Delegation/prioritization
The nurse is caring for a child with juvenile idiopathic arthritis (JLA). The nurse should identify which problem as a priority? 1. Complaints of acute pain 2. Unsteadiness when ambulating 3. Embarrassment about appearance 4. Inability to perform self-hygienic measures
Answer: 1 Rationale: All the problems presented are appropriate for the child with JLA. The priority problem relates to complaints of acute pain. Acute pain needs to be managed before other problems can be addressed.
The nurse implements a plan of care for a client receiving a chemotherapy treatment with intravenous bleomycin sulfate. The nurse should document which priority intervention in the plan? 1 monitor for dyspnea. 2 monitor for alopecia. 3 monitor for anorexia. 4 monitor for a change in bowel patterns.
Answer: 1 Rationale: Bleomycin sulfate, an antineoplastic medication, can cause interstitial pneumonitis that can progress to pulmonary fibrosis. The nurse needs to monitor for dyspnea and monitor lung sounds for adventitious sounds that indicate pulmonary toxicity. Pulmonary function studies along with hematological, hepatic, and renal function tests need to be monitored. Also, the nurse needs to notify the primary health care provider immediately if pulmonary toxicity occurs. Alopecia (hair loss) can occur, but monitoring for it is not a priority intervention. Monitoring for anorexia and bowel pattern changes are important but are not the priority.
A client returns to the nursing unit from the post-anesthesia care unit (PACU) following a transurethral resection of the prostate (TURP). The nurse should perform which action first? 1 Check the client's respirations. 2 Check the color of the client's urine. 3 Check the urinary (Foley) catheter for patency. 4 Read the nursing notes written by the PACU nurse.
Answer: 1 Rationale: The first action of the nurse is to assess the patency of the airway, and the nurse should observe the client and assess the breathing pattern and respirations. If the airway is not patent and the client is not breathing, immediate measures must be taken for the survival of the client. The nurse then assesses cardiovascular function, the condition of the surgical site, the tubes or drains for patency and drainage, and function of the central nervous system. the PACU nurse normally provides a verbal report. Even so, reading the nursing notes would not be the first action.
A client is being admitted to the neurological unit from the emergency department with a diagnosis of a cervical (c4) spinal cord injury. Which data should the nurse collect first when admitting the client to the nursing unit? 1 listen to breath sounds 2 check peripheral pulses 3 check for muscle flaccidity 4 determine extremity muscle strength
Answer: 1 Rationale: because compromise of respiration is a leading cause of death in cervical cord injury, collecting data on the respiratory system is the highest priority. Checking peripheral pulses and muscle strength can be done after adequate oxygenation is ensured.
A client is brought to the emergency department by emergency medical services after having seriously lacerated both wrists. The nurse should perform which action first? 1 assess and treat the wounds sites. 2 contact the crisis intervention team. 3 collect data on psychosocial aspects. 4 encourage the client to talk about his or her feelings.
Answer: 1 Rationale: the initial action when a client has attempted suicide is to assess and treat any injuries. Although options 2, 3, and 4 may be appropriate at some point, the initial action would be to treat the wounds.
A hospitalized client with type 1 diabetes mellitus tells the nurse that she feels like she is having a hypoglycemic reaction. The nurse should take which action first? 1. Obtain a blood glucose reading. 2. Give the client 4 oz of orange juice. 3. Prepare to administer 50% dextrose intravenously. 4. Prepare to administer subcutaneous glucagon hydrochloride.
Answer: 1 Rationale: Management of hypoglycemia depends on the severity of the reaction. To reverse mild hypoglycemia, a 15-g simple carbohydrate is given and works quickly to increase blood glucose levels. However, a blood glucose test (with a glucose meter) should be performed first as soon as manifestations begin. If a meter is not available, it is safest to treat hypoglycemia. Fifty-percent dextrose and glucagon hydrochloride are used to treat severe hypoglycemia particularly in the unconscious client.
A client is admitted to the emergency department with complaints of severe, radiating chest pain, and a myocardial infarction (heart attack) is suspected. The nurse immediately applies oxygen to the client and plans to take which action next? 1. Obtain a 12-lead electrocardiogram (ECG). 2. Call radiology to prescribe a chest radiograph. 3. Call the laboratory to prescribe stat blood work. 4. Notify the coronary care unit to inform them that the client will need admission.
Answer: 1 Rationale: The initial action is to apply oxygen, because the client may be experiencing myocardial ischemia. Based on the options provided, an ECG will be done next because this test can provide evidence of cardiac damage and the location of myocardial ischemia. Vital signs are also measured and may be done just before obtaining the ECG or quickly thereafter. Nitroglycerin, a coronary artery vasodilator, may also be administered. The nurse should then obtain blood work because it can assist in determining the diagnosis and choice of treatment. Although the chest radiograph may show cardiac enlargement, it does not influence the immediate treatment. Notifying the coronary care unit to inform them that the client will need admission should be done once the diagnosis is confirmed and admission is deemed necessary.
The nurse is planning the client assignments for the day. Which client should the nurse assign to the unlicensed assistive personnel (UAP)? 1. A client on strict bed rest 2. A client scheduled for discharge to home 3. A client scheduled for a cardiac catheterization 4. A postoperative client who had an emergency appendectomy
Answer: 1 Rationale: The nurse is legally responsible for client assignments and must assign tasks based on the guidelines of nurse practice acts and the job descriptions of the employing agency. A client scheduled for discharge to home, a client scheduled for a cardiac catheterization, or a postoperative client who had an emergency appendectomy has both physiological and psychosocial needs that require care by a licensed nurse. The UAP has been trained to care for a client on bed rest. The nurse provides instructions to the UAP, but the tasks required are within the role descriptions of a UAP.
The nurse is preparing to perform oral auctioning on a client who has coughed, resulting in secretions in the mouth, and is unable to expectorate the secretions adequately. The nurse determines that there is a health care provider's prescription for the procedure and explains the procedure to the client. Which actions should the nurse take to perform this procedure? 1 wash hands. 2 applies a face shield. 3 removes the client's oxygen mask. 4 Tells the client not to cough or breathe during the procedure. 5 Applies a clean disposable glove on the dominant hand and attaches the suction catheter to the connecting tubing. 6 Inserts the catheter into the client's mouth and moves the catheter around the mouth, pharynx, and the gum line until secretions are cleared.
Answer: 1, 2, 3, 5, 6 Rationale: The nurse always washes the hands before performing any procedure, applies a face shield because suctioning may cause splashing of bodily fluids, and then dons a clean glove. A clean rather than sterile glove can be used in this procedure because the oral cavity is not sterile. The nurse then completes preparations by attaching the suction catheter to the connecting suction tubing. The nurse removes the oxygen mask just before Implementing the procedure so that the client is oxygenated as much as possible (remember that suctioning can deplete oxygen). The catheter is then inserted into the client's mouth until secretions are cleared. If the client is not tolerating the procedure, then the catheter is removed and the oxygen mask is reapplied. The nurse next encourages the client to cough because coughing moves secretions from the lower to the upper airways into the mouth. At this point, suctioning is repeated if necessary. The oxygen mask is then reapplied.
A client receiving a blood transfusion develops signs of a blood transfusion reaction. The nurse stops the transfusion and maintains the intravenous (IV) line with normal saline. Which action should the nurse take next? 1. Document the occurrence. 2. Check the client's vital signs. 3. Send the blood bag and tubing to the blood bank for examination. 4. Check the client's urine output, and obtain a urine specimen for analysis.
Answer: 2 Rationale: If a transfusion reaction is suspected, the transfusion is stopped and then normal saline is infused pending further health care provider prescriptions. This maintains a patent IV access line and aids in maintaining the client's intravascular volume. The nurse should next check the client's vital signs and notify the health care provider and the blood bank about the reaction. The nurse should obtain a urine specimen for analysis to check for hemolysis of red blood cells. The nurse then sends the blood bag and tubing to the blood bank for examination and documents the occurrence on the transfusion report and in the client's chart.
A postoperative client who underwent pelvic surgery suddenly develops dyspnea. The nurse suspects that the client has a pulmonary embolism and should prepare to take which action first? 1 insert a urinary (Foley) catheter 2 administer low-flow oxygen through a nasal cannula 3 obtain an intravenous (IV) infusion pump to administer heparin. 4 increase the rate of the IV fluids infusing to prevent hypotension.
Answer: 2 Rationale: pulmonary embolism is a life-threatening emergency. Maintenance of cardiopulmonary stability is the first priority. The nurse should prepare to administer low-flow oxygen by nasal cannula first. Hypotension is treated with fluids as prescribed. IV anticoagulation may be initiated. Some clients may require endotracheal intubation to maintain adequate PaO2. A perfusion scan, among other tests, may be performed, an the electrocardiogram (ECG) is monitored for the presence of dysrhythmias. In addition, a urinary catheter may be inserted. However, the first nursing action is to administer oxygen.
The community health nurse is assisting residents involved in a hurricane and flood. Many of the older residents are emotionally despondent and refuse to evacuate their homes. With regard to rescue and relocation of the older residents, the nurse should plan to perform which action first? 1. Contact families. 2. Attend to emotional needs. 3. Attend to nutritional and basic needs. 4. Arrange for transportation to shelters.
Answer: 3 Rationale: Attending to people's basic needs of food, shelter, and clothing is the priority. Options 1, 3, and 4 may or may not be needed at a later time.
A client is hospitalized with chest pain, and myocardial infarction is suspected. The client tells the nurse that the chest pain has returned, and the nurse administers one 0.4-mg nitroglycerin tablet sublingually as prescribed. What should the nurse do next before administering another sublingual nitroglycerin tablet if the pain is not relieved? 1. Notify the health care provider. 2. Place the client in a flat position. 3. Check the client's blood pressure. 4. Encourage the client to deep breathe.
Answer: 3 Rationale: In the hospitalized client, nitroglycerin tablets are usually administered 1 every 5 minutes, not exceeding 3 tablets, for chest pain as long as the client maintains a systolic blood pressure of 100 mm Hg or above (client's prescriptions are always followed). The nurse should check the client's blood pressure before administering a second nitroglycerin tablet. The health care provider is notified if the chest pain is not relieved after administering 3 tablets. If there is a sudden drop in blood pressure, the client is placed in a flat position and the health care provider is notified. Deep breathing will not relieve the chest pain that occurs as a result of myocardial infarction.
A client with the a diagnosis of sickle cell crisis is being admitted to the hospital. The nurse anticipates that which priority intervention will be prescribed? 1. Laboratory studies 2. Genetic counseling 3. Oxygen administration 4. Electrolyte replacement therapy
Answer: 3 Rationale: Oxygen, intravenous fluids, pain medication, and red blood cell transfusions for treating sickle cell crisis. Laboratory studies may also be prescribed but are not the priority in the care of the client. Genetic counseling is recommended but not during the acute phase of illness. Electrolyte replacement therapy may be necessary, but this treatment would be based on the results of the laboratory studies.
A child with a diagnosis of pertussis (whooping cough) is being admitted to the pediatric unit. As soon as the child arrives on the unit, which action should the nurse perform first? 1 Weigh the child. 2 Take the child's temperature. 3 Place the child on a pulse oximeter. 4 Administer the prescribed antibiotic.
Answer: 3 Rationale: To adequately determine if the child is getting enough oxygen, the child is placed on a pulse oximeter. The pulse oximeter will then provide ongoing information on the child's oxygen level. The child is also immediately placed on a cardiorespiratory monitor to provide early identification of periods of apnea and bradycardia. The nurse should then perform an assessment, including taking the child's temperature and weight and asking the parents about the child. An antibiotic may be prescribed, but the child's airway status needs to be addressed first.
The nurse notes redness, warmth, and a purulent drainage at the insertion site of a central venous catheter in a client receiving total parenteral nutrition (TPN). The nurse should take which priority action? 1 change the intravenous tubing. 2 slow the rate of infusion of the TPN. 3 notify the primary health care provider. 4 call the pharmacy for a new bag of TPN solution.
Answer: 3 Rationale: redness, warmth, and purulent discharge are signs of an infection. Infections of a central venous catheter site can lead to septicemia; therefore, the primary health care provider needs to be notified. Although the nurse may change the intravenous tubing and hang a new bag of TPN solution, these are not priority actions. The nurse should not adjust the rate of an intravenous solution without a specific prescription to do so. In addition, this action is unrelated to the client's complication.
The nurse is caring for a client in Buck's extension traction. The nurse should identify which client problem as the priority? 1. Expresses feelings of social isolation 2. Observed inability to distract oneself 3. Verbalized anger about the need for immobility 4. Observed skin redness around the edges of the boot appliance
Answer: 4 Rationale: Buck's extension traction is a type of skin traction in which weights are attached to the skin with the use of a boot or elastic bandage. A priority problem for the client in this type of traction is the potential for breaks in the skin. The potential for alteration in neurovascular status is also a concern. Options 1, 2, and 3 may be problems for the client in Buck's extension traction, but redness around the edges of the boot appliance presents the greatest risk for skin breakdown.
The nurse hears the alarm sound on the telemetry monitor, quickly looks at the monitor, and notes that a client is in ventricular tachycardia. The nurse rushes into the client's room, and on reaching the client's bedside, the nurse should perform which action first? 1 Opens the airway 2 Delivers two effective breaths 3 Begins chest compressions 4 Determines unresponsiveness
Answer: 4 Rationale: Determining unresponsiveness is the first action to take. When a client is in ventricular tachycardia, there is a significant decrease in cardiac output. However, assessing for unresponsiveness ensures that the client is affected by the decreased cardiac output. If the client is unresponsive the nurse proceeds through CAB-compressions, airway, and breathing- of cardiopulmonary resuscitation (CPR), remembering that the nurse should assess before taking an action.
An antepartum client at 32 weeks' gestation positioned herself supine on the examination table to await the obstetrician. The nurse enters the examination room, and the client says, "I'm feeling a little light-headed and sick to my stomach." The nurse recognizes that the client may be experiencing vena cava syndrome (hypotensive syndrome) and should take which immediate action? 1. Give the client an emesis basin. 2. Place a cool cloth on the client's forehead. 3. Call the obstetrician to see the client immediately. 4. Place a folded towel or sheet under the client's right hip.
Answer: 4 Rationale: Lying supine (on the back) applies additional gravity pressure on the abdominal blood vessels (iliac vessels, inferior vena cava, and ascending aorta), has increasing compression and impeding blood flow and cardiac output. This results in hypotension, dizziness, nausea, pallor, clammy (cool, damp) skin, and sweating. Raising one hip higher than the other reduces the pressure on the vena cava, restoring the circulation and relieving the symptoms. Although an emesis basin and a cool cloth may be helpful, these are not the immediate actions. It is not necessary to call the obstetrician immediately unless the client's complaints are unrelieved following repositioning.
A client is scheduled for a diagnostic procedure requiring the injection of a radiopaque dye. The nurse should check which most important information before the procedure? 1. Intake and output 2. Height and weight 3. Baseline vital signs 4. Allergy to iodine or shellfish
Answer: 4 Rationale: Procedures that involve the injection of a radiopaque dye require informed consent. The risk for allergic reaction exists if the client has an allergy to iodine or shellfish. The risk of allergic reaction and anaphylaxis must be determined before the procedure. Although options 1, 2, and 3 identify information obtained before the procedure, these items are not the most important.
Quinipril hydrochloride is prescribes as an adjunctive therapy in the treatment of heart failure. After administering the first dose, the nurse should specifically monitor which parameter as the priority? 1 respirations 2 urine output 3 lung sounds 4 blood pressure
Answer: 4 Rationale: Quinapril hydrochloride is an angiotensin-converting enzyme (ACE) inhibitor. It is used in the treatment of heart failure. Excessive hypotension ("first dose syncope") can occur in clients with heart failure or in clients who are severely salt or volume depleted. Although respirations, urine output, and lung sounds should be monitored, the nurse should specifically monitor the client's blood pressure.
The nurse is assessing a client with a diagnosis of bulimia nervosa who has problems with nutrition. The nurse should obtain information from the client about which finding first? 1 Lack of control 2 previous and current coping skills 3 feelings about self and body weight 4 eating patterns, food preferences, concerns about eating
Answer: 4 Rationale: The nurse should first identify the client's eating patterns, food preferences, and concerns about eating when assessing a client with bulimia nervosa to determine a baseline for further planning and because this information about lack of control, previous and current coping skills, and the client's feelings about self and body weight, but this information is secondary to eating patterns and food preferences.
The nurse is creating a plan of care for a postoperative client who is receiving morphine sulfate by continuous intravenous infusion for pain. The nurse should include monitoring of which item as a priority nursing action in the plan of care? 1 constipation 2 urine output 3 temperature 4 blood pressure
Answer: 4 Rationale: morphine sulfate suppresses respirations and decreases the client's blood pressure; therefore, monitoring for both decreased blood pressure are priority nursing actions. Although monitoring of options 1, 2, and 3 may be a component of the plan of care for this client, option 4 identifies the priority nursing action.
A client has been newly diagnosed with diabetes mellitus. The nurse should perform which action as the first step in teaching the client about the disorder? 1. Decide on the teaching approach. 2. Plan for the evaluation of the session. 3. Gather all available resource materials 4. Identity the client's knowledge and needs
Answer: 4 Rationale: Determining what to teach a client begins with an assessment of the client's own knowledge and learning needs. Once these have been determined, the nurse can effectively plan a teaching approach, the actual content, and the resource materials that may be needed. The evaluation is done after the teaching is completed.
The nurse is caring for a client with a brain injury to the brainstem. The nurse should monitor which parameter as the priority? 1. Urine output 2. Electrolyte results 3. Peripheral vascular status 4. Respiratory rate and rhythm
Answer: 4 Rationale: The respiratory center is located in the brainstem. Therefore, monitoring the respiratory status is a priority in a client with a brainstem injury; however, the nurse may also monitor urine output, electrolyte results, and peripheral vascular status.
