Complex Care: Order of Importance

A client with malignant pleural effusions has dyspnea and chest pain. Place the following interventions that the nurse should perform in the correct order of priority. 1. Administer morphine sulfate 2 mg IV 2. Coach the client on deep breathing exercise 3. Educate the client in anticipation of a thoracentesis 4. Apply oxygen at 2 L via nasal cannula

4. Apply oxygen at 2 L via nasal cannula 1. Administer morphine sulfate 2 mg IV 2. Coach the client on deep breathing exercise 3. Educate the client in anticipation of a thoracentesis

Prior to draining a pleural effusion, the nurse must take the following actions in what priority from first to last? 1. Check the primary health care provider's prescription 2. Assess the client's respiratory rate, status, breath sounds, and discomfort level 3. Perform hand hygiene 4. Gather drainage kit supplies

1. Check the primary health care provider's prescription 4. Gather drainage kit supplies 3. Perform hand hygiene 2. Assess the client's respiratory rate, status, breath sounds, and discomfort level

The nurse has just received morning change-of-shirt report on four assigned clients. In what order from first to last should the nurse do the following? 1. Notify the physician about a client with a serum potassium level of 6.2 2. Call the physician to request an antimetic for a client who has been vomiting 3. Begin discharge paperwork for a client with a serum potassium level or 6.2 4. Discuss the plan for the day with the nursing assistant, delegating duties as appropriate

1. Notify the physician about a client with a serum potassium level of 6.2 2. Call the physician to request an antimetic for a client who has been vomiting 4. Discuss the plan for the day with the nursing assistant, delegating duties as appropriate 3. Begin discharge paperwork for a client with a serum potassium level or 6.2

A nurse is caring for a client who is having an allergic reaction to a blood transfusion. In what order should the nurse provide care for this client? 1. Stop the transfusion 2. Keep the vein open with normal saline solution 3. Send the blood bag and blood slip to the blood bank 4. Administer an antihistamine as directed

1. Stop the transfusion 2. Keep the vein open with normal saline solution 4. Administer an antihistamine as directed 3. Send the blood bag and blood slip to the blood bank

A client with a Sengstaken-Blakemore tube has a sudden drop in SpO2 and increase in respiratory rate of 40 breaths/minute. The nurse should do which of the following in order from first to last. 1. Deflate the tube by cutting with bedside scissors. 2. Affirm airway obstruction by the tube 3. Apply oxygen via face mask 4. Remove the tube

2. Affirm airway obstruction by the tube 1. Deflate the tube by cutting with bedside scissors. 4. Remove the tube 3. Apply oxygen via face mask

A nurse is instructing a client who had abdominal surgery that day to do deep-breathing exercise. In which order should the nurse teach the client to perform diaphragmatic breathing and coughing 1. Cough deeply from the lungs 2. Splint the incision site 3. Exhale through pursed lips 4. Inhale through the nose

2. Splint the incision site 4. Inhale through the nose 3. Exhale through pursed lips 1. Cough deeply from the lungs

A client with a history of cocaine abuse is receiving intravenous therapy and exits the hospital "to visit a friend." The client returns to the nursing unit 1 hour later, agitated, aggressive, combative and reporting "chest pain." Place the nurse's actions in priority order 1. Initiate a referral to obtain drug rehabilitation counseling. 2. Contact the security department 3. Obtain a prescription for a urine sample. 4. Obtain an EKG

2. Contact the security department 4. Obtain an EKG 3. Obtain a prescription for a urine sample. 1. Initiate a referral to obtain drug rehabilitation counseling.

A nurse is obtaining an ankle-brachial index for a client with arteriosclerosis. Identify the correct order for obtaining the ankle-brachial index 1. Record the highest systolic blood pressure readings in both arms 2. Place the client in the supine position 3. Record the ankle systolic blood pressure reading when the Doppler sound returns 4. Place a Doppler probe at a 45-degree angle to the correct pulse (dorsalis pedis or posterior tibial)

2. Place the client in the supine position 1. Record the highest systolic blood pressure readings in both arms 4. Place a Doppler probe at a 45-degree angle to the correct pulse (dorsalis pedis or posterior tibial) 3. Record the ankle systolic blood pressure reading when the Doppler sound returns

Which is the correct order, from first to last, for proper placement of a urinary catheter? 1. Ensure free flow of urine 2. Prepare a sterile field 3. Insert the catheter far enough into the bladder to prevent trauma to the urethral tissue 4. Lubricate the catheter adequately with a water-soluble lubricant.

2. Prepare a sterile field 4. Lubricate the catheter adequately with a water-soluble lubricant. 3. Insert the catheter far enough into the bladder to prevent trauma to the urethral tissue 1. Ensure free flow of urine

While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and bathroom. In which order of priority from first to last should the nurse take the following actions? 1. Document as required by the facility 2. Notify the client's physician and family 3. Assess the client's current condition and vital signs 4. If the client shows no signs of acute injury, get help and carefully assist the client back to bed

3. Assess the client's current condition and vital signs 4. If the client shows no signs of acute injury, get help and carefully assist the client back to bed 2. Notify the client's physician and family 1. Document as required by the facility

A client on telemetry reports that he has been having chest pains. The hospital unit has standing orders that allows the nurse to begin treating the client before notifying the physician. Place the following nursing action in proper chronological order. Use all options. 1. Administer sublingual nitroglycerin 2. Report findings to the physician 3. Check vital signs, particularly blood pressure 4. Document the effectiveness of the treatment given 5. Evaluate the effectiveness of the treatment given

3. Check vital signs, particularly blood pressure 1. Administer sublingual nitroglycerin 5. Evaluate the effectiveness of the treatment given 4. Document the effectiveness of the treatment given 2. Report findings to the physician

A nurse is assessing a client's abdomen after abdominal surgery. Place the following assessment techniques in the order in which the nurse should conduct them: 1. Auscultation 2. Percussion 3. Inspection 4. Palpitation

3. Inspection 1. Auscultation 2. Percussion 4. Palpitation

A nurse has received report on her clients and notices that they're of varying ages. To prepare for the shift, the nurse reviews Erik Erickson's five stages of psychosocial development. Place the stages in chronological order from infancy to adolescence. Use all options. 1. Identity versus role confusion 2. Initiative versus guilt 3. Trust versus mistrust 4. Industry versus inferiority 5. Autonomy versus shame and doubt

3. Trust versus mistrust 5. Autonomy versus shame and doubt 2. Initiative versus guilt 4. Industry versus inferiority 1. Identity versus role confusion

A nurse is teaching a client to use a metered-dose inhaler (MDI) to administer his bronchodilator medication. Indicate the correct order of the steps the client should take to use the MDI appropriately 1. Activate the MDI on inhalation 2. Breathe out through the mouth 3. Hold breath for 5 to 10 seconds and then exhale 4. Shake the inhaler immediately before use

4. Shake the inhaler immediately before use 2. Breathe out through the mouth 1. Activate the MDI on inhalation 3. Hold breath for 5 to 10 seconds and then exhale

The nurse is taking care of a client who has an IV infusion pump. The pump alarm rings. What should the nurse do in order from first to last? 1. Assess the tubing for hindrances to flow of solution 2. Determine if the infusion pump is plugged into an electrical outlet 3. Assess the client's access site for infiltration or inflammation 4. Silence the pump alarm

4. Silence the pump alarm 3. Assess the client's access site for infiltration or inflammation 1. Assess the tubing for hindrances to flow of solution 2. Determine if the infusion pump is plugged into an electrical outlet

The nurse's assignment consists of the following four clients. From highest to lowest priority, in which order should the nurse assess the clients after receiving morning report? 1. The client with acute pancreatitis who is requesting pain medication 2. The client with hepatitis B who has questions about his discharge instructions 3. The client who is 1 day postoperative following a cholecystectomy and has a T-tube inserted. 4. The client with cirrhosis who became confused and disoriented during the night

4. The client with cirrhosis who became confused and disoriented during the night 1. The client with acute pancreatitis who is requesting pain medication 3. The client who is 1 day postoperative following a cholecystectomy and has a T-tube inserted. 2. The client with hepatitis B who has questions about his discharge instructions

A nurse is preparing a staff education program about pulmonary circulation. Place the options below in the order that matches the path of pulmonary circulation. Use all options. 1. Arterioles and alveoli 2. Pulmonary vein 3. Left Atrium 4. Pulmonary artery 5. Right Ventricle

5. Right Ventricle 4. Pulmonary artery 1. Arterioles and alveoli 2. Pulmonary vein 3. Left Atrium

The nurse is assisting a client who has had a spinal fusion apply a back brace. In which order of priority should the nurse assist the client applying the brace? 1. Assist the client to log roll and rise to a sitting position 2. Have the client in a side-lying position 3. Ask the client to stand with arms held away from the body 4. Verify the order from the settings for the brace

4. Verify the order from the settings for the brace 2. Have the client in a side-lying position 1. Assist the client to log roll and rise to a sitting position 3. Ask the client to stand with arms held away from the body

The nurse sees a client walking in the hallway who begins to have a seizure. The nurse should do which of the following in priority order? 1. Ease the client to the floor 2. Maintain a patient airway 3. Record the seizure activity observed 4. Obtain vital signs

1. Ease the client to the floor 2. Maintain a patient airway 4. Obtain vital signs 3. Record the seizure activity observed

The nurse is instructing a client with COPD how to do pursed-lip breathing. In which order would the nurse explain the steps to the client 1. "Breathe out slowly through pursed lips for 4 counts (while counting to yourself one, two, three, four)" 2. "Pucker your lips as if you were going to whistle" 3. "Relax your neck and shoulder muscles." 4. " Breathe in normally through your nose for 2 counts (while counting to yourself: one, two)"

3. "Relax your neck and shoulder muscles." 4. " Breathe in normally through your nose for 2 counts (while counting to yourself: one, two)" 2. "Pucker your lips as if you were going to whistle" 1. "Breathe out slowly through pursed lips for 4 counts (while counting to yourself one, two, three, four)"

The nurse is caring for a client with pneumonia who is confused about time and place and has intravenous fluids infusion. Despite the nurse's attempt to reorient the client and provide distraction, the client has begun to pull at the IV tubing. After increasing the frequency of observation, in which order should the nurse implement the following interventions to ensure the client's safety? 1. Review the client's medication for interactions that may cause or increase confusion 2. Contact the physician and request an order for soft wrist restraints 3. Ensure the client does not need toileting or pain medications. 4. Assess the client's respiratory status including oxygen saturation

4. Assess the client's respiratory status including oxygen saturation 3. Ensure the client does not need toileting or pain medications. 1. Review the client's medication for interactions that may cause or increase confusion 2. Contact the physician and request an order for soft wrist restraints

A client who is receiving a blood transfusion suddenly experiences chills and a temperature of 101F. The client also has a headache and appears flushed. Place the following actions in order in which the nurses should perform them to properly respond to this client's situation: 1. Obtain a blood culture from the client 2. Infuse normal saline to keep the vein open 3. Send the blood bag and administration set to the blood bank 4. Stop the blood transfusion

4. Stop the blood transfusion 2. Infuse normal saline to keep the vein open 1. Obtain a blood culture from the client 3. Send the blood bag and administration set to the blood bank

Knowing Maslow's hierarchy of needs can assist a nurse in understanding a client's behavior. Place the stages of Maslow's hierarchy of needs in order from the most basic to most complex. Use all options. 1. Self-esteem 2. Self-Actualization 3. Safety and security 4. Love and belonging 5. Physiologic needs

5. Physiologic needs 3. Safety and security 4. Love and belonging 1. Self-esteem 2. Self-Actualization

A client has massive bleeding from esophageal varices. In what order should the nurse and care team provide care from this client? 1. Relieve the client's anxiety 2. Replace fluids 3. Maintain a patent airway 4. Control hemorrhaging

3. Maintain a patent airway 4. Control hemorrhaging 2. Replace fluids 1. Relieve the client's anxiety

A client with a hemorrhagic stroke is slightly agitated, heart rate is 118, respiration are 22, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88 and oral secretions are noted. What order of interventions should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion? 1. Suction the mouth 2. Hyperoxygenate 3. Provide sedation 4. Suction the airway

3. Provide sedation 2. Hyperoxygenate 4. Suction the airway 1. Suction the mouth

A client receives 12 units of intermediate-or-long-action insulin and 6 units of fast-acting insulin each morning. Place the following actions in chronological order of how the nurse would demonstrate how to mix insulin. Use all options 1. Inject 12 units of air into the intermediate-or-long-acting insulin vial 2. Inject 6 units of air into the fast-acting insulin vial 3. Wipe off the vials with an alcohol swab 4. Withdraw 12 units of intermediate-or-long-acting insulin 5. Withdraw 6 units of fast-acting insulin

3. Wipe off the vials with an alcohol swab 1. Inject 12 units of air into the intermediate-or-long-acting insulin vial 2. Inject 6 units of air into the fast-acting insulin vial 5. Withdraw 6 units of fast-acting insulin 4. Withdraw 12 units of intermediate-or-long-acting insulin

A client is having a blood transfusion reaction. The nurse must do the following in what order of priority from first to last? 1. Keep the IV open with normal saline infusion 2. Complete the appropriate Transfusion Reaction Form(s) 3. Notify the attending physician and blood bank 4. Stop the transfusion

4. Stop the transfusion 1. Keep the IV open with normal saline infusion 3. Notify the attending physician and blood bank 2. Complete the appropriate Transfusion Reaction Form(s)