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The nurse notes blanching, coolness, and edema at a client's peripheral intravenous (IV) site. Which nursing action is the priority?

1 Remove the IV catheter.

The nurse is assigned to the following clients. The nurse would assess the clients in which order of priority? Place the client in the order of priority for assessment. All options must be used.

1-4 2-3 3-1 4-2

The nurse assigned to four clients reviews client data at the beginning of the shift. To which information would the nurse give highest priority?

2 Pulse oximetry reading 89%

The nurse has received the client assignment for the day. Which client would the nurse care for first?

2 The 53-year-old client with heart failure who has gained 4 lb (1.8 kg) since yesterday and is short of breath

The nursing instructor asks the nursing student to identify the priorities of care for an assigned client. The nursing instructor determines that the nursing student understands the client's needs when which statement is made?

1 "Actual or life-threatening concerns are the priority."

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

The nurse just received the client assignments for the day. Which client would the nurse see first?

1 The client who is agitated following surgery

A home health care nurse is planning client visits and nursing activities for the day. The nurse begins the visits at 9:00 a.m. All clients live within a 5-mile radius. In order of priority, how would the nurse plan the assignments for the day? Arrange the actions in the order that they would be performed. All options must be used.

1-4 2-3 3-5 4-2 5-1 6-6

The nurse is caring for a client receiving hemodialysis. The client begins to experience dyspnea, tachypnea, chest pain, low oxygen saturation, and hypotension. The nurse suspects an air embolism. Place the actions that the nurse would take in order of priority. All options must be used.

1-5 2-4 3-1 4-6 5-3 6-2

The nurse is caring for four pediatric clients. After receiving reports from the night shift, which child would the nurse assess first?

2 A 6-week-old infant admitted to the hospital for decreased level of consciousness; shaken baby syndrome is suspected

The nurse has developed a teaching plan for a client with hypertension regarding the administration of prescribed medications. What is the initial nursing action?

2 Assess the client's readiness to learn.

The clinic nurse is caring for a client complaining of a foreign agent splashed into the eye. What intervention would the nurse employ before treatment?

2 Evaluate the client's visual acuity.

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client would the nurse plan to care for first?

4 A client with a white blood cell count of 14,000 mm3 (14 × 109/L) and a temperature of 38.4° C

The nurse is assigned to care for four clients on a medical-surgical unit. Which client would the nurse assess first?

4 A client with acute pancreatitis and epigastric pain rated as a 10 on a 0 to 10 pain scale; the client is reported to have a hard and rigid abdomen

The nurse is assigned to care for four clients. In planning client rounds, which client would the nurse assess first?

4 A client with asthma who requested a breathing treatment during the previous shift

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse would assign priority to which client?

4 A client with chest pain who states just ate pizza that was made with a very spicy sauce

After correctly completing the rights of medication administration, performing hand hygiene, and ensuring the correct position of the client, which steps would the nurse take to administer medication via a volume control container? Arrange the actions in the order that they would be performed. All options must be used.

Clean injection 1-3 Close the clamp and check 1-2 Regulate intravenous 3-5 Dispose of the syringe 4-6

A unit of packed red blood cells has been ordered for a client with low hemoglobin and hematocrit, and typing and crossmatching has been done. The nurse receives a telephone call from the blood bank and is informed that the unit of blood is ready for administration. In order of priority, how would the nurse plan the actions to take? Arrange the actions in the order that they would be performed. All options must be used.

close look at this one reposition 1-2 oxytocin 1-1 vaginal exam 3-4 blood pressure 4-5 8 to 10 L/min 5-3 reduce uterine activity 6-6

Which client would the emergency department triage nurse classify as emergent?

3 A client with crushing substernal pain who is short of breath

A client with breast cancer is receiving intravenous morphine sulfate for pain. When writing the plan of care for this client, the nurse would include which action as the priority action?

3 Monitor respiratory status.

The emergency department nurse is caring for a child with suspected epiglottitis and has ensured that the child has a patent airway. Which action is the next priority in the care of this child?

3 Prepare the child for a chest radiograph.

The nurse has received the client assignment for the day. Which client would the nurse care for first?

4 The client admitted with a medical diagnosis of neutropenia who is afebrile and is complaining of pain with urination

The nurse determines that which client has the highest priority needs?

4 The client who has an irregular apical pulse of 120 beats per minute

The nurse is the first responder at the scene of an accident in which a tire blowout caused a bus to roll over several times. Which victim would the nurse attend to first?

4 The confused 12-year-old with bright red blood pulsing from an open fracture of the femur

The nurse is a responder at the scene of a building collapse. Which victim would the nurse care for first?

4 Victim with an apparent chest wall defect and asymmetrical chest wall movement

The nurse manager of a medical-surgical unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply.

1 Client postoperative day 1 after inguinal herniorrhaphy, vital signs stable 2 Client 5 days after a myocardial infarction, vital signs stable, absence of dysrhythmias 3 Client 1 day after cardiac catheterization, normal study results, groin site free of hematoma

A child with an autism spectrum disorder (ASD) is being admitted to the hospital for diagnostic tests. Which room assignment is the most appropriate for the child?

1 Private room

When planning care, which client would the nurse assess first?

1 The client with a chest tube for a pneumothorax

The nurse is triaging clients in the waiting room of the emergency department. In what order would the nurse triage the clients from highest priority to lowest?

1-2 2-3 3-1 4-4

A hospitalized client with type 1 diabetes mellitus received Humulin N and Humulin R insulin 2 hours ago (at 7:30 a.m.). The client calls the nurse and reports is feeling hungry, shaky, and weak. The client ate breakfast at 8:00 a.m. and is due to eat lunch at noon. Arrange the actions that the nurse will take in the order that they would be performed. All options must be used.

1-3 2-4 3-1 4-2 5-5 6-6

A unit of packed red blood cells has been ordered for a client with low hemoglobin and hematocrit, and typing and crossmatching has been done. The nurse receives a telephone call from the blood bank and is informed that the unit of blood is ready for administration. In order of priority, how would the nurse plan the actions to take? Arrange the actions in the order that they would be performed. All options must be used.

1-6 2-4 3-2 4-3 5-1 6-6

The nurse is assigned to four clients on a postoperative surgical unit at a rural hospital. When prioritizing the care, the nurse recognizes that the highest priority is focused on which client?

2 The client with problems clearing the airway related to abdominal incision pain

The nurse is working on a medical-surgical unit. Which client would the nurse see first based on the client's risk for experiencing delirium?

3 A client being treated for a urinary tract infection (UTI)

After receiving client assignments for the day, the nurse prioritizes seeing which client first?

4 A client admitted for a gastrointestinal (GI) bleed with stable hemoglobin and hematocrit

The nurse has received the client assignment for the day. Which client would the nurse care for first?

4 A client recently admitted after a motor vehicle accident still in cervical spine precautions

The nurse has received the client assignment for the day. Which client would the nurse check first?

4 A client who has just returned from surgery

The nurse working in the emergency department has four charts of clients who need to be assessed. Which client would be assessed first?

4 A client with a history of schizophrenia threatening to harm themself

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse would assign priority to which client?

4 A client with chest pain who states that they just ate pizza that was made with a very spicy sauce

An emergency department nurse is preparing to receive four clients as a result of a motor vehicle crash. Which victim would the nurse attend to first?

4 A client with chest pain, shortness of breath, and diaphoresis

The nurse has received the client assignment for the day. Which client would the nurse care for first?

4 A client with postoperative pain reported at 7 out of 10, with 10 being the worst

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

4 A client who has a peripheral (index finger) oxygen saturation percentage of 85%

During morning report, the day nurse is given information on the assigned clients. Which client would the nurse assess first?

3 The 60-year-old client with leukemia who is receiving the first round of chemotherapy, which was started at 0630 and is scheduled to end at noon

The nurse just received shift hand-off and is preparing for the day. Which client would the nurse see first?

4 A client requiring a 12-lead electrocardiogram (ECG) for suspicion of ST-segment elevation, noted on the cardiac monitor

The labor and delivery room nurse has just received reports on four clients. After reviewing the client data, the nurse would assess which client first?

4 A client who has just received an intravenous loading dose of magnesium sulfate to stop preterm labor

The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action?

4 Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse would inform those attending the session that the first priority intervention in the event of this occurrence is which action?

4 Move the victim to a safe area away from the snake and encourage the victim to rest.