Prioritizing Care Adaptive Quizzing

The nurse is teaching a group of student nurses about caring for the client with sealed implants of radioactive sources. Which comments by the student nurse indicate the need for the further teaching? Select all that apply.

"I should keep visitors at least 3 feet from the source of radiation." "I should keep the door to the room of the client open as a nursing priority."

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.

"The case manager advocates for the client and family." "Case managers help control the costs for high-risk, high-cost client populations." "Case management includes the client, family, and all healthcare provider involvement."

A client after a trauma has difficulty opening his or her eyes to pain, has abnormal flexion motor response, and speaks inappropriate words. What is the status of the client utilizing the Glasgow Coma Scale? Record your answer using a whole number.

8

A client has a severe, unilateral throbbing headache that has lasted for 2 days. What should be the priority nursing care?

Administering sumatriptan

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

Airway Cervical spine

In which environments is the functional model of care most likely to be utilized? Select all that apply.

Ambulatory clinics Extended care facilities

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

Analyze status of clients' movement through clinical pathways. Match clinical pathway actions with expected diagnostic-related grouping activities. Coordinating communication among all departments in the organization.

A client's chest tube has accidentally dislodged. What is the nursing action of highest priority?

Apply a petroleum gauze dressing over the site.

The nurse is assessing a client who has been sexually assaulted. Which action of the nurse is most appropriate?

Asking the client to stand on a sheet to remove the clothing

Which primary step should be followed by the nurse when prioritizing care for a hypertensive client?

Assess for a severe headache.

The nurse plans to provide a back massage to a client. What should the nurse do first in this situation?

Assess the client's preference for touch and massage.

Which skills are essential for the nurse who is setting priorities for client care? Select all that apply.

Assessment Critical thinking Clinical decision-making

Which nursing action is appropriate when conducting a secondary survey during the emergency assessment?

Assigning a nurse to support family members

The nurse is assisting a client out of bed. Which is the priority nursing action?

Assisting the client from a supine to an upright position

The nurse is hired to work in a Magnet hospital. What should the nurse expect when providing care in this organization?

Attend clinical care conferences to discuss client care needs

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.

Average length of stay per client is 42 hours. Average experience of registered nurses is 16 months. Budget for salaries 120% over estimates for the last fiscal quarter.

The client is receiving high-flow intravenous (IV) fluid replacement therapy. Which nursing assessment findings are consistent with fluid volume overload? Select all that apply.

Bounding pulse Presence of dependent edema Neck vein distention in the upright position

Which complication involving the simple venous catheter requires the nurse to assess history of catheter use?

Catheter lumen occlusion

Which area of the body would the nurse explain is affected by pituitary and hypothalamic dysfunction due to the effects of radiation therapy?

Central nervous system

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

Client B

The healthcare team is caring for clients in a mass casualty event. Which clients should be given the least priority of care?

Client reporting leg sprain

The healthcare team is caring for clients who sustained injuries in an accidental fire. Which client should be provided with immediate care based on priority?

Client with burns to the head

The healthcare team is caring for the clients in emergency department. Which client should the nurse provide with immediate care based on priority?

Client with repeated tonic-clonic seizures

Which clients would the nurse consider to require a high intensity of resources to provide effective care?

Client with respiratory distress

What is an expectation of a primary nurse?

Coordinate all aspects of a client's care.

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 terms, synonymous with critical pathways, will the nurse educator include in a presentation regarding the role of the case manager? Select all that apply.

Critical path Integrated care pathway Collaborative care pathway Multidisciplinary care pathway

Which nursing action allows for a thorough assessment of a trauma client to prioritize the client's care?

Cutting fabric that is stuck to the client's skin with scissors

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.

Documenting the client's care Administering tetanus prophylaxis to the client

What are the priority interventions to be followed in the critical rescue of clients with snakebites? Select all that apply.

Encourage the client to rest. Move the client to a safe area. Remove the clothing and jewelry.

What is considered to be the highest priority for an assault victim who presents to the emergency department?

Ensuring the client's emotional and physical safety

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

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

Having the client descend to lower altitude

What characteristics should be included when devising care plans for use with the total client care delivery system? Select all that apply.

Holistic Continuous Client-centered Comprehensive

The nurse is caring for a client with a spinal cord injury. Which priority intervention should be performed by the nurse immediately?

Immobilizing and stabilizing cervical spine

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

Immobilizing the cervical spine Preparing for chest tube insertion Applying direct pressure to a wound

Which phase of the strategic planning process is executed according to order of priority?

Implementation

The nurse is providing care to a client who has a suspected pelvic fracture as the result of a motor vehicle accident. Which is the priority nursing action?

Inspecting the genitalia

What is the priority nursing care for the client receiving anthracycline chemotherapy?

Instructing the client to report a chronic cough and shortness of breath

A client with respiratory distress due to an overdose of antidepressant drugs is hospitalized. Which intervention should be performed as a priority?

Intubating the client

The nurse has accepted a position as a navigator. What should the nurse expect to learn during training for this role? Select all that apply.

Learning ways to work through the health systems Strategies to teach clients about disease, including prevention and treatment Assessing barriers that clients have encountered while attempting to receive care Helping clients cope with delays in receiving treatment until barriers are overcome

Which is an advantage to the use of a team nursing approach to client care?

Lower level organizational decision making

Which roles require the nurse to prioritize when implementing a primary nursing model of client care? Select all that apply.

Manager Advocate Decision maker Care coordinator

Which task involves setting up priorities for care?

Managing

The client presents to the emergency department with increasing incoherence and periods of stupor. According to the EMS, the client was found wandering outside in the cold without a coat. Which condition would the nurse consider to be responsible for the client's signs and symptoms?

Moderate hypothermia

Which statement describes the practice partnership model of care delivery?

Nurse and unlicensed assistive personnel work the same shifts and days.

Who is responsible for client outcomes in the functional model of care?

Nurse manager

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?

Obtain a urinalysis.

Which priority assessment findings would the nurse expect to see when caring for a client with sinus tachycardia? Select all that apply.

Orthopnea Shortness of breath Decreased blood pressure

What is the priority nursing intervention for a client injured by lightning?

Performing cardiopulmonary resuscitation

The registered nurse teaches the student nurse regarding the priority of care provided to clients with eye injuries due to chemical exposure. Which activity performed by the student nurse indicates effective learning?

Performing ocular irrigation

A client who sustained a spinal cord injury experienced an episode of autonomic dysreflexia. Which intervention should the nurse perform first?

Place the client in sitting position.

What should the associate nurse use to provide client care within the primary nursing delivery model?

Plan of care

Which is the priority nursing action when providing care to a trauma client whose primary survey indicates a Glasgow Coma Scale of 7?

Preparing for intubation

What is the priority of care to promote client safety directly after esophagogastroduodenoscopy? Select all that apply.

Preventing aspiration Monitoring for signs of perforation

The nurse is assessing a client with multiple injuries due to a severe motor vehicle accident. Which nursing intervention should the nurse perform first?

Providing bag-valve-mask ventilation

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.

Reaction to pain Response to voice

The nurse is applying capsaicin to a client with diabetic neuropathy. Which action should the nurse perform immediately after applying the medication?

Remove gloves and wash hands.

While reviewing the laboratory results of a client in an acute care setting, the nurse finds urine output of 250 mL in 24 hours, blood osmolality of 310 milliosmoles per kg, and a systolic blood pressure of 90 mm Hg. What is the priority nursing intervention in this situation?

Request an increase in the intravenous fluid rate from the healthcare provider.

Which behavior indicates that a nurse is functioning as a case manager?

Reviews evidence-based practice prior to identifying interventions for a client

The nurse is caring for a client with a head injury. The Glasgow Coma Scale score of the client is 9. Which nursing intervention should be performed in the client immediately?

Stabilize cervical spine.

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

Staff meeting conducted every Tuesday at 1 pm Assigned tasks rotated among same category of care providers

During post-operative care, the nurse finds that a client has hypotension. Which priority intervention does the nurse expects to begin?

Starting O 2 therapy

What is the priority nursing intervention for an older client with diabetes mellitus who presents with a large leg ulcer?

Teaching how to transfer from a bed to chair in the least painful manner

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

The nurse protects the client's privacy. The nurse assesses the client's blood loss and urine. The nurse provides supplies and equipment on the basis of the surgical team's needs.

The 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?

The nurse should aspirate the drug from a short peripheral catheter.

The nurse is administering medication through an implanted port. What nursing safety priority should the nurse follow in this scenario?

The nurse should withhold the drug until patency and adequate noncoring needle placement of the port are established.

When should a nurse cut away all the client's clothing? Select all that apply.

When fabric may get fused to the client's skin due to burns When rapid access to the client's body is critical for resuscitation

How soon should a client with multiple traumas receive treatment according to the five-level emergency severity index (ESI)?

Within 10 minutes

The client's blood test results show a ferritin level of 3 ng/mL and a hemoglobin level of 5 mg/dL. Which triage priority tag would the nurse state is appropriate for the client?

Yellow tag

When using the AMPLE memory aid to conduct a health history during the emergency assessment, which questions will the nurse ask? Select all that apply.

"Do you smoke or drink?" "When was your last meal?" "Do you have any drug allergies?" "When was your last tetanus shot?"

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

A biased approach to care

What should the manager take into consideration when identifying a delivery model for client care? Select all that apply.

Budget Unit objectives Client population Organizational goals

Which phrases best describe functional nursing? Select all that apply.

Originated during a nursing shortage Care provided similar to an assembly line Tasks assigned according to scope of practice Charge nurse coordinates care and assignments

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.

"I should assess for low blood pressure." "I should assess for increased digitalis toxicity." "I should assess for a decreased rate of ventilation in respiratory alkalosis."

The nurse is teaching a group of student nurses about caring for a hospitalized immunosuppressed client. Which statement(s) made by the student nurse indicates the need for further teaching? Select all that apply.

"I should inspect the client's mouth at least every 4 hours." "I should monitor the vital signs of the client every 8 hours. "I should ensure that that the client's room and bathroom are cleaned at least once a week."

The nurse is teaching a group of student nurses about emergency treatment procedures for the local complication of intravenous therapy involving thrombosis. Which statements made by the student nurse require correction? Select all that apply.

"I should lower the extremity of the client." "I should apply warm compresses to stabilize the clot." "I should stop the infusion, but keep the short peripheral catheter in place."

A nurse is teaching a group of healthcare workers about the prevention of human immunodeficiency virus (HIV) transmission by healthcare workers. Which statements made by a healthcare worker indicate the need for the further teaching? Select all that apply.

"I should never re-use equipment used in invasive procedures." "If I am infected with HIV, I am restricted from practice of non-exposure-prone procedures."

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.

"The client would show signs of hyporeflexia." "The client would show signs of paresthesias."

What must triage nurses employ when prioritizing care with any model? Select all that apply.

A caring ethic A systematic approach to care Solid clinical decision-making skills

The nurse is assessing four clients with ischemic stroke. Which client requires a medium priority of care according to the National Institutes of Health Stroke Scale (NIHSS) score?

A client with facial palsy score of 1

According to the three-tiered triage system, which client requires urgent treatment? Select all that apply.

A client with renal colic A client with severe abdominal pain A client with multiple displaced fractures

The charge nurse is identifying tasks for staff caring for clients using functional nursing. Which tasks should be assigned to the licensed practical/licensed vocational nurse (LPN/LVN)? Select all that apply.

Administering topical and oral medications Measuring capillary blood glucose level for five clients

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

Client with bronchiolitis

The nurse is caring for a client with bomb blast injuries. Which are priority emergency assessments that need to be performed? Select all that apply.

Airway Breathing Circulation Exposure or environmental control

What are the priority nursing interventions for a grieving client? Select all that apply.

Allowing the client to express feelings Respecting the feelings of the client and creating a comfortable environment

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

Actions occur in steps. Client improvement is measured against criteria. Algorithms are used in the provision of client care. Care requires participation by physical and occupational therapists.

The client was admitted to the hospital with low dose amitriptyline poisoning. Which nursing intervention should be provided based on priority?

Administering activated charcoal

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.

Administering heated oxygen gas Positioning the client in supine position Applying external heat with heating blankets

The nurse is conducting a primary survey during the emergency assessment. Which nursing actions are appropriate during the airway assessment? Select all that apply.

Assessing for edema Checking for foreign bodies Monitoring for respiratory distress

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

Class II

The nurse is assessing four clients in different medical units. Which client is instructed to limit the number of visitors as a safety priority?

Client A

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

The nurse is assessing four clients in the hospital. Which client does the nurse categorize as urgent level according to the three-tiered triage system?

Client C

The nurse is assessing four clients in the obstetric unit. Which client requires high priority care?

Client C

The nurse is caring for four clients admitted at the same time under mass casualty conditions. Based on this data, which client should be given the highest priority for treatment?

Client C

The nurse is caring for a vulnerable population that is affected by heavy pollution. Four clients were identified with different respiratory disorders. Which client is considered the least priority?

Client D

The triage nurse is providing tags to different clients in an emergency department. Which client should the nurse give a red tag based on priority?

Client with abdominal trauma

The registered nurse is teaching a student nurse about caring for clients in emergency conditions. Which client if selected by the student nurse for immediate care would indicate effective learning? Select all that apply.

Client with an active hemorrhage Client with a substernal chest pain

Which nursing intervention helps to rapidly reduce the core body temperature of the client who sustained injuries from a fire?

Drenching the client with ice water

Which assessment data related to the client's airway would indicate the need for priority intervention by the nurse? Select all that apply.

Dyspnea Agonal breaths Inability to speak

What is a nursing priority to prevent complications in clients with respiratory acidosis?

Monitoring breathing status

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

Navigator

What are the priority nursing interventions for a client with neutropenia in an emergency department? Select all that apply.

Obtain blood cultures immediately. Administer antibiotic STAT as prescribed.

The nurse is seeking a position as a clinical nurse leader in a major city hospital. What should the nurse prepare to do in order to secure this type of nursing role? Select all that apply.

Pass the certification exam. Complete a master's degree in nursing.

The care delivery committee is considering client-focused care units for a 300-bed community hospital. What cost information should the committee prepare to help the hospital's board of directors make this decision? Select all that apply.

Redesigning all care areas Cross-training support personnel

If there is a fire at the healthcare facility, which priority action by the nurse ensures care to the clients? Select all that apply.

Removing the clients from immediate danger Moving the bedridden clients on stretchers, wrapped in blankets Maintaining manual respiration to the client on life support

An older client with depression is prescribed a tricyclic antidepressant. What is the priority nursing intervention in this situation?

Requesting that the physician change the drug

A health care organization is planning to implement differentiated nursing practice. What should be prepared prior to implementing this care delivery system? Select all that apply.

Salary ranges Position descriptions Expected competencies Degree of participation in decision-making

The nurse is caring for clients who are admitted with injuries due to a bus accident. Which conditions of the clients are prioritized under the emergent classification? Select all that apply.

Shock Airway obstruction