Prioritization and Delegation

A client is admitted with an eating disorder. Which client response should the nurse address first? a. "My life is over if I gain weight." b. "I feel dizzy and light-headed when I get up." c. "I cannot eat because my teeth hurt." d. "I do not have the same energy that I used to have."

b. "I feel dizzy and light-headed when I get up." Explanation: The priority intervention, by the nurse, would be to assess the client's vital signs to note any alterations. A client stating "My life is over if I gain weight" is an example of catastrophizing. Dental erosion and caries are commonly found in a client with an eating disorder. Muscle weakness is also commonly found in a client with an eating disorder.

Which client is most at risk for developing acute lymphocytic leukemia? a. A 25-year-old black male b. A 4-year-old white female c. A 44-year-old white male d. A 51-year-old Asian female

b. A 4-year-old white female Explanation: Acute lymphocytic leukemia is most common in young children and in adults age 65 and older. It's also more common in whites than in blacks or Asians.

A client is receiving CPR from paramedics as he arrives in the emergency department (ED). The paramedics are ventilating the client through an endotracheal tube placed prior to transport. During a pause in compressions, the cardiac monitor shows narrow QRS complexes and a heart rate of 55 bpm with a palpable pulse. Which action should the nurse take first? a. Start an IV line and administer amiodarone b. Check ET tube placement c. Obtain an arterial blood gas (ABG) sample d. Administer 1 mg atropine IV

b. Check ET tube placement Explanation: Endotracheal tube placement should be confirmed as soon as the client arrives in the ED. Once the airway is verified, oxygenation and ventilation should be confirmed using an end-tidal carbon dioxide monitor and pulse oximetry. Next, the nurse should establish IV access. If the client experiences symptomatic bradycardia, atropine should be administered as ordered. The ABG sample would verify effectiveness of CPR ventilations. Amiodarone is indicated for ventricular tachycardia, ventricular fibrillation, and atrial flutter.

A preschool-age child has just been admitted to the pediatric unit with a diagnosis of bacterial meningitis. What is the nurse's priority intervention? a. Assess LOC every 12 hours. b. Monitor temperature every 4 hours. c. Decrease environmental stimulation. d. Encourage the parents to hold the child.

c. Decrease environmental stimulation. Explanation: A child with the diagnosis of meningitis is more comfortable in an environment with decreased stimuli. Noise and bright lights would stimulate this child and cause the child to cry, in turn, increasing intracranial pressure. Vital signs should be assessed initially every hour and temperature monitored every 2 hours. Neurological signs should be assessed according to the child's condition, but more frequently that every 12 hours. Children are usually much more comfortable if allowed to lie flat because this position reduces meningeal irritation.

A three-year-old child is given a preliminary diagnosis of acute epiglottitis. Which initial nursing intervention is most appropriate? a. obtain a throat culture b. place the child in a side-lying position c. have emergency airway equipment readily available d. obtain blood cultures

c. have emergency airway equipment readily available Explanation: With acute epiglottitis, the glottal structures become edematous. Emergency airway equipment and humidified oxygen should be readily available. The nurse should not attempt to visualize the epiglottis, use tongue blades or throat culture swabs, which can cause the epiglottis to spasm, and totally occlude the airway. Throat inspection should only be attempted when immediate intubation or tracheostomy can be performed in the event of further or complete obstruction. The child should always remain in a position that provides the most comfort, security, and ease of breathing. The child will often assumes a classic tripod posture with the trunk leaning forward, neck hyperextended, and chin thrust forward.

The nurse is making assignments for the next shift. Which client can be assigned to a licensed practical nurse/licensed vocational nurse (LPN/LVN)? Select all that apply. - A client who just had coronary artery bypass graft (CABG) - A client who needs initial admission assessment - A client who needs assistance with colostomy irrigation - A client who is receiving glargine subcutaneously - A client who has C3 to C5 spine injury

- A client who needs assistance with colostomy irrigation - A client who is receiving glargine subcutaneously Explanation: An LPN/LVN can perform colostomy irrigation and administer subcutaneous injections. A client who just had CABG is unstable and needs to be monitored by an RN. The initial admission assessment should also be performed by an RN. C3 to C5 injury may cause respiratory compromise. Possible paralysis of diaphragm due to phrenic nerve involvement may occur. This client is unstable and should be assigned to an RN.

A client with a pulmonary embolism is experiencing chest pain and apprehension. What is the nurse's priority intervention? a. Administering ordered analgesic b. Using visual guided imagery c. Positioning the client on the left side d. Providing emotional support

a. Administering ordered analgesic Explanation: Once a pulmonary embolism has been diagnosed and the amount of hypoxia determined, chest pain and the accompanying apprehension can be treated with analgesics as long as respiratory status isn't compromised. Guided imagery and emotional support can be used in conjunction with pain medication. Positioning the client on his left side when a pulmonary embolism is suspected may prevent a clot from breaking off and traveling through the heart into the arterial circulation.

A client is 2 days postoperative from a femoral popliteal bypass. During assessment, the nurse finds the client's left leg is cold and pale. What is the nurse's initial action? a. Check distal pulses. b. Notify the health care provider. c. Elevate the foot of the bed. d. Wrap the leg in a warm blanket.

a. Check distal pulses. Explanation: The nurse must assess the client for postsurgical complications. Before the health care provider is notified, the nurse must assess circulation by checking for distal pulses that could be altered by a clot. Elevating the foot of the bed would promote venous return but decrease arterial blood flow and should be avoided. The leg should be lightly covered after circulation is assessed.

An order has been written to discontinue an infusion of total parenteral nutrition (TPN) for a child. What is the priority nursing action? a. Gradually reduce the rate of the TPN per health care provider order. b. Prepare to infuse a glucose solution after discontinuing the TPN. c. Notify pharmacy to prevent additional preparation of the expensive fluid. d. Prepare to administer insulin for prevention of hyperglycemia.

a. Gradually reduce the rate of the TPN per health care provider order. Explanation: Gradually reducing the rate will avoid a sudden loss of the highly concentrated solution of amino acids, glucose, and other nutrients, and allow the child's body to adapt. Infusing a glucose solution after discontinuing TPN is not necessary when the infusion rate has been tapered. A glucose solution may need to be infused if discontinuation was sudden to avoid an abrupt drop in blood glucose. Administering insulin after discontinuing TPN would result in hypoglycemia. The pharmacy should be notified so that additional TPN is not prepared, but that is not a priority nursing action.

The nurse is caring for a child with acute glomerulonephritis. What action is most important for the nurse to do? a. Obtain and monitor daily weight. b. Increase oral fluid intake. c. Provide sodium supplements. d. Monitor for signs of hypokalemia.

a. Obtain and monitor daily weight. Explanation: The child with acute glomerulonephritis should be monitored for fluid imbalance, which is done through daily weights. Increasing oral intake and providing sodium supplements aren't part of the therapeutic management of acute glomerulonephritis. Impaired renal function is associated with increased, not decreased, potassium levels.

A client, who underwent femoral-popliteal (fem-pop) bypass surgery, is scheduled to return from the post-anesthesia care unit. Which staff member should receive this client? a. Registered nurse with one year of experience b. Licensed practical nurse (LPN) with five years of experience c. Nursing assistant with 15 years of experience d. Charge nurse with 10 years of experience

a. Registered nurse with one year of experience Explanation: Because this client requires frequent neurovascular assessments, a registered nurse should receive him. Although experienced and able to collect data, an LPN doesn't have the education to assess this client. The nursing assistant lacks the necessary assessment skills. The charge nurse needs to be available to direct the care of other clients.

A child has ingested a bottle of over-the-counter medication and is brought into the emergency department by the parents. The nurse expedites rapid first aid for poisoning by immediately accessing what resource? a. contacting the Poison Control Center by phone b. reviewing the treatment for overdose on the medication bottle c. reviewing the emergency department poison control guidelines d. consulting the current Compendium of Pharmaceuticals and Specialties (CPS)

a. contacting the Poison Control Center by phone Explanation: Despite having directions on the bottle or in the CPS about what to do in the event of overdose of medications, best practice dictates the nurse contact the Poison Control Center for directions. Often, medication labels are outdated and should not be followed. Written hospital guidelines may also be out of date. Although making the call takes time, it guarantees the best treatment for the poisoning.

The nurse is reinforcing the health care provider's treatment plan with parents of a preterm neonate with patent ductus arteriosus. What first line treatment will the nurse teach the parents about? a. indomethacin b. prostaglandin E1 c. surgical ligation d. cardiac catheterization

a. indomethacin Explanation: Preterm neonates with good renal function may receive oral indomethacin, a prostaglandin inhibitor, to encourage ductal closure. If this is not effective, surgery is suggested. Prostaglandin E1 is used in maintaining a patent ductus arteriosus in neonates. This is primarily useful when the threat of premature closure of the ductus arteriosus exists in a neonate with ductal-dependent congenital heart disease, including cyanotic lesions. Surgical ligation and a cardiac catheterization procedure may also be performed in infants and children if medication is not effective.

The nurse is preparing to feed an infant diagnosed with pyloric stenosis prior to surgical repair. What is the nurse's most important intervention? a. Give feedings quickly. b. Burp the infant frequently. c. Encourage parental participation. d. Don't give more feedings if the infant vomits.

b. Burp the infant frequently. Explanation: These infants usually swallow a lot of air from sucking on their hands and fingers because of their intense hunger. Burping frequently will reduce gastric distention, and increase the likelihood that the infant will retain the feeding. Feedings should be given slowly with the infant lying in a semi-upright position. Parental participation should be encouraged to the extent possible, but this will not increase the likelihood that the feeding will be retained. Record the type, amount, and character of the vomit, as well as its relation to the feeding. The amount of feeding volume lost is usually refed to the infant.

A client is admitted to the labor and delivery unit in labor with blood flowing down her legs. What would be the priority nursing intervention? a. Place an indwelling catheter. b. Monitor fetal heart tones. c. Perform a cervical examination. d. Prepare the client for cesarean birth.

b. Monitor fetal heart tones. Explanation: Monitoring fetal heart tones would be the priority, due to a possible placenta previa or abruptio placentae. Although an indwelling catheter may be placed, it is not a priority intervention. Performing a cervical examination would be contraindicated because any agitation of the cervix with a previa can result in hemorrhage and death for the mother or fetus. Preparing the client for a cesarean birth may not be indicated. A sonogram will need to be performed to determine the cause of bleeding. If the diagnosis is a partial placenta previa, the client may still be able to deliver vaginally.

The nurse is monitoring a client, who is six hours post embolectomy, for an acute arterial occlusion of the left leg. When a Doppler ultrasound fails to detect a pedal pulse, the nurse notifies the surgeon who requests that the client be prepared for immediate surgery. The client refuses to consider additional surgery. What is the nurse's initial intervention? a. Reinforce the risks of not having the surgery b. Notify the provider immediately c. Notify the nursing supervisor d. Record the client's refusal in the nurses' notes

b. Notify the provider immediately Explanation: The nurse should notify the health care provider. The health care provider is responsible for providing information regarding the procedure, risks, benefits and expected outcomes. After notifying the provider, the nurse should document the situation and client response in the client's record.

A nurse is caring for a client exhibiting mild contractions and a cervical dilation of 4 cm. Using an external fetal monitor, the nurse observes variable decelerations. Which action should the nurse take first? a. Prepare for imminent birth. b. Place the client on her left side. c. Administer oxygen by face mask. d. Increase the I.V. rate.

b. Place the client on her left side. Explanation: Variable decelerations in fetal heart rate are caused by compression of the umbilical cord. Typically, variable decelerations are corrected by placing the client in a left lateral position to alleviate cord pressure. Since variable decelerations are usually transient and correctable, the nurse would not prepare for an imminent birth. Increasing the I.V. rate is not needed or ordered. If other measures have been ineffective in correcting the variable deceleration, oxygen may be administered.

The nurse is assessing a child with type 1 diabetes mellitus who recently came to the emergency department with signs and symptoms consistent with diabetic ketoacidosis. What is the nurse's priority when planning care for this child? a. Make a referral to the pediatric diabetes nurse. b. Prepare to administer intravenous fluids and insulin per order. c. Teach the family about the prevention of this complication of diabetes. d. Monitor the child closely in the emergency department before transfer to the medical unit.

b. Prepare to administer intravenous fluids and insulin per order. Explanation: Diabetic ketoacidosis, the most complete state of insulin deficiency, is a life-threatening condition. The child should be admitted to an intensive care unit for management. Treatment would consist of rapid assessment, adequate insulin to reduce the elevated blood glucose level, fluids to overcome dehydration, and electrolyte replacement. Education would be a priority after the child has stabilized.

The nurse is planning interventions for a client who is having an acute gout attack. What is the priority nursing intervention for this client? a. Instruct the client to change their dietary intake b. Instruct the client about relaxation techniques c. Administer prescribed analgesics d. Encourage increased fluid intake

c. Administer prescribed analgesics Explanation: Administering prescribed analgesics to relieve pain would be the priority. The other actions are appropriate measures, but aren't the priority.

A local chemical plant has had an environmental leak requiring the mass evacuation of its employees and neighbors in the surrounding area. The emergency room nurse is in the triage area when the first client is brought to the hospital. What should the nurse do first? a. Cut off the client's clothing and dispose of it in hazardous waste containers. b. Place the fully clothed client in a shower for decontamination. c. Determine what decontamination measures took place in the field before approaching the client. d. Discharge or admit all current clients in the emergency department.

c. Determine what decontamination measures took place in the field before approaching the client. Explanation: During a disaster the nurse's priority is personal safety. Determining what decontamination measures have already taken place will inform the nurse of necessary precautions. The nurse should not cut off the clothing or place the client in the shower until an assessment of the hazardous material has been completed. Containing the exposed clients in one area, free from other clients, is important, but the safety of the healthcare workers is the priority.

A six-week-old infant is brought to the emergency department not breathing. A preliminary finding of sudden infant death syndrome (SIDS) is made to the parents. Which initial intervention should the nurse take? a. call their spiritual advisor b. explain the etiology of SIDS c. allow them to see their infant d. collect the infant's belongings and give them to the parents

c. allow them to see their infant Explanation: The parents need time with their infant to assist with the grieving process. Calling their pastor and collecting the infant's belongings are also important steps in the plan of care, but are not priorities. The parents may be too upset to understand an explanation of SIDS at this time.

What is the priority nursing measure for a client with von Willebrand's disease who is having epistaxis? a. Lay the client supine. b. Avoid packing the nostrils. c. Apply a warm cloth to the bridge of the nose. d. Apply pressure to the nose.

d. Apply pressure to the nose. Explanation: Applying pressure to the nose may stop the bleeding because most bleeds occur in the anterior part of the nasal septum. Pressure should be maintained for at least 10 minutes to allow clotting to occur. Mouth breathing should be encouraged until the bleeding is under control. The child should be instructed to sit up and lean forward to avoid aspiration of blood. Packing with tissue or cotton may be used to help stop bleeding if applying pressure is unsuccessful, but care must be taken while removing packing to avoid dislodging the clot. Applying heat to the face would dilate blood vessels and increase the bleeding.

The parent of a 2-year-old with epiglottitis states a need to pick up the older child from school. The 2-year-old child begins to cry and appears more stridorous. What is the nurse's priority action? a. Ask how long the parent will be gone. b. Tell the 2-year-old child everything will be all right. c. Tell the 2-year-old child the nurse will stay. d. Ask the parent if there's anyone else who can meet the older child.

d. Ask the parent if there's anyone else who can meet the older child. Explanation: Increased anxiety and agitation should be avoided to prevent airway obstruction. A 2-year-old child fears separation from parents, and the parent should be encouraged to stay. Other means of picking up the older child should be found. Telling the child that everything will be all right may not decrease agitation. The parent is the primary caregiver and important to the child for emotional and security reasons.

What is the priority nursing action for a client with generalized anxiety disorder who is working to develop coping skills? a. Determine whether the client has fears or obsessive thinking b. Monitor the client for overt and covert signs of anxiety c. Teach the client how to use effective communications skills d. Assist the client to identify coping mechanisms used in the past

d. Assist the client to identify coping mechanisms used in the past Explanation: To help a client develop effective coping skills, the nurse must know the client's baseline functioning. Determining whether the client has fears or obsessive thinking, monitoring for signs of anxiety, and teaching about effective communications skills are later priorities.