Prioritization

Of the following new pts, who should be assessed first by the nurse? a. a pt with a diagnosis of alcohol abuse with impending delirium tremens (DTs) b. a pt with a newly casted fractured fibula, complaining of pain c. a pt admitted 2 hrs ago who is scheduled for a nephrectomy in the morning d. a pt diagnosed with appendicitis who has a temperature of 37.8 C (100.2 F) orally

a. a pt with a diagnosis of alcohol abuse with impending delirium tremens (DTs) Leadership and Management

The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. Which statement indicates that the student correctly identifies the priority client needs? 1. actual or life-threatening concerns 2. completing care in a reasonable time frame 3. time constraints related to the client's needs 4. obtaining needed supplies to care for the client

1. actual or life-threatening concerns (pt problems that involve actual or life-threatening concerns are always considered first) NCLEX

The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend to first? 1. a pregnant woman who exclaims, "My baby is not moving." 2. a child who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" 3. a young child standing next to an adult family member who is screaming, "I want my mommy!" 4. an older victim who is sitting next to her husband sobbing, "My husband is dead. My husband is dead."

2. a child who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" -child who is bleeding badly is priority - the bleeding could be from an arterial vessel -pregnant pt is next priority, but absence of fetal movement may indicate fetal demise NCLEX

The nursing assistive personnel (NAP) informs you that the electronic blood pressure machine on the patient who has recently returned from surgery following removal of her gallbladder is flashing a blood pressure of 65/46 and alarming. What is the correct order for care activities? 1. Press the start button of the electronic blood pressure machine to obtain a new reading. 2. Obtain a manual blood pressure with a stethoscope. 3. Check the patient's pulse distal to the blood pressure cuff. 4. Assess the patient's mental status. 5. Remind the patient not to bend her arm with the blood pressure cuff.

4, 1, 3, 2, 5 4. Assess the patient's mental status. 1. Press the start button of the electronic blood pressure machine to obtain a new reading. 3. Check the patient's pulse distal to the blood pressure cuff. 2. Obtain a manual blood pressure with a stethoscope. 5. Remind the patient not to bend her arm with the blood pressure cuff. Fundamentals ch 30

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? 1. a client who is ambulatory demonstrating steady gait 2. a postoperative client who has just received an opioid pain medication 3. a client scheduled with physical therapy for the first crutch-walking session 4. a client with a white blood cell count of 14,000 mm³ and a temperature of 38.4 C

4. a client with a white blood cell count of 14,000mm³ and a temperature of 38.4 C (waiting for pain medication to take effect before providing care to the postoperative pt is best) NCLEX

The nurse is assigned to care for 4 clients. In planning client rounds, which client should the nurse assess first? 1. a postoperative client preparing for discharge with a new medication 2. a client requiring daily dressing changes of a recent surgical incision 3. a client scheduled for a chest x-ray after insertion of a nasogastric tube 4. a client with asthma who requested a breathing treatment during the previous shift

4. a client with asthma who requested a breathing treatment during the previous shift (airway is always the highest priority - the pt requesting a breathing treatment indicates that he is experiencing difficulty breathing) NCLEX

The nurse employed in an emergency department is assigned to triage clients coming into the emergency department on the evening shift. The nurse should assign priority to which client? 1. a client complaining of muscle aches, a headache, and history of seizures 2. a client who twisted her ankle when rollerblading and is requesting medication for pain 3. a client with a minor laceration on the index finger sustained while cutting an eggplant 4. a client with chest pain who states that he just ate pizza that was made with a very spicy sauce

4. a client with chest pain who states that he just ate pizza that was made with a very spicy sauce (chest pain = priority) NCLEX

The licensed practice nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient do you need to assess first? a. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89% b. 54-year-old woman admitted after surgery for fractured arm, BP 160/86 mm Hg, HR 72 c. 63-year-old man with venous ulcers from diabetes, temperature 37.3° C (99.1° F), HR 84 d. 77-year-old woman with left mastectomy 2 days ago, RR 22, BP 148/62

a. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89% (SpO2 89% is a critical value and requires immediate attention. Other values require attention but are not life threatening.) Fundamentals ch 30

The staff's RN assignment on the 7am to 3pm shift includes a newly admitted pt with pneumonia who has arrived on the unit, a new postoperative surgical pt requesting pain medication, and a pt diagnosed with nephrolithiasis who is complaining of nausea. What should the nurse do first after shift report? a. assess the newly admitted pneumonia pt b. give morphine to the new postoperative pt c. set up the 9am medications d. administer Zofran (ondansetron hydrochloride) to the pt complaining of nausea

a. assess the newly admitted pneumonia pt Leadership and Management

As a nurse, you are assigned to four patients. Which patient do you need to see first? a. The patient who had abdominal surgery 2 days ago who is requesting pain medication b. A patient admitted yesterday with atrial fibrillation with decreased level of consciousness c. A patient with a wound drain who needs teaching before discharge in the early afternoon d. A patient going to surgery for a mastectomy in 3 hours who has a question about the surgery

b. A patient admitted yesterday with atrial fibrillation with decreased level of consciousness (pt is experiencing the physiological problem of decreased level of consciousness, which is an immediate threat to his or her survival and safety) Fundamentals ch 21

Which pt from the previous question would you make rounds on second? a. pt who is concerned that he has had no bowel movement for 2 days b. pt who has suffered several acute asthma attacks within the last 24 hrs c. pt who is now comfortable but has had several episodes of breakthrough pain since yesterday d. pt who is severely allergic to peanuts who just ate potato chips fried in peanut oil

b. pt who has suffered several acute asthma attacks within the last 24 hrs Leadership and Management

A new graduate RN organizing her assignments asks the charge nurse, "Of the list of pts assigned to me, who do you think I should see first?" What is the best response the nurse could make? a. "Check the policy and procedure manual for whom to assess first." b. "Assess the pts in order of their room number to stay organized." c. "I would assess the pt who is having respiratory distress first." d. "See the pt who takes the most time last."

c. "I would assess the pt who is having respiratory distress first." Leadership and Management

A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the priority? a. a client who received crush injuries to the chest and abdomen and is expected to die b. a client who has a 4-inch laceration to the head c. a client who has partial-thickness and full-thickness burns to his face, neck, and chest d. a client who has a fractured fibula and tibia

c. a client who has partial-thickness and full-thickness burns to his face, neck, and chest -pt A = expectant category: class IV -pt B = nonurgent category: class III -pt C = emergent category: class I -pt D = urgent category: class II ATI Fundamentals

The nurse has just finished the change of shift report. Which pt should the nurse assess first? a. a postoperative cholecystectomy pt who is complaining of pain but received an IM injection of morphine 5 min ago b. a postoperative appendectomy who will be discharged in the next few hrs c. a pt with asthma who had difficulty breathing during the prior shift d. an elderly pt with diabetes who is on the bedpan

c. a pt with asthma who had difficulty breathing during the prior shift Leadership and Management

The nurse has just come on duty and finished hearing morning report. Which pt will the nurse see first? a. the pt who is being discharged in a few hrs b. the pt who requires daily dressing changes c. the pt who is receiving continuous IV heparin per pump d. the pt who is scheduled for an IVP Pyelogram this shift

c. the pt who is receiving continuous IV heparin per pump Leadership and Management

The nurse has just completed listening to morning report. Which pt will the nurse see first? a. the pt who has a leaking colostomy bag b. the pt who is going for a bronchoscopy in 2 hrs c. the pt with a sickle cell crisis and an infiltrated IV d. the pt who has been receiving blood transfusions for the past 2 hrs and had a recent Hgb of 7.2 g/dL

c. the pt with a sickle cell crisis and an infiltrated IV Leadership and Management

A 3-year-old girl is admitted with epiglottis. She is drooling, sitting upright, unable to swallow, and looking panicky. Which of the following equipment is most important for the nurse to place at the pt's bedside? a. suction b. croup tent c. tracheotomy set d. padded bedsides for seizure precautions

c. tracheotomy set Leadership and Management

You have received report on the following pts. Who would you make pt care rounds on first? a. pt who is concerned that he has had no bowel movement for 2 days b. pt who has suffered several acute asthma attacks within the last 24 hrs c. pt who is now comfortable but has had several episodes of breakthrough pain since yesterday d. pt who is severely allergic to peanuts who just ate potato chips fried in peanut oil

d. pt who is severely allergic to peanuts who just ate potato chips fried in peanut oil Leadership and Management