Evolve Prioritizing Care

The nurse is assessing four clients in the postoperative unit. Which client will be monitored for fluid volume overload as nursing safety priority? 1 Client A - client with lymph node dissection 2 Client B - client with laparoscopic cholecystectomy 3 Client C - client with surgical intervention for hemorrhoids 4 Client D - client with liver transplantation

1 Client A - client with lymph node dissection The nursing safety priority for client A with lymph node dissection is monitoring for manifestations of fluid overload. The nursing safety priority for client B with laparoscopic cholecystectomy is to assess the oxygen saturation level frequently until the effects of the anesthesia have passed. The nursing safety priority for client C with surgical intervention for hemorrhoids is ensuring the presence of someone near the client during the first postoperative bowel movement because it is very painful. The nursing safety priority for client D with liver transplantation is monitoring for clinical manifestations of rejection such as tachycardia and fever.

The nurse is caring for a client with an anterior nosebleed due to an accident. Which priority action by the nurse would prevent entry of blood into the stomach? 1 Packing loosely of both nares with nasal gauze 2 Positioning of client upright and leaning forward 3 Instructing the client not to blow the nose for 24 hours 4 Applying direct lateral pressure to the nose for 10 minutes

2 The priority intervention to be followed for the client with an anterior nosebleed is to position upright and leaning forward, which will prevent blood from entering the stomach. Nasal gauze is provided to the client only if needed. To prevent rebleeding and dislodging clots, the client should be instructed not to blow the nose for 24 hours. Direct lateral pressure is applied to the nose to prevent bleeding.

Which is the priority nursing action when providing care to a client with a penetrating abdominal wound? 1 Assessing bowel sounds 2 Stabilizing the impaled object 3 Administering prescribed pain medication 4 Scheduling a CT scan to determine retroperitoneal bleeding

2 Stabilizing the impaled object The priority nursing action when providing care to a client with a penetrating abdominal wound is to stabilize the impaled object to prevent further injury. While assessing bowel sounds, administering pain medication, and schedule a CT scan to determine retroperitoneal bleeding are important interventions, these are not the priorities in this situation.

Which client should the nurse consider to need the highest priority care? 1 A client with a CURB-65 score of 0 2 A client with a CURB-65 score of 2 3 A client with a CURB-65 score of 3 4 A client with a CURB-65 score of 5

4 A client with a CURB-65 score of 5 Healthcare providers use tools such as the CURB-65 scale as a supplement to assess a client with pneumonia. A client with a CURB-65 score of 5 needs immediate admission to an intensive care unit and high priority treatment. A client with a CURB-65 score of 0 can be treated at home, which indicates the least priority. Client with CURB-65 scores of 2 or 3 needs moderate priority and admission in a primary healthcare center.

Which client requires an emergent priority? 1 client with acne 2 client with psoriasis 3 client with Nevus of Ota 4 client with Battle sign

4 client with Battle sign Battle sign, bruising directly behind the ear, indicates a fracture at the base of the posterior portion of the skull that may lead to facial paralysis and vertigo. Therefore the client in option 4 needs emergency treatment. The client in option 1 has acne, an inflammatory disorder of the sebaceous glands, which can be treated either by mechanical removal or by using isotretinoin. Therefore it is least priority. The client in option 2 has psoriasis, an autoimmune chronic dermatitis that involves epidermal cells, which is treated by topical and systemic medications. It is of moderate priority because it does not threaten the client's life. The client in option 3 has Nevus of Ota, a flat gray to blue pigmentation in the upper trigeminal area, which is more common in dark-skinned individuals.