to address first? A. "I'm feeling really short of breath." B. "I don't eat a healthy diet." C. "I don't have the energy to exercise." D. "I'm having a lot of leg pain."
A. "I'm feeling really short of breath." Rationale: During the diagnosis phase of the nursing process, the nurse analyzes and synthesizes assessment data to formulate client-specific nursing diagnoses. The nurse also identifies emergent and urgent problems that require immediate attention and provides prompt client care as indicated. Nursing diagnoses that are reflective of safety risks or infectious disease transmission should be addressed immediately. The client's complaint of feeling short of breath is reflective of a physiologic need that, if unmet, could severely compromise the client's safety. As such, the nurse should address the client's oxygenation needs prior to addressing those needs related to comfort, activity intolerance, and nutrition.
A patient with Crohn's Disease is taking corticosteroids. The patient is complaining of extreme thirst, polyuria, and blurred vision. What is your next nursing action? A. Check the patient's blood glucose B. Give the patient a food containing sugar (ex: orange juice) C. Administer oxygen via nasal cannula D. Assess bowel sounds
A. Check the patient's blood glucose A side effect of corticosteroids is hyperglycemia. Extreme thirst, polyuria, and blurred vision are classic signs and symptoms of hyperglycemia. Therefore, the nurse should check the patient's blood glucose to confirm the hyperglycemia.
During a class discussion, the 50-year-old professor suddenly feels left-sided chest pain, dizziness, and diaphoresis. What is the priority action when he arrives in the ED triage area? a) Supply oxygen via nasal cannula b) Place intravenous (IV) access c) Notify the ED physician d) Set the client on continuous electrocardiographic monitoring
A. Supply oxygen via nasal cannula ·Option A: Prioritization. Increasing myocardial oxygenation is the priority goal. ·Options B, C, and D: The other actions are also appropriate and should be done immediately.
After exposure to hot weather and sun, clients with signs and symptoms of heat-related ailment rush to the Emergency Department (ED). Sort clients into those who need critical attention to those with less serious condition. 1. An abandoned person who is a teacher; has altered mental state, weak muscle movement, hot, dry, pale skin; and whose duration of heat exposure is unknown 2. An elderly traffic enforcer who complains of dizziness and syncope after standing under the heat of the sun for several hours to perform his job 3. A comparatively healthy housewife who states that the air conditioner has been down for 5 days and who exhibits hypotension, tachypnea, profuse diaphoresis, and fatigue 4. A sportsman who complains of severe leg cramps and nausea, and displays paleness, tachycardia, weakness, and diaphoresis. A. 4, 3, 2, 1 B. 1, 2, 4, 3 C. 1, 4, 2, 3 D. 4, 1, 3, 2
Answer: B. 1, 2, 4, 3Option B: Prioritization. (1) The abandoned person has symptoms of heat stroke, a medical emergency, which heightens the risk of brain damage. (2) The elderly traffic enforcer is at risk for heat syncope and should be instructed to relax in a cool environment and withdraw from approaching related circumstances. (4) The sportsman is experiencing heat cramps, which can be treated with rest and fluids. (3) The homemaker is having heat exhaustion and management includes IV or oral fluids and settle in a cool area.
Which client should the nurse assess first after receiving the change-of-shift report? A. A client with hypertension with a blood pressure of 168/88 mmHg B. A client with heart failure who is complaining of shortness of breath C. A client with a bowel obstruction who is complaining of nausea D. A client with type 1 diabetes mellitus with blood glucose of 82 mg/dL
B. A client with heart failure who is complaining of shortness of breath Rationale: Using the ABCs (airway, breathing, and circulation) as a guide, the nurse should first assess the client with shortness of breath. This would take priority over a client complaining of nausea, a client with an elevated (but not critically elevated) blood pressure, and a client with a normal blood glucose reading.
The home care nurse is planning the order of clients for the day. Which client should the nurse prioritize as needing to be seen first? A. A client requiring indwelling catheter change due to leakage B. A newly diagnosed diabetic client who is administering morning insulin independently for the first time C. A client with daily dressing change, normally done at 0800 per client preference D. A client being seen poststroke for rehabilitation and education about poststroke care
B. A newly diagnosed diabetic client who is administering morning insulin independently for the first time Rationale: A newly diagnosed client who is administering insulin independently for the first time creates a time constraint. The nurse would see this client first to ensure that the insulin is being administered properly. While client preferences are an important consideration, the time constraint of the insulin would be a higher priority. A client being seen poststroke for rehabilitation and education as well as a client with a leaking indwelling catheter would also be lower priorities when planning the order of clients for the day.
The nurse is preparing to send the client who is one-day postoperative from a hip arthroplasty for physical therapy. Which intervention should the nurse perform first? A. Apply sequential compression stockings B. Administer analgesics C. Administer a diuretic D. Provide the client lunch
B. Administer analgesics Rationale: The nurse should administer analgesics about 30-60 minutes prior to attending physical therapy. This minimizes pain during exercise and allows better movement. The nurse would not administer a diuretic prior to going to therapy because the client would have to urinate frequently. The client can eat lunch, but it is not a priority. Sequential stockings can only be used while the client is in bed.
A client who was treated for a long bone fracture suddenly has a respiratory rate of 28 breaths/ min with an oxygen saturation of 86% on room air. The client is confused and restless. Which collaborative intervention is appropriate? A. Intubating the client immediately B. Applying oxygen and continuing to assess respiratory status C. Immediately immobilizing the pelvic area D. Administering corticosteroids as ordered
B. Applying oxygen and continuing to assess respiratory status Rationale: This client is showing signs of fat embolism syndrome (FES). Priority treatment is to administer oxygen and continue to assess respiratory status to try to prevent intubation. Approximately 50% of the clients will have to be intubated eventually, but the goal is to prevent this invasive treatment. Corticosteroids and immobilization of the injured area may reduce the risk of FES but will not treat the syndrome once it occurs.
The medical-surgical nurse is planning the day immediately after receiving report. Which should be the primary nursing intervention when prioritizing care? A. Assigning staff to clients B. Assessing client situations C. Analyzing collected data D. Ascertaining interventions
B. Assessing client situations Rationale: The first step when prioritizing care is assessment. Assessment is the process of gathering information to make decisions. Assessment includes knowing individual clients' health statuses to prepare for anticipated or unanticipated changes. Ascertaining interventions would occur after the assessment. Analyzing collected data would occur after an assessment. Assigning staff to clients would occur after knowing the number and level of caregivers available to provide care.
The nurse working in a community clinic is reviewing the clients to be seen for the day. Which client should require more time in the schedule? A. A 50-year-old who is being seen for blood pressure recheck B. A 75-year-old with recent cognitive decline C. A 20-year-old who is being seen for evaluation of insulin pump management D. A 32-year-old with newly diagnosed diabetes who is returning for a blood glucose recheck
B. A 75-year-old with recent cognitive decline Rationale: An older client with cognitive issues may require more time than do other clients due to both developmental and cognitive issues. Blood pressure rechecks, insulin pump follow-up, and blood glucose rechecks of young and middle-aged adults would not necessarily require more time
An older adult client with Parkinson disease uses a walker, speaks in a slurred manner with poor articulation, but tries to speak louder to accommodate for this impairment. The client states, "I catch my daughter looking at me angrily sometimes, but she doesn't say anything." Which nursing diagnosis is the priority? A. Nutrition, Imbalanced: Less than Body Requirements B. Caregiver Role Strain C. Falls, Risk for D. Communication: Verbal, Impaired
B. Caregiver Role Strain Rationale: The client is making accommodations for preventing falls by using a walker. Being the primary caregiver, the client's daughter assists the client in feeding so imbalanced nutrition is not a risk. The client is also practicing speech by speaking louder. It is the caregiver's role strain that is the major risk for this client. (NANDA-I © 2014)
The nurse administered blood pressure medications to the wrong client. Upon realizing the error, the nurse notes that the last blood pressure assessment of the client who received the wrong medication was 82/50 mmHg. Which level of urgency would be required to address this situation? A. Imminent death B. Critical C. Nonacute D. Acute
B. Critical Rationale: In this situation, a blood pressure medication was administered to the wrong client who has low blood pressure, creating a critical situation to which the nurse needs to respond quickly since the client's condition could become life threatening. This would not be an acute or nonacute situation, as it is a medium-high priority. It is not likely that this error would result in death of the client, so the choice of imminent death would not be appropriate.
The nurse caring for a client with diabetes mellitus receives a report from another nurse that the client is experiencing a hypoglycemic episode. The nurse immediately prepares to administer 50 mL of D50 IVP. Upon entering the room, the nurse notes that the client seems alert and does not have any current complaints and decides not to administer the D50. Which pitfall was avoided by the nurse in this situation? A. Incomplete assessment B. Relying solely on another's assessment C. Poor time management D. Failure to do periodic assessments
B. Relying solely on another's assessment Rationale: In this situation, the nurse prepared to administer D50 IVP based on the other nurse's assessment. Using this information to set priorities could have resulted in a negative client outcome. The potential pitfall in this situation was not created by an incomplete assessment, poor time management, or failure to do periodic assessments.
The nurse prioritizes care for a client with diabetes mellitus using Maslow's hierarchy of needs. Which need is identified as the priority for this client? A. The client joins the local American Diabetes Association support group. B. The nurse teaches the client how to properly change dressings on the right-leg amputation site. C. The nurse teaches the client proper home safety techniques to prevent diabetic wounds. D. The client attends classes to deal with body image after amputation of the right leg.
B. The nurse teaches the client how to properly change dressings on the right-leg amputation site. Rationale: When prioritizing care based on Maslow's hierarchy of needs, physiological needs will come before safety, social, and esteem needs. Caring for an amputation site is meeting a physiological need. Attending a class to deal with body-image issues addresses an esteem need. Teaching the client about safety techniques to prevent diabetic wounds addresses a safety need. Joining a support group meets an esteem need.
The nurse working on a busy medicalsurgical unit is caring for five clients. As the nurse is preparing to administer routine medications to the assigned clients, she is informed that a new admission will be arriving to the unit shortly. Which type of situation challenges the nurse's time management and organizational skills? A. Emergent B. Pop-up C. Urgent D. Pitfall
B. Pop-up Rationale: Events such as new admissions that are unexpected and require that nurses take time and attention away from their plan for the day are referred to as pop-ups. Pitfalls are unforeseen situations that harbor consequences for nurses and can result in client harm. Urgent and nonurgent events are methods of triaging and setting priorities for care.
The nurse is organizing care for the day for the assigned clients. Which client should the nurse give highest prioritization to ensure appropriate medication administration? A. A client with diabetes requiring insulin coverage QID B. A client who is receiving daily dialysis C. A client receiving several intravenous antibiotics, each to be infused over 30-60 minutes D. A client with unstable vital signs receiving multiple blood pressure medications
C. A client receiving several intravenous antibiotics, each to be infused over 30-60 minutes Rationale: When the nurse is caring for multiple clients, setting of priorities is determined by the significance of the interventions for the clients. In this situation, the client receiving several intravenous antibiotics, each of which need to be infused over a specific time frame, would need to be prioritized to ensure adequate medication administration. QID insulin coverage, regularly scheduled blood pressure medications, and daily scheduled dialysis would not have higher prioritization than would the client receiving multiple intravenous antibiotics that must be administered in the correct order over the appropriate time frame.
A client is admitted to the emergency department with a rash on the trunk and extremities. The client reports difficulty breathing, chest tightness, and weakness. Respirations are 24 breaths/min and even, pulse is 90 beats/min and thready, and blood pressure is 96/70 mmHg. The client reports a recent history of a urinary tract infection and having been on sulfasalazine for the past 5 days. Which is the priority nursing assessment for this client? A. Gastrointestinal disturbances B. Peripheral edema C. Airway patency D. Urine discoloration
C. Airway patency Rationale: Using the ABCs (airway, breathing, and circulation) to establish priority nursing interventions, the nurse would first establish airway patency based on the client's symptoms of difficulty breathing. This would take priority over assessment for edema, urine discoloration, and gastrointestinal disturbances.
The nurse in an emergency department (ED) shares with a fellow nurse that, due to the busy pace of the day, he has not even been able to go to the bathroom since he arrived for his shift 6 hours ago. Which response by the fellow nurse should best address this situation? A. Encouraging the nurse to let the supervisor know so that appropriate actions can be taken B. Discussing better ways to prioritize and manage time with the nurse so that in the future he will be able to take needed breaks C. Offering to oversee the nurse's clients so that a 15-minute break can be taken D. Listening to the nurse's concerns and offering verbal encouragement to make it through the rest of the shift
C. Offering to oversee the nurse's clients so that a 15-minute break can be taken Rationale: It is important that nurses take quick 15-minute breaks to refresh, reenergize, and take care of bodily functions, so the best response by the fellow nurse would be to cover for the nurse to allow this break to occur. Encouraging the nurse to let the supervisor know, listening to the nurse's concerns, and discussing better ways to manage time and prioritize would not provide the much-needed break for the nurse.
A new graduate nurse is having difficulty prioritizing care and leaving the shift in a timely manner. The nurse manager notes that the new nurse rarely delegates tasks to the unlicensed assistive personnel (UAP) since a recent incident in which the new nurse delegated an inappropriate task to a UAP. Which action by the nurse manager should best help to address this situation? A. Reminding the nurse that she will quickly burn out if she does not delegate some care to the UAP B. Encouraging the nurse not to let the recent experience impact future actions C. Reviewing state and facility guidelines concerning delegation with the nurse D. Having the UAP discuss with the nurse appropriate activities that he can do to assist the nurse with client care
C. Reviewing state and facility guidelines concerning delegation with the nurse Rationale: To avoid pitfalls concerning delegation of activities, the nurse should be aware of state and facility guidelines. Thus, the best action of the nurse manager would be to discuss these guidelines with the new nurse. Encouraging the nurse not to let past experience guide future actions would not help the nurse to understand appropriate guidelines for delegation. Reminding the nurse that she will burn out quickly if she does not delegate tasks does not help the nurse learn to delegate tasks appropriately. Nurses should not rely solely on UAPs to indicate which tasks can appropriately be delegated; they should follow state and facility guidelines.
The nurse is providing care for several clients with neurologic dysfunction. Which client should be placed closest to the nurses' station? A. A preoperative 68-year-old client who was diagnosed with an astrocytoma B. An 80-year-old client with viral meningitis who was admitted 3 days ago C. A 72-year-old client who is 2 days postoperative for a carotid endarterectomy D. A newly admitted 65-year-old client who experienced an acute subdural hematoma
D. A newly admitted 65-year-old client who experienced an acute subdural hematoma Rationale: When prioritizing care, the nurse needs to consider all relevant factors. A newly admitted client with a recent subdural hematoma would be considered a high priority due to risk for seizures, stroke, brain herniation, and so forth and should be placed closest to the nurses' station. A client 3 days postmeningitis, a preoperative client, and a client who is 2 days postoperative for a carotid endarterectomy would have more stability and less priority than a newly admitted client with a subdural hematoma.
A homeless client presents to the emergency department (ED) complaining of severe chest pain. The client is well known to the ED, coming in frequently for various minor complaints. Which ethical principles should be most important for the nurse to consider? A. Privacy and confidentiality B. Accountability and responsibility C. Nonmaleficence and beneficence D. Justice and fairness
D. Justice and fairness Rationale: The principle of justice guides nurses in making decisions about setting priorities. Additionally, nurses must show fairness in treating individuals as equals. In this scenario, the nurse must treat the homeless client like any other client seeking care for chest pain. Accountability, responsibility, privacy, confidentiality, nonmaleficence, and beneficence are all important ethical considerations for the nurse but are not directly relevant to the situation.
A client presents to the emergency department (ED) complaining of pain and burning on urination. The client also tells the triage nurse that she noted blood in the urine the past few times she urinated, so she thought she should come to the emergency department. In which category should the nurse classify the client's problem to prioritize care in relation to other clients in the ED? A. Emergent B. Urgent C. Immediate D. Nonurgent
D. Nonurgent Rationale: Symptoms indicate that this client may be experiencing a urinary tract infection, which would be considered nonurgent since a delay in treatment would not result in a life-threatening situation. It would not meet the criteria for urgent or emergent/immediate.
A client sustained a radial fracture and a cast was just applied. The client states that there is unrelieved pain and numbness in the fingers on the affected side. Which intervention should be a priority? A. Preparing for fasciotomy B. Elevating the extremity C. Performing frequent neurovascular checks D. Notifying the healthcare provider for cast removal
D. Notifying the healthcare provider for cast removal Rationale: Compartment syndrome occurs when edema and swelling cause increased pressure in a muscle compartment, leading to decreased blood flow and potential muscle and nerve damage. This leads to dilation of the blood vessels, causing more edema and increasing pressure in the limb. This is a medical emergency; the first step in treatment is to remove the tight cast by notifying the healthcare provider. A fasciotomy is indicated when internal pressure is causing the symptoms but would not be indicated unless the cast removal did not relieve the pressure. Neurovascular checks would be performed frequently, but cast removal is the priority. Elevating the extremity is indicated to prevent compartment syndrome, not to treat the problem if it occurs. This would actually decrease circulation to the extremity.
Which action should the nurse take to best involve hospitalized clients in their care and avoid pitfalls related to not involving clients in their own care? A. Orienting the client and family to the hospital facility and routines B. Informing clients of the daily schedule of care C. Asking the client's family about usual patterns of behavior D. Observing client behaviors for cues about preferences
D. Observing client behaviors for cues about preferences Rationale: To avoid pitfalls related to not involving clients in their own care, the nurse should observe client behaviors for cues about preferences. Informing clients about the daily schedule of care and orienting clients and families to the hospital routine do not provide information about client preferences. While a family may be able to provide information concerning client preferences, it is best to ask or observe the client to determine preferences.
The nurse is assessing a client's peripheral circulation after cardiac catheterization. Which finding is the highest priority? A. Pulses are palpable and bounding. B. The client's toes are warm and pink. C. The femoral site is soft and free of hematoma or bleeding. D. The client is experiencing numbness in the toes.
D. The client is experiencing numbness in the toes. Rationale: After cardiac catheterization, a finding that the client is experiencing numbness may indicate a complication of the procedure, thus it would be the highest priority. Warm and pink toes, palpable, bounding pulses, and a femoral site free of hematoma and bleeding are all normal findings. Next question
A nurse is caring for a client with stage IV heart failure. Which nursing diagnosis would be a priority? A. Cardiac Output, Decreased B. Knowledge, Deficient C. Activity Intolerance D. Fluid Volume: Excess
D. Fluid Volume: Excess Rationale: Compensatory mechanisms are activated in heart failure, specifically neuroendocrine responses. The cascade of decreased cardiac output and decreased renal perfusion stimulates the renin-angiotensin system, which stimulates the release of aldosterone from the adrenal cortex and ADH from the posterior pituitary. ANP and BNP are released and blood flow is redistributed to the heart and brain. As a result, there is salt and water retention by the kidneys and water excretion is inhibited, causing pulmonary congestion, renal vasoconstriction and decreased renal perfusion, and increased preload and afterload. According to Maslow's Hierarchy of Needs, oxygenation is the priority need for a client in stage IV heart failure, and therefore Fluid Volume: Excess is the priority diagnosis, since oxygenation is compromised with fluid overload in the lungs. The second one would be Cardiac Output, Decreased, then Activity Intolerance and Knowledge, Deficient. (NANDA-I © 2014)
A client with heart failure is being discharged home with his wife. What is the priority goal for this client? A. To lose 2 pounds every week B. To consume a high-salt diet C. To walk 5 miles per day D. To not gain more than 5 pounds in a week
D. To not gain more than 5 pounds in a week Rationale: Clients with heart failure should be on a no-salt diet due to fluid retention. Walking 5 miles per day is not a safe or appropriate goal for a client with heart failure. Losing 2 pounds per week is not an appropriate goal, as the client could become fluid deficient. Gaining2-3pounds in 24 hours or 5 or more pounds in a week is not an appropriate goal for a client with heart failure and must be re-evaluated by a healthcare provider.
A nurse has just administered a dose of hydralazine hydrochloride (Apresoline) intravenously to a client. Based on the action of this medication, the nurse would initially assess the client's: a) cardiac rhythm b) oxygen saturation c) blood pressure d) respiratory rate
Hydralazine is a powerful vasodilator that exerts it action on the smooth muscle walls of arterioles. After an intravenous dose is administered, the nurse should check the client's blood pressure every 5 minutes until stable and every 15 minutes thereafter (or per agency procedure). Although options A, B, and D are a component of the assessment, based on the action of the medication the nurse would initially check the client's blood pressure
Several clients arrive in the ED with the same complaint of abdominal pain. Designate them for care in order of the severity of their condition. 1. A 12-year-old girl with a low-grade fever, anorexia, nausea, and right lower quadrant tenderness for the past 2 days 2. A 25-year-old woman complaining of dizziness and severe left lower quadrant pain who states she is probably pregnant 3. A 38-year-old man complaining of severe occasional cramps with three episodes of watery diarrhea hours after meal 4. A 42-year-old woman with moderate right upper quadrant pain who has vomited little amounts of yellow bile and whose symptoms have worsened over the past week 5. A 53-year-old man who experiences discomforting mid-epigastric pain that is worse between meals and during the night 6. A 68-year-old man with a pulsating abdominal mass and sudden onset of "tearing" pain in the abdomen and flank within the past hour a) 2, 6, 4, 1, 5, 3 b) 6, 2, 4, 1, 3, 5 c) 2, 6, 1, 4, 5, 3 d) 6, 2, 1, 4, 3, 5
Option D: Prioritization. (6) The 68-year-old man with pulsating mass is experiencing abdominal aneurysm that may rupture, and he may abruptly deteriorate. (2) The 25-year-old woman with lower left quadrant pain is at risk for ectopic pregnancy, which is a life-threatening condition. (1) The 12-year-old girl needs evaluation to rule out appendicitis. (4) The 42-year-old woman with vomiting needs evaluation for gallbladder problem, which seems to be worsening. (3) The 38-year-old man has food poisoning, which is usually self-limiting. (5) The 53-year-old man with mid-epigastric pain may have ulcer, but followup diagnostic testing and educating lifestyle modification can be scheduled with the primary health care provider.
You have just received nursing report from the previous shift and you are performing your morning patient assessments. You have a total of 4 patients that are either post-op or pre-op for surgery. Which assessment finding requires a priority nursing action? A. Orange-colored urine in a patient who is taking Pyridium and is post-op day 3 from a TURP. B. No stool excretion in a patient who is post-op day 2 from a colostomy. C. Shoulder pain in a patient who is post-op day 1 from a laparoscopic cholecystectomy. D. Pain rating that has decreased from a 10 to 0 in a patient who is awaiting an appendectomy.
Option D: The patient reports decreased pain from a 10 to 0. This on the surface may sound good....maybe you are thinking the previous shift must have given the patient pain medication that helped control the pain. However, the red flag in this option is that the patient is awaiting an appendectomy. An appendectomy is usually ordered for cases of severe appendicitis. Therefore, if a patient with appendicitis goes from having severe pain to no pain, the nurse must take further action because the appendix has possibly ruptured. Although, the patient feels better right now, peritonitis and sepsis can happen quickly which can lead to death. This is the correct answer.
A nurse enters a room and finds a patient lying face down on the floor and bleeding from a gash in the head. Which action should the nurse perform first? a) Determine the level of consciousness. b) Push the call button for help c) Turn the client face up to assess d) Go out in the hall to get the nursing assistant to stay with the client while the nurse calls the physician.
a) Determine the level of consciousness. Assessing the level of consciousness should be the first action when dealing with clients that might have fell over.
A client is brought to the emergency department by the police after having lacerated both wrists in a suicide attempt. The nurse should take which initial action? a) examine and treat the wound sites b) obtain and record a detailed history c) encourage and assist the client to ventilate feelings d) administer an anti-anxiety agent
a) examine and treat the wound sites The client has a physiological injury, and the nurse would initially examine and treat the wound sites because of bleeding. Although options B,C, and D may be appropriate at some point, the initial action would need to be to treat the wounds.
A client arrives at the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. The priority nursing action is to: a) obtain vital signs b) ask the client about the precipitating events c) complete an abdominal physical assessment d) insert a nasogastric (NG) tube and Hematest the emesis
a) obtain vital signs The priority action is to obtain vital signs to determine whether the client is in shock from blood loss and to obtain a baseline by which to monitor the progress of treatment. The client may not be able to provide subjective data until the immediate physical needs are met. Insertion of an NG tube may be prescribed but is not the priority action. A complete abdominal physical assessment needs to be performed but is not the priority.
The nurse plans care for a client in the post anesthesia care unit. The nurse should assess first the client's: a) respiratory status b) level of consciousness c) level of pain d) reflexes and movement of extremities
a) respiratory status Assessing respiratory status is the first priority. Remember ABC
Nurse Channing is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first? a) A client with diabetes being discharged today. b) A 35-year-old male with tracheostomy and copious secretions c) A teenager scheduled for physical therapy this morning d) A 78-year-old female client with pressure ulcer that needs dressing change.
b) A 35-year-old male with tracheostomy and copious secretions The patient with problem of the airway should be given highest priority. Remember Airway, Breathing, and Circulation (ABC) is a priority
Prior to oral defense, a 21-year-old nursing student goes straight to the clinic due to tingling sensations, palpitations, and chest tightness. Deep, rapid breathing and carpal spasms are also observed. What is the nursing priority action for this situation? a) Give supplemental oxygen b) Allow the student to breathe into a paper bag c) Report to the physician immediately d) Get an order for an anxiolytic medication
b) Allow the student to breathe into a paper bag Option B: Prioritization. The student is hyperventilating secondary to anxiety, and breathing into paper bag will provide rebreathing of carbon dioxide. Encouraging slow breathing will also help.·Options A and D: Other options such as oxygen and drug administration may be needed if other causes are known.
What is regarded as one of the priority actions that must be accomplished when a primary assessment of a trauma client is conveyed? a) Taking a full set of vital sign measurements b) Completing a brief neurologic assessment c) Monitoring pulse oximetry reading d) Palpating and auscultating the abdomen
b) Completing a brief neurologic assessment ·Option B: Prioritization. A brief neurologic assessment to ascertain level of consciousness and pupil reaction is part of the primary survey. Options A, C, and D: Vital sign measurements, monitoring pulse oximetry readings, and assessment of abdomen are basically part of the secondary survey
A nurse responds to an external disaster that occurred in a large city when a building collapsed. Numerous victims require treatment. Which victim will the nurse attend to first? a) an alert victim who has numerous bruises on the arms and legs b) a victim with a partial amputation of a leg who is bleeding profusely c) a hysterical victim who received a head injury d) a victim who sustained multiple serious injuries and is deceased
b) a victim with a partial amputation of a leg who is bleeding profusely The nurse determines which victim will be attended to first on the basis of the acuity level of the victims involved in the disaster. The priority victim is the one who must be treated immediately or life, limb, or vision will be threatened. This victim is categorized as emergent (option 2). The victim who requires treatment, but life, limb, or vision is not threatened if care can be provided within 1 to 2 hours is considered urgent and is the second priority (option 3). The victim who requires evaluation and possible treatment but for whom time is not a critical factor is categorized as nonurgent and is the third priority (option 1).
A nurse manager of a medical-surgical unit returns to work after being on vacation for a week. It is the beginning of the shift, and the nurse manager is faced with several activities that need attention. Which activity will the nurse manager attend to first? a) a crash cart needs checking b) client assignments for the day c) a phone message that indicates that the charge nurse of the next shift is ill and will not be reporting to work d) a stack of mail from the education department and administrative services
b) client assignments for the day The nurse manager needs to attend to the client assignments first. Client care is the priority. In addition, the nursing staff needs assignments so that they can begin client assessments and begin delivering client care. The nurse manager should next check the crash cart (which is normally done every shift) to ensure that needed equipment is available in the event of an emergency. The nurse manager could also delegate this task to another registered nurse while client assignments are being planned. The nurse manager would next begin the problem-solving process related to finding a charge nurse for the next shift. Because this activity directly affects client care, this would be done before reading the stack of mail.
A client admitted to the hospital with a diagnosis of cirrhosis has massive ascites and difficulty breathing. The nurse performs which intervention as a priority measure to assist the client with breathing? a) repositions side to side every 2 hours b) elevates the head of the bed 60 degrees c) auscultates the lung field every 4 hours d) encourages deep breathing exercises every 2 hours
b) elevates the head of the bed 60 degrees The client is having difficulty breathing because of upward pressure on the diaphragm from the ascitic fluid. Elevating the head of the bed enlists the aid of gravity in relieving pressure on the diaphragm. The other options are general measures to promote lung expansion in the client with ascites, but the priority measure is the one that relieves diaphragmatic pressure.
A nurse is assessing a 39 year old Caucasian female client. The client has a blood pressure (BP) of 152/92 mm Hg at rest, a total cholesterol of level of 190 mg/dL, and a fasting blood glucose level of 110 mg/dL. The nurse would place priority on which risk factor for coronary heart disease (CHD) in this client? a) age b) hypertension c) hyperlipidemia d) glucose intolerance
b) hypertension Hypertension, cigarette smoking, and hyperlipidemia are major risk factors for CHD. Glucose intolerance, obesity, and response to stress are also contributing factors. An age of more than 40 years is a nonmodifiable risk factor. A cholesterol level of 190 mg/dL and a blood glucose level of 110 mg/dL are within the normal range. The nurse places priority on major risk factors that need modification.
A nurse is formulating a plan of care for a client receiving enteral feedings. The nurse identifies which nursing diagnosis as the highest priority for this client? a) diarrhea b) risk for aspiration c) risk for deficient fluid volume d) imbalanced nutrition, less than body requirements
b) risk for aspiration Any condition in which gastrointestinal motility is slowed or esophageal reflux is possible places a client at risk for aspiration. Although options 1, 3, and 4 may be a concern, these are not the priority.
A client with a history of suicide attempts is admitted to the mental health unit with the diagnosis of depression. Upon the client's arrival, the client's therapist reports to the nurse that the clients telephoned the therapist earlier in the evening and reported having a overwhelming suicidal thoughts. Keeping this information in mind, the priority of the nurse is to assess for: a) interaction with peers b) the presence of suicidal thoughts c) the amount of food intake for the past 24 hours d) information regarding the past medication regimen
b) the presence of suicidal thoughts The critical information from the therapist is that the client is having thoughts of self-harm; therefore, the nurse needs further information about present thoughts of suicide so that the treatment plan may be as appropriate as possible. The nurse must make sure the client is safe. The items in options A, C, and D should be assessed; however, evaluation for suicide potential is most important
A high school student comes in the triage area alert and ambulatory, and his uniform is soaked with blood. He and his classmates are sounding, "We were running around outside the school and he got hit in the abdomen with a stick!" Which statement should be a priority? ·a) "The stick was absolutely filthy and muddy." b) "He has a family history of diabetes, so he requires attention right now." c) "He pulled the stick out because it was too painful for him." d) "There was plenty of blood so we used three gauzes."
c) "He pulled the stick out because it was too painful for him." · Option C: Prioritization. An impaled object may be giving a tamponade effect, and removal can result in abrupt hemodynamic decompensation.· Options A and B: Information such as the dirt on the stick or history of diabetes, is significant in the overall treatment plan but can be addressed next.· Option D: Additional history including a more precise extent of blood loss, depth of penetration, and medical history should be collected.
Nurse Skye is on the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first? a) A client scheduled for cardiac ultrasound this morning b) A client with syncope being discharged today c) A client with chronic bronchitis on nasal oxygen d) A client with diabetic foot ulcer that needs a dressing change
c) A client with chronic bronchitis on nasal oxygen A client with airway problems should be attended first
A client with multiple injuries is rushed to the ED after a head-on car collision. Which assessment finding takes priority? a) Irregular apical pulse b) Ecchymosis in the flank area c) A deviated trachea d) Unequal pupils
c) A deviated trachea A deviated trachea is a symptom of tension pneumothorax, which will result in respiratory arrest if not managed.· Options A, B, and D: The remaining options are of lower priority but still need to be addressed.
A nurse is scheduling a client for diagnostic studies of gastrointestinal (GI) system. Which of the following studies, if ordered, should the nurse schedule last? a) ultrasound b) colonoscopy c) barium enema d) computed tomography
c) barium enema When barium is instilled into the lower GI tract, it may take up to 72 hours to clear the GI tract. The presence of barium could cause interference with obtaining clear visualization and accurate results of the other tests listed, if performed before the client has fully excreted the barium. For this reason, diagnostic studies that involve barium contrast are scheduled at the conclusion of other medical imaging studies.
A client is 3 hours postoperative following a right upper lobectomy. The collection chamber of the closed pleural drainage system contains 400 ml of bloody drainage. The client's vital signs are blood pressure 100/50 mmHg, heart rate of 100 beats per minute, and respiratory rate 26 breaths per minute. There is intermittent bubbling in the water seal chamber. One hour following the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant and the client appears dyspneic. The nurse should first check: a) lung sounds b) vital signs c) the chest tube connections d) the amount of drainage
c) the chest tube connections Constant bubbling in the water seal chamber indicates an air leak. This is most likely related to an air leak caused by a loose connection. Other causes might be a tear or incision in the pulmonary pleura, which requires physician intervention. Although the items in options A, B, and D need to be assessed, they should be performed after initial attempts to locate and correct the air leak.
A client presents to the emergency room with dyspnea, chest pain, and syncope. The nurse assesses the client and notes that the following assessment cues: pale, diaphoretic, blood pressure of 90/60, respirations of 33. The client is also anxious and fearing death. Which action should the nurse take first? a) Administer pain medications b) Administer IV fluids c) Administer dopamine d) Administer oxygen via nasal cannula.
d) Administer oxygen via nasal cannula. Promotion of adequate oxygenation is the most vital to life and therefore should be given highest priority by the nurse.
Nurse Vivian is reviewing immunizations with the caregiver of a 72-year-old client with a history of cerebrovascular disease. The caregiver learns that which immunization is a priority for the client? a) Hepatitis A vaccine b) Lyme's disease vaccine c) Hepatitis B vaccine d) Pneumococcal vaccine
d) Pneumococcal vaccine Pneumococcal vaccine is a priority immunization amongst elderly especially those with chronic illnesses.
A nurse in a postanesthesia care unit (PACU) receives a client transferred from the operating room. The PACU nurse assesses the client for which of the following first? a) active bowel sounds b) adequate urine output c) orientation to the surroundings d) a patent airway
d) a patent airway After a transfer from the operating room, the PACU nurse performs an assessment of the client. The ABCs'airway, breathing, and circulation'must be assessed first. Urine output and orientation to the surroundings might also be assessed, but these are not the first actions. The client might not have active bowel sounds at this time because of the effects of anesthesia.
A nurse is caring for a client who has wrist restraints applied. Which nursing intervention would receive highest priority regarding the wrist restraints? a) providing range-of-motion exercises to the wrists b) removing the restraints periodically per agency guidelines c) applying lotion to the skin under the restraints d) assessing color, sensation, and pulses distal to the restraint
d) assessing color, sensation, and pulses distal to the restraint Assessing color, sensation, and pulses distal to the restraint determines the presence of neurovascular compromise that is associated with the use of restraints. All of the other interventions should be implemented, but option 4 is the priority.
A community health nurse is working with older residents who were involved in a recent flood. Many of the residents are emotionally despondent, and they refused to leave their homes for days. When planning forth rescue and relocation of these older residents, what is the first item that the nurse needs to consider? a) contacting the older resident's families b) attending to the emotional needs of the older residents c) arranging for ambulance transportation for the oldest residents d) attending to the nutritional status and basic needs of the older residents
d) attending to the nutritional status and basic needs of the older residents The question asks about the first thing that the nurse needs to consider. The ABCs of community health are always attending to people's basic needs of food, shelter, and clothing. Options A, B, and C are other activities that may or may not be needed at a later date.
A group of health nurse is caring for a group of homeless people. When planning for the potential needs of this group, what is the most immediate concern? a) peer support through structured groups b) finding affordable housing for the group c) setting up a 24-hour crisis center and hotline d) meeting the basic needs to ensure that adequate food, shelter, and clothing are available
d) meeting the basic needs to ensure that adequate food, shelter, and clothing are available The question asks about the immediate concern. The ABCs of community health are always attending to people's basic needs of food, shelter, and clothing. Options A, B, and C are other activities that may be completed at a later time.
A registered nurse (RN) has delegated care of a newly postoperative client to a licensed practical nurse (LPN). The LPN notifies the RN that the client's blood pressure and respirations are elevated from the baseline readings and that the client is complaining of pain and dyspnea. The RN takes which action next? a) the RN need not to carry out further assessment because the LPN is very experienced and trustworthy b) the RN requests that the LPN offer the client a opioid analgesic, which has ordered postoperatively c) the RN places a call to the attending surgeon and reports that the client is having pain and dyspneic d) the RN assesses the client, checks the client's surgical notes, and gathers additional data before calling the surgeon
d) the RN assesses the client, checks the client's surgical notes, and gathers additional data before calling the surgeon The RN must not depend exclusively on the judgment of an LPN because the RN is responsible for supervising those to whom client care has been delegated. The client has recently had surgery, and there is the potential for complications, which may be signaled by alterations in vital signs and respiratory status. An analgesic may be needed, but in order to make that determination, the RN must have more information. A call to the surgeon may be warranted, but the RN has insufficient data at this time. In order to provide the client with the degree of care required, the nurse must assess the client, gather additional information, and analyze that information before notifying the surgeon.