management Final EAQ

An adolescent with a history of asthma arrives in the emergency department experiencing respiratory distress. The primary health care provider admits the adolescent. Implementing which prescription is the nurses priority? physical assessment: dyspnea flaring of nares productive cough; sputum is frothy, clear, and gelatinous wheezing adolescent indicates shortness of breath, chest discomfort, headache, and feeling tired Primary healthcare provider's orders: Bedrest complete blood count SMA: 12 Albuterol 2.5 mg via nebulizer, one dose chest physiotherapy BID Incentive spirometer Oxygen via mask at 8L referral to allergist VS: temp: 98.8 Pulse: 108 RR: 30 BP: 130/86 A. Administer the nebulizer treatment to facilitate breathing B. Obtain a blood specimen to send to the laboratory for tests C. Notify the respiratory therapist to perform chest physiotherapy D. Send a requisition to central supply for an incentive spirometer

A. Administer the nebulizer treatment to facilitate breathing

which client in the post operative unit would a safety priority for the nurse to monitor for fluid volume overload? A. Client A: Client with lymph node dissection B. Client B: client with laparoscopic cholecystectomy C. Client C: Client with surgical intervention for hemorrhoids D. Client D: Client with liver transplantation

A. Client A: Client with lymph node dissection

Which priority nursing intervention would the nurse implement for a client on diuretic therapy who has developed metabolic alkalosis? A. Fall prevention measures B. Monitoring electrolytes C. Administering antiemetics D. Adjusting the diuretic therapy

A. Fall prevention measures

which nursing goal would be priority for an adolescent who has a history of fighting, stealing, vandalizing property, running away from home, and has been suspended from school repeatedly? A. Preventing violence B. encouraging insight C. Supporting self-esteem D. Promoting social interaction

A. Preventing violence

which priority concern would the nurse monitor for while working with clients withdrawing from cocaine A. Risk for self-injury B. potential for seizures C. Danger of dehydration D. Probability of injuring others

A. Risk for self-injury

What is the priority nursing action immediately after the insertion of a subclavian central venous access catheter for a client who is to begin total parenteral nutrition (TPN)? A. Obtain a chest x-ray to determine placement B. Auscultate the lungs to evaluate breath sounds C. Draw a blood sample to assess blood glucose level. D. assess the right upper extremity for neurological deficits

B. Auscultate the lungs to evaluate breath sounds

Which color tag is assigned the lowest Priority for care in a mass casualty event? A. Red B. Black C. Green D. Yellow

B. Black

which is the priority intervention for dependent client with peptic ulcer disease (PUD) who is vomiting bright red blood? A. Apply oxygen B. Place the client in side-lying position C. Prepare to admin packed red blood cells D. Assess the client's pulse and blood pressure

B. Place the client in side-lying position

A post menopausal client with cancer of the breast decides to have a lumpectomy followed by chemotherapy. After receiving chemotherapy for several weeks, she is not feeling well. The nurse reviews the medical record data presented in the image. After analysis of the available history, laboratory test, and clinical manifestations, which goal has the highest priority for this client? Medications: cyclophosphamide Doxorubicin Fluorouracil Labs: RBC: 4.2 WBC: 3000 HGB: 12.5 HCT: 39% PLT: 190,000 VS: temp: 99.8 pulse: 88 RR: 24 BP: 126/88 A: promote rest B. Prevent infection C. Avoid bodily harm D. Maintain fluid balance

B. Prevent infection

which intervention is the primary priority for decreasing a client's risk for morbidity and mortality? A. Treatment B. Prevention C. Rehabilitation D. Surgical therapy

B. Prevention

Client who underwent open heart surgery died two days after the surgery because of septicemia. Which tool will the nurse use to determine the cause of the clients death? A. Plan-do-study-act (PDSA) B. Root cause analysis (RCA) C. Failure mode effective analysis (FMEA) D. Computerized physician order entry (CPOE)

B. Root cause analysis (RCA)

In the immediate post injury., Which action is the priority focus of nursing care for a client with a spinal cord injury? A. inhibiting urinary tract infections B. Preventing contractures and atrophy C. Avoiding flexion or hyperextension of the spine D. Preparing the client for vocational rehabilitation

C. Avoiding flexion or hyperextension of the spine

For a client admitted to the hospital with partial- and full- thickness burns of the chest and face obtained while attempting to extinguish a brush fire, which concern would the nurse establish as a priority? A. Loss of skin integrity caused by the burns B. Potential infection as a result of the burn injury C. Inadequate gas exchange caused by smoke inhalation D. Decreased fluid volume because of the depth of the burns

C. Inadequate gas exchange caused by smoke inhalation

Based on the information in the chart of a client with emphysema and recovering from a cute myocardial infarction, which prescribed medication with the nurse consider the priority at this time? Labs: WBC: 10,000 mm HGB: 11 gm/dL HCT: 34% INR 2.5 Vitals: Temp: 100 Pulse: 100 BPM, regular rhythm RR: 24 BP: 176/96 Physical assessment: Using pursed lip breathing pulse bounding face appears flushed Reports a headache and dizziness A. Albuterol B. Warfarin C. Metoprolol D. Acetaminophen

C. Metoprolol

Which assessment is a nursing priority to prevent complications in clients with respiratory acidosis? A. Observing the nail beds B. Listening to breath sounds C. Monitoring breathing status D. Checking muscle contractions

C. Monitoring breathing status

Which intervention would be a priority for the nurse to include in the plan of care for a client with a gun shot wound who has severe hemiplegia associated with abnormal body posturing and fixed and dilated pupils? A. Monitoring skin integrity B. Monitoring bowel patterns C. Monitoring respiratory rate D. Monitoring nutritional status

C. Monitoring respiratory rate

Client with hyper emesis gravidarum is receiving rehydration infusion therapy at home. Which is the priority nursing activity for the home health nurse? A. Determining fetal well-being B. Monitoring for signs of infection C. Monitoring the client for signs of electrolyte imbalance D. Teaching about changes in nutritional needs during pregnancy

C. Monitoring the client for signs of electrolyte imbalance

Which priority parameter would the nurse assess when caring for an older adult client with a neurocognitive disorder who demonstrates disorientation and numerous unmanageable behaviors? A. Orientation to time, place, and person B. Ability to preform daily activities without assistance from others C. Stressors that appear to precipitate the client's disruptive behavior D. Cognitive impairments until complete adjustments are accomplished

C. Stressors that appear to precipitate the client's disruptive behavior

Which task should the nurse classify as low priority when planning client care for the day? A. Drawing arterial blood gasses on a client in Respiratory distress B. Turning and positioning a client after hip replacement surgery C. Teaching self-administration of insulin before discharge D. Obtaining and recording vital signs every 2 hours on a postoperative client

C. Teaching self-administration of insulin before discharge

Which statement made by the nurse indicates a need for further teaching when educating staff about integrating the Joint Commission's National Patient Safety Goals (NPSG) into the behavioral health unit? A. " We should screen all clients for the risk of suicidal ideation" B. "It is important to perform hand hygiene for at least 15 seconds." C. "It is required to obtain a current medication list upon admission." D. "We should use one client identifier before giving medications"

D. "We should use one client identifier before giving medications"

Which client would the triage nurse classify as requiring the least priority of care? A. Client A: Extreme respiratory distress d/t COPD B. Client B: Severe respiratory distress d/t asthma C. Client C: moderate shortness of breath d/t tuberculosis D. Client D: Foreign body aspiration d/t pneumonia

D. Client D: Foreign body aspiration d/t pneumonia

Which priority treatment with the nurse help implement for a newly admitted client with anorexia nervosa? A. medications to reduce anxiety B. Family psychotherapy sessions C. Separation from family members D. Correction of electrolyte imbalances

D. Correction of electrolyte imbalances

When providing care for a client during the first few hours after admission to the burn unit with full thickness burns of the trunk and head, which goal is the nurses priority during the emergent phase of this injury? A. Preventing pain B. Managing leukopenia C. Preventing infection D. Managing fluid loss

D. Managing fluid loss

Which nursing intervention would be the priority for an older client with depression who is prescribed a tricyclic antidepressant? A. Providing psychotherapy to the client B. Teaching strategies to overcome depression C. Encourage the client to walk for 30 minutes D. Requesting that the health care provider change the medication.

D. Requesting that the health care provider change the medication.

Which intervention with the nurse classify as the highest priority for an older client with lower extremity ulcerations due to chronic venous insufficiency? A. Teaching Techniques for dressing changes B. Informing the client about insurance companies C. Discussing community resources to obtain support D. Teaching how to transfer from bed to chair in the least painful manner

D. Teaching how to transfer from bed to chair in the least painful manner