Evolve Hesi Leadership- Prioritizing Care

The nurse is inspecting the chest of a client with a suspected heart attack after a fire. Which order of interventions should the nurse follow?

INSPECT, PALPATE, AUSCULTATE, EVALUATE, EKG

What are the steps of performing a primary survey according to priority to assess a client with severe injuries from a bomb blast?

A,B,C,D,E

Which are the priority nursing actions after the completion of the secondary survey when providing care for a trauma client with a penetrating wound? Select all that apply.

DOCUMENT, ADMIN

Which priority interventions should be followed by the nurse when caring for a client with malignant hyperthermia? Select all that apply.

OXYGEN, ENDO TUBE, STOP ALL

Which health care provider would best help a homeless client receive needed medication for a communicable disease?

NAVIGATOR

After assessing a client's reports, the nurse confirms that the client has moderate hypothermia. What should be the nurse's immediate intervention? Select all that apply.

02, SUPINE, HEATING BLANKETS

The nurse is assessing a client brought to the emergency department after a bomb blast. What are the steps in order in which the nurse prioritizes care to the client?

AIRWAY, CERVICAL SPINE, BREATH, CIRCULATION, CONSCIOUSNESS, BLANKET

The nurse is caring for a client who sustained a soft tissue injury while playing sports. Following an assessment of the extent of the injury, what should be the order of nursing interventions according to priority?

ASSESS NUERO, ELEVATE, COMPRESSION BANDAGE, XRAY

Which actions indicate that a manager is helping staff adjust to functional nursing? Select all that apply.

STAFF MEETING, TASKS ROTATED

Which charge-nurse remark would be expected in a care area that is using team nursing as a care delivery method?

HAVE YOU DISCUSSED

The nurse is teaching a group of students about neuromuscular manifestations of alkalosis with hypocalcemia. Which statements provided by a student nurse indicate the need for further learning? Select all that apply.

HYPOREFLEXIA, PARASTHESIA

Which comment by a team leader exemplifies team nursing the way it was intended?

RN1

The care delivery committee is determining whether primary nursing would be appropriate to implement in a 500-bed acute care hospital. Which information would support the selection of another care delivery approach? Select all that apply.

42 HOURS, 16 MONTHS, FISCAL QUARTER

The nurse is performing a secondary survey systematically for a group of clients during an emergency situation. What is the proper order of this assessment process?

VITALS, ADJUNCTS, FAMILY, COMFORT, INSPECT

Which statement best describes the navigator?

REMOVES BARRIERS TO REVIEVING HEALTH CARE

Which delivery system was developed to provide care through others as an adaptation to functional nursing?

TEAM

Which behaviors indicate that a care provider is functioning as a primary nurse? Select all that apply.

PLAN OF CARE, ACILLARY, RESPONSES

Which triage classification of clients requires an urgent nursing priority in case of a mass casualty?

CLASS 2

Which are disadvantages to the functional system of care delivery? Select all that apply.

COMMUNICATION, FRAGMENTATION, CHANGES IN CLIENT STATUS GO UNNOTICED

What is the correct order of nursing interventions while assessing airway with simultaneous cervical spine stabilization?

JAW THRUST, REMOVE FOREIGN BODY, INSERT AIRWAY, STABALIZE NECK

Which actions should be completed by the manager of a group of nursing case managers? Select all that apply.

ANALYSE, MATCH, COORDINTATE

What is the priority nursing care for a client who is prescribed hydroxychloroquine (Plaquenil)?

BLURRED VISION

Which client should be treated first according to the National Institutes of Health Stroke Scale (NIHSS)?

FACIAL PALSEY

The registered nurse is caring for a client in the emergency department. Which conditions of the client made the nurse stabilize the cervical spine as the primary nursing intervention? Select all that apply.

FLAIL, HEAD, FACIAL

The primary healthcare team is caring for four different groups of clients who were affected by a mass casualty burn event. Which group of clients is considered the lowest priority for care?

GROUP B

The emergency department nurse is called to care for a client with a snake bite. What are the nursing interventions performed by the nurse in the order of priority?

MOVE PATIENT, REMOVE LOTHING, EMOBILIZE, CALL 911, TAKE PIC

The nurse is caring for a client with breathing difficulty and is unable to auscultate any breath sounds on one side. Which action should be implemented first by the nurse?

Prepare for needle

A severely traumatized client is brought into the emergency department. During the assessment, the nurse finds the client has difficulty breathing because of debris in the mouth, external hemorrhaging, symptoms of severe hypoglycemia, and bruises on the skin. What are the nursing interventions performed by the nurse in the order of priority?

AIRWAY, CIRCULATION, BS, BRUISES

The student nurse is performing a rapid baseline assessment using a disability mnemonic (AVPU) in a client with drug abuse. Which parameters should the student nurse consider for proper assessment? Select all that apply.

ALERT, VOICE, PAIN, UNRESPONSIVENESS

The nurse is caring for four clients in an emergency department. Which client should be provided with immediate care based on priority?

BRONICHOLITIS

Which client should the nurse consider to need the highest priority care?

CURB65-5

The patient who has a history of allergy to bee stings is brought to the emergency department following a bee sting. What are the interventions to be followed in correct order?

EPI, REMOVE STINGER, BENADRIL, SALINE

The nurse is caring for victims of a bomb blast in the emergency department who are receiving different pain medications. Which client must be placed on electrocardiogram equipment?

NAPROXEN

Which nurse would be the best to create clinical pathways for joint replacement surgeries in an environment that supports differentiated nursing practice?

NURSE WITH MASTERS DEGREES

The nurse is caring for an older client during the intraoperative stage. The anesthesia process has already begun and the nurse has already removed the dentures, eyeglasses, and hearing aids. After the nurse performs these actions, what would be the order the intraoperative nursing interventions should take place?

PILLOW UNDER HEAD, PLACES INTO POSITION, POSITION JOINTS, PAD BONY PROMINCES, WARMING, DEVICE , COVER HEAD AND FEET, WARM FLUIDS, ASPETIC, I&O

The nurse is caring for a client with a platelet count of 50,000 cells per microliter. Which recommendation is inappropriate for the client?

RAZOR BLADE

Which is a theme in the design of "Transforming Care at the Bedside"

RELIABILITY

For which situations would total client care be an appropriate delivery system? Select all that apply.

SEPSIS, GRAFT SURGERY, SHUNT

Which health care providers should be considered when filling a position as case manager for a community health care center? Select all that apply.

SOCIAL WORKER, RN

The nurse is treating a client for leakage of a nonvesicant intravenous (IV) solution into the extravascular tissue. In what order should the nurse treat the infiltration?

STOP INFUSION, APPLY STERILE DRESSING, ELEVATE EXTRIMITY, COMRESSION, NEW CATH, OBTAIN STUDY, INS

Which factor is known to threaten the nurse's ability to triage and prioritize client care accurately?

A BIASED APPOACH TO CARE

What is the priority nursing intervention for a client bitten by a snake?

IMMOBILIZE AND SPLINT

Which information supports the development of a critical pathway? Select all that apply.

STEPS, CRITERIA, CARE, THERAPIST

A client with tongue occlusion has loss of gag reflex and alterations in level of consciousness. The blood gas test shows oxygen saturation as 40mm Hg and carbon dioxide saturation as 75 mm Hg. Which type of support provides immediate relief to the client?

TRACH

A client is admitted to the emergency department with acute abdominal pain due to pelvic inflammatory disease. Which initial nursing intervention is most suitable in this condition?

UA

The nurse is assessing four clients in the postoperative unit. Which client will be monitored for fluid volume overload as nursing safety priority?

LYMPH DISECTION

The registered nurse is teaching the student nurse about care provided for clients according to the five level triage system of the Emergency Severity Index (ESI). Which statement made by the student nurse indicates effective learning? Select all that apply.

ESI4 STABLE VITALS, RESPIRATORY DISTRESS ESI1

The nurse is providing education to a client with systemic lupus erythematosus. Which education will the nurse consider as high priority?

PROTECT SKIN

Which member of the healthcare team, when using the team nursing approach, is responsible for prioritizing client care?

TEAM LEADER

The emergency department (ED) nurse is providing care to a burn trauma client. Which is the priority for the nurse to monitor for after removing the client's clothing?

HYPOTHERMIA

Which priority assessments should be included by the nurse when caring for a client who is experiencing depression? Select all that apply.

APPITITE, ACTIVITY, EMOTIONAL

nurse is providing treatment to a client for the leakage of a vesicant intravenous solution into the extravascular tissue via the short peripheral catheter. What is the most important nursing priority after the nurse has stopped the infusion and disconnected administration set?

ASPIRATE

The nurse is reviewing the medication records of four clients. Which client is taught to report shortness of breath as a prioritynursing care?

IMFLIXIMAB

A client climbing a mountain experiences symptoms of acute mountain sickness. What is the priority nursing action performed by the nurse as prehospital care?

LOWER ALTITUDE

Which organism would the nurse explain is consistent with a protozoal infection in clients with acquired immunodeficiency syndrome (AIDS)?

TOXOPLASMOSIS

The nurse is caring for four different clients in a healthcare facility. Which client should be provided with immediate care?

85 O2 SAT

Case management is being implemented in a major city hospital. What should the manager include when instructing the nursing staff about this care delivery method? Select all that apply.

ADVOCATE, POPULATION, INVOLEMENT

The nurse is assessing a client with severe burn wounds. What are the nursing interventions performed by the nurse in the order of priority?

AIRWAY, CIRCULATION, FLUID, WOUND

Which are the highest priorities when conducting a primary client survey during the emergency assessment? Select all that apply.

AIRWAY, CSPINE

The health care triage team is caring for a group of different clients who were injured due to a large industrial accident. For which client should the nurse provide care immediately?

CLIENT C

Which action should the nurse take when caring for clients through a Community-Based Care Transition Program (CCTP)?

CONTACTING THE CLIENT

The nurse ensures that the client's airway is patent and that resuscitation equipment is immediately available after the client is bitten by a snake. What kind of snakebite has led to this priority intervention by the nurse?

CORAL SNAKE

Which nursing actions are appropriate during the primary survey of the emergency assessment process? Select all that apply.

IMMOBILIZE, PREPARE FOR CHEST TUBE, DIRECT PRESSURE

A client is severely injured with burns and sustained major trauma from a fire incident. What is the order of assessments according to priority in this situation?

JAW THRUST, VENTILATION, RADIAL, BP, COMA, CLOTHES

Why is the Glasgow Coma Scale used by the nurse while performing an assessment in a traumatized client?

LEVEL OF CONCIOUSNESS

The nurse is caring for four clients. Following the three-tiered triage model of care, which client should the nurse care for first?

LOBE ABCESS

What is the priority nursing intervention for a client with stroke who is transitioned from ED to other settings?

LOC

The nurse is teaching a group of students about assessing for respiratory system manifestations of alkalosis as a nursing priority. Which statement made by the student nurse indicates the need for further teaching? Select all that apply.

LOW BLOOD PRESSURE, INCREASE MED TOXICITY, DECREASED VENTILATION

The healthcare team is caring for four clients in an emergency department. The nurse has been delegated the task to assign tags to the clients. Which client is issued the appropriate tag?

MAJOR INJURIES-YELLOW

What are the priorities of a circulating nurse when a surgery is taking place? Select all that apply.

PRIVACY, ASSESS BLOOD AND URINE LOSS, PROVIDE EQUIPMENT AND TOOLS

The body temperature of a heat stroke client is above 104° F (40° C). What is the priority order the nurse would use for cooling the client so that breathing and circulation are not impaired?

REMOVE CLOTHES, ICE PACKS, COLD WATER, FAN

A major city hospital is planning to implement primary nursing. What issues must be considered prior to the implementation of this care approach? Select all that apply.

SALARIES, DISPOSITIONS, EDUCATION, NUMBER

The emergency department (ED) nurse is triaging clients. Which client should be prioritized?

SCHOOL AGE DYSPNEA

The nurse is teaching a client how to teach the supraglottic method of swallowing. Arrange the prioritizing order of statements by the nurse for teaching the client.

UPRIGHT POSITION, CLEAR THROAT, TAKE A DEEP BREATH, FOOD IN MOUTH, HOLD BREATH , SWOLLOW TWICE

What is the correct order of steps involved in secondary survey?

VITALS, COMFORT MEASURES, PATIENT HISTORY, HEAD TO TOE ASSESSMENT