Prioritization

The nurse performs admission assessments on 4 clients. Which client assessment information is most concerning and needs priority care? 1. 17-year-old with suspected meningococcal meningitis who has a fever of 103 F (39.4 C), headache with photophobia, and stiff neck. 2. 36-year-old who is an IV drug user with cellulitis of the arm, a fever of 103.2 F (39.6 C), and foul-smelling drainage from self-injection sites. 3. 45-year-old with diabetes mellitus and osteomyelitis of the foot who has a fever of 100.9 F (38.3 C) and a serum glucose of 295 mg/dL (16.4 mmol/L) 4. 76-year-old with chronic bronchitis who has a fever of 101 F (38.3 C) and a productive cough of thick green mucus(7%)

1. 17-year-old with suspected meningococcal meningitis who has a fever of 103 F (39.4 C), headache with photophobia, and stiff neck. Meningococcal meningitis is a highly contagious condition that involves inflammation and bacterial infection in the tissues covering the brain and spinal cord (meninges). It is transmitted through direct contact or by inhaling droplets from infected individuals (ie, upper respiratory tract infections) and is prevalent among those living in close proximity (eg, prisons, dormitories). Characteristic signs include fever, headache, nuchal rigidity (stiff neck), photophobia, nausea, vomiting, and changes in mental status. If any of these are present, prompt testing (eg, lumbar puncture [LP], cultures) and initiation of antibiotic therapy immediately following the LP are critical as this is a life-threatening medical emergency.

Which client in the emergency department should the nurse see first? 1. 2-year-old with fever and sore throat who is restless and drooling. 2. 7-year-old with appendicitis who has right lower quadrant pain and vomiting. 3. 9-year-old with immune thrombocytopenia who has generalized petechiae. 4. 17-year-old with cystic fibrosis who is coughing up thick, blood-tinged sputum.

1. 2-year-old with fever and sore throat who is restless and drooling. Acute epiglottitis is a supraglottic inflammatory process that occurs most commonly in children with Haemophilus influenzae type b (Hib) infection. Inflammation of the epiglottis can cause airway obstruction and is a medical emergency. Common signs of impending airway obstruction include restlessness, stridor, and drooling due to dysphagia. The nurse should prepare to assist with emergent endotracheal intubation. (Option 2) If left untreated, the inflamed appendix may rupture, causing peritonitis, major abscess, or partial bowel obstruction. The client with acute appendicitis may require antibiotic administration and emergent surgical appendectomy. Although appendicitis is an emergent condition, a client with impending airway obstruction from epiglottitis must be seen immediately. (Option 3) Immune thrombocytopenia (ITP) is an acquired disorder in which antibodies cause decreased platelet survival and production. Petechiae, pinpoint lesions on the skin from capillary hemorrhages, are a common sign of ITP. Acute ITP usually resolves spontaneously without complications, and management is primarily supportive (eg, platelet monitoring, corticosteroids, IV immunoglobulin). (Option 4) Cystic fibrosis affects the secretory glands, resulting in thick sputum that may become blood-tinged from frequent coughing. A client with cystic fibrosis who has blood-tinged sputum should be evaluated but is not a priority.

Four clients enter the emergency department at the same time. Which should the triage nurse see first? 1. 25-year-old client with sudden-onset chest pain and heart rate of 110/min 2. 45-year-old client with type 2 diabetes who is traveling and has lost insulin glargine 3. 60-year-old client with pain, swelling, erythema, and warmth in the right leg 4. 70-year-old client with left lower abdominal pain and diarrhea for 2 days

1. 25-year-old client with sudden-onset chest pain and heart rate of 110/min An ECG should be performed immediately on all adult clients with chest pain; all chest pain should be considered cardiac until proven otherwise. After the initial ECG, the client with chest pain will need to be placed on a cardiac monitor and assessed by the health care provider before the other 3 clients. (Option 2) This client will need a prescription renewal. Glargine (Lantus) is given once a day, typically in the evening, as basal insulin. The consequence of late administration is hyperglycemia. A single temporary rise in glucose will not have a significant negative impact. The damage to vessels in a diabetic client comes from long-term uncontrolled diabetes. The other clients are a higher priority. (Option 3) This client may have a deep vein thrombosis and will probably require anticoagulant therapy. However, this client is hemodynamically stable without evidence of active pulmonary embolism and can safely wait to be seen after the higher-risk client with chest pain. (Option 4) This client may have acute diverticulitis and should be seen urgently, but after the client with chest pain. Prioritization should be based on which client is most ill and not on advanced age.

The nurse receives report on 4 pediatric clients in the emergency department. Which client should be seen first? 1. 3-week-old with fever who is sleeping more than usual and refuses to feed 2. 4-month-old who has painless, new-onset, bilateral testicular swelling 3. 8-month-old who ingested a bottle of children's bubble soap 30 minutes ago 4. 2-year-old with fever, runny nose, cough, and sore throat for the past 2 days

1. 3-week-old with fever who is sleeping more than usual and refuses to feed Sepsis neonatorum is a medical emergency. Newborns may not exhibit obvious signs of infection but instead may have elevated temperature or be hypothermic. Subtle changes such as irritability, increased sleepiness, and poor feeding should be considered red flags. Blood, urine, and cerebrospinal fluid cultures should be obtained immediately and broad-spectrum antibiotics started. Educational objective:Sepsis in a newborn is life-threatening. Newborns with fever, lethargy, and refusal to feed require a full septic workup. Broad-spectrum antibiotics should be started immediately after obtaining blood, urine, and cerebrospinal fluid cultures.

Four clients are seen by the emergency department nurse. Which client is a priority for treatment and definitive care? 1. 7-day-old fussy infant with a rectal temperature of 100.6 F (38.1 C) and 6 wet diapers today 2. Client receiving radiation therapy who has 6-in (15.2-cm) arm laceration that is not actively bleeding 3. Client with purulent drainage and crusting of the eyelid with vision unaffected 4. New parent who is crying and overwhelmed, and denies suicidal ideation

1. 7-day-old fussy infant with a rectal temperature of 100.6 F (38.1 C) and 6 wet diapers today Infants <30 days old have immature immune systems and a blunted response to infection. The 7-day-old infant is at high risk for bacteremia. Infectious manifestations are often subtle at this age (eg, fever can be the only symptom), although some infants may have hypothermia, lethargy, poor feeding, or decreased urine output. Rectal temperature >100.4 F (38.0 C) or <96.8 F (36.0 C) is a "red flag" in a neonate. Educational objective:Infectious manifestations are often subtle in neonates (eg, fever can be the only symptom), although some may have hypothermia, lethargy, poor feeding, or decreased urine output. Rectal temperature >100.4 F (38.0 C) or <96.8 F (36.0 C) is a "red flag" in a neonate.

The nurse is caring for the assigned clients on a pediatric inpatient unit. Which client is the priority? 1. 8-year-old with sickle cell crisis who has sudden-onset unilateral arm weakness. 2. 11-year-old with viral meningitis requesting pain medication for headache. 3. Male child scheduled for surgery for intussusception who has reddish mucoid stool. 4. Male child with hemophilia who has hemarthrosis and is receiving desmopressin.

1. 8-year-old with sickle cell crisis who has sudden-onset unilateral arm weakness. Children can have strokes. Ischemic strokes are more common in children with sickle cell disease. Other causes can include carotid abnormalities/dissection. The most common presentation of an ischemic stroke is the sudden onset of numbness or weakness of an arm and/or leg. These are handled with a similar emergent approach as for stroke in an adult. Children may require exchange blood transfusion to prevent the stroke from worsening. (Option 2) Viral meningitis can cause fever, headache, and meningeal signs (neck stiffness). Headache is expected and not a priority over a client with stroke. (Option 3) Intussusception occurs when one portion of the intestine prolapses and then telescopes into another. It is a frequent cause of intestinal obstruction during infancy. Onset is abrupt, initially with pain and brown stool. The condition then progresses to bilious emesis, palpable abdominal mass, and stools with a red, "currant jelly" appearance due to blood and mucus. This is an expected finding for this condition, and surgery is already scheduled to address it. (Option 4) Hemophilia is seen primarily in males and is due to a lack of clotting factors. Symptoms include spontaneous bleeding (hemarthrosis) into the joints, especially the knee, ankle, or elbow. Treatment includes replacing the missing clotting factor. Desmopressin (DDAVP) stimulates the release of factor VIII. The child is receiving treatment already and joint rest has been prescribed. The sudden neurological change in the child with sickle cell crisis is a priority.

The nurse assesses 4 children in the clinic. Which assessment finding requires the nurse's priority action? 1. A 3-month-old with fever, vomiting, high-pitched cry, and irritability 2. A 9-month-old with diarrhea who is refusing fluids and cries without tears. 3. An 11-month-old with cold symptoms and an abdominal breathing pattern. 4. An 18-month-old who cries when the caregiver leaves.

1. A 3-month-old with fever, vomiting, high-pitched cry, and irritability Infants with underlying infection and increased intracranial pressure (ICP) will be very irritable and have fever and a high-pitched cry. Other signs of increased ICP include changes in pupillary reaction, sunset eyes, dilated scalp veins, poor feeding, vomiting, and bulging fontanelles. The 3-month-old needs to be seen first due to the potential for bacterial meningitis. If bacterial meningitis is suspected, droplet precautions should be initiated and the infant should be treated with antibiotics immediately. (Option 2) The absence of tears when crying indicates moderate dehydration. This infant needs evaluation but is not the priority. (Option 3) In children under age 6 years, the diaphragm is the major respiratory muscle. This infant is displaying normal respiratory effort. Furthermore, cold symptoms are common in children. (Option 4) Separation anxiety (distress when the primary caregiver is absent) is common in this age group (age 8 months to 2 years).

The post-anesthesia care unit nurse is caring for 4 clients during the immediate postoperative period. Which client would be the priority for the nurse to see first? 1. A client post cholecystectomy reporting increased nausea 2. A client post myomectomy with mild oozing of blood from the surgical site 3. A client post spinal surgery requesting additional pain medication 4. A client post transurethral resection of the prostate with reddish-pink drainage

1. A client post cholecystectomy reporting increased nausea Immediate postoperative nursing care focuses on management of the airway, breathing, circulation, bleeding, and pain. Although antiemetic medications are typically administered immediately after surgery to control nausea and vomiting, nausea is still a common complication caused by anesthetic side effects and decreased gastrointestinal motility. Clients are at high risk for aspiration (and possible asphyxiation) due to their altered level of consciousness, which is caused by anesthesia. Clients reporting nausea should be placed immediately on their side to prevent aspiration of vomit. (Option 2) Mild oozing of blood from the surgical site is normal during the postoperative period. The nurse will note the amount and appearance of the drainage, reinforce the dressings, and continue to monitor the client. This client would be seen third. (Option 3) Pain control after surgery is important for client recovery. Because short-acting pain medications are given to minimize respiratory depression, a client's pain can increase quickly. This client would be seen second. (Option 4) After transurethral resection of the prostate, continuous bladder irrigation for 24-36 hours flushes out small clots and prevents obstruction. Reddish-pink drainage is expected in the immediate postoperative period. This client would be seen last.

A blizzard is predicted to hit a large city within a few hours. The home care nurse is prioritizing and revising the schedule and estimates that 3 home visits can be made before the blizzard hits. Which clients should the nurse see? Select all that apply. 1. A client who fell and hit the head but refuses to go to the emergency department 2. A client who is due for a maintenance dose of cyanocobalamin 3. A client who needs pre-filled insulin syringes 4. A client who was discharged from the hospital yesterday after heart failure treatment 5. A client with a stage 3 pressure injury in need of a dressing change

1. A client who fell and hit the head but refuses to go to the emergency department 3. A client who needs pre-filled insulin syringes 5. A client with a stage 3 pressure injury in need of a dressing change In this scenario, it is unknown when home care visits will resume due to severe inclement weather. The high-priority clients are those who are at risk for harm if a scheduled visit cannot be made in 24 hours or more. The client who fell could have sustained a head injury and needs assessment. The client in need of pre-filled insulin syringes could become hyperglycemic if insulin is unavailable. The client with the stage 3 pressure injury has a scheduled dressing change for a serious wound and this should not be postponed.

The emergency nurse is triaging clients. Which report is most concerning and would be given priority for definitive diagnosis and care? 1. Abrupt, tearing, moving (upper to lower) back pain and epigastric pain. 2. Severe lower back pain after lifting heavy boxes. 3. Sharp calf ache with ambulation that improves with rest. 4. Unilateral leg swelling with 2+ pitting edema after an airplane trip.

1. Abrupt, tearing, moving (upper to lower) back pain and epigastric pain. An aortic dissection occurs when the arterial wall intimal layer tears and allows blood between the inner (intima) and middle (media) layers. Clients with ascending aortic dissections typically have chest pain, which can radiate to the back. Descending aortic dissection is more likely associated with back pain and abdominal pain. It is frequently abrupt in onset and described as "worst ever," "tearing," or "ripping" pain. Hypertension is a contributing factor. Extending dissection from uncontrolled hypertension can cause cardiac tamponade or arterial rupture, which is rapidly fatal. Emergency treatment includes surgery and/or lowering the blood pressure. (Option 2) Severe lower back pain after lifting heavy boxes is likely due to disc herniation. Some clients may report radiculopathy pain radiating down the leg below the knee. While uncomfortable, this is not life-threatening. (Option 3) This is a description of intermittent claudication in the lower extremity due to peripheral artery disease. It is an ischemic muscle pain (due to the buildup of lactic acid from anaerobic metabolism) related to exercise that resolves with rest. (Option 4) This is a description of a deep venous thrombosis (DVT) resulting from immobility during a flight. The embolization of DVT can cause life-threatening pulmonary embolism; the client with aortic dissection already has a life-threatening condition.

After morning report, the nurse must perform which action first when caring for assigned clients? 1. Administer IV bumetanide to a client with heart failure who has bilateral crackles and dyspnea. 2. Hang the second unit of packed red blood cells for a client with a hemoglobin of 6 g/dL (60 g/L). 3. Replace the empty IV opioid medication syringe in a patient-controlled analgesia pump. 4. Replace the heparin infusion bag that has 100 mL remaining and is infusing at 50 mL/hr.

1. Administer IV bumetanide to a client with heart failure who has bilateral crackles and dyspnea. Heart failure involves the inability of the heart to pump blood effectively to meet the body's oxygen needs. The nurse should first administer the IV bumetanide (Bumex) or furosemide (Lasix) to promote diuresis and mobilize excess fluid in the systemic circulation and lungs. This is the priority action as it improves oxygenation and gas exchange in the lungs and helps relieve dyspnea. (Option 2) The second unit of packed red blood cells is required to raise the hemoglobin to increase the blood's oxygen-carrying capacity, but this is not as urgent as improving gas exchange in the lungs. (Option 3) The patient-controlled analgesia tubing is connected to a running IV that is attached to an IV pump, so the IV line should remain patent even if the opioid syringe is empty. A short delay in receiving analgesia does not pose a threat to the client's survival, so this is not the priority action. (Option 4) An electronic IV pump is used to administer a heparin infusion. A new IV container is replaced when 50 mL is remaining to ensure the bag does not run dry. At the current rate of 50 mL/hr with 100 mL remaining, the new bag should be hung in about 1 hour, so this is not the priority action.

The nurse is managing assigned clients on the evening shift. Which client presentation is a priority? 1. Blunt head trauma with projectile vomiting 2. History of Alzheimer disease with agitation 3. History of carpal tunnel syndrome with hand numbness 4. History of third cranial nerve pathology with double vision

1. Blunt head trauma with projectile vomiting A client with a traumatic head injury from blunt force can have delayed symptoms if there is bruising in the brain and subdural hematoma/cerebral edema develops. A subdural hematoma is typically a slower venous bleed, and symptoms appear 24-48 hours later. Signs and symptoms are similar to those of increased intracranial pressure and include change in level of consciousness, projectile vomiting, ataxia, ipsilateral (unilateral) pupil dilation, and seizures. Brain herniation can occur if the condition is not recognized and treated. Educational objective:A client with a head injury and signs of increased intracranial pressure (eg, change in level of consciousness, projectile vomiting, pupil dilation, ataxia) is a priority.

The nurse in the emergency department receives 4 clients. Which client should the nurse see first? 1. Child who is confused and irritable and whose parent claims 2 glyburide pills are missing 2. Child with an abscess on the buttock that is red, swollen, and warm to the touch 3. Child with immune thrombocytopenia who fell off a bike and reports shoulder pain 4. Child with low-grade fever, barking cough, and runny nose who has mild retractions.

1. Child who is confused and irritable and whose parent claims 2 Glyburide is used to treat diabetes mellitus, and it can cause significantly low blood sugar if ingested by a client who does not have diabetes, especially a child. Based on the symptoms the child is exhibiting (irritability, confusion), hypoglycemia is likely. This client requires immediate intervention as severe hypoglycemia can result in coma and/or death. (Option 2) Buttock abscess, although painful, is not an emergency. Incision and drainage are needed. (Option 3) Immune thrombocytopenia can be a serious condition due to the risk for bleeding. A client with this condition should be assessed for internal bleeding following an injury, especially to the head. Shoulder pain is not a symptom associated with life-threatening bleeding; therefore, this client is not the top priority. (Option 4) This child with brassy (barking) cough most likely has croup, which can be life-threatening and needs urgent assessment. However, because this client seems to be stable, the child with possible glyburide ingestion should be seen first. This child has mild retractions, a sign that the child is still moving air but work of breathing has increased. The presence of stridor or severe suprasternal, subcostal, and intercostal retractions would make this client a higher priority.

The nurse receives report on 4 clients. Which client should the nurse see first? 1. Client 2 hours post foot amputation surgery has a surgical dressing saturated with bright red blood 2. Client scheduled for whirlpool bath in 20 minutes has the dressing on the infected foot ulcer fall off 3. Client with arteriovenous graft for hemodialysis access has new-onset pain and redness at graft site 4. Client with urinary retention and infection receiving antibiotics is confused and trying to pull out Foley catheter.

1. Client 2 hours post foot amputation surgery has a surgical dressing saturated with bright red blood. The nurse should assess the postoperative client first by monitoring vital signs, examining the dressing and amount and appearance of the drainage, and performing a neurovascular assessment (eg, pulses, skin color and temperature, sensation, movement). Serosanguineous (pink) drainage would be expected 2 hours after surgery, but a dressing saturated with sanguineous (bright red) drainage indicates excessive blood loss with possible hemorrhage; it should be reported immediately to the health care provider for evaluation. A pressure dressing may be required to provide wound hemostasis, or the client may need to return to the operating room for cauterization of a bleeding vessel. This client is at highest risk for morbidity and mortality (Option 1).

The nurse on the orthopedic unit receives information during evening report. Which client should the nurse assess first? 1. Client 3 hours postoperative tibial fracture repair who reports severe pain and pressure under the cast and is requesting opioids every hour 2. Client 6 hours postoperative rotator cuff repair with a sling immobilizer who has moderate swelling and tingling of the hand and fingers 3. Client 8 hours postoperative total knee arthroplasty who has 2 closed-wound suction drains and a total output of 200 mL sanguineous drainage. 4. Male client 1 day postoperative total hip replacement prescribed enoxaparin who has a hematocrit of 37% (0.37) and hemoglobin of 12.5 g/dL (125 g/L)

1. Client 3 hours postoperative tibial fracture repair who reports severe pain and pressure under the cast and is requesting opioids every hour Compartment syndrome results from swelling and increased pressure within a confined space (a compartment). It is most common with lower extremity injuries but can also occur in the arm. Pressure from bleeding/edema can exceed capillary perfusion pressure and lead to decreased perfusion and tissue ischemia below the site of increased pressure. Early manifestations include increasing pain unrelieved by opioids or elevation, pain with passive motion, pallor, and paresthesia due to nerve compression and ischemia. If the pressure is not relieved within 4-6 hours of onset (eg, surgical fasciotomy, cast removal), irreversible nerve and muscle injury can occur.

The nurse has received report on the following clients. Which client should the nurse assess first? 1. Client 4 hours postoperative colon resection who has a blood pressure of 90/74 mm Hg(33%) 2. Client receiving palliative care who has Cheyne-Stokes respiration with 20-second periods of apnea(10%) 3. Client with anemia and hemoglobin level of 7 g/dL (70 g/L) who has a pulse of 110/min after ambulation(6%) 4. Client with diabetic ketoacidosis who has rapid, deep respirations at a rate of 32/min(48%)

1. Client 4 hours postoperative colon resection who has a blood pressure of 90/74 mm Hg(33%) The nurse should first assess the client who had bowel surgery as hypotension can be a manifestation of bleeding, hypovolemia, and early septic shock. The nurse should check vital signs and perform a cardiovascular assessment. Postoperative hypotension can be a manifestation of bleeding, hypovolemia, and sepsis. Changes in vital signs (eg, decreased systolic pressure, tachycardia, tachypnea) and cool, pale skin can indicate decreased cardiac output and altered tissue perfusion.

The nurse has just received report. Which client should the nurse assess first? 1. Client admitted from coronary angiography in the past hour with back pain 2. Client with a deep vein thrombosis (DVT) on heparin drip at 1250 units/hr with an activated partial thromboplastin time (aPTT) of 60 seconds 3. Client with a head injury and a Glasgow Coma Scale of 14 4. Postoperative day 2 coronary artery bypass graft client with incisional pain rated 6 on pain scale

1. Client admitted from coronary angiography in the past hour with back pain Post-procedure care of a client who has undergone heart catheterization should focus on evaluating hemodynamics - blood pressure, heart rate, strength of the distal pulses, color, and temperature of extremities. The client should be also assessed several times per hour for active bleeding, hematoma, or pseudoaneurysm formation at the incision. The first hour after cardiac catheterization requires assessment every 15 minutes. Any report of back or flank pain should be assessed for possible retroperitoneal bleeding as back pain, tachycardia, and hypotension may be the only indication of internal bleeding. More than a liter of blood can pool behind the peritoneum in the pelvis undetected, and it may take up to 12 hours before a significant drop in hematocrit can be measured. Internal bleeding after cardiac catheterization is particularly dangerous due to frequent use of anticoagulant prescriptions in these clients. Educational objective:Clients with any indication of compromised airway, breathing, or circulation always take priority. Signs of retroperitoneal bleeding are subtle and the onset of back pain or hypotension after angiography always requires further assessment for internal bleeding.

The oncoming nurse is receiving report on 4 clients. Which should be the priority assessment? 1. Client who had a carotid endarterectomy that day with a blood pressure of 160/88 mm Hg 2. Client who is 1 day post bowel resection with absent bowel sounds 3. Client with a pulse of 109/min who has a history of atrial fibrillation 4. Client with pancreatitis whose total parenteral nutrition is almost finished

1. Client who had a carotid endarterectomy that day with a blood pressure of 160/88 mm Hg A carotid endarterectomy is a surgical procedure that removes atherosclerotic plaque from the carotid artery. Clients with carotid artery disease are at increased risk for transient ischemic attack and stroke. Post-surgical risks include cerebral ischemia and infarction as well as bleeding. Blood pressure is closely monitored during the first 24 hours post surgery. Hypertension may strain the surgical site and trigger hematoma formation, which can cause hemorrhage or airway obstruction. Systolic blood pressure is maintained at 100-150 mm Hg to ensure adequate cerebral perfusion and avoidance of hemorrhage or strain. Educational objective:Clients post carotid endarterectomy are at risk for cerebral ischemia and infarction as well as hemorrhage. Systolic blood pressure is maintained at 100-150 mm Hg to ensure adequate cerebral perfusion and reduce the likelihood of hematoma formation or hemorrhage at the surgical site.

The unit secretary notifies the nurse that 4 clients called the nurses' station reporting pain. Which client should the nurse assess first? 1. Client who had a foot amputation today reporting left shoulder pain radiating down the arm 2. Client who has acute pancreatitis reporting severe, continuous, penetrating abdominal pain 3. Client who has multiple myeloma reporting deep pelvic pain after walking down the hall 4. Client who has sickle cell disease reporting severe pain in the arms and upper back

1. Client who had a foot amputation today reporting left shoulder pain radiating down the arm Clients undergoing lower-extremity amputation may experience surgical site pain or phantom limb pain. However, shoulder pain radiating down the arm is an unexpected finding following an extremity amputation and may indicate myocardial ischemia. Women, older adults, or clients with diabetes may have atypical presentations (eg, indigestion, jaw/shoulder pain, dyspnea, diaphoresis, nausea/vomiting) other than chest pain during a myocardial infarction (Option 1). Educational objective:Women, older adults, or clients with diabetes may have atypical presentations (eg, indigestion, jaw/shoulder pain, dyspnea, diaphoresis, nausea/vomiting) other than chest pain during a myocardial infarction.

The nurse on the medical unit finishes receiving the change of shift hand-off report at 7:30 AM. Which assigned client should the nurse see first? 1. Client with a gastrointestinal bleed, who is receiving a unit of packed red blood cells 2. Client with an ulcerative colitis flare-up has temperature 101 F (38.3 C) and abdominal cramping. 3. Client with atrial fibrillation, on telemetry, prescribed warfarin, with an International Normalized Ratio (INR) of 3.2. 4. Client with chronic kidney disease scheduled for bedside hemodialysis at 8:00 AM, with a serum creatinine of 8.4 mg/dL (743 µmol/L).

1. Client with a gastrointestinal bleed, who is receiving a unit of packed red blood cells The nurse should check on the assigned clients in the following order: Client with the gastrointestinal bleed receiving packed red blood cells (PRBCs) - the nurse should: Check the infusion device; flow rate; and IV site, tubing, and filter Collect baseline physical assessment data against which to compare subsequent assessments Assess for complications associated with the administration of PRBCs, which include fluid overload and an acute transfusion reaction; these can occur at any time during the transfusion (Option 1) To prioritize client care, the nurse first identifies the type of problem, its associated complications, and the desired outcomes. The nurse then decides which client has the most urgent problems and needs and assesses that client first.

The nurse in a pulmonary clinic triages telephone messages left by several clients. Which client should the nurse call back first? 1. Client with a history of asthma who reports scoring a peak flow of 45% of personal best 2. Client with a pneumothorax who reports scant, clear drainage from the Heimlich valve 3. Client with active tuberculosis reporting dark red-orange urine after starting rifampin 4. Client with chronic obstructive pulmonary disease with an oxygen saturation of 90%

1. Client with a history of asthma who reports scoring a peak flow of 45% of personal best Peak expiratory flow rate (PEFR) is the peak velocity of exhaled air during forced exhalation. Clients with asthma use a peak flow meter to monitor their PEFR and determine their level of asthma control. An optimal PEFR is determined by recording the client's personal best peak flow number during 2 weeks of well-controlled asthma symptoms. Guided by their personal best, clients are taught asthma self-care using peak flow "zones": Green zone (≥80% of personal best): no intervention needed Yellow zone (50%-79% of personal best): intervention needed (eg, short-acting bronchodilator [eg, albuterol]) and/or treatment plan modification by the health care provider) Red zone (<50% of personal best): emergency medical care and short-acting bronchodilators required and hospital admission possible (Option 1) (Option 2) Clients with small, uncomplicated pneumothoraxes may have a flutter (Heimlich) valve placed but can be safely discharged home. Scant, clear pleural drainage is expected. (Option 3) Rifampin, an antibiotic used to treat tuberculosis, may cause reddish-orange body fluids (eg, urine, sweat, tears). This discoloration may stain contact lenses but is harmless. (Option 4) Clients with chronic obstructive pulmonary disease (COPD) may be chronically hypoxic and hypercapnic. An oximetry reading of ≥88% is generally acceptable in an asymptomatic client with COPD.

The nurse receives report on 4 clients. Which client should the nurse see first? 1. Client with a history of chronic hypertension exhibiting epistaxis and blurred vision 2. Client with a unilateral, pulsating headache reporting sensitivity to light. 3. Client with episodes of vomiting and abdominal cramps following a outdoor party. 4. Client with multiple sclerosis reporting blurred vision and right arm weakness.

1. Client with a history of chronic hypertension exhibiting epistaxis and blurred vision Hypertensive encephalopathy (HE) is a medical emergency caused by a sudden elevation in blood pressure (eg, hypertensive crisis) creating cerebral edema and increased intracranial pressure (ICP). Triggers of HE include an acute exacerbation of pre-existing hypertension, drug use, MAOI-tyramine interaction, head injury, and pheochromocytoma. The client may report severe headache, visual impairment, anxiety, confusion, and observed epistaxis, seizures, or coma. HE may precipitate life-threatening complications such as myocardial infarction, hemorrhagic stroke, and acute kidney injury. The client with a history of chronic hypertension and active signs of increased ICP (eg, anxiety, epistaxis) requires immediate assessment and treatment (Option 1). (Option 2) The client with a unilateral, pulsating headache has symptoms consistent with migraine. Supportive care for this client includes pain and environmental management but is not a priority over a client with HE. (Option 3) The client with abdominal cramping and vomiting may likely have food poisoning and require nonemergency supportive care, along with additional assessment. (Option 4) The client with multiple sclerosis (MS) may have recurrent exacerbations, including symptoms of blurred vision (due to optic neuritis), focal weakness, and/or sensory abnormalities (eg, numbness, tingling). MS exacerbations are treated with corticosteroids but are not immediately life-threatening.

A nurse working in the office of a health care provider receives 4 telephone messages. Which client call should the nurse return first? 1. Client with acute sinusitis prescribed azithromycin 3 days ago now has hives. 2. Client with chronic low back pain requests an oxycodone medication prescription refill 3. Client with fever of 100 F (37.7 C) has aching and itching at site after getting a flu shot yesterday. 4. Client with newly diagnosed asthma has palpitations after using an albuterol rescue inhaler.

1. Client with acute sinusitis prescribed azithromycin 3 days ago now has hives. The first phone call the nurse should return is to the client with acute sinusitis prescribed azithromycin 3 days ago and now reporting hives. Hives can be a manifestation of hypersensitivity to the macrolide antibiotic azithromycin. Anaphylaxis is a potential complication, and the drug should be discontinued immediately. Anaphylaxis poses the greatest threat to survival, so this is the priority call.

The nurse receives the change of shift report for assigned clients at 7 AM. Which client should the nurse assess first? 1. Client with change in level of consciousness who fell in the nursing home 2. Client with chronic headaches who is scheduled for an MRI at 9 AM 3. Client with chronic obstructive pulmonary disease (COPD) and pulse oximeter reading of 90% 4. Client with heart failure and 3+ pitting edema of the lower extremities.

1. Client with change in level of consciousness who fell in the nursing home Change in level of consciousness is a high priority problem as it can indicate a neurologic deficit that can be associated with a closed head injury. At the beginning of the shift, the nurse must perform a basic neurologic assessment (eg, pupil size and response, level of consciousness (LOC), mentation, speech, hand grasps). This is done to obtain the baseline data against which subsequent assessments can be compared and to assess for indicators of increased intracranial pressure (eg, change in LOC, Cushing's triad, pupillary changes). (Option 2) The client with chronic headaches is scheduled for an MRI in 2 hours. Preparation for the test is not urgent at this time; this client's assessment does not take priority. (Option 3) A pulse oximeter reading of 89%-92% is adequate and is an expected finding in a client with COPD who often relies on the hypoxemic drive to breathe. This finding is nonurgent and this client's assessment does not take priority. (Option 4) When the heart does not pump effectively, excess fluid in the body develops, blood accumulates in the veins of the legs, and fluid from the capillaries leaks into the interstitial spaces, causing pitting edema. Pitting edema in the lower extremities is an expected finding in a client with heart failure. This is a nonurgent finding and this client's assessment does not take priority.

The nurse assesses 4 clients in the emergency department. Which client should the nurse prioritize first? 1. 12-year-old with right lower quadrant abdominal pain that started in the periumbilical region 2. 14-year-old with severe scrotal pain; right testis is tender, swollen, and more elevated than the left 3. 16-year-old with sickle cell disease who has excruciating generalized body pain 4. 34-year-old with sudden-onset, right-sided flank pain radiating to the right groin

2. 14-year-old with severe scrotal pain; right testis is tender, swollen, and more elevated than the left Testicular torsion is an emergency condition in which blood flow to the testis (scrotum) has stopped. The testicle rotates and twists the spermatic cord, initially causing venous drainage obstruction that leads to swelling and severe pain. Arterial blood supply is subsequently interrupted, resulting in testicular ischemia and necrosis, which require surgical removal of the testis. The condition can be diagnosed with ultrasound. There is a short time frame in which testicular torsion can be treated (to untwist the rotation), generally 4-6 hours, making this condition a priority. Educational objective:Testicular torsion can result in testicular ischemia and necrosis from inadequate blood supply. There is a short time frame (4-6 hours) in which testicular torsion can be treated to prevent death of the testicle, and the client will most likely require emergency surgery.

The student nurse completes a clinical rotation in the emergency department. The instructor knows the student is able to prioritize care appropriately when the student visits which client first? 1. 9-year-old crying with pain and swelling of the left ankle after a popping sound while playing soccer 2. 29-year-old with neck swelling and increased pain 2 days after thyroidectomy 3. 43-year-old with blood glucose of 423 mg/dL (23.5 mmol/L), dehydration, and trace ketones in urine 4. 72-year-old who is incontinent with acute altered mental status and is yelling at staff

2. 29-year-old with neck swelling and increased pain 2 days after thyroidectomy Swelling of the neck and increased pain after a thyroidectomy may indicate hematoma formation or increased tissue inflammation. These complications have a high priority due to potential interference with airway patency. The nurse should assess for signs and symptoms of airway compromise (eg, stridor, use of accessory muscles, restlessness). Suction equipment should be available to clear the airway of secretions, and a tracheostomy tray should be at the bedside in case an emergency tracheotomy is required. Educational objective:Clients with possible airway obstruction, respiratory distress, or compromised circulation take priority for assessment and intervention. Neck swelling and increasing pain after a thyroidectomy can indicate hematoma formation or increased tissue inflammation that could lead to airway obstruction.

Multiple clients present to the emergency department. Which client should the triage nurse prioritize for diagnostic testing and definitive care? 1. 26-year-old IV drug user reporting fever and right arm redness and swelling 2. 32-year-old kidney transplant client reporting low-grade fever and generalized body pains 3. 69-year-old with diverticulosis reporting left lower quadrant pain and fever 4. 74-year-old with right knee replacement reporting fever and right knee swelling

2. 32-year-old kidney transplant client reporting low-grade fever and generalized body pains The kidney transplant client is likely immunosuppressed by steroids and anti-rejection drugs (eg, cyclosporine, tacrolimus). In general, organ transplant clients will have a blunted response to infection, such as a low-grade fever. This client has systemic symptoms, which may indicate a serious underlying infection. Some of these clients develop fulminant sepsis within a few hours if the antibiotics are delayed. As a whole, management of systemic signs/symptoms takes priority over that of localized signs/symptoms. Educational objective:Organ transplant (eg, kidney, heart, lung, liver) clients are usually on strong immunosuppressant medications. Infection in these clients can be rapidly progressive and fatal. Even a low-grade fever is a priority due to their blunted response to infection.

Four clients with different skin alterations come to the emergency department. Which client should the nurse advise that the health care provider (HCP) see first? 1. 8-year-old client who uses corticosteroid inhaler and has white patches on the tongue 2. 50-year-old client who developed a smooth, red, pinpoint rash after taking sulfa 3. 60-year-old client with pain and crusted blisters along the back 4. 70-year-old client who has erythema with a small pustule at the hair follicle

2. 50-year-old client who developed a smooth, red, pinpoint rash after taking sulfa Petechiae (small pinpoint red/purple spots on mucus membrane or skin) and purpura (irregular purplish blotches) can be a sign of blood dyscrasia, including thrombocytopenia due to a severe drug response. This systemic symptom takes priority over a more localized dermatological presentation. Educational objective:Petechiae (small circles) and purpura (blotches) are reddish/purple rashes that do not blanch. They indicate systemic blood dyscrasias and are a priority for treatment.

The primary care provider's office nurse must return telephone calls concerning 4 clients. Which client has the most emergent situation and requires an immediate call back? 1. 28-year-old woman is requesting antibiotic to be called to pharmacy due to another bladder infection 2. 55-year-old man who takes trazodone is reporting a painful erection of 3 hours duration 3. 78-year-old man with sinusitis who takes pseudoephedrine is having difficulty voiding 4. 84-year-old man with prostate cancer and spine metastasis is requesting increased pain medication

2. 55-year-old man who takes trazodone is reporting a painful erection of 3 hours duration Priapism is a prolonged, painful erection (>2 hours) caused by trapping of blood in the penile vasculature that can lead to erectile tissue hypoxia and necrosis. The condition is usually idiopathic, secondary to prescription medications (eg, sildenafil, trazodone) or a preexisting medical condition (eg, sickle cell disease, cocaine use). The nurse should return this call first as the condition is a medical emergency that can result in permanent erectile dysfunction; it requires urgent treatment in the emergency department. Educational objective:Priapism is a prolonged, painful erection not necessarily related to sexual arousal. It requires urgent treatment in the emergency department as it can lead to erectile tissue ischemia and necrosis.

The pediatric nurse receives report on 4 clients. Which client should the nurse see first? 1. A 2-month-old awaiting evaluation for possible hip dislocation; parents are at the bedside 2. A 6-year-old just returned from a bronchoscopy; a parent is at the bedside 3. A 7-year-old just returned from a noncontrast abdominal CT scan; no parents are at the bedside 4. An 11-year-old scheduled for ear surgery today; no parents are at the bedside

2. A 6-year-old just returned from a bronchoscopy; a parent is at the bedside A bronchoscopy is an invasive procedure that allows visualization of the internal air passages via a flexible tube (bronchoscope) passed through either the nose or mouth to the internal airways. Following the procedure, the client will need to be monitored for complications such as bleeding, bronchial perforation, pneumothorax, and bronchial spasm. Potential for airway compromise requires that this client be seen first. Educational objective:When deciding which client to see first, the nurse should apply the "ABC" (airway, breathing, circulation) guideline to problems that clients may have or could develop.

A nurse on a medical surgical unit receives a report on multiple clients. Based on this report, which client should the nurse assess first? 1. A client who underwent a colon resection 3 hours ago and is bleeding 2. A client who was rescued from a burning building and shows evidence of smoke inhalation 3. A client with gastroenteritis who is throwing up large amounts of vomit 4. A client with peritonitis who has pain level of "8" on a scale from 1-10

2. A client who was rescued from a burning building and shows evidence of smoke inhalation The ABC priority framework stands for airway, breathing, and circulation. This is the order in which clients should be assessed and treated. Smoke inhalation is the leading cause of death in burn clients as it causes thermal injury to the upper airways, chemical injury to the tracheobronchial tree, and carbon monoxide and/or cyanide poisoning. Clients should receive 100% oxygen to displace carbon monoxide and cyanide from hemoglobin. Intubation is indicated if there is evidence of upper airway edema with respiratory distress. An obstructed airway can lead to cardiac arrest if not treated immediately. Educational objective:The ABC priority framework is used to quickly evaluate the order in which clients should be assessed. This framework is appropriate in all settings, both emergency and non-emergency. Airway is the priority, followed by breathing, and finally circulation. Clients with acute asthma exacerbation, tension pneumothorax, anaphylaxis/angioedema, and flail chest need emergency evaluation.

All of these events are occurring at the same time. Which one should the registered nurse deal with first? 1. A health care provider (HCP) is asking to speak to the nurse 2. A visitor is seen lying on the hallway floor 3. A client is requesting an analgesic for pain rated an "8" on a 1-10 scale 4. The intravenous (IV) pump is beeping on a client who is receiving blood

2. A visitor is seen lying on the hallway floor The nurse must deal with the visitor on the floor first, either by approaching/assessing the visitor or asking another nurse/charge nurse to deal with it urgently. The visitor could have fallen and hit the head. Responsiveness must be established and the need for any life-saving measures (eg, providing respirations or compression) must be ruled out. Visitor status does not matter, this individual is on hospital property and the nurse is obligated to respond. The nurse should evaluate a person in the facility that may need life-saving measures first, regardless of whether the person is a client or a visitor (eg, vendor, employee).

The clinic nurse receives phone calls about the following 4 clients. Which call should the nurse return first? 1. A 6-month-old who received the diphtheria, tetanus, acellular pertussis vaccine 18 hours ago and developed fever of 102 F (38.9 C) and injection site redness 2. An 11-month-old with inconsolable crying and drawing up of the legs toward the abdomen 3. A 4-year-old diagnosed with right lung pneumonia 2 days ago who has chest pain when breathing deeply 4. A 15-year-old whose eyes are red and itchy and have a yellow discharge

2. An 11-month-old with inconsolable crying and drawing up of the legs toward the abdomen. Inconsolable crying and drawing up of the legs toward the abdomen in a child age 6-36 months could indicate intussusception or some other abdominal pathology (eg, appendicitis). Additional findings in intussusception include stools that have mucus and blood, often called "currant jelly" stools, and vomiting. Intussusception occurs when one section of bowel telescopes over another, which can block the passage of intestinal contents, interrupt blood supply, and cause intestinal tears (perforation). It is an emergency, and the client should be brought to the emergency department for further evaluation. Intussusception occurs when one section of bowel telescopes over another. Inconsolable crying, drawing up of the legs toward the abdomen, and "currant jelly" stools (mixed with blood and mucus) are the classic findings. It is an emergency and can lead to bowel obstruction, decreased blood supply, and perforation.

The nurse has just received shift report. Which client should be seen first? 1. Client 1 day post-op abdominal aortic aneurysm (AAA) repair who has hypoactive bowel sounds in all 4 quadrants 2. Client 2 days post-op below-the-knee amputation (BKA) who reports same-leg foot pain rated as 7 on the pain scale 3. Client with a deep venous thrombosis (DVT) who is up to use the bathroom for the second time 4. Client with Raynaud's phenomenon who reports throbbing, tingling, and swelling of fingers in both hands

2. Client 2 days post-op below-the-knee amputation (BKA) who reports same-leg foot pain rated as 7 on the pain scale The client with a BKA is experiencing phantom limb pain, pain/tingling felt in a missing portion of a limb. It is real pain that many amputees experience immediately following surgery and that sometimes becomes chronic. This client is rating the pain at a high level on the scale (7 of 10). The nurse should prioritize this client and administer prescribed opiates or other analgesics. Educational objective:Phantom limb pain should be prioritized and treated just as any other client report of pain. It is typically treated with opioids early in the post-surgical period. Chronic phantom limb pain may be treated with antidepressants, anticonvulsants, or therapies such as nerve stimulation, mirror therapy, or acupuncture.

The nurse is reviewing phone messages from clients in a surgery clinic. Which client would be the priority to call back first? 1. Client 1 week postoperative appendectomy who has not had a bowel movement in 4 days 2. Client 8 days postoperative ileostomy placement who reports nausea, vomiting, and abdominal bloating 3. Client postoperative right below-the-knee amputation who is concerned about a new tingling sensation in the right foot 4. Client with a temperature of 101.2 F (38.4 C) who is scheduled for a shoulder arthroplasty the next morning

2. Client 8 days postoperative ileostomy placement who reports nausea, vomiting, and abdominal bloating Nausea, vomiting, abdominal distension, and decreased stool production may signal a bowel obstruction or obstructed ileostomy. Bowel obstruction can lead to electrolyte disturbances, dehydration, bowel perforation and infection (eg, peritonitis), and/or tissue necrosis. It is urgent and potentially life-threatening. The client must be evaluated by the health care provider in a timely manner. Educational objective:A bowel or stoma obstruction is urgent and requires immediate medical attention. Signs of obstruction may include nausea, vomiting, abdominal pain, bloating, and decreased stool output. If left untreated, bowel obstruction can lead to electrolyte disturbances, dehydration, bowel perforation and infection (eg, peritonitis), and/or tissue necrosis.

The nurse receives the hand-off shift report on assigned clients. Which information is most concerning and prompts the nurse to assess that client first? 1. Client 1 day post colon resection who is receiving continual epidural morphine and reports severe itching 2. Client admitted 2 hours ago with gastroenteritis who has been vomiting for 36 hours and has muscle cramps and weakness 3. Client who has received IV bumetanide for 3 days for heart failure and experiences dizziness when standing up 4. Client with acute poststreptococcal glomerulonephritis who is receiving antibiotics and has gross hematuria

2. Client admitted 2 hours ago with gastroenteritis who has been vomiting for 36 hours and has muscle cramps and weakness The nurse should assess first the newly admitted client with gastroenteritis as prolonged vomiting increases the risk for dehydration, acid-base and electrolyte disturbances (eg, orthostatic hypotension, acid loss, hypokalemia, hyponatremia), and potential cardiac dysrthythmias. The client is exhibiting manifestations of hypokalemia, including muscle cramps and muscle weakness. Hypokalemia can lead to dangerous cardiac arrhythmias (Option 2). Educational objective:A newly admitted client with gastroenteritis and prolonged vomiting is at risk for acid-base, fluid, and electrolyte disturbances and dehydration related to body fluid and acid loss. The nurse should assess the client for orthostatic hypotension, manifestations of metabolic alkalosis, hypokalemia, hyponatremia, and cardiac dysrhythmias.

A nurse on the medical surgical unit has just received report. Which client should be seen first? 1. Client 1 day post femoral-popliteal bypass grafting who has an intravenous (IV) antibiotic due now 2. Client diagnosed with deep venous thrombosis (DVT) yesterday who reports some chest discomfort and cough. 3. Client with hypertension and blood pressure of 180/92 mm Hg who reports a headache 4. Client on fall precautions who just called the nurses' station for assistance in using the bathroom immediately.

2. Client diagnosed with deep venous thrombosis (DVT) yesterday who reports some chest discomfort and cough. The client with DVT who is experiencing chest discomfort and cough should be seen first. This client is exhibiting possible signs of pulmonary embolism (PE), which can be a life-threatening complication. Signs and symptoms of PE include dyspnea, hypoxemia, tachypnea, cough, chest pain, hemoptysis, tachycardia, syncope, and hemodynamic instability. The nurse should elevate the head of the bed, administer oxygen, and assess the client. The health care provider should be notified of these findings.

The nurse in a women's health clinic is returning client phone calls. Which client would be the priority to call first? 1. Client 4 days post cesarean delivery who has not had a bowel movement since surgery 2. Client who gave birth vaginally a few days ago who states, "They want to hurt my baby." 3. Client who gave birth vaginally recently who states, "I think I am experiencing incontinence." 4. Client's spouse who is concerned that the client wants to sleep instead of care for the baby

2. Client who gave birth vaginally a few days ago who states, "They want to hurt my baby." Postpartum psychosis is a rare but serious perinatal mood disorder. Research suggests a multifactorial etiology, including genetic predisposition and hormone fluctuation after birth. Risk factors include history of bipolar disorder and previous discontinuation of mood-stabilizing medications (eg, lithium). Signs appear within 2 weeks after birth and include hallucinations, delusions, paranoia, severe mood changes, delirium, and feelings that someone will harm the baby (Option 2). Postpartum psychosis is a psychiatric emergency requiring hospitalization, pharmacologic intervention, and long-term supportive care. Women exhibiting signs of postpartum psychosis are at increased risk of suicide and infanticide, and their assessment should take priority to ensure the safety of mother and baby. Educational objective:Postpartum psychosis is a rare but serious perinatal mood disorder characterized by hallucinations, paranoia, severe mood swings, and feelings of harm toward the baby. This form of psychosis is an emergency and requires immediate assessment and intervention.

The nurse receives the following information in the hand-off report. Which client should the nurse assess first? 1. Client with a paralytic ileus following a colon resection who has abdominal distension, no audible bowel sounds, and nausea 2. Client with alcoholic cirrhosis who has coffee ground nasogastric drainage, blood pressure of 90/60 mm Hg, and pulse of 110/min 3. Client with bacterial peritonitis following surgery for a ruptured appendix who is receiving IV tobramycin and has a temperature of 101 F (38.3 C) 4. Client with dysphagia and a sore throat who has a nasogastric tube to administer contrast media for an abdominal CT scan

2. Client with alcoholic cirrhosis who has coffee ground nasogastric drainage, blood pressure of 90/60 mm Hg, and pulse of 110/min The nurse should first assess the client with alcoholic cirrhosis, as this condition is associated with gastritis, clotting abnormalities (eg, thrombocytopenia, coagulation disorders), and esophageal varices that increase the risk for hemorrhage (coffee ground emesis from oxidized blood). Hypotension and tachycardia in the presence of blood loss can indicate hypovolemia. The nurse should monitor for signs of hemodynamic instability (eg, hypotension, decreased urine output, peripheral vasoconstriction, pallor) and notify the health care provider of any significant changes from baseline as immediate esophagogastroduodenoscopy is necessary to determine the bleeding site. Treatment to stop the bleeding (eg, heat probe, sclerotherapy) may be indicated. Educational objective:Clients with alcoholic cirrhosis are at increased risk for hemorrhage due to esophageal varices and coagulation disorders. Hypotension and tachycardia in the presence of blood loss can indicate hypovolemia and require immediate assessmen

Multiple clients arrive at the emergency department. Which client should the triage nurse prioritize for the health care provider to see first? 1. Client at 24 weeks gestation, showing no signs of labor, with cough productive of yellow phlegm 2. Client with dementia arriving with new-onset restlessness and confusion 3. Client with epilepsy who had a seizure earlier but is now alert and oriented 4. Client with newly deformed forearm with normal circulation and sensation, pain rated 8/10

2. Client with dementia arriving with new-onset restlessness and confusionClients with dementia are expected to be alert, with a gradual development of symptoms showing cognitive decline (eg, disorientation, forgetfulness). The sudden onset of a new behavior (eg, restlessness, confusion) may indicate delirium caused by an infection (eg, pneumonia, urinary tract infection) or another serious etiology (eg, hypoglycemia, stroke, hypoxemia) and is considered a priority (Option 2). Educational objective:Clients with dementia are expected to be in an alert but disoriented state with gradual development of symptoms. The sudden onset of a new behavior (eg, restlessness, confusion) may indicate delirium caused by an infection or another serious etiology (eg, hypoglycemia, stroke, hypoxemia) and is considered a priority.

An emergency department nurse is assigned to triage. Which client should the nurse assess first? 1. Five-year-old with a superficial leg laceration 2. Lethargic 3-month-old with diarrhea for the past 12 hours 3. Seven-year-old with a elevated temperature of 101 F (38.3 C) and hematuria 4. Seventeen-year-old with severe, acute abdominal pain

2. Lethargic 3-month-old with diarrhea for the past 12 hours Triaging clients involves decision-making about whose needs/problems are most urgent and create the greatest risk to survival. Two popular frameworks can assist the nurse in making these decisions and setting priorities. In the "First, Second, and Third" priority level framework, the priority needs progress from the first (most immediate) to the third (least) level of risk. They include: ABCs plus V - airway, breathing, circulation, and vital signs Mental status changes, acute pain, unresolved medical issues, acute elimination problems, abnormal laboratory values, and risk Longer-term issues such as health education, rest, and coping Maslow's Hierarchy of Needs is a 5-level framework in which the priority needs progress from the bottom to the top level of the pyramid. Infants have a high percentage of body water (70%-80% of body weight) and become dehydrated rapidly. This client is at increased risk for fluid and electrolyte disturbances. In addition, the infant is lethargic (listless), indicating a change in level of consciousness. This client would be assessed first (Option 2). Educational objective:The "First, Second, and Third" priority level framework is used in emergency and non-emergency settings to prioritize client needs from the highest to the lowest level of risk as follows: ABCs plus V - airway, breathing, circulation, and vital signs Mental status changes, acute pain, unresolved medical issues, acute elimination problems, abnormal laboratory values, and risks Longer-term issues such as health education, rest, and coping

The nurse receives a report on 4 clients. Which client should the nurse assess first? 1. A 29-year-old heroin user admitted for arm cellulitis 24 hours ago has abdominal cramps and is restless 2.A 34-year-old admitted with femur fracture 24 hours ago is confused and has SpO2 of 91% 3. A 65-year-old admitted with serum sodium of 125 mEq/L (125 mmol/L) 8 hours ago is confused 4. A 78-year-old admitted for urinary tract infection 6 hours ago is disoriented to time and place

2.A 34-year-old admitted with femur fracture 24 hours ago is confused and has SpO2 of 91% A fat embolism is life-threatening; therefore, the client with the femur fracture is the priority. There is a risk for the formation of fat emboli following certain fractures, typically those of the long bones and pelvis. Globules of fat leave the bone and travel through the bloodstream to the lungs, skin, and brain where they cause damage by occluding small vessels. Altered mental status will result from blocked blood vessels in the brain. An embolism to the lung would result in respiratory distress. A hallmark sign of fat emboli is the presence of petechiae (pin-sized red/purple spots) that result from small-vessel clotting and appear across the chest, in the axillae, and in the soft palate. Educational objective:Clients with pelvic or long-bone fractures are at risk for the development of life-threatening fat embolism syndrome. Respiratory distress, mental status changes, and petechiae (on chest, axillae, and soft palate) are the classic manifestations.

The nurse is triaging clients in the emergency department. Which client needs to be seen first? 1. 18-year-old female with fever, suprapubic pain, and dysuria 2. 21-year-old male with diffuse abdominal pain and a rigid abdomen 3. 64-year-old male with a pulsatile mass in the periumbilical area and back pain 4. 75-year-old with nausea, fever, and left lower quadrant pain

3. 64-year-old male with a pulsatile mass in the periumbilical area and back pain Abdominal aneurysms may present with a pulsatile mass in the periumbilical area slightly to the left of the midline. A bruit may be auscultated over the site. Back/abdominal pain can be present due to compression of nearby anatomical sites or nerve compression from an expanding/rupturing abdominal aortic aneurysm (AAA). Rupture of an abdominal aneurysm can quickly cause exsanguination and death. This client may need emergency surgery to repair the aneurysm. Educational objective:Clients with an impending aortic aneurysm rupture present with abdominal/back pain, and a pulsatile abdominal mass. They may also have a bruit. Rupture of an abdominal aneurysm can lead to exsanguination and death in minutes.

The nurse receives report on 4 clients. Which client conditions require priority assessment? 1. 34-year-old with acute pericarditis reporting left-sided chest pain that is worse with inspirations. 2. 54-year-old post right femoropopliteal bypass surgery reporting sudden-onset severe right foot pain 3. 64-year-old post hip replacement reporting sudden-onset right-sided chest pain and dyspnea 4. 70-year-old with pneumonia; rapid, irregular pulse of 140/min; and blood pressure of 130/86 mm Hg.

3. 64-year-old post hip replacement reporting sudden-onset right-sided chest pain and dyspnea Clients who are bedridden, have undergone major surgery (eg, hip or knee replacement), or are taking estrogen-containing contraceptive pills are at high risk of developing deep venous thrombosis. This condition can result in subsequent embolus and life-threatening pulmonary embolism. When blood flow is blocked to certain parts of the lung, the area can become infarcted, resulting in chest pain, shortness of breath, and cough. These clients require immediate anticoagulation to prevent extension of the blood clot. (Option 1) Clients with acute pericarditis have chest pain that is worse with inspiration/coughing and improves with leaning forward. This is an expected finding. Large pericardial effusion with resultant cardiac tamponade is more serious and is evidenced by jugular venous distension, hypotension, and muffled heart sounds. (Option 2) This client who underwent femoropopliteal surgery likely has acute occlusion of the graft and is at risk of limb loss if flow is not restored. However, loss of life is a priority over loss of limb. (Option 4) Atrial fibrillation requires assessment but is not immediately life-threatening in most situations. This client has stable blood pressure and is not the priority.

The nurse assistant reports vital signs on 4 clients. Which client should be a priority for the nurse to assess? 1. 28-year-old with infective endocarditis and heart rate of 105/min 2. 45-year-old with acute pancreatitis and sinus tachycardia of 120/min 3. 65-year-old with tachycardia of 110/min after liver biopsy 4. 74-year-old on diltiazem drip with atrial fibrillation and heart rate of 115/min

3. 65-year-old with tachycardia of 110/min after liver biopsy The liver is a highly vascular organ and bleeding is a major complication. Tachycardia is an early sign of internal hemorrhage. The 65-year-old client should be assessed first. (Option 1) Tachycardia can be caused by underlying infection and can resolve with treatment of the infection. Valve infections can require several weeks of antibiotics. This client is not the priority. (Option 2) Pancreatitis is a very painful condition and sinus tachycardia is expected. These clients are also at risk of developing complications such as third spacing of volume and require large quantities of IV fluids. This client is the second priority. (Option 4) Atrial fibrillation is commonly treated with calcium channel blockers such as diltiazem. The dosage needs to be adjusted to achieve a goal heart rate of <100/min. Atrial fibrillation is usually not immediately life-threatening.

Several clients check into the emergency department at the same time. Which client should be seen first? 1. 8-month-old with persistent vomiting and diarrhea for several days. 2. 5-year-old who has a foreign body in the right naris. 3. 7-year-old who is restless after tonsillectomy surgery 3 days ago. 4. 9-year-old with a second-degree burn to the arm who is crying inconsolably.

3. 7-year-old who is restless after tonsillectomy surgery 3 days ago. A client who is status post tonsillectomy and adenoidectomy is at risk for hemorrhage up to 14 days after surgery. Because of the location of the surgery, hemorrhage can lead to life-threatening airway compromise. The client who had a tonsillectomy 3 days ago and has signs of hemorrhage (eg, restlessness, frequent swallowing or clearing of the throat, vomiting of blood, pallor) should be seen first. The client may require surgery to cauterize the bleeding vessel(s). To decrease the risk of hemorrhage, the nurse should educate the client to limit coughing, gargling, and clearing of the throat. (Option 1) Persistent vomiting and diarrhea in an 8-month-old would warrant concern for dehydration. IV fluid resuscitation may be required. This client, with potential circulatory compromise, should be seen second. (Option 2) A foreign body lodged in the nose does not compromise the airway and therefore is not life threatening. This client should be seen last. (Option 4) A second-degree burn is not full thickness and is not considered life threatening. This client needs treatment for pain and infection prevention and should be seen third.

Four children are brought to the emergency department. Which child should be assessed first? 1. A 13-month-old who ingested an unknown quantity of children's multivitamins 2. A 15-month-old with a fever of 100.5 F (38.1 C) after being vaccinated 3. A 3-year-old with a forehead laceration and colorless nasal drainage 4. A 4-year-old with enlarged tonsillar lymph nodes who is crying in pain

3. A 3-year-old with a forehead laceration and colorless nasal drainage Clear, colorless fluid draining from the nose or ears after head trauma is suspicious for cerebrospinal fluid (CSF) leakage (Option 3). When the drainage is clear, dextrose testing can be used to determine if the drainage is CSF. However, the presence of blood would make this test unreliable as blood also contains glucose. This child is at risk for intracerebral bleeding and meningitis. Vascular compromise may occur with even minimal head trauma; therefore, the nurse should evaluate any changes in level of consciousness and temperature as well as assess the head and neck for subcutaneous bleeding. The nurse should anticipate a CT scan of the head and neck and prophylactic antibiotics. Educational objective:The child with head trauma who is leaking cerebrospinal fluid (CSF) is at risk for meningitis and intracerebral bleeding. If the drainage is clear, a dextrose test is used to determine if the drainage is CSF. The nurse should assess for signs of bleeding (eg, change in level of consciousness) and infection (eg, increased temperature) and anticipate a CT scan and prophylactic antibiotics.

The charge nurse on a telemetry unit is training a new registered nurse (RN). The charge nurse assists the new RN in prioritizing assessments of multiple clients. Which client should be assessed first? 1. A client in atrial fibrillation with an International Normalized Ratio of 4.0 who has a warfarin dose due 2. A client who had coronary artery bypass surgery 2 days ago, has a temperature of 99 F (37.2 C), and has a dose of vancomycin due 3. A client who is 48 hours post myocardial infarction, is experiencing ventricular bigeminy, and has a dose of amiodarone due 4. A client whose NPO status has just been discontinued after 8 hours and who is anxious to drink fluids

3. A client who is 48 hours post myocardial infarction, is experiencing ventricular bigeminy, and has a dose of amiodarone due Ventricular bigeminy is a rhythm in which every other heartbeat is a premature ventricular contraction (PVC). PVCs in the presence of a myocardial infarction (MI) indicate ventricular irritability and increase the risk for a more serious dysrhythmia (eg, ventricular tachycardia, ventricular fibrillation). Possible causes of ventricular bigeminy include electrolyte imbalances and ischemia. After assessing the client's vital signs, the nurse should assess potassium and magnesium levels and apical-radial pulse, administer the scheduled amiodarone, and notify the health care provider (HCP). Educational objective:Ventricular bigeminy in a client following a myocardial infarction indicates risk for developing ventricular tachycardia or ventricular fibrillation, both potentially life-threatening dysrhythmias. The nurse should assess the client's vital signs, electrolytes, and apical-radial pulse, and notify the health care provider.

The nurse has been assigned to the staging area of a disaster response to an act of terrorism that deployed a caustic chemical agent. A client comes to the triage area with burns to the skin, severe pain, and visible chemical residue. What is the nurse's priority action? 1. Assess skin to determine severity of burns and wounds. 2. Assign client to a cot with other similarly triaged clients. 3. Assist the client to the designated showering area. 4. Prepare supplies to establish intravenous access.

3. Assist the client to the designated showering area. In the event of a disaster involving the release of hazardous substances (eg, bioterrorism, chemical warfare agents), decontamination is vital to limit injury to the client and prevent exposure to other clients and staff (Option 3). Disaster triage areas typically include a decontamination area (eg, showering station, cleansing station) that should be used to eliminate any residual hazardous materials and debris from the client. In addition to bathing the client under copious amounts of running water, the nurse should remove any clothing or personal effects and discard them appropriately to further eliminate sources of hazardous material. After clients are appropriately decontaminated, necessary activities of care (eg, full assessment, diagnosis, intervention/treatment, planning) can be safely performed. (Options 1 and 4) As long as the chemical remains on the skin, further injury may occur. The priority remains to remove the chemical agent through decontamination methods. In addition, residual chemical on the client may be spread to staff caring for the client and cause injury. (Option 2) Triaging mass casualties in a disaster may involve grouping similarly triaged clients by type and severity of illness/injury; however, this should not be done before the client is decontaminated as grouping presents the risk of exposure to other clients and staff.

Which client does the nurse assess first after receiving the morning report? 1. Client has cellulitis from injecting heroin; threatening to leave against medical advice if more morphine is not given right now 2. Client is 1 day postoperative colectomy; night nurse medicated client with morphine 15 minutes ago 3. Client is 2 days postoperative open gastric bypass surgery; now reporting nausea and dry heaving 4. Client is 3 days postoperative total knee replacement; waiting to be discharged

3. Client is 2 days postoperative open gastric bypass surgery; now reporting nausea and dry heaving Vomiting and dry heaving place increased mechanical stress on surgical wound edges and increase the risk for wound dehiscence and evisceration. Obese clients who have undergone extensive abdominal surgery are especially vulnerable. Therefore, the nurse should first assess the client who is nauseated and dry heaving and administer an antiemetic medication (Option 3). Educational objective:Postoperative nausea, vomiting, and dry heaving should be treated with antiemetic medication as soon as possible as it increases a client's risk for wound dehiscence and evisceration (medical emergency).

A nurse receives information in a change of shift report. Which client is the priority? 1. Client prescribed levothyroxine to treat hypothyroidism who reports nervousness, sweating, and insomnia 2. Client receiving intravenous antibiotics for bacterial pneumonia who reports cough with blood-tinged sputum 3. Client with a femoral external fixator who has a temperature of 100.9 F (38.3 C) and redness and pain around the pin sites 4. Client with chronic pancreatitis who reports upper abdominal pain and voluminous, foul-smelling, fatty stools

3. Client with a femoral external fixator who has a temperature of 100.9 F (38.3 C) and redness and pain around the pin sites External fixation stabilizes bone by inserting metal pins through skin into the bone and attaching them to a metal rod outside the skin. The nurse should assess this client first as any signs and symptoms of an infection (eg, low-grade fever, drainage, pain, redness, swelling) warrant immediate evaluation and treatment. Localized pin tract infection can progress to osteomyelitis, a serious bone infection that requires long-term treatment with antibiotics. Educational objective:An external fixator stabilizes bone by inserting metal pins through skin into the bone and attaching them to a metal rod outside the skin. Signs and symptoms of infection (eg, fever, drainage, pain, redness, swelling) warrant immediate evaluation and treatment with antibiotics as these can progress to osteomyelitis, a serious bone infection.

The charge nurse in an intensive care unit is rounding and reviewing hemodynamic data for clients in the unit. Which client requires immediate intervention? 1. Client who is septic due to pneumonia with central venous pressure of 6 mm Hg 2. Client who recently underwent a coronary artery bypass graft with cardiac output of 5 L/min 3. Client with a gastrointestinal bleed and mean arterial pressure of 58 mm Hg 4. Client with an adrenal gland tumor and blood pressure of 168/95 mm Hg

3. Client with a gastrointestinal bleed and mean arterial pressure of 58 mm Hg Central venous pressure (CVP) 2-8 mm Hg Measure of right ventricular preload (pressure in the ventricle after filling) Indicates fluid volume status Mean arterial pressure (MAP) 70-105 mm Hg Average arterial pressure Indicates perfusion of organs & tissues MAP = (SBP + [2 × DBP])/3 Cardiac output (CO) 4-8 L/min Volume of blood ejected by heart Indicates cardiac function. Mean arterial pressure (MAP) is the average pressure within the arteries. Compared to blood pressure alone, MAP is a more precise measurement of the body's ability to perfuse organs and tissues. MAP of at least 60 mm Hg is required to adequately perfuse vital organs, but MAP ≥70 mm Hg is optimal. Without intervention, MAP <60 mm Hg may progress to ischemia, organ damage, and death (Option 3). Common causes of low MAP include hypovolemia (eg, hemorrhage, severe dehydration), sepsis, and heart failure. Typical interventions include replacing intravascular volume (eg, IV fluids, albumin, blood products) and administering IV medications such as vasopressors (eg, norepinephrine, vasopressin) to induce peripheral vasoconstriction and inotropes (eg, dobutamine) to increase cardiac contractility. MAP is calculated automatically by intra-arterial blood pressure monitors and some noninvasive blood pressure machines. MAP can also be calculated manually using the systolic blood pressure (SBP) and diastolic blood pressure (DBP) readings and the following formula: MAP = (SBP + [2 × DBP])/3.

The nurse receives morning report on 4 clients who were admitted 24 hours earlier for injuries incurred in motor vehicle collisions. Which client should the nurse assess first? 1. Client with a fractured pelvis who has a large area of ecchymosis and bruising over the pelvic region 2. Client with a fractured tibia and leg cast who has pink skin under the cast edge and swollen toes 3. Client with a lung contusion who has an oxygen saturation of 90% and severe inspiratory chest pain 4. Client with a pneumothorax and a chest tube who has intermittent bubbling in the water-seal chamber

3. Client with a lung contusion who has an oxygen saturation of 90% and severe inspiratory chest pain A lung contusion (bruised lung) caused by blunt force can occur when an individual's chest hits a car steering wheel. This injury is potentially life-threatening because bleeding into the lung and alveolar collapse can lead to acute respiratory distress syndrome. Clients should be monitored for 24-48 hours as symptoms (eg, dyspnea, tachypnea, tachycardia) are usually absent initially but develop as the bruise worsens. Inspiratory chest pain can lead to hypoventilation, and an oxygen saturation of 90% (normal: 95%-100%) indicates hypoxemia. Therefore, the nurse should assess this client with lung contusion first and then notify the health care provider as immediate interventions to decrease the work of breathing and improve gas exchange (eg, supplemental oxygen, medications, ventilatory support) may be necessary. Educational objective:A lung contusion (bruised lung) caused by a blunt force to the chest is potentially life-threatening. Clients should be monitored for 24-48 hours after the injury for manifestations of hypoventilation and hypoxemia as these are usually absent initially but develop as the bruise worsens.

The nurse receives report on 4 clients. Which client should the nurse assess first? 1. Client with end-stage renal disease receiving hemodialysis who reports fever with chills and nausea 2. Client taking ibuprofen for ankylosing spondylitis who reports black-colored stools 3. Client with altered mental status who is not following commands starts vomiting 4. Client with acute diverticulitis receiving antibiotics who reports increasing abdominal pain

3. Client with altered mental status who is not following commands starts vomiting This client with altered mental status and not following commands is at risk for aspiration and airway compromise from vomiting. This client should be assessed first; the client needs to be placed in the lateral position with head elevated and may need emergent intubation if airway cannot be protected. Educational objective:A client with altered mental status and not following commands is at risk for aspiration and airway compromise from vomiting.

Which client should the nurse assess first after receiving the hand-off morning report? 1. Client 1 day postoperative exploratory abdominal laparotomy who has a nasogastric tube and absent bowel sounds in 4 quadrants. 2. Client with a peripherally inserted central catheter who has a 5-cm (2-in) increase in external catheter length since yesterday. 3. Client with chronic diarrhea from malabsorption syndrome who is receiving 10% dextrose in water via a peripheral IV line. 4. Client with type 2 diabetes mellitus who is scheduled for discharge and has a hemoglobin A1C level of 9%.

3. Client with chronic diarrhea from malabsorption syndrome who is receiving 10% dextrose in water via a peripheral IV line. A peripherally inserted central catheter (PICC) is inserted via the basilic or cephalic veins into the superior vena cava. The nurse should measure and document the external length of the PICC during dressing changes. A change in the length of the external portion of the catheter can indicate migration of the tip of the catheter from its original position. The nurse should hold IV fluids and medications, secure the PICC to prevent further movement, and notify the health care provider for x-ray evaluation of catheter tip placement. (Option 1) After abdominal surgery, placement of a nasogastric tube to decompress the stomach and the absence of bowel sounds for 24-72 hours due to postoperative paralytic ileus would be expected. (Option 3) The client with malabsorption syndrome is unable to digest and absorb nutrients by the gastrointestinal tract. Peripheral parenteral nutrition with 10% dextrose is an expected treatment. (Option 4) The hemoglobin A1C level of 9% is above the recommended level (ie, <7%) and reflects inadequate glycemic control, which can be expected in a client with diabetes mellitus.

A nurse in the emergency department assesses 4 clients. Based on the laboratory results, which client is the highest priority for treatment? 1. Client with abdominal pain, respirations 28/min, and blood alcohol level 80 mg/dL (0.08 mg% [17.4 mmol/L]) 2. Client with chronic obstructive pulmonary disease, pH 7.34, pO2 86 mm Hg (11.5 kPa), pCO2 48 mm Hg (6.4 kPa), and HCO3 30 mEq/L (30 mmol/L) 3. Client with dull headache, pulse oximeter reading 95%, and serum carboxyhemoglobin level 20% 4. Client with emesis of 100 mL coffee-ground gastric contents and serum hemoglobin 15 g/dL (150 g/L)

3. Client with dull headache, pulse oximeter reading 95%, and serum carboxyhemoglobin level 20% Carbon monoxide (CO) is a toxic inhalant that enters the blood and binds more readily to hemoglobin than oxygen does. When hemoglobin is saturated with CO, the pulse oximeter reading is falsely normal as conventional devices detect saturated hemoglobin only and cannot differentiate between CO and oxygen. The diagnosis of CO poisoning is often missed in the emergency department because symptoms are nonspecific (eg, headache, dizziness, fatigue, nausea, dyspnea) and the pulse oximeter reading often appears within normal limits. A serum carboxyhemoglobin test is needed to confirm the diagnosis. Normal values are <5% in nonsmokers and slightly higher (<10%) in smokers. This client with CO poisoning is the highest priority for treatment and requires immediate administration of 100% oxygen to increase the rate at which CO dissipates from the blood to prevent tissue hypoxia and severe hypoxemia (Option 3). Clients with carbon monoxide (CO) poisoning have elevated serum carboxyhemoglobin levels (normal <5% in nonsmokers) and false-normal pulse oximeter readings. They require immediate administration of 100% oxygen to correct hypoxemia and eliminate toxic CO from the blood.

The emergency department nurse receives report on 4 clients. Which client should the nurse assess first? 1. Client with acute cholecystitis who reports right shoulder pain. 2. Client with gastroparesis who reports persistent nausea and vomiting. 3. Client with intractable lower back pain who reports new urinary incontinence 4. Client with Ménière disease who reports increasing tinnitus.

3. Client with intractable lower back pain who reports new urinary incontinence Cauda equina syndrome is a disorder that results from injury to the lumbosacral nerve roots (L4-L5) causing motor and sensory deficits. The main symptoms are severe lower back pain, inability to walk, saddle anesthesia (ie, motor weakness/loss of sensation to inner thighs and buttocks), and bowel and bladder incontinence (late sign). Cauda equina syndrome is a medical emergency. Treatment requires urgent reduction of pressure on the spinal nerves to prevent permanent damage. This client displays characteristic late signs of cauda equine syndrome (i.e incontinence); therefore, the nurse should this client first.

The emergency department nurse is assigned to triage. Which client should the nurse assess first? 1. Client who smokes who has intermittent leg pain that is worse with walking and eases with rest 2. Client with diabetes mellitus who has a temperature of 100.7 F (38.2 C) 3. Client with leg swelling and calf pain who was on a 15-hour flight 2 days ago 4. Client with pain, edema, and redness in the leg following a dog bite 1 hour ago

3. Client with leg swelling and calf pain who was on a 15-hour flight 2 days ago Life-threatening physiological problems (eg, airway, breathing, circulation) are the highest priority followed by less threatening problems (eg, pain, potential for infection). Unilateral edema and calf pain could be signs of a deep venous thrombosis (DVT), a high-priority circulation problem in which a lower-extremity clot may dislodge, travel, and cause life-threatening complications (eg, pulmonary embolism). Prolonged immobilization (eg, airplane travel, bed rest) increases the risk for DVT. Educational objective:Unilateral lower-extremity edema and calf pain in a client who has recently been immobile for a prolonged period (eg, bed rest, long flight) may indicate the presence of a deep venous thrombosis (DVT). A DVT is a high-priority circulation problem as the clot can dislodge, travel, and cause life-threatening complications (eg, pulmonary embolism).

The nurse receives handoff report on 4 clients. Which client should the nurse assess first? 1. Client with chronic anxiety disorder taking buspirone and diphenhydramine who has a dry mouth 2. Client with chronic heart failure taking metoprolol and lisinopril who has dizziness when standing up 3. Client with major depressive disorder taking phenelzine and pseudoephedrine who has a headache 4. Clint with type 2 diabetes taking metformin and lovastatin who has stomach upset and nausea

3. Client with major depressive disorder taking phenelzine and pseudoephedrine who has a headache Monoamine oxidase inhibitors (MAOIs) (eg, isocarboxazid [Marplan], phenelzine [Nardil], tranylcypromine [Parnate]) are often prescribed for depression. MAOIs deactivate an enzyme that breaks down norepinephrine, dopamine, and serotonin. Increased levels of norepinephrine can increase blood pressure. This increased norepinephrine level combined with certain medications that also increase blood pressure (eg, nasal decongestants [eg, pseudoephedrine, oxymetazoline]) may lead to hypertensive crisis, a complication that can result in hemorrhagic stroke and death. Headache is a common, early symptom of hypertensive crisis that should be evaluated immediately in clients taking MAOIs (Option 3). Educational objective:Monoamine oxidase inhibitors (MAOIs) such as phenelzine (Nardil) are prescribed for the management of depression. A client who reports headache and has taken an MAOI and a nasal decongestant (eg, pseudoephedrine) should be evaluated immediately for hypertensive crisis.

The nurse receives handoff of care report on four clients. Which client should the nurse assess first? 1. Client with Graves disease who has a heart rate of 110/min and blood pressure of 122/85 mm Hg. 2. Client with pneumonia and temperature of 101.8 F (38.8 C) who is unable to receive antibiotics due to an occluded IV catheter. 3. Client with sickle cell disease whose pain rating has increased from 3 to 9 on a scale of 0-10 over the last hour. 4. Client with type 2 diabetes whose fingerstick glucose level is 220 mg/dL (12.2 mmol/L)

3. Client with sickle cell disease whose pain rating has increased from 3 to 9 on a scale of 0-10 over the last hour. Sickle cell disease (SCD) is a group of hereditary blood disorders characterized by RBCs that become sickle-shaped, rather than oval, when deoxygenated. Sickled RBCs are prone to clump together and obstruct blood vessels, particularly during periods of dehydration or stress (eg, infection), which causes a sickle cell crisis (SCC). When caring for clients with SCD, it is critical to observe for indicators of SCC. Severe, acute pain is a common symptom of SCC due to impaired capillary blood flow (ie, vasoocclusion) and tissue ischemia. Without prompt recognition and intervention, vasoocclusion may lead to irreversible tissue damage (eg, myocardial infarction, limb necrosis, stroke) and death (Option 3). (Option 1) New or worsening tachycardia in clients with Graves disease, a common cause of hyperthyroidism, may be an indicator of acute thyrotoxicosis (thyroid storm). However, tachycardia can also occur normally in clients with hyperthyroidism and is less concerning in the presence of other normal vital signs. This client requires further assessment but is not the priority. (Options 2 and 4) Administration of antibiotics (after changing the occluded catheter) and correction of hyperglycemia can be safely addressed after resolving potentially life-threatening complications.

The nurse prepares to administer the prescribed 8 AM medications to 4 clients. The nurse should administer medication to which client first? 1. Client 2 days postoperative abdominal surgery who is to receive enoxaparin for venous thromboembolism prophylaxis. 2. Client with hypertension who has a blood pressure of 196/98 mm Hg and is to receive IV hydralazine. 3. Client with suspected sepsis who has a temperature of 102.3 F (39.1 C) and is to receive an initial dose of IV ceftazidime. 4. Client with type 2 diabetes mellitus and blood sugar of 500 mg/dL (27.8 mmol/L) who is to receive subcutaneous regular insulin and insulin glargine.

3. Client with suspected sepsis who has a temperature of 102.3 F (39.1 C) and is to receive an initial dose of IV ceftazidime. Sepsis is a condition associated with a serious infection in the bloodstream. Evidence-based guidelines recommend the early administration of antibiotic therapy to reduce mortality. Cultures should be obtained quickly and antibiotics administered as soon as possible. Failure to treat early sepsis can lead to septic shock (persistent hypotension) and multiorgan dysfunction syndrome. (Option 1) Subcutaneous venous thromboembolism prophylaxis with enoxaparin following abdominal surgery is usually prescribed once every 24 hours, so administration is not urgent. (Option 2) This client has high blood pressure and needs treatment. However, this is not immediately life-threatening. If nausea, vomiting, and headache were also present, then the client would likely have hypertensive urgency or encephalopathy and need to be treated emergently. (Option 4) This client has high blood glucose and needs to be treated. However, it is not immediately life-threatening unless the client has hyperosmolar hyperglycemic syndrome or diabetic ketoacidosis.

The nurse reviews the assigned clients' laboratory results and medication administration records. Which finding is the highest priority for the nurse to follow-up with the health care provider? 1. Gram-negative infection and positive blood cultures in a client prescribed tobramycin 2. Serum B-type natriuretic peptide (BNP) 650 pg/mL (650 ng/L) in a client prescribed furosemide 3. Serum potassium 5.7 mEq/L (5.7 mmol/L) in a client prescribed spironolactone 4. Serum sodium 132 mEq/L (132 mmol/L) in a client prescribed IV normal saline solution at 175 mL/hr

3. Serum potassium 5.7 mEq/L (5.7 mmol/L) in a client prescribed spironolactone This client who was prescribed spironolactone (Aldactone), a potassium-sparing diuretic that counteracts the potassium loss caused by other diuretics, has high serum potassium (normal 3.5-5.0 mEq/L [3.5-5.0 mmol/L]). The continuation of this medication puts this client at risk for life-threatening hyperkalemia-induced cardiac dysrhythmias. This finding is of highest priority for the nurse to follow-up with the health care provider (HCP). Educational objective:A nurse should monitor clients receiving spironolactone, a potassium-sparing diuretic, for hyperkalemia. The continuation of this medication in the presence of an elevated serum potassium level puts a client at risk for life-threatening cardiac dysrhythmias.

The nurse in the student health center at a large university received student telephone messages. Which return telephone call is the priority? 1. Student who feels well but is concerned about possible exposure to viral meningitis at an off-campus party 2 weeks ago 2. Student who was in a baseball tournament yesterday and is now unable to lift the arm past the waist due to extreme shoulder pain. 3. Student who woke from a deep sleep in an unfamiliar dormitory room and is panic-stricken with severe vaginal pain. 4. Student with itchy, cottage-cheese-like vaginal discharge who is sexually active and worried about having a sexually transmitted infection.

3. Student who woke from a deep sleep in an unfamiliar dormitory room and is panic-stricken with severe vaginal pain. Sexual assault is a medical emergency requiring a thorough head-to-toe physical examination by a specially trained health care provider (eg, sexual assault nurse examiner) to identify and treat injuries. A student reporting potential sexual assault (eg, waking in a strange room, signs of physical assault) should be instructed to seek immediate medical attention and not to bathe, brush teeth, urinate, douche, or change clothes. These activities can delay a medical-forensic examination and interfere with evidence retrieval and preservation. Many college and university health centers have providers for this specialized physical and emotional care, but if they do not, the student should be referred to a local hospital emergency department. (Option 1) The student should be reassured that although contracting viral meningitis is possible, it is unlikely as the incubation period is 1 week and typical symptoms include headache, fever, photophobia, and stiff neck. (Option 2) The student most likely has a rotator cuff injury and should be instructed to rest, apply ice and heat, take a nonsteroidal anti-inflammatory drug, and seek medical evaluation. (Option 4) The student's vaginal discharge is most likely related to a candidiasis (ie, yeast) fungal infection. The student should be instructed to seek medical attention and refrain from sexual activity until testing for sexually transmitted diseases is completed.

The nurse has just received report on the telemetry unit. Which client should be seen first? 1. The client 2 days post coronary artery bypass; the night shift nurse reports diminished lung sounds in the bases 2. The client 4 hours post permanent pacemaker insertion that is 100% paced 3. The client with a deep venous thrombosis (DVT) who has a dose of enoxaparin due 4. The client with coronary artery disease and atrial fibrillation who has a dose of warfarin due

3. The client with a deep venous thrombosis (DVT) who has a dose of enoxaparin due The client with a DVT should be seen first. This client has a current clot and is at risk for development of a pulmonary embolism (PE) if the clot mobilizes. Enoxaparin is a low-molecular-weight heparin given as an anticoagulant and should not be delayed. The nurse should monitor the client for signs and symptoms of bleeding and clinical manifestations of a PE such as dyspnea, chest pain, or hypoxemia. Educational objective:The nurse should prioritize the administration of an anticoagulant to the client with a DVT as this client is at risk for clot mobilization and development of a PE.

The nurse in the emergency department receives report on 4 clients. Which client should be seen first? 1. 5-year-old with an accidental epinephrine auto-injector stick and a heart rate of 124/min 2. 7-year-old who is crying, has vaginal lacerations and bruising, and has a heart rate of 118/min. 3. 10-year-old with a large, draining abscess on the left buttock and a temperature of 101.2 F (38.4 C) 4. 14-year-old who is lethargic after playing a football game and has a temperature of 104.1 F (40.1 C)

4. 14-year-old who is lethargic after playing a football game and has a temperature of 104.1 F (40.1 C Heatstroke occurs when excessive environmental heat exposure and/or overexertion (eg, athletics) cause hyperthermia and depletion of fluid and electrolytes (sweating, increased respirations), specifically sodium. Eventually, hypothalamic thermoregulation fails and sweat production stops, causing a rapid elevation of core temperature. Symptoms include: Temperature ≥104 F (40 C) Hot, dry skin Hemodynamic instability (tachycardia, hypotension) Altered mental status/neurological symptoms (confusion, lethargy, coma) Risk for permanent neurological injury or death from heatstroke is related directly to the degree and duration of hyperthermia. Treatment involves stabilization of ABCs and rapid cooling interventions (eg, cool water immersion, cool IV fluid infusion). Antipyretics are ineffective as hyperthermia is unrelated to the inflammatory process (infection). (Option 1) Epinephrine auto-injectors (eg, EpiPen) for emergency treatment of allergic reactions can be accidentally injected, potentially causing adverse effects related to adrenergic activation (eg, tachycardia and hypertension). This client requires monitoring and supportive care (eg, antihypertensive medications). (Option 2) A child with vaginal lacerations requires evaluation for possible sexual abuse (ie, physical examination, evidence collection, mandatory reporting). This client needs treatment but is not the priority. (Option 3) An abscess requires treatment with antibiotics and, possibly, surgical intervention. However, this client is presently stable and not the priority.

The nurse receives report on 4 clients. Which client should be seen first? 1. 10-month-old with audible congestion and mucus-producing cough 2. 10-year-old with an active nose bleed who is applying pressure 3. 12-year-old with urinary frequency and burning, and fever 4. 15-year-old with painful right hip, fever, and limited range of motion

4. 15-year-old with painful right hip, fever, and limited range of motion This client is exhibiting localized (eg, pain, limited range of motion) and systemic infection symptoms (eg, fever), which may indicate septic arthritis. Possible causes include recent surgery, injections, trauma, or spread from adjacent infection (eg, cellulitis). A septic hip is considered a surgical emergency. The hip joint is prone to develop avascular necrosis (eg, damage to the femoral head) from compromised blood supply due to infection or injury (eg, fracture). This can result in sequelae that are significant in both the short term (eg, sepsis, death) and long term (eg, joint destruction). Management includes culturing synovial fluid and blood, giving antibiotics, and debriding the infected joint. Educational objective:Pain, limited range of motion, and fever indicate joint infection (septic joint). A septic hip is a surgical emergency as impaired blood supply may lead to permanent joint destruction, sepsis, and/or death. The nurse should expect management to include cultures, antibiotics, and surgical debridement.

A nurse is assigned to multiple clients. Which client should the nurse reassess as a priority after administering IV morphine for pain relief? 1. 22-year-old with sickle cell anemia admitted for acute pain crisis 2. 26-year-old with pneumonia reporting sharp right side chest pain on deep inspiration 3. 55-year-old who is 1-day postoperative bowel resection reporting pain at the incision site 4. 67-year-old with obstructive sleep apnea reporting pain at the fractured right tibia

4. 67-year-old with obstructive sleep apnea reporting pain at the fractured right tibia Obstructive sleep apnea (OSA) is characterized by partial or complete airway obstruction that occurs from relaxation of the pharyngeal muscles, airway closure, and lack of airflow. This leads to repeated episodes of apnea (≥10 seconds) and hypopnea (≤50% of normal ventilation), resulting in hypoxemia and hypercapnia. Administration of general anesthesia or sedating medications (eg, opioids and benzodiazepines) can exacerbate OSA by decreasing pharyngeal muscle tone and increasing airway closure even further. Therefore, being on continuous positive airway pressure (CPAP) is very important in these clients, especially during sleep. The nurse should assess level of consciousness, lung sounds, vital signs, and pulse oximeter readings, and then compare these with the client's baseline measurements. The nurse should also continue to monitor respiratory status as IV morphine peaks in 20 minutes and has a duration of 3-4 hours. Educational objective:Clients with obstructive sleep apnea (OSA) who are receiving sedatives or narcotics require frequent monitoring as these can exacerbate OSA symptoms. These clients are at increased risk for respiratory complications such as oversedation, respiratory depression, hypoxia, and hypercapnia.

The office nurse receives 4 telephone messages. Which client should the nurse call back first? 1. 28-year-old female client who fell on ice yesterday and has low back pain and spasm 2. 42-year-old male client who developed sharp, burning leg pain radiating from buttock to knee after lifting heavy weights 3. 65-year-old female client 10 days post spinal fusion who has increased persistent back pain and fever of 101.2 F (38.4 C) 4. 70-year-old male client with peripheral vascular disease who has acute-onset abdominal pain radiating to the low back

4. 70-year-old male client with peripheral vascular disease who has acute-onset abdominal pain radiating to the low back An abdominal aortic aneurysm (AAA) is a blood-filled bulge in the abdominal aorta caused by weakening in the vessel wall due to increased pressure. Risk factors include male sex, age >65, coronary artery and peripheral vascular diseases, hypertension, and family and smoking history. AAA dissection (blood leakage into a vessel tear) or rupture may manifest as acute-onset abdominal pain radiating to the back and is typically associated with symptoms of hemorrhagic shock (eg, decreased systolic pressure; increased, weak pulses; pallor). This client's symptoms could indicate impending rupture, which can lead to life-threatening vascular hemorrhage. Educational objective:Clients with atherosclerotic vascular disease in one system (eg, stroke, peripheral vascular disease) are more likely to have undiagnosed, underlying atherosclerotic vascular disease in other areas (eg, coronary disease, aortic aneurysm). Evaluation and treatment of a suspected abdominal aortic aneurysm dissection or rupture are critical as a vascular bleed is potentially life-threatening.

he nurse is performing beginning of shift assessments on 4 clients. Which client's assessment findings should the nurse immediately report to the health care provider? 1. 36-year-old client with alcohol withdrawal who is receiving IV lorazepam every 3 hours for agitation and has a blood pressure of 190/98 mm Hg 2. 56-year-old client with stable angina who has chest and jaw pain relieved with nitroglycerin, blood pressure of 98/70 mm Hg, and dizziness when getting up 3. 60-year-old client with chronic kidney disease who has a blood pressure of 168/88 mm Hg, serum creatinine level of 5.0 mg/dL (442 µmol/L), and reports nausea and itching 4. 82-year-old client with a pressure injury who has a change in mental status, temperature of 96.4 F (35.8 C), pulse of 110/min, and blood pressure of 96/72 mm Hg

4. 82-year-old client with a pressure injury who has a change in mental status, temperature of 96.4 F (35.8 C), pulse of 110/min, and blood pressure of 96/72 mm Hg Sepsis is an exaggerated response to an infection in the bloodstream, often originating from a local infection (eg, pressure injury), that results in potentially life-threatening organ impairment. Older adults are at increased risk for sepsis due to normal, age-related decreases in the immune and inflammatory response (ie, immunosenescence). Because of altered immune function, older adults often do not develop typical signs of infection (eg, fever, leukocytosis). Instead, nurses must observe for and immediately report atypical indicators of infection (eg, altered mental status, hypothermia, leukopenia) because early identification and intervention reduce mortality (Option 4). (Option 1) Chronic use of central nervous system depressants (eg, alcohol) causes a reflexive increase in catecholamine production (eg, epinephrine). During alcohol withdrawal, hypertension, agitation, and anxiety occur because catecholamine production is no longer inhibited. (Option 2) Clients with stable angina (ie, chest and jaw pain relieved with sublingual nitroglycerin) often experience orthostatic hypotension, an adverse effect of nitrate drugs. (Option 3) Clients with chronic kidney disease (CKD) commonly experience nausea and pruritus due to buildup of nitrogenous wastes in the blood (ie, azotemia). Elevated creatinine is an expected finding in CKD. Hypertension does require intervention by the nurse after management of infection and sepsis.

The clinic nurse receives multiple phone calls regarding client status. Which call should the nurse return first? 1. A 3-year-old diagnosed with Kawasaki disease 2 weeks ago developed skin peeling 2. A 7-year-old has had a high fever, cough, and sore throat for the past 2 days 3. A 14-year-old with asthma controlled with a corticosteroid inhaler developed oral white patches 4. A 16-year-old diagnosed with mononucleosis 10 days ago reports abdominal pain

4. A 16-year-old diagnosed with mononucleosis 10 days ago reports abdominal pain Infectious mononucleosis is caused by the Epstein-Barr virus. Spleen rupture is a serious complication of infectious mononucleosis that can occur spontaneously and present with sudden onset of left upper quadrant abdominal pain. The 16-year-old client should be taken to the emergency department for close monitoring of hemoglobin levels, supportive care to prevent hemorrhagic shock, and possible surgery. Educational objective:A serious complication of infectious mononucleosis is a ruptured spleen, which would cause sudden onset of severe abdominal pain in the left upper quadrant.

The nurse is caring for pediatric clients in an acute care setting. Which of these clients should the nurse see first? 1. A 1-day post tubal myringotomy client with purulent tympanic drainage 2. A 4-day post valve replacement client with a temperature of 102 F (38.8 C) and petechiae 3. A 10-day-old client with a patent ductus arteriosus who has a continuous murmur 4. A 6-year-old client with epiglottitis who is drooling and has a severe sore throat

4. A 6-year-old client with epiglottitis who is drooling and has a severe sore throat Epiglottitis refers to inflammation of the epiglottis that may result in life-threatening airway obstruction. Haemophilus influenzae type b (Hib) was the most common cause, but the incidence has decreased dramatically with widespread Hib vaccination. Symptoms begin with abrupt onset of high-grade fever and a severe sore throat, followed by the 4 Ds: drooling, dysphonia, dysphagia, and distressed airway (inspiratory stridor). Children are typically toxic-appearing and may be "tripoding" (sitting up and leaning forward) with inspiratory stridor. This client should be assessed first due to being unstable from an airway disorder. The client has a respiratory illness and is drooling, which indicates respiratory distress (Option 4). (Option 1) Purulent drainage is expected in a 1-day post tubal myringotomy client. The drainage shows the procedure was successful. (Option 2) A fever of 102 F (38.8 C) and petechiae in a post valve replacement client could indicate endocarditis. This client would need to be seen second, as this is a circulation disorder. (Option 3) A murmur is expected in a client with a patent ductus arteriosus. It is best heard at the left infraclavicular area and has a continuous "machinery" quality.

The nurse receives report for clients on the neurology floor. Which client is important for the nurse to assess first? 1. A 25-year-old client with multiple sclerosis who had bladder incontinence last night 2. A 37-year-old client with Guillain-Barré syndrome who has "0" deep tendon patellar reflexes 3. A 58-year-old client with Parkinson disease who is drooling 4. A 78-year-old client with dementia who has new-onset agitation and confusion

4. A 78-year-old client with dementia who has new-onset agitation and confusion New-onset agitation is a change in mental status for someone with dementia and requires assessment. It is possible for a client to develop delirium in addition to dementia. Delirium is a sign of a different issue, such as worsening infection/condition, fluid and electrolyte imbalance, or drug-drug interaction. Educational objective:A change in level of consciousness from baseline is concerning even when the client has dementia.

The registered nurse is performing triage at a pediatric emergency department. Which client should be seen first? 1. Child with history of cystic fibrosis (CF) has new yellow sputum and cough today 2. Crying infant with fiery redness and moist papules in the diaper region 3. Grade-school client with swollen ecchymotic ankle after playing basketball 4. Adolescent client with abdominal pain, heart rate 120/min, and respirations 26/min

4. Adolescent client with abdominal pain, heart rate 120/min, and respirations 26/min The client with abdominal pain has abnormal vital signs, which is a sign of a systemic condition. Adult criteria apply to adolescent clients in terms of physiological signs/symptoms. A pulse of 120/min signals dehydration and this client's respirations are above normal. This is the most serious acuity. Educational objective:In prioritization, the severity of ABC is more important than absolute order. As a result, a severe "C" client comes before a stable "B" client. The priority principle is to take "life before limb" in this order. When care must be prioritized, young children do not automatically go first.

A nurse receives the following change-of-shift morning report for the assigned clients. Which client should the nurse assess first? 1. Client 1 day postoperative with fine inspiratory crackles in the lung bases on auscultation who is to ambulate for the first time this morning. 2. Client 1 day postoperative with serosanguineous drainage on the abdominal surgical dressing and temperature of 100.4 F (38 C). 3. Client 2 days postoperative receiving intermittent epidural bolus analgesia who now reports incisional pain as a 4 on a 0-10 scale. 4. Client 2 days postoperative receiving fluids infusing at 125 mL/hr, with a Foley catheter and urine output of 100 mL during the last 8 hours.

4. Client 2 days postoperative receiving fluids infusing at 125 mL/hr, with a Foley catheter and urine output of 100 mL during the last 8 hours. Low urine output in the first 24 hours after surgery is expected due to fluid restriction before surgery, hormonal responses to the physiological stress of surgery, and fluid losses during surgery. Urine output should increase by the second postoperative day. The total intravenous intake for this client for the last 24 hours is 3000 mL (125 mL x 24 hours). The urine output for an adult of average weight (154 lb [70 kg]) should be at least 0.5 mL/kg/hr (ie, 70 kg x 0.5 mL/hr = 35 mL/hr x 8 hours = 280 mL in 8 hours). This client is becoming oliguric (100 mL in 8 hours). The nurse should take vital signs to assess for hypotension, which can result in decreased renal perfusion, prerenal failure, and acute kidney injury, and assess for bladder distension and Foley catheter patency before notifying the health care provider (HCP). This assessment takes priority due to the potential for prerenal failure and acute kidney injury. (Option 1) Auscultating fine crackles in the base of the lungs is common 1 day postoperative and is usually related to atelectasis caused by hypoventilation, especially in a client who has not yet ambulated. This assessment does not take priority. (Option 2) A surgical dressing with serosanguineous drainage and a low-grade temperature related to the inflammatory response due to stress of surgery are expected findings 1 day postoperative. This assessment does not take priority. (Option 3) Epidural analgesia (eg, continual, intermittent bolus, patient-controlled) provides excellent long-lasting postoperative pain control as it distributes the opioid medication directly to the opioid receptors in the spinal cord through a catheter placed in the epidural space. The nurse will perform a pain assessment and report to the anesthesia HCP, as a bolus of pain medication through the catheter may be needed. This assessment does not take priority.

The nurse receives a report on the assigned clients for the shift. Which client should the nurse assess first? 1. 1-day postoperative client with lower abdominal pain and no urine output for 6 hours 2. An elderly client with blood pressure 190/88 mm Hg who is asymptomatic 3. Client with hepatitis C virus who has alanine aminotransferase/aspartate aminotransferase (ALT/AST) values 4 times the normal value 4. Client who underwent thyroidectomy yesterday and now has positive Trousseau's sign

4. Client who underwent thyroidectomy yesterday and now has positive Trousseau's sign The prioritization principle is that systemic symptoms are more important than local symptoms. Trousseau's sign (carpal spasm with blood pressure cuff inflation) indicates hypocalcemia. This is a known risk after a thyroidectomy as the parathyroid gland can be inadvertently removed during the surgery due to its very small size. Acute hypocalcemia can cause tetany, laryngeal stridor, seizures, and cardiac dysrhythmias. Assessing this client is a priority over pain or expected findings. Educational objective:Acute hypocalcemia can be life-threatening due to seizures, tetany (laryngeal stridor), and cardiac arrhythmias. Inadvertent removal of the parathyroid gland can result in rapid development of severe hypocalcemia.

The nurse receives report on 4 clients. Which client should the nurse assess first? 1. Client 1 day postoperative receiving patient-controlled analgesia with morphine who reports itching and nausea. 2. Client receiving maintenance IV normal saline solution with labeled tubing indicating that tubing was changed 48 hours ago. 3. Client with a pulmonary embolus receiving continuous IV heparin infusion and warfarin who has an International Normalized Ratio of 1.9. 4. Client with a resistant bacterial infection receiving IV vancomycin who reports discomfort at the peripheral IV site.

4. Client with a resistant bacterial infection receiving IV vancomycin who reports discomfort at the peripheral IV site. Phlebitis is an inflammation of a vein. Common manifestations include pain, swelling, warmth at the site, and redness extending along the vein. Causes include irritating drugs (eg, vancomycin), catheter movement within the vein (eg, inadequate stabilization), or bacteria (eg, poor aseptic technique). If signs of phlebitis are present, immediate removal of the catheter is necessary as phlebitis can lead to thrombophlebitis and emboli or a bloodstream infection. (Option 1) Itching (pruritus) and nausea are common and expected adverse effects associated with the administration of opioids. Histamine blockers, such as diphenhydramine (Benadryl) or hydroxyzine (Atarax), and an antiemetic, such as ondansetron (Zofran), can provide relief. (Option 2) Evidence-based practice guidelines recommend changing a continuous IV peripheral tubing administration set no earlier than every 72 hours unless it becomes contaminated (institutional policies and procedures vary). Intermittent infusions and hypertonic solutions (eg, total parenteral nutrition, propofol, blood) require more frequent changes (eg, 4-24 hours) due to increased risk for infection. (Option 3) Parenteral and oral anticoagulant medications are administered concurrently until the International Normalized Ratio reaches a therapeutic range of 2-3, at which time the heparin infusion can be discontinued and the warfarin continued. This therapy is expected.

After making initial rounds on all the assigned clients by 8:00 AM, which client should the nurse care for first? 1. Client 1-day postoperative who was medicated with tramadol 50 mg orally 1.5 hours ago. 2. Client 1-day postoperative with pink colored urine after transurethral resection of the prostate (TURP). 3. Client scheduled for discharge today who needs instruction on how to change a sterile dressing. 4. Client with adenocarcinoma scheduled for a lobectomy at 9:00 AM who was restless and awake all night.

4. Client with adenocarcinoma scheduled for a lobectomy at 9:00 AM who was restless and awake all night. The nurse should care for the client with adenocarcinoma scheduled for a lobectomy at 9:00 AM first. Not being able to sleep the night before surgery is a common manifestation of anxiety and fear; these emotions can negatively affect recovery. For this reason, it is important to identify and listen to the client's concerns (eg, diagnosis of cancer, fear of death, pain, anesthesia), teach the client about what to expect following surgery (eg, pain control, tubes, intensive care environment), and provide emotional support to help alleviate the fear and anxiety. The nurse can provide for the physical preparation of the client and complete the preoperative checklist as well. (Option 1) Tramadol (Ultram) 50-100 mg orally every 4-6 hours is prescribed for moderate-to-severe postoperative pain. The client was medicated 1.5 hours ago. The drug onset is 1 hour, the peak is 2-3 hours, and the duration is 4-6 hours. Therefore, this client is most likely stable at this time. The nurse does not need to care for this client first. (Option 2) Moderate-to-mild bleeding 1-2 days after undergoing TURP is expected. Pink urine is a normal assessment finding. The nurse does not need to care for this client first. (Option 3) The client who is scheduled for discharge is stable and needs teaching about how to change the surgical dressing. The nurse does not need to care for this client first.

The nurse is planning to assess 4 assigned clients. Which client situation is of greatest concern and warrants immediate assessment? 1. Client scheduled for hemodialysis in an hour who has a serum creatinine level of 9.2 mg/dL (813 µmol/L) and refuses to take prescribed medications 2. Client taking diphenhydramine for urticaria who reports difficulty urinating and increasing lower abdominal pain 3. Client with an infected venous leg ulcer prescribed IV vancomycin who has a dressing saturated with yellow, foul-smelling drainage 4. Client with an inguinal hernia who rates abdominal pain as 10 on a 0-10 scale and reports bloating, nausea, and vomiting

4. Client with an inguinal hernia who rates abdominal pain as 10 on a 0-10 scale and reports bloating, nausea, and vomiting An inguinal hernia is a protrusion of intraperitoneal contents (eg, bowel, tissue) through a weakened area in the abdominal wall (eg, groin, scrotum). Clients may experience dull pain exacerbated by exercise or straining and a palpable bulge on assessment. A hernia is reducible if the organs can be returned to the peritoneal cavity by applying pressure to the bulge; and incarcerated, if they cannot. Manifestations of a mechanical bowel obstruction (eg, pain, distension, nausea, vomiting) are caused by compressed loops of bowel incarcerated by the hernia. Subsequent bowel ischemia and strangulation can lead to infection and death. Immediate evaluation and urgent surgical intervention are critical. Educational objective:Intestinal obstruction and strangulated bowel are life-threatening complications associated with an incarcerated hernia and require immediate evaluation and urgent surgical intervention.

The nurse receives report on 4 clients. Which client should the nurse assess first? 1. Client with cellulitis of the right foot, medicated with hydromorphone IV 1 hour ago, reports pain as 6 on a scale of 0-10 (3%) 2. Client with chronic kidney disease with hemoglobin 8 g/dL (80 g/L) and hematocrit 24% (0.24) reports shortness of breath with activity (17%) 3. Client with heart failure exacerbation and a large pleural effusion with serum sodium of 132 mEq/L (132 mmol/L) reports headache (46%) 4. Client with pneumonia and asthma, who just received nebulized albuterol, now appears to be resting after a sudden decrease in wheezing (32%)

4. Client with pneumonia and asthma, who just received nebulized albuterol, now appears to be resting after a sudden decrease in wheezing (32%) After receiving report, the nurse should assess clients with airway and respiratory problems first (eg, airway, breathing, circulation). The client with asthma may have silent chest (sudden decrease in wheezing related to severe decrease in airflow) and require immediate attention. The client with pneumonia and asthma is at risk for problems related to airway management and should be assessed first. Clients with symptomatic asthma will receive inhaled beta agonists (eg, albuterol); however, even after medication, it is a priority to assess this client's lung sounds, work of breathing, and level of consciousness to determine respiratory status. A sudden decrease in wheezing may signal the development of silent chest, where airflow is rapidly reduced due to increased bronchial constriction. This scenario can quickly progress to status asthmaticus, respiratory failure, unconsciousness, and death.

The night nurse receives the hand-off report on assigned clients. Which client should the nurse assess first? 1. Client with acute kidney injury scheduled for hemodialysis in the morning has a urine output of 200 mL for the past 8 hours 2. Client with an indwelling urinary catheter who is 1-day postoperative prostatectomy reports severe bladder spasms 3. Client with an ureteral stent placed this morning after laser lithotripsy reports burning on urination and hematuria 4. Client with spinal cord injury (above T6) requiring intermittent catheterization reports a throbbing headache and nausea

4. Client with spinal cord injury (above T6) requiring intermittent catheterization reports a throbbing headache and nausea Autonomic dysreflexia (hyperreflexia) can occur in any individual with a spinal cord injury at or above T6. The condition causes an exaggerated sympathetic nervous system response resulting in uncontrolled hypertension. Common triggers include bladder or rectum distention and pressure ulcers. Characteristic manifestations include acute onset of throbbing headache, nausea, and blurred vision; hypertension and bradycardia; and diaphoresis and skin flushing above the level of the injury. It is a medical emergency that requires immediate intervention (eg, bladder catheterization) to remove the precipitating trigger. (Option 1) Oliguria (<0.5 mL/kg/hr or <280 mL in 8 hours for an adult of average weight [154 lb or 70 kg]) is an expected finding in a client with kidney injury scheduled for hemodialysis; this client assessment is not the priority. (Option 2) Bladder spasms are an expected finding in a client with an indwelling urinary catheter following a prostatectomy. The nurse can administer prescribed analgesic and antispasmodic drugs (eg, Belladonna-opium suppositories, oxybutynin) to alleviate discomfort. However, this client assessment is not the priority. (Option 3) Laser lithotripsy breaks down a large stone into small fragments to ease stone elimination. The ureteral stent maintains ureter patency by preventing obstruction caused by edema or stone fragments. Burning on urination and hematuria are common expected side effects associated with this procedure. This client assessment is not the priority.

Four clients come to the emergency department and are assessed by the triage nurse. Which client should be prioritized for more definitive care? 1. Client with history of gout who has severe pain in the right foot 2. Client with history of migraines reporting headache and photophobia 3. Client with severe epigastric pain radiating to the back after an alcohol binge 4. Client with sudden onset of the "worst headache of my life"

4. Client with sudden onset of the "worst headache of my life" A subarachnoid intercerebral bleed is an emergent, serious presentation often described as the "worst headache of my life." The onset is usually abrupt due to rupture of the vessel. Subarachnoid hemorrhage has a high mortality from recurrent bleeding and is the highest priority presentation. Educational objective:The "worst headache of my life" are classic descriptions by a client with a subarachnoid hemorrhage and require emergent evaluation.

Which client should the nurse assess first? 1. Client with atrial fibrillation with a new prescription for warfarin 2. Client with chronic obstructive pulmonary disease with an oxygen saturation of 91% 3. Client with postoperative pain rated 8 out of 10 4. Client with third-degree heart block with a pulse of 42/min

4. Client with third-degree heart block with a pulse of 42/min Third-degree atrioventricular (AV) block, or complete heart block, occurs when electrical conduction from the atria to the ventricles is blocked, causing decreased cardiac output (eg, dizziness, syncope, mental status changes, heart failure, hypotension, bradycardia). The client with third-degree AV block is a high priority, as the client may decompensate to cardiogenic shock and even periods of asystole (Option 4). Treatment includes administration of atropine and temporary pacing (eg, transcutaneous) until a permanent pacemaker can be placed. (Option 1) Atrial fibrillation puts clients at risk for development of atrial thrombi, which can embolize and cause a stroke. Administration of warfarin (a long-term anticoagulant) is important to prevent thrombus formation; however, symptomatic third-degree AV block is a higher priority. (Option 2) Clients with chronic obstructive pulmonary disease often have pulse oximetry readings that are lower than normal (eg, 91%). The goal in this client population is to keep the oxygen saturation 88-92%. (Option 3) The client experiencing severe postoperative pain should be assessed for surgical complications (eg, infection), and the pain should be treated (eg, with hydrocodone). However, severe pain does not take priority over third-degree AV block. The nurse can see the client as soon as possible or ask another nurse for help.

The nurse is working in a busy emergency department and is assigned 4 clients. Which client should the nurse see first? 1. Client receiving cyclophosphamide reporting bloody urine 2. Client who reports severe nausea and vomiting after chemotherapy 3. Client with an elbow abrasion and a lip laceration possibly requiring sutures 4. Homeless client who appears drowsy with a temperature of 95 F (35 C)

4. Homeless client who appears drowsy with a temperature of 95 F (35 C) The client with a low body temperature and drowsiness needs immediate intervention to prevent and/or reverse physiologic compromise. Signs of hypothermia include a core temperature (eg, rectal) less than 95 F (35 C), mental status changes, shivering, and impaired coordination. Alterations in acid-base balance, coagulation values, and cardiac function may also occur. Hypothermia can lead to cardiac and respiratory failure and coma (Option 4). Homeless clients are at higher risk for hypothermia from exposure to the elements, infections, and poorly managed chronic health conditions. The nurse should anticipate a workup for sepsis and various types of shock, in addition to environmental factors, while addressing this client's hypothermia. (Option 1) Hemorrhagic cystitis (eg, bladder inflammation) is a well-known complication of cyclophosphamide (immunosuppressant and chemotherapy agent). The client is instructed to drink plenty of fluids. This client may need IV hydration and other preventive measures (eg, mesna therapy). Bleeding is usually minimal and occasionally requires a blood transfusion, but is rarely life threatening. (Option 2) Nausea and vomiting are expected side effects after chemotherapy. This client needs IV access established (if the chemotherapy port cannot be accessed) to address the nausea and prevent dehydration. However, this client would not take priority. (Option 3) This client needs to have all wounds cleaned and irrigated prior to suturing, but would not take priority.

The nurse reviews the most current laboratory results for assigned clients. Which finding is the highest priority for the nurse to report to the health care provider? 1. CD4+ cell count of 500/mm3 (0.5 × 109/L) in a client with oral candidiasis and HIV who is receiving fluconazole orally 2. Hemoglobin A1C of 7.3% in a client with community-acquired pneumonia and type 2 diabetes who is receiving IV levofloxacin. 3. Platelet count of 148,000/mm3 (148 × 109/L) in a client with a venous thrombosis who is receiving a continuous heparin infusion. 4. Serum glucose of 68 mg/dL (3.8 mmol/L) in a client with radiation enteritis who is receiving total parenteral nutrition.

4. Serum glucose of 68 mg/dL (3.8 mmol/L) in a client with radiation enteritis who is receiving total parenteral nutrition. The American Society for Parenteral and Enteral Support (ASPEN) recommends 140-180 mg/dL (7.8-10.0 mmol/L) as the target range for glucose control in clients receiving nutritional support. Hypoglycemia (serum glucose <70 mg/dL [3.9 mmol/L]) can be due to slowing the rate of the infusion. Although it occurs less frequently in clients receiving total parenteral nutrition (TPN) than hyperglycemia (serum glucose >180 mg/dL [10.0 mmol/L]) does, hypoglycemia can lead to life-threatening complications (eg, seizures, nervous system dysfunction). Therefore, the serum glucose of 68 mg/dL (3.8 mmol/L) is the laboratory finding of highest priority for the nurse to report to the health care provider (HCP). (Option 1) A CD4+ cell count of 500/mm3 (0.5 × 109/L) in a client with HIV who is receiving oral fluconazole (Diflucan) to treat oral candidiasis is within normal limits (500-1,200/mm3 [0.5-1.2 × 109/L]) and does not need to be reported to the HCP. (Option 2) A hemoglobin A1C (HbA1c) of 7.3% in a client with type 2 diabetes who is receiving IV levofloxacin to treat pneumonia is not exceptionally high; the recommended goal is <7%. A bacterial infection causes physiologic stress and increased serum glucose. This increases insulin requirements but would not affect the current HbA1c level, as it reflects glucose control over a 2-3 month period. Therefore, this finding is not the highest priority for the nurse to report to the HCP. (Option 3) Heparin can lead to thrombocytopenia. However, a platelet count of 148,000/mm3 (148 × 109/L) is just below normal limits (150,000-400,000/mm3 [150-400 × 109/L]). Therefore, this finding does not need to be reported to the HCP.

The nurse has received report on the following pediatric clients. Which action should the nurse perform first? 1. Administer water enema to the 2-year-old with intussusception who has severe abdominal pain 2. Call the health care provider about the 4-year-old with leukemia who has a low-grade fever 3. Measure head circumference of the 3-month-old with ventriculoperitoneal shunt placement 4. Suction the 3-month-old with bronchiolitis who is irritable and scheduled for a feeding

4. Suction the 3-month-old with bronchiolitis who is irritable and scheduled for a feeding Bronchiolitis is a lower respiratory tract infection most commonly caused by respiratory syncytial virus. It causes inflammation and obstruction of the lower respiratory tract. Depending on the severity of the infection, infants with bronchiolitis can experience mild cold symptoms or respiratory distress. The infant will have difficulty feeding and can become dehydrated. Medical care is supportive and includes suctioning, oxygen, and hydration. The infant with irritability may be exhibiting signs of hypoxia. The nurse should see this client first. Educational objective:A client with bronchiolitis will require frequent suctioning, especially before feeding. The nurse should use the ABC (airway, breathing, circulation) guidelines and see this client first.

The emergency department nurse is triaging clients. Which client is a priority for diagnostic workup and definitive care? 1. Fell, twisting the right knee; heard a "pop" 2. History of glomerulonephritis; has "iced tea"-colored urine 3. Pain 10/10 in reddened eye; wears contact lens 4. Took a handful of amitriptyline tablets after a fight with spouse

4. Took a handful of amitriptyline tablets after a fight with spouse Overdoses are generally a priority due to the unpredictability of dosing and client response. Specifically, the tricyclic antidepressant amitriptyline (Elavil) is lethal if taken in overdose, especially if consumed with alcohol. It is estimated that 70%-80% of clients with tricyclic antidepressant overdose die before reaching the hospital. Amitriptyline was historically used for depression; it is now used for insomnia and neuropathic pain. Death results from serious cardiac arrhythmias. Educational objective:Priority is given to clients with overdose, especially those who have taken tricyclic antidepressants as they are at risk for lethal cardiovascular arrhythmias.

Four clients come to the emergency department (ED). Which client should the triage registered nurse (RN) assign as highest priority for definitive diagnosis and treatment? 1. Client with chronic obstructive pulmonary disease (COPD) with yellow expectoration and an oxygen saturation of 91% 2. Healthy child with new-onset fiery-red rash on cheeks and the "flu" 3. Middle-aged client with vaginal itching and white, curd like discharge 4. Unconscious elderly client who smells of alcohol and has fresh vomit on the face.

4. Unconscious elderly client who smells of alcohol and has fresh vomit on the face. Although this elderly client may be unconscious due to intoxication, vomit and decreased level of consciousness place this client at risk for airway obstruction. Treatment of this client is a priority, and measures must be taken to protect the airway (eg, rescue position, head of bed elevation, intubation).

Unlicensed assistive personnel report 4 situations to the registered nurse. Which situation warrants the nurse's intervention first? 1. Room 1: Client on a 24-hour urine collection had a specimen discarded by mistake 2. Room 2: Client and family request clergy to administer last rites 3. Room 3: Puncture-resistant sharps disposal container on the wall is full 4. Room 4: Client with diabetes mellitus has an 8 AM fingerstick glucose of 80 mg/dL (4.4 mmol/L)

Health care workers are required to abide by Occupational Safety and Health Administration standards and regulations to reduce work-related injuries (eg, sharps) and exposure to bloodborne pathogens (eg, HIV, hepatitis B and C). A sharps disposal container should not be overfilled and should be replaced on a regular basis to reduce the risk for a needle stick during disposal. Educational objective:Prevention of injury and safety in the workplace should be a priority when the nurse is delegating, planning, or providing nursing care.

The nurse reviews the laboratory results for 4 assigned clients. Which result is most important for the nurse to report to the primary health care provider? 1. Client with atrial fibrillation receiving warfarin for 7 days with an International Normalized Ratio (INR) of 1.3 2. Client with chronic bronchitis who has a hematocrit of 56% [0.56] and hemoglobin of 19 g/dL (190 g/L) 3. Client with Clostridium difficile infection who has a white blood cell count of 15,000/mm3 (15 × 109/L) 4. Client with sepsis receiving gentamycin who has a creatinine of 0.6 mg/dL (53 µmol/L)

The client with atrial fibrillation is at increased risk for the development of atrial thrombi due to blood stasis, which can embolize and lead to an ischemic brain attack. The INR (normal 0.75-1.25) is a measurement used to assess and monitor coagulation status in clients receiving anticoagulation therapy. The therapeutic INR level for a client receiving warfarin (Coumadin) to treat atrial fibrillation is 2-3. The subtherapeutic INR of 1.3 is the most important result to report to the health care provider (HCP) as the client is at increased risk for a stroke and dose adjustment is needed. (Option 2) A client with chronic obstructive pulmonary disease and chronic bronchitis has chronic alveolar hypoxia, which stimulates erythropoiesis (red blood cell production) and leads to polycythemia (hematocrit >53% [0.53] in males, >46% [0.46] in females; hemoglobin >17.5 g/dL [175 g/L] in males, >16 g/dL [160 g/L] in females). Increased hematocrit and hemoglobin are expected in this client and are not the most important results to report to the HCP. (Option 3) Leukocytosis (white blood cells >11,000/mm3 [11 × 109/L]) is expected in a client with C difficile infection and is not the most important result to report to the HCP. (Option 4) A client receiving gentamycin, a nephrotoxic drug, has a normal creatinine level (0.6-1.3 mg/dL [53-115 µmol/L), which is not the most important result to report to the HCP.