NCLEX: Prioritizing
The nurse notes blanching, coolness, and edema at a client's peripheral intravenous (IV) site. Which nursing action is the priority? 1. Remove the IV catheter. 2. Apply a warm compress. 3. Check for a blood return. 4. Measure the area of infiltration.
1. Remove the IV catheter. Rationale: Blanching, coolness, and edema of the IV site all are classic signs of infiltration. Because infiltration can be damaging to the surrounding tissue, the nurse should remove the IV catheter to prevent any further damage. Warm compresses may be applied to the infiltrated area only after the IV catheter is removed and only if the infiltrated solution is not damaging to the surrounding tissues. The nurse should not depend solely on the blood return for assurance that the cannula is in the vein because a blood return may be present even if the cannula is only partially in the vein. Measuring the area of infiltration would be done after the IV catheter has been removed to assess for any further tissue damage.
When planning care, which client should the nurse assess first? 1. The client with a chest tube for a pneumothorax 2. The client who had a cholecystectomy 2 days earlier 3. The client who is receiving total parenteral nutrition and lipids 4. The client who is on contact isolation for methicillin-resistant Staphylococcus aureus (MRSA)
1. The client with a chest tube for a pneumothorax Rationale: The client with a chest tube for a pneumothorax should be assessed first, based on the airway compromise. This client could very well have problems with breathing. A client with total parenteral nutrition and lipids will need a site and rate check. The client who had a cholecystectomy 2 days earlier needs to have the incision checked, and the client on contact isolation for MRSA has to be assessed by the nurse, but these conditions are not life threatening, as an alteration in breathing could be.
The nurse assigned to 4 clients reviews client data at the beginning of the shift. To which information should the nurse give highest priority? 1. Urine output 240 mL/8 hr 2. Pulse oximetry reading 89% 3. Hemoglobin 12.2 g/dL (122 mmol/L) 4. Potassium level 3.6 mEq/L (3.6 mmol/L)
2. Pulse oximetry reading 89% Rationale: Priorities are classified as high, intermediate, and low. Setting priorities requires a sound nursing knowledge base. The pulse oximetry is well below normal and indicates the highest priority. Inadequate oxygenation to tissues is life threatening. The hemoglobin level and the potassium level are within normal range, and these are low priorities. The urine output reading is marginal: 240 mL in an 8-hour period would indicate adequate but low urine output; this presents an intermediate priority.
The nurse is giving a bed bath to an assigned client when an unlicensed assistive personnel (UAP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? 1. Finish the bed bath and then administer the pain medication to the other client. 2. Ask the UAP to find out when the last pain medication was given to the client. 3. Ask the UAP to tell the client in pain that medication will be administered as soon as the bed bath is complete. 4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.
4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. Rationale: The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not a responsibility of the UAP.
The nurse has received her client assignment for the day. Which client should the nurse check first? 1. A client experiencing severe pain 2. A client who is hearing voices in his head 3. A client who has just returned from surgery 4. A client who is in 4-point leather restraints
3. A client who has just returned from surgery Rationale: Priority clients are those who have a problem or potential problem with airway, breathing, or circulation. A client who has just returned from surgery could experience problems with all three. The client experiencing severe pain would be attended to next. Then the nurse would care for the client who is hearing voices in his head, followed by the client who is in 4-point leather restraints.
The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? 1. A client who is ambulatory demonstrating steady gait 2. A postoperative client who has just received an opioid pain medication 3. A client scheduled for physical therapy for the first crutch-walking session 4. A client with a white blood cell count of 14,000 mm3 (14.0 × 109/L) and a temperature of 101°F (38.4°C)
4. A client with a white blood cell count of 14,000 mm3 (14.0 × 109/L) and a temperature of 101°F (38.4°C) Rationale: The nurse should plan to care for the client who has an elevated white blood cell count and a fever first because this client's needs are the priority. The client who is ambulatory with steady gait and the client scheduled for physical therapy for a crutch-walking session do not have priority needs. Waiting for pain medication to take effect before providing care to the postoperative client is best.
The labor and delivery room nurse has just received reports on 4 clients. After reviewing the client data, the nurse should assess which client first? 1. A primigravida client in the active stage of labor 2. A multigravida client who was admitted for induction of labor 3. A client who is not contracting but has suspected premature rupture of the membranes 4. A client who has just received an intravenous loading dose of magnesium sulfate to stop preterm labor
4. A client who has just received an intravenous loading dose of magnesium sulfate to stop preterm labor Rationale: Magnesium sulfate is a central nervous system depressant, and the client could experience adverse effects that include depressed respiratory rate (fewer than 12 breaths/minute), severe hypotension, and absent deep tendon reflexes. This client should be seen before the clients in all other options because their conditions are stable.
The clinic nurse is caring for a client complaining of a foreign agent splashed into the eye. What intervention should the nurse employ before treatment? 1. Put on gloves. 2. Evaluate the client's visual acuity. 3. Place the client in a supine position. 4. Place a strip of pH paper in the lower sac of the client's affected eye.
2. Evaluate the client's visual acuity. Rationale: Before performing an ocular irrigation on a client who had an episode of splashing in the eye, the nurse must first evaluate the client's visual acuity. All of the other options can then be performed.
The nurse has received her client assignment for the day. Which client should the nurse care for first? 1. The 43-year-old client admitted for observation who has absence of bowel sounds 2. The 53-year-old client with heart failure who has gained 4 pounds (1.8 kg) since yesterday and is short of breath 3. The 49-year-old client who is scheduled for surgery within the next 2 hours and will undergo a hysterectomy 4. The 12-hour postoperative client who has undergone pneumonectomy and is completing a blood transfusion
2. The 53-year-old client with heart failure who has gained 4 pounds (1.8 kg) since yesterday and is short of breath Rationale: Airway, breathing, and circulation take precedence, in that order of priority. The client with shortness of breath takes priority over the other clients. The clients in options 3 and 4 would be cared for next, followed by assessment of the client who was admitted for observation.
The nursing instructor asks the nursing student to identify the priorities of care for an assigned client. The nursing instructor determines that the nursing student understands the client's needs when which statement is made? 1. "Actual or life-threatening concerns are the priority." 2. "Completing care in a reasonable time frame is the priority." 3. "Time constraints related to the client's needs are the priority." 4. "Obtaining the needed supplies to care for the client is the priority."
1. "Actual or life-threatening concerns are the priority." Rationale: Setting priorities means deciding which client needs or problems require immediate action and which can be delayed until a later time because they are not urgent. Client problems that involve actual or life-threatening concerns are always considered first. Although completing care in a reasonable time frame, time constraints, and obtaining needed supplies are components of time management, these items are not the priority in planning care for the client, based on the options provided.
The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. Which statement indicates that the student correctly identifies the priority client needs? 1. Actual or life-threatening concerns 2. Completing care in a reasonable time frame 3. Time constraints related to the client's needs 4. Obtaining needed supplies to care for the client
1. Actual or life-threatening concerns Rationale: Setting priorities means deciding which client needs or problems require immediate action and which can be delayed until a later time because they are not urgent. Client problems that involve actual or life-threatening concerns are always considered first. Although completing care in a reasonable time frame, time constraints, and obtaining needed supplies are components of time management, these items are not the priority in planning care for the client, based on the options provided.
The nurse is assigned to 4 clients on a postoperative surgical unit at a rural hospital. When prioritizing the care, the nurse recognizes that the highest priority is focused on which client? 1. The client who lacks knowledge regarding postoperative home care 2. The client with problems clearing the airway related to abdominal incision pain 3. The client with tissue perfusion alterations related to postoperative venous stasis 4. The client who is at risk for infection related to a history of smoking for 20 years
2. The client with problems clearing the airway related to abdominal incision pain Rationale: Priority care is focused on the client who has an ineffective airway. Although postoperative home care teaching is essential before discharge, there is no indication that the client is ready for discharge. The client with venous stasis has a circulatory issue related to immobility but no indication of an absence of arterial circulation. The potential for infection as a result of long-term smoking is a risk but not the most immediate concern. All 3 problems are important, but the client in the correct option has an airway concern, which supersedes the other clients' immediate needs.
An emergency department nurse is preparing to receive 4 clients as a result of a motor vehicle crash. Which victim should the nurse attend to first? 1. A child with a bleeding laceration 2. A 54-year-old woman with a fractured wrist 3. A 67-year-old woman with first-degree burns on her hands and arms 4. A 45-year-old man with chest pain, shortness of breath, and diaphoresis
4. A 45-year-old man with chest pain, shortness of breath, and diaphoresis Rationale: Triage is the decision-making process used to determine client treatment priorities based on the severity of injury and priority for treatment. Depending on the acuteness of the client's condition, a priority rating based on the severity of illness or injury is assigned, after which the client proceeds with emergency department registration or is taken into the treatment area for immediate care. Airway is always a priority, and a client who complains of chest pain is assigned an immediate care priority rating. In the case of the child with a bleeding laceration (option 1), additional pressure can be applied to control the bleeding. The clients in options 2 and 3 do not have injuries that are life threatening, and these clients can wait to be treated.
The nurse manager of a medical-surgical unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply. 1. Client postoperative day 1 after inguinal herniorrhaphy, vital signs stable 2. Client 5 days after a myocardial infarction, vital signs stable, absence of dysrhythmias 3. Client 1 day after cardiac catheterization, normal study results, groin site free of hematoma 4. Client who is vomiting, unable to take oral fluids, and receiving intravenous fluids at 125 mL/hr 5. Client on nasal oxygen at 3 L/min, bibasilar crackles, and pulse oximetry readings of 88% to 92% 6. Client with white blood cell count of 2200 mm3 (2.2 × 109/L), temperature of 102°F (38.9°C), and blood pressure of 90/40 mm Hg
1. Client postoperative day 1 after inguinal herniorrhaphy, vital signs stable 2. Client 5 days after a myocardial infarction, vital signs stable, absence of dysrhythmias 3. Client 1 day after cardiac catheterization, normal study results, groin site free of hematoma Rationale: Clients in options 1, 2, and 3 demonstrate no evidence of instability and can be discharged safely. The client in option 4 is demonstrating impaired gas exchange and fluid overload and requires oxygen. The client in option 5 requires intravenous fluid replacement because of vomiting. Without fluid replacement, the client is at risk for dehydration and electrolyte imbalances. The client in option 6 demonstrates signs of infection and hemodynamic instability and is at risk for developing septic shock. These clients should not be discharged at this time.
A child with an autism spectrum disorder (ASD) is being admitted to the hospital for diagnostic tests. Which room assignment is the most appropriate for the child? 1. Private room 2. Semiprivate room 3. 4-bed ward room 4. Contact isolation room
1. Private room Rationale: ASDs are complex neurodevelopmental disorders of unknown etiology composed of qualitative alterations in social interaction and verbal impairment with repetitive, restricted, and stereotype behavioral patterns. Children with ASDs are unable to relate to persons or respond to social and emotional cues. Characteristically, these children engage in repetitive behaviors, including head banging, twirling in circles, biting themselves, and flapping their hands or arms. Abnormal communication patterns include verbal and nonverbal communication. A child with an ASD needs decreased stimulation, with limited visual and auditory distractions. A private room would be the best environment, allowing for control of visual and auditory distractions. The semiprivate and 4-bed ward rooms would be too stimulating for the child with an ASD. ASD is not a disorder that requires contact isolation.
The nurse is caring for 4 pediatric clients. After receiving reports from the night shift, which child should the nurse assess first? 1. A 6-year-old child being treated for bacterial meningitis and on the tenth day of antibiotic treatment 2. A 6-week-old infant admitted to the hospital for decreased level of consciousness; shaken baby syndrome is suspected 3. A 2-year-old child with cerebral palsy being admitted to the hospital for surgical placement of a gastrostomy feeding tube the next day 4. A 16-year-old child with a ventriculoperitoneal shunt that was placed at birth for hydrocephalus; possible shunt malfunction is suspected, and the child is scheduled and ready for a computed tomography (CT) scan of the head
2. A 6-week-old infant admitted to the hospital for decreased level of consciousness; shaken baby syndrome is suspected Rationale: The infant or child who is the most unstable should be assessed first. A 6-week-old infant with an altered level of consciousness suspected to have resulted from shaken baby syndrome is the most unstable client because the infant could be developing increased intracranial pressure (ICP) and require interventions for the complications associated with increased ICP. The 6-year-old child on day 10 of antibiotics for bacterial meningitis is a stable client. The 2-year-old child with cerebral palsy being admitted for surgical placement of a gastrostomy tube will need an admission assessment, but this child is stable. The 16-year-old with a possible shunt malfunction could become unstable, but because this child is older and ready for the CT scan, he or she is stable at this time.
The nurse has developed a teaching plan for a client with hypertension regarding the administration of prescribed medications. What is the initial nursing action? 1. Set priorities for the client. 2. Assess the client's readiness to learn. 3. Find out whether anyone lives with the client. 4. Use only 1 teaching method to prevent confusion.
2. Assess the client's readiness to learn. Rationale: Until the client is ready to learn, teaching sessions will be ineffective. Teaching should be in short sessions, early in the day, when the client is well rested. It is important to include the client in the development of the teaching plan and to set priorities with him or her. Although it may be important to determine whether anyone lives with the client, this is not the initial nursing action. Varied teaching methods are best, such as verbal instruction with visual aids and the provision of written material for later reference.
The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply. 1. Open doors to client rooms. 2. Move beds away from windows. 3. Close window shades and curtains. 4. Place blankets over clients who are confined to bed. 5. Relocate ambulatory clients from the hallways back into their rooms.
2. Move beds away from windows. 3. Close window shades and curtains. 4. Place blankets over clients who are confined to bed. Rationale: In this weather event, the appropriate nursing actions focus on protecting clients from flying debris or glass. The nurse should close doors to each client's room and move beds away from windows, and close window shades and curtains to protect clients, visitors, and staff from shattering glass and flying debris. Blankets should be placed over clients confined to bed. Ambulatory clients should be moved into the hallways from their rooms, away from windows.
A client with cancer is receiving intravenous morphine sulfate for pain. When writing the plan of care for this client, the nurse should include which action as the priority action? 1. Monitor temperature. 2. Monitor urine output. 3. Monitor respiratory status. 4. Encourage increased fluids.
3. Monitor respiratory status. Rationale: Morphine sulfate depresses respirations. The nurse monitors the client's respiratory status closely. Although the incorrect options may be components of the plan of care, the correct choice identifies the priority nursing action.
The emergency department nurse is caring for a child with suspected epiglottitis and has ensured that the child has a patent airway. Which action is the next priority in the care of this child? 1. Prepare the child for tracheotomy. 2. Prepare to administer epinephrine. 3. Prepare the child for a chest radiograph. 4. Assist the health care provider with intubation.
3. Prepare the child for a chest radiograph. Rationale: If epiglottitis is suspected, the priorities are to maintain a patent airway and obtain a chest radiograph to confirm the diagnosis. If epiglottitis is present, the child is taken promptly to the operating room for tracheal intubation or immediate placement of a surgical airway. Epinephrine is not used in the treatment of epiglottitis.
During morning report, the day nurse is given information on the assigned clients. Which client should the nurse assess first? 1. The 80-year-old client with metastatic cancer to the brain who is confused and on 1-to-1 observation with a sitter in the room 2. The 55-year-old client with breast cancer who is scheduled for a computed tomographic (CT) scan of the brain at 0900 to rule out metastasis 3. The 60-year-old client with leukemia who is receiving the first round of chemotherapy, which was started at 0630 and is scheduled to end at noon 4. The 70-year-old client who was admitted at 0500 with the medical diagnosis of pneumonia and a temperature of 102.6°F (39.2°C). This client received acetaminophen at 0600 and now has a temperature of 100.0°F (37.8°C).
3. The 60-year-old client with leukemia who is receiving the first round of chemotherapy, which was started at 0630 and is scheduled to end at noon Rationale: The nurse would plan to first see the client who is receiving chemotherapy for the first time. This is the highest priority because of the potential side and adverse effects of the medication and the fact that this is the first dose the client has received. The confused client with a sitter is safe. The client who is scheduled for a CT scan can wait because her scheduled test is not until 0900. The client with fever is stable for now.
The nurse is assigned to care for 4 clients. Which client should the nurse assess first? 1. A client who has a tympanic temperature of 99.8°F 2. A client who has a regular radial pulse of 96 beats/minute 3. A client who has a supine resting blood pressure of 148/90 mm Hg 4. A client who has a peripheral (index finger) oxygen saturation percentage of 85%
4. A client who has a peripheral (index finger) oxygen saturation percentage of 85% Rationale: An oxygen saturation percentage of 85% is abnormal. If this is an accurate measurement, immediate intervention is needed to maintain the client's oxygenation status. A tympanic temperature of 99.8°F is mildly elevated and should be monitored, but it is a lower priority than respiratory status. A radial pulse of 96 beats/minute is elevated, as is the supine resting blood pressure of 148/90 mm Hg; both merit further assessment but are a lower priority than respiratory status.
The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? 1. A postoperative client preparing for discharge with a new medication 2. A client requiring daily dressing changes of a recent surgical incision 3. A client scheduled for a chest x-ray after insertion of a nasogastric tube 4. A client with asthma who requested a breathing treatment during the previous shift
4. A client with asthma who requested a breathing treatment during the previous shift Rationale: Airway is always the highest priority, and the nurse would attend to the client with asthma who requested a breathing treatment during the previous shift. This could indicate that the client was experiencing difficulty breathing. The clients described in options 1, 2, and 3 have needs that would be identified as intermediate priorities.
The nurse has received her client assignment for the day. Which client should the nurse care for first? 1. A client requiring a preoperative intravenous antibiotic 2. A client with emphysema who has shortness of breath after just ambulating 3. A client with serous drainage on an incisional spinal wound post laminectomy 4. A client with postoperative pain reported at 7 out of 10, with 10 being the worst
4. A client with postoperative pain reported at 7 out of 10, with 10 being the worst Rationale: In this situation, the client with the pain reported at 7 out of 10 should be cared for first. The pain will intensify and be harder to manage if treatment is delayed. Caring for the client in pain may delay administration of the preoperative antibiotic but does not jeopardize safe and effective care. Shortness of breath is expected in a client with emphysema after ambulation and therefore is not the priority. Serous drainage is expected from a surgical incision and does not indicate an emergency.
The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first priority intervention in the event of this occurrence is which action? 1. Immobilize the affected extremity. 2. Remove jewelry and constricting clothing from the victim. 3. Place the extremity in a position so that it is below the level of the heart. 4. Move the victim to a safe area away from the snake and encourage the victim to rest.
4. Move the victim to a safe area away from the snake and encourage the victim to rest. Rationale: In the event of a snakebite, the first priority is to move the victim to a safe area away from the snake and encourage the victim to rest to decrease venom circulation. Next, jewelry and constricting clothing are removed before swelling occurs. Immobilizing the extremity and maintaining the extremity at the heart level would be done next; these actions limit the spread of the venom. The victim is kept warm and calm. Stimulants such as alcohol or caffeinated beverages are not given to the victim because these products may speed the absorption of the venom. The victim should be transported to an emergency facility as soon as possible.
The nurse has received the client assignment for the day. Which client should the nurse care for first? 1. The client receiving chemotherapy who is on day 3 of a 5-day regimen and has a question about nutrition 2. The client receiving external radiation who has complaints of dryness and itching skin at the treatment area 3. The client who had a radical mastectomy 36 hours ago and is complaining of tightness and pulling at the incision site 4. The client admitted with the medical diagnosis of neutropenia who is afebrile and is complaining of pain with urination
4. The client admitted with the medical diagnosis of neutropenia who is afebrile and is complaining of pain with urination Rationale: The client admitted with neutropenia should be cared for first. The white blood cells serve as the primary defense against infections by destroying bacteria in the blood. The client is complaining of painful urination; therefore, the nurse should suspect urinary tract infection and act promptly to contact the health care provider because clients with neutropenia are more susceptible to bacterial infections. The client who is tolerating the chemotherapy regimen and has a question is not a priority. It is not urgent that the nurse see the client with dryness and itching from radiation first. This is an expected effect from radiation therapy. The client who has a mastectomy is expected to have sensations of tightness and pulling.
The nurse determines that which client has the highest priority needs? 1. The client who has a rectal temperature of 99.8°F 2. The client who has a blood pressure of 110/70 mm Hg 3. The client who has an oxygen saturation percentage of 95% 4. The client who has an irregular apical pulse of 120 beats per minute
4. The client who has an irregular apical pulse of 120 beats per minute Rationale: An elevated and irregular pulse rate requires immediate evaluation. A rectal temperature of 99.8°F (37.7°C) is also normal. The blood pressure reading of 110/70 mm Hg does not present a concern unless the client is symptomatic. An oxygen saturation percentage of 95% is a normal oxygen saturation reading.
The nurse is the first responder at the scene of an accident in which a tire blowout caused a bus to roll over several times. Which victim should the nurse attend to first? 1. The 11-year-old with burns to 10% of both legs 2. The sobbing 10-year-old with an obvious fracture of the forearm 3. The unconscious 14-year-old whose breathing is shallow at 12 respirations per minute 4. The confused 12-year-old with bright red blood pulsing from an open fracture of the femur
4. The confused 12-year-old with bright red blood pulsing from an open fracture of the femur Rationale: Triage systems identify who should be treated first. Rankings are based on immediacy of needs, including immediate threats to life such as airway compromise or hemorrhagic shock. The 12-year-old who is demonstrating confusion is becoming hypoxic because of profound blood loss. The other victims are more stable and could wait.
The nurse is a responder at the scene of a building collapse. Which victim should the nurse care for first? 1. Victim with an open fracture of the left lower extremity 2. Victim who is crying hysterically and complaining of pain in the right ankle 3. Victim who is unresponsive and not breathing and whose left pupil is fixed and dilated 4. Victim with an apparent chest wall defect and asymmetrical chest wall movement
4. Victim with an apparent chest wall defect and asymmetrical chest wall movement Rationale: The victim in option 4 will continue to have a decline in respiratory status and imminent threat to life unless immediate intervention is instituted. The victims in options 1 and 2 have conditions that can wait to be treated. The victim in option 3 is dead.