HESI Prioritizing Care
Which is a potentially life-threating condition found during the primary triage survey that would necessitate priority nursing care? 1 Cystitis 2 Concussion 3 Lacerated arm 4 Fractured femur
Concussion A concussion, which is a type of head injury, is a potentially life-threatening condition found during the primary triage survey that would necessitate priority nursing care. Cystitis, a lacerated arm, and a fractured femur would not necessitate priority nursing care.
The nurse is providing care to a trauma client. What is the correct order of steps the nurse will implement when providing care to this client? 1. Protect the cervical spine 2. Clear the airway 3. Perform chest compressions 4. Provide supplemental oxygen
Clear the airway Protect the cervical spine Provide supplemental oxygen Perform chest compressions The first step the nurse takes when providing care to a trauma client is to clear the airway. The second step is to protect the cervical spine. The third step is to provide supplemental oxygen. The fourth step is to perform chest compressions.
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? 1 Client with arrhythmia 2 Client with pressure ulcers 3 Client with abdominal trauma 4 Client with second degree burns
Client with abdominal trauma The client with abdominal trauma should be treated immediately because it is a life-threatening complication. The client with arrhythmia may be given next priority of care. Care for the client with pressure ulcers can be delayed because it is not a life-threatening complication. The client with second degree burns should be given second priority of care because the client's condition may worsen if treatment is not provided as early as possible.
Client-focused care is being planned in an acute care facility. What should the nurse manager prepare to do once this method is implemented? 1 Train staff to perform phlebotomy. 2 Coordinate all client care activities. 3 Schedule the nursing staff's hours of work. 4 Review tasks with unlicensed assistive personnel.
Coordinate all client care activities The nurse manager orchestrates all care activities required by the client and family during the hospitalization. The manager will not personally train staff on any skills. The manager is responsible for all staff from traditional centralized departments so the manager will have to schedule all of the staff. Reviewing tasks with unlicensed assistive personnel (UAP) is a characteristic of function nursing and not client-focused care.
A client is hospitalized with an overdose of benzodiazepines and presents with a respiratory rate less than 10 breaths per minute. Which nursing intervention should be provided as the first priority? 1 Give oxygen. 2 Secure airway. 3 Administer flumazenil. 4 Assess the intravenous site.
Give oxygen Oxygen should be given as the first priority intervention for clients with a respiratory rate below 10 breaths per minute due to an overdose of benzodiazepines. Securing the airway is done before starting benzodiazepine antagonist therapy. Drugs such as flumazenil should be administered after providing the client with a sufficient oxygen supply. An intravenous site should be assessed because flumazenil can cause thrombophlebitis at the injection site.
What is the immediate nursing intervention for a client experiencing autonomic dysreflexia? 1 Administering an alpha blocker 2 Placing the client in a sitting position 3 Giving nifedipine or nitrate as prescribed 4 Monitoring blood pressure every 15 minutes
Placing the client in a sitting position The immediate nursing intervention for a client experiencing autonomic dysreflexia is to place the client in sitting position to prevent falls. A client with recurrent autonomic dysreflexia is administered an alpha blocker as a prophylactic treatment. Nifedipine or nitrates are given after the client is placed in a stable sitting position. Blood pressure is monitored after the client is in a stable position.
If there is a fire at the healthcare facility, which priority action by the nurse ensures care to the clients? Select all that apply. 1 Opening doors and windows of the facility 2 Removing the clients from immediate danger 3 Moving the bedridden clients on stretchers, wrapped in blankets 4 Making an attempt to extinguish the fire, putting the nurse's life at risk 5 Maintaining manual respiration to the client on life support
Removing the clients from immediate danger Moving the bedridden clients on stretchers, wrapped in blankets Maintaining manual respiration to the client on life support The first priority is for the nurse to remove the clients from immediate danger. The nurse, with the assistance of ambulatory clients, may move bedridden clients from the fire area to a safe zone by covering them with blankets and using stretchers or wheelchairs. The nurse should remove a client on life support from the fire area by maintaining his or her respiratory status manually. This helps to ensure the safety of the client in critical condition. Closing the door and windows of the healthcare center reduces oxygen supply to the fire. The nurse should not risk injury to self, other staff members, or clients by attempting to extinguish the fire.
The nurse is caring for a client with chronic pain who is on opioid treatment. The client has constipation, nausea, vomiting, level 3 sedation, respiratory rate of 8 breaths per minute, and pruritus. Which conditions of the client should the nurse consider as highest priority? Select all that apply. 1 Pruritus 2 Sedation 3 Constipation 4 Respiratory rate 5 Nausea and vomiting
Sedation Respiratory rate Chronic use of opioids for pain may lead to constipation, nausea, vomiting, sedation, and respiratory distress. The client with a level 3 of sedation has frequent drowsiness, arousals, and episodes of sleep during conversation and needs immediate intervention. A respiratory rate of 8 breaths per minute leads to respiratory distress, which must be supported by adequate oxygenation. Pruritus can be resolved slowly because it is less life threatening. Constipation can be relieved by providing the client with stimulant laxative and a stool softener. Nausea and vomiting may be resolved by providing antiemetics to the client.
Which order of steps would the nurse teach the client to follow while performing expansion breathing? 1. Place hands on each side of lower ribcage, just above the waist. 2. Sit in an upright position with knees slightly bent. 3. Exhale, first moving the chest and then lower ribs inward while gently squeezing the ribcage, forcing air out of the base of lungs. 4. Take a deep breath through your nose, using shoulder muscles to expand your lower ribcage outward during inhalation.
Sit in an upright position with knees slightly bent. Place hands on each side of lower ribcage, just above the waist. Take a deep breath through your nose, using shoulder muscles to expand your lower ribcage outward during inhalation. Exhale, first moving the chest and then lower ribs inward while gently squeezing the ribcage, forcing air out of the base of lungs. While performing expansion breathing, the client should sit in an upright position with slightly bent knees because it decreases tension on the abdominal muscles and respiratory resistance and discomfort. Then the client should place hands on each side of the lower ribcage, just above the waist. A deep breath through the nose is taken, using shoulder muscles to expand the lower ribcage outward during inhalation. The client then exhales by first moving the chest and then lower ribs inward while gently squeezing the ribcage, forcing air out of the lungs.
What is the priority nursing care for a client who is prescribed hydroxychloroquine (Plaquenil)? 1 Teaching the client to report blurred vision 2 Teaching the client to report signs of infection 3 Teaching the client to report shortness of breath 4 Teaching the client to report stomach discomfort
Teaching the client to report blurred vision Plaquenil is a hydroxychloroquine used to treat rheumatoid arthritis. The adverse effect of Plaquenil is retinal damage; therefore, a client on Plaquenil is taught to report blurred vision. A client on steroids is taught to report signs of infection. A client on infliximab is taught to report shortness of breath. Plaquenil causes mild stomach discomfort, which is normal and is not related to priority nursing care.
Which organism would the nurse explain is consistent with a protozoal infection in clients with acquired immunodeficiency syndrome (AIDS)? 1 Candidiasis 2 Tuberculosis 3 Cryptococcosis 4 Toxoplasmosis
Toxoplasmosis Toxoplasmosis is a protozoal infection in the AIDS client and an AIDS-defining condition in adults. Candidiasis is an indication of fungal infection. Tuberculosis is a bacterial infection. Cryptococcosis is a fungal infection.
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? 1 A client with visual score of 3 2 A client with facial palsy score of 1 3 A client with level of consciousness score of 0 4 A client with motor and drift of each extremity score of 4
A client with facial palsy score of 1 A client with ischemic stroke and a facial palsy score of 1 has minor paralysis is a medium priority. A client with a visual score of 3 who may be blind or have bilateral hemianopsia is a high priority. A client with a consciousness score of 0 is stable and will be least priority. A client with a motor and drift score of 4 indicates no movement and requires an emergent priority.
The nurse is providing emergency care to a client suffering from heat stroke. What should be the order of nursing interventions in this scenario? 1. Remove the client's clothing. 2. Ensure a patent airway. 3. Pour or spray cold water on the client's body and scalp. 4. Remove the client from the hot environment. 5. Place ice in cloth or bags and position the packs on the client's scalp. 6. Fan the client with newspapers or whatever is available.
Ensure a patent airway. Remove the client from the hot environment. Remove the client's clothing. Pour or spray cold water on the client's body and scalp. Fan the client with newspapers or whatever is available. Place ice in cloth or bags and position the packs on the client's scalp. Emergency care should be provided to the client with heat stroke to restore thermoregulation. First the nurse should ensure a patent airway. Then the nurse should remove the client from the hot environment into air conditioning or shade and remove his or her clothing. Then the nurse should pour or spray cold water on the client's body and scalp. The client should be fanned with newspapers or whatever is available. This should be followed by placing ice in cloth or bags and positioning the packs on the client's scalp.
The nurse observes that a client who is on intravenous medication is experiencing an anaphylactic reaction. What is the priority nursing intervention in this situation? 1 Elevate lower extremities of the client. 2 Start normal saline infusion immediately. 3 Report to the primary healthcare provider immediately. 4 Stop intravenous medication and administer epinephrine (adrenaline).
Stop intravenous medication and administer epinephrine (adrenaline). Intravenous medications can cause an anaphylactic reaction. During anaphylactic reactions, the nurse should immediately stop the intravenous medication and administer epinephrine (adrenaline). The nurse can elevate the client's lower extremities, but only after administering epinephrine (adrenaline). The nurse can start a normal saline infusion and report to the primary healthcare provider, but only after stopping the intravenous medication and administering epinephrine (adrenaline).
The nurse is performing triage based on tier levels for a group of clients who were impacted by a tornado. Which client conditions should receive higher priority? Select all that apply. 1 Stroke 2 Skin rash 3 Active hemorrhage 4 Respiratory distress 5 Chest pain with diaphoresis 6 Displaced or multiple fractures
Stroke Active hemorrhage Respiratory distress Chest pain with diaphoresis Clients presenting with signs of a stroke, active hemorrhage, or respiratory distress, and chest pain with diaphoresis should be triaged under the emergent tier level because the conditions are life threatening. Clients with a skin rash are categorized as nonurgent because treatment can be delayed. Displaced or multiple fractures are triaged as urgent, which needs quick treatment but is not immediately life threatening.