RN PassPoint- Prioritization and Delegation

A client with gestational hypertension is experiencing abdominal pain and vaginal bleeding. Which assessment should the nurse perform first?

fetal heart tones

What is the most important intervention for the nurse to include in the care plan for a male infant following surgical repair of hypospadias?

frequent assessment of the tip of the penis

A three-year-old child is given a preliminary diagnosis of acute epiglottitis. Which initial nursing intervention is most appropriate?

have emergency airway equipment readily available

A nurse is teaching a group of parents about urinary tract infections (UTIs) in children. What is the priority educational topic for this group of parents?

interventions to prevent UTIs

What is the nurse's priority when caring for a 10-month-old infant with meningitis?

maintaining an adequate airway

A neonate returns from the operating room after surgical repair of a tracheoesophageal fistula and esophageal atresia. What is the nurse's priority intervention?

maintaining nasogastric tube patency

The nurse is planning care for a neonate with a cleft lip and palate. What is the nurse's priority area of concern?

parental reaction

A nurse suspects a client is experiencing alcohol withdrawal syndrome. What is the nurse's priority action?

promoting an environment free from emotional distress

The nurse is planning care for a child admitted to the pediatric unit with neonatal bronchopulmonary dysplasia (chronic lung disease). Which intervention should the nurse perform first?

provide humidified oxygen

The nurse in pediatric intensive care is caring for an infant whose respiratory rate is 50 with nasal flaring, grunting and experiencing thick yellow nasal discharge. Vital signs are stable with oxygen saturation of 96% on 0.25 L of oxygen via face mask. Chest physiotherapy has been completed, and the infant is sleeping in the supine position. What should be the nurse's next intervention?

suction the nares

A client experiencing alcohol withdrawal reports being upset about going through detoxification. Which goal is the priority for this client?

working with the nurse to remain safe

A client is admitted with an eating disorder. Which client response should the nurse address first?

"I feel dizzy and light-headed when I get up."

An unlicensed assistive personnel (UAP) reports to the nurse that the client had a large amount of blood on the adult brief in a skilled nursing home. Place the steps the nurse will take to assess and care for the client in order. All options must be used.

1. Ask the unlicensed assistive personal to recover the adult brief. 2. Examine the adult brief. 3. Assess the client's perineal area for any further drainage. 4. Obtain the client's vital signs. 5. Report the findings to the healthcare provider. 6. Report the event to the family with any change in treatment.

The nurse has a five client assignment on a medical surgical unit. Place in order the priority which the nurse will assess the clients. All options must be used.

1. Client admitted with renal failure receiving a unit of packed red blood cells for the past 30 minutes. 2. Client admitted with uncontrolled hypertension with last blood pressure of 160/95 mmHg. 3. Client admitted with fever with last temperature of 100.2 degrees Fahrenheit. 4. Client admitted with end stage bladder cancer receiving oral morphine for pain control every two hours. 5. Client admitted with arm cellulitis after a cat bite.

Which client is most at risk for developing acute lymphocytic leukemia?

A 4-year-old white female

The nurse is assigned to care for four clients. Which client should the nurse assess first?

A client admitted one hour ago with new-onset atrial fibrillation who is receiving IV diltiazem

The nurse is assigned four clients. Which client is at highest risk for impaired skin integrity?

A client having reconstructive breast surgery

Which client would benefit most from information explaining the importance of receiving an annual Papanicolaou (PAP) test?

A client infected with the human papillomavirus (HPV)

Which client, diagnosed with pneumonia, is most likely to have community-acquired pneumonia?

A client newly admitted to a long-term care facility

A nurse is assigned to four clients. Which client should the nurse see first?

A client who is being prepared for a major surgery receiving clopidogrel

A nurse is caring for clients who have a history of genital herpes infection. Which client is most at risk for an outbreak of genital herpes?

A client who reports genital pruritus and paresthesia

Which client would be considered to be at the highest risk for respiratory failure?

A client with Guillain-Barré syndrome

A nurse has been assigned to four clients. Which client should the nurse see first?

A client with hemophilia who is receiving acetylsalicylic acid (ASA) for joint pain

A nurse's initial client assessment indicates probable opioid overdose complicated by alcohol ingestion. What intervention should the nurse perform first?

Administer IV naloxone

A client ingested a large amount of acetaminophen at 1:00 am. Two hours later, the client comes to the emergency department, and is diagnosed with acetaminophen poisoning. What is the priority intervention for this client?

Administer acetylcysteine.

A client receiving hemodialysis treatments arrives at the hospital with a blood pressure of 200/100 mmHg, a heart rate of 110 bpm, and a respiratory rate of 36 breaths/min. Oxygen saturation on room air is 89%. The client reports shortness of breath, and has + 2 pedal edema. The last hemodialysis treatment was yesterday. Which intervention should be done first?

Administer oxygen

The nurse is planning interventions for a client who is having an acute gout attack. What is the priority nursing intervention for this client?

Administer prescribed analgesics

A client with a pulmonary embolism is experiencing chest pain and apprehension. What is the nurse's priority intervention?

Administering ordered analgesic

A male neonate has just been circumcised. Which nursing intervention is part of the initial care of a circumcised neonate?

Apply petroleum jelly to the site for 24 to 48 hours.

What is the priority nursing measure for a client with von Willebrand's disease who is having epistaxis?

Apply pressure to the nose.

During assessment, a client verbally rates pain as 9 out of 10 on a 0-10 pain scale. There is no indication of pain relief, even though the previous nurse signed for an opioid for this client one hour prior. The client denies receiving anything for pain since the previous night. Which action should the nurse take next?

Approach the nurse who signed for the opioid to seek clarification about the missing drug.

A staff nurse receives a phone call and is told there is a bomb in a client's room. What is the nurse's priority action?

Ask the caller for details about the bomb placement.

A client who developed gestational diabetes mellitus during the pregnancy has just been admitted in the labor and delivery unit. What is the priority nursing action for this client?

Ask the client about her most recent blood glucose levels.

While performing the morning postpartum assessment, the nurse notices that a client's perineal pad is completely saturated with lochia rubra. What is the nurse's best action?

Ask the client when she last changed her perineal pad.

At the beginning of a shift, the team leader notices that all of the I.V. antibiotics for a client are still in the medication room. What is the team leader's first action?

Ask the nurse assigned to this client about the medications.

The nurse is assessing a laboring client. The client suddenly screams and exclaims, "My baby is coming." What is the priority action by the nurse?

Assess for crowning.

A client is brought to the emergency department after a house fire. What is the priority assessment by the nurse?

Assess oxygen saturation and the client's ability to speak.

The nurse is planning care for an infant with bronchiolitis. What is the nurse's priority intervention for this child?

Assess respiratory status frequently.

Parents bring a preschool-age client to the emergency department with suspected ingestion of an unknown toxic substance. What intervention should the nurse perform first?

Assess the child's vital signs and neurological status.

The nurse is assessing a client who has been experiencing black stools for the past month. The client suddenly reports chest and stomach pain. What is the most important action by the nurse?

Assess the client's vital signs

A 49-year-old client is admitted to the emergency department frightened and reporting hearing voices telling the client to do bad things. Which intervention should be the nurse's priority?

Assess the nature of the commands by asking what the voices are saying.

The nurse is caring for a client who has just undergone electroconvulsive therapy (ECT) for the treatment of severe depression that is unresponsive to medication. What is the nurse's most important intervention immediately postprocedure?

Assess vital signs.

The nurse is caring for a client diagnosed with Graves' disease. What is the nurse's priority intervention for this client?

Assessment of temperature

What is the priority nursing action for a client with generalized anxiety disorder who is working to develop coping skills?

Assist the client to identify coping mechanisms used in the past

A nurse is planning preoperative care for a child diagnosed with Wilms' tumor. What is the nurse's most important intervention?

Avoid abdominal palpation or manipulation.

A physical therapist has instructed the nursing staff on how to perform range-of-motion (ROM) exercises for an infant with torticollis. The nurse is uncomfortable when the infant cries and grimaces during the exercises. What is the most important action for the nurse to take?

Call the physical therapist.

What is the most important intervention for the nurse to implement while caring for a neonate with an omphalocele?

Carefully position and handle the omphalocele.

A client is 2 days postoperative from a femoral popliteal bypass. During assessment, the nurse finds the client's left leg is cold and pale. What is the nurse's initial action?

Check distal pulses.

A postpartum mother is concerned about a noted decrease in her breast milk production. Which response by the nurse best addresses this mother's concern?

Decrease supplemental feedings with formula.

A client, admitted with angina, reports severe chest pain and suddenly appears to lose consciousness and pulse. After calling for help and establishing unresponsiveness, which action should the nurse take next?

Deliver chest compressions

A local chemical plant has had an environmental leak requiring the mass evacuation of its employees and neighbors in the surrounding area. The emergency room nurse is in the triage area when the first client is brought to the hospital. What should the nurse do first?

Determine what decontamination measures took place in the field before approaching the client.

A client with acute renal failure has a serum potassium level of 7.0 mEq/L (mmol/L). What is the nurse's priority action for this client?

Electrocardiogram (ECG) results

A child with hemophilia is hospitalized with bleeding into the knee. Which action should the nurse take first?

Elevate the affected part.

A client with venous insufficiency reports swelling in the feet and ankles. What is the most appropriate intervention for the nurse to recommend?

Elevate the feet several times a day.

A client is scheduled for amniocentesis. What priority intervention should the nurse implement?

Have the client void.

The nurse is teaching the parents of a child diagnosed with celiac disease. What is the nurse's priority goal?

Help the parents and child follow the prescribed dietary restrictions.

The nurse notes what appears to be a ventricular fibrillation rhythm on a client's telemetry monitor. What should the nurse do first?

Immediately assess the client's level of consciousness.

A client who is experiencing thoughts of self-harm is brought to the crisis response center by family members. Which action is most important for the nurse to implement?

Implementing suicide precautions.

The nurse has just admitted a client with sickle cell crisis. What is the nurse's priority intervention?

Increasing fluid intake and giving analgesics

A client in early labor tells the nurse that she has a thick, yellow discharge from both of her breasts. What is the nurse's most appropriate intervention?

Inform the client that the discharge is colostrum, and a normal finding.

A nurse is preparing a client for cardiac catheterization. What is the nurse's priority assessment?

Known allergies

While performing a cervical examination on a client in labor, a nurse's fingertips feel pulsating tissue. What is the most appropriate nursing intervention?

Leave the fingers in place and press the nurse call light.

A client has just been diagnosed with pneumonia. What is the nurse's priority action?

Maintain airway clearance.

A 76-year-old woman, with a history of osteoporosis is 24-hours postoperative for a total right hip replacement. What is the priority nursing action for this client?

Managing pain

A client is admitted to the labor and delivery unit in labor with blood flowing down her legs. What would be the priority nursing intervention?

Monitor fetal heart tones.

An adolescent client is admitted for treatment of anorexia nervosa with a body mass index (BMI) of 13. What is the nurse's priority in planning the care?

Monitor the client's urine output and vital signs.

What is the nurse's priority action in caring for a client who has just had a liver biopsy?

Monitor vital signs.

A client is admitted with intervertebral disk prolapse, and shows new symptoms of urinary incontinence and paralysis of both legs. What is the priority action by the nurse?

Notify the provider immediately

A young female client with a history of sickle cell disease reports abdominal pain. What is the priority intervention by the nurse?

Obtaining a history of the sequence of symptoms

A multiparous client who has been in labor for 2 hours states that she feels the urge to move her bowels. What would the nurse do first?

Perform a pelvic examination.

What action should the nurse take first when a client is coughing up pink, frothy sputum?

Place the client in high-Fowlers position

A nurse is caring for a client exhibiting mild contractions and a cervical dilation of 4 cm. Using an external fetal monitor, the nurse observes variable decelerations. Which action should the nurse take first?

Place the client on her left side.

A client displays signs associated with a possible ruptured aortic aneurysm. What is the priority nursing intervention?

Prepare the client for surgical intervention

Which nursing intervention is a priority for a child with hemophilia, who has fallen, and has an acutely bruised leg?

Pressure on the site and administration of the required clotting factor

The nurse is caring for a client with terminal lung cancer. What is the priority nursing intervention for this client?

Provide pain control.

A client is admitted to the labor and delivery unit for birth of a known anencephalic fetus. What is the most appropriate intervention by the nurse?

Provide privacy and emotional support.

The nurse is caring for a recently circumcised newborn. Based on the progress note, what would be the most appropriate nursing intervention?2/10 0800Progress Note TabThree-day-old male, two days post-circumcision by Mogen clamp. Small amount of yellow-white exudate noted around glans. No bleeding or swelling noted. Axillary temp 36.4° C (97.5° F). Nursing eagerly, latching on well. Voided x4 post-circ.

Provide routine care to the circumcised area.

A nurse walks into the room of a client diagnosed with congestive heart failure (CHF). The client is lying supine and is diaphoretic, anxious, and dyspneic. What is the nurse's priority action?

Raise the head of the bed to 45°.

A parent reports that the school-age child has been reprimanded for daydreaming during class. The parent is concerned because the child's sibling has been diagnosed with absence seizures. This behavior is new, and the child's grades are dropping. What is the most appropriate action by the nurse?

Refer the child to the primary health care provider to assess for absence seizures.

Which nursing intervention is a priority for a pregnant adolescent during her first trimester?

Refer the client to a dietitian for nutritional counseling.

A client, who underwent femoral-popliteal (fem-pop) bypass surgery, is scheduled to return from the post-anesthesia care unit. Which staff member should receive this client?

Registered nurse with one year of experience

A nurse administers incorrect medication to a client. After assessing the client, and completing an incident report, which is the priority action by the nurse?

Report the incident to risk management.

A nurse suspects an infant may have a tracheoesophageal fistula or esophageal atresia. What is the most important intervention by the nurse?

Report the suspicion to the health care provider.

A 25-year-old male client has just had a plaster cast applied to his right forearm following the reduction of a closed radius fracture due to an inline skating accident. What is the priority nursing assessment for this client?

Sensation and movement of the fingers

Which health education topic is the priority when teaching parents ways to prevent urinary tract infections (UTIs) in their children?

Teach parents to promote adequate fluid intake.

Four clients have been admitted to the cardiac intensive care unit after experiencing acute myocardial infarctions. Each client has sustained a percentage of cardiac damage. Which client is most in need of interventions to prevent the development of cardiogenic shock?

The client with 40% damage

The nurse is developing a plan of care for a hospitalized client who is at risk for suicide. What is the most important intervention for the nurse to include?

Use a caring approach to maintain close observation of the client

A client is admitted to a mental health unit. While assessing the client, the nurse finds the client exhibiting signs of hyperexcitability, increasing agitation, and distractibility. Based on this assessment, which nursing intervention has priority?

Use a quiet room for the client away from others.

A nurse is caring for a 3-year-old child following the removal of a Wilms' tumor. The parent states that the child is in pain, and requests pain medication. What is the nurse's priority in regard to this parent's request?

Use the Faces Pain Scale to assess the child's degree of pain.

The nursing team consists of one RN, one LPN, and one unlicensed assistive personnel (UAP). Which assignment should the RN delegate to the LPN?

administering daily am medications

A six-week-old infant is brought to the emergency department not breathing. A preliminary finding of sudden infant death syndrome (SIDS) is made to the parents. Which initial intervention should the nurse take?

allow them to see their infant