Practice Prioritization Questions
The nurse plans care for a client in the post anesthesia care unit. The nurse should assess first the client's: a) respiratory status. b) level of consciousness. c) level of pain. d) reflexes and movement of extremities
a
When dealing with clients that might have fallen over, what is the first thing a nurse should assess? a) LOC b) wounds c) how the event occurred d) pain level
a
Nurse Janus enters a room and finds a client lying on the floor. Which of the following actions should the nurse perform first? a) Call for help to get the client back in bed. b) Establish whether the client is responsive. c) Assist the client back to bed. d) Ask the client what happened
b
Nurse Channing is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first? a) A client with diabetes being discharged today. b) A 35-year-old male with tracheostomy and copious secretions. c) A teenager scheduled for physical therapy this morning. d) A 78-year-old female client with pressure ulcer that needs dressing change.
b (airway problem treated first - ABC)
Nurse Skye is on the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first? a) A client scheduled for cardiac ultrasound this morning. b) A client with syncope being discharged today. c) A client with chronic bronchitis on nasal oxygen. d) A client with diabetic foot ulcer that needs a dressing change
c
After change of shift, you are assigned to care for the following patients. Which patient should you assess first? a) 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab b) 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation c) 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics d)50-year old with asthma who complains of shortness of breath after using a bronchodilator
d (in COPD patients, 90% is normal)
A client presents to the emergency room with dyspnea, chest pain, and syncope. The nurse assesses the client and notes that the following assessment cues: pale, diaphoretic, blood pressure of 90/60, respirations of 33. The client is also anxious and fearing death. Which action should the nurse take first? a) Administer pain medications. b) Administer IV fluids. c) Administer dopamine. d) Administer oxygen via nasal cannula
d (promotion of adequate oxygenation is the most vital to life and therefore should be given highest priority by the nurse)
