NUR 401 QUIZ - Prioritization

A nurse is planning care for a client who has anorexia nervosa. The nurse should make which of the following client goals the priority? A. Attain a weight that is greater than the 75th percentile for age and height. B. Make positive statements about improvements in body image. C. Feel in control of her behavior. D. Identify changes within the family unit that promote the client's autonomy.

A. Attain a weight that is greater than the 75th percentile for age and height.

A charge nurse is working with an assistive personnel (AP) who provides excellent care to clients and is an effective team member. Which of the following actions should the nurse take first to recognize the AP's contributions to client care? A. Give positive feedback directly to the AP. B. Tell other nurses what an effective team member the AP is. C. Nominate the AP for the Employee of the Month award. D. Detail the AP's contributions to the nurse manager.

A. Give positive feedback directly to the AP.

A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take? A. Perform a neurovascular assessment. B. Explain the discharge instructions to the client and parents. C. Provide reassurance to the client and parents. D. Apply an ice pack to the casted leg.

A. Perform a neurovascular assessment.

A nurse overhears two assistive personnel (AP) from the medical-surgical unit discussing a hospitalized client while in the cafeteria. Which of the following is the priority nursing action? A. Quietly tell the APs that this is not appropriate. B. Ask the nurse manager to provide an inservice program about confidentiality to the staff on the unit. C. Complete an incident report. D. Document the occurrence in a personal log.

A. Quietly tell the APs that this is not appropriate.

A nurse is assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first? A. A client who has diarrhea and requests clear liquids for breakfast B. A client who has a cast on the left leg and reports numbness and paresthesia C. A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150 D. A client who has pneumonia and has an axillary temperature of 38° C (101° F)

B. A client who has a cast on the left leg and reports numbness and paresthesia

A nurse on a pediatric unit is reviewing her client assignment following the shift report. Which of the following clients should the nurse plan to assess first? A. A school-age child who has diabetes mellitus and requires blood glucose monitoring B. An infant who has pertussis and is receiving oxygen via nasal cannula C. An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions D. A toddler who has both arms in casts and needs to be fed his breakfast

B. An infant who has pertussis and is receiving oxygen via nasal cannula

A nurse is receiving change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process? A. Critically analyze client data to determine priorities. B. Collect and organize client data. C. Set client-centered, measurable and realistic goals. D. Determine effectiveness of interventions.

B. Collect and organize client data.

A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parental nutrition administration and reports a pain level of 6 on a scale from 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first? A. Weigh the second client. B. Obtain vital signs for both clients. C. Administer pain medication to the first client. D. Change the dressings of both clients.

B. Obtain vital signs for both clients.

A nurse is assigned a group of clients at the start of the shift. Which of the following clients should the nurse plan to care for first? A. A client who needs assistance with a bath B. A client requesting a referral for home health services C. A client asking about his PCA pump that contains morphine D. A client who has questions about his new prescription

C. A client asking about his PCA pump that contains morphine

A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately? A. An adolescent female client who is belligerent and has slurred speech B. A toddler who has a laceration on his forehead and is screaming C. A middle adult male who is diaphoretic and reports epigastric pain D. A young adult with a painful sunburn of his face and arms

C. A middle adult male who is diaphoretic and reports epigastric pain

A nurse is triaging clients in the emergency department. Which of the following clients should the nurse ask the provider to care for first? A. A toddler who has asthma and has a pulse oximetry reading of 95% while receiving oxygen at 2 L/min B. A toddler who has otitis media, a temperature of 39.2° C (102.6° F), and purulent ear discharge C. A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough D. An adolescent who has sickle cell disease, reports pain as 7 on a scale of 0 to 10, and requests pain medication

C. A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough

A nurse is completing the initial admission assessment and history for a client. Which of the following is the priority action for the nurse to take? A. Teach the client about his diagnosis. B. Provide a schedule of visiting hours to the client's family. C. Document the client's allergies in the electronic medical record. D. Develop a plan of care for the client.

C. Document the client's allergies in the electronic medical record.

A client commits suicide in an acute mental health facility. Which of the following is the priority intervention for staff following this incident? A. Provide professional counseling for staff members. B. Change policies for staff observation of clients who are suicidal. C. Identify cues in the client's behavior that might have warned them that he was contemplating suicide. D. Give the family an opportunity to talk about their feelings.

C. Identify cues in the client's behavior that might have warned them that he was contemplating suicide.

A nurse is receiving shift report about a group of assigned clients. Which of the following actions should the nurse plan to take first? A. Ask the provider about advancing a client's diet. B. Reinsert an intravenous catheter that was removed due to infiltration. C. Suction the tracheostomy of a client who has copious secretions D. Check the laboratory findings of a preoperative client scheduled for surgery later in the shift.

C. Suction the tracheostomy of a client who has copious secretions

An RN is delegating care activities to a licensed practical nurse (LPN). Which of the following is the priority criterion the RN should consider when delegating? A. Agency policies for the LPN B. The documented experience level of the LPN C. The documented skill level of the LPN D. State Nurse Practice Act for the LPN

D. State Nurse Practice Act for the LPN