prioritization

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(10%) 2. Client with a fractured tibia and leg cast who has pink skin under the cast edge and swollen toes(16%) 3. Client with a lung contusion who has an oxygen saturation of 90% and severe inspiratory chest pain(60%) 4. Client with a pneumothorax and a chest tube who has intermittent bubbling in the water-seal chamber(12%)

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. (Option 1) Ecchymosis and bruising due to trauma would be expected. (Option 2) Skin irritation under rough cast edges is common; oval strips of adhesive or moleskin tape applied to the cast edge (petals) can provide padding. Neurovascular assessment and elevation are necessary as swelling can indicate venous compression. This is not a life-threatening priority. (Option 4) In a client with a pneumothorax, intermittent bubbling in the water-seal chamber consistent with respirations (due to air escaping from the pleural space) is expected until the lung has fully expanded.

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(77%) 2. 11-year-old with viral meningitis requesting pain medication for headache(10%) 3. Male child scheduled for surgery for intussusception who has reddish mucoid stool(6%) 4. Male child with hemophilia who has hemarthrosis and is receiving desmopressin(5%)

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 has received report on 4 clients at the start of the shift. Which client should the nurse assess first? 1. Client in body cast who reports abdominal pain and bloating(40%) 2. Client post mastectomy who reports numbness at the surgical site(7%) 3. Client post neck dissection who reports difficulty chewing(41%) 4. Client receiving antibiotics who reports new-onset vaginal itching(10%)

Clients with large body casts are at risk for bowel obstruction, which can be caused by decreased peristalsis or by cast syndrome (ie, superior mesenteric artery [SMA] syndrome). Cast syndrome is a rare complication of an overly tight cast that involves compression of the duodenum by the SMA. Immobilization of clients in body casts decreases peristalsisand may cause a paralytic ileus (ie, bowel obstruction). If severe, bowel obstruction can result in bowel ischemia. The nurse should immediately report symptoms of a bowel obstruction (eg, abdominal pain, distension, nausea, vomiting) (Option 1). If cast syndrome is suspected, the cast may have a window cut out over the abdomen to relieve pressure. (Option 2) After a mastectomy, tingling, numbness, and itching are common at the incision site. A client experiencing this likely requires reassurance, but this is a lower priority. (Option 3) Chewing may be difficult after a neck dissection due to tissue trauma. A client experiencing this may require a diet change, but this is a lower priority. (Option 4) Antibiotics disrupt normal vaginal flora and may precipitate the development of a yeast infection, which presents with vaginal discharge and itching. A client reporting this needs to be assessed, but this is a lower priority.

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(22%) 2. 26-year-old with pneumonia reporting sharp right side chest pain on deep inspiration(39%) 3. 55-year-old who is 1-day postoperative bowel resection reporting pain at the incision site(5%) 4. 67-year-old with obstructive sleep apnea reporting pain at the fractured right tibia(32%)

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. (Option 1) This 22-year-old with sickle cell crisis will likely need large doses of narcotics due to increased tolerance from prior use. The nurse needs to assess the pain and any complications from narcotic use. However, this is not the first priority. (Option 2) This 26-year-old has pneumonia and right side pain on deep inspiration, which indicate pleuritic pain (inflammation of the 2 layers of pleura). Pleuritic pain is an expected finding associated with pneumonia and is not the priority assessment. (Option 3) Moderate to severe postoperative pain and lack of audible bowel sounds (due to general anesthesia, bowel manipulation, and opioid drugs) are expected findings 1 day after major abdominal surgery. This client is not the priority.

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(34%) 2. 4-month-old who has painless, new-onset, bilateral testicular swelling(16%) 3. 8-month-old who ingested a bottle of children's bubble soap 30 minutes ago(46%) 4. 2-year-old with fever, runny nose, cough, and sore throat for the past 2 days(2%)

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. (Option 2) This infant has signs of a hydrocele, a fluid-filled testicular mass. Most hydroceles resolve before the first birthday and are not a medical emergency. (Option 3) Children's bubble soap is non-toxic. As a precaution, the poison control center should be contacted, but this is not a priority over a newborn with fever. (Option 4) This child likely has an upper respiratory viral or bacterial (streptococcal) infection. This localized infection is not a priority over generalized/bloodstream infection (neonatal sepsis).

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(3%) 2. 21-year-old male with diffuse abdominal pain and a rigid abdomen(41%) 3. 64-year-old male with a pulsatile mass in the periumbilical area and back pain(45%) 4. 75-year-old with nausea, fever, and left lower quadrant pain(9%)

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. (Option 1) Fever, suprapubic pain, and dysuria in a young female client indicate urinary tract infection, a much lower priority than AAA. (Option 2) Diffuse pain and a rigid abdomen indicate peritonitis (eg, from ruptured appendicitis or perforated bowel). Peritonitis is also an emergency but not immediately life-threatening like AAA rupture. This client should be seen next after the client with AAA. (Option 4) Fever and left lower quadrant pain in an elderly client are usually due to acute diverticulitis. The client needs bowel rest, antibiotics, and IV fluids. This is a lower priority than AAA and peritonitis.

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(27%) 2. Client receiving maintenance IV normal saline solution with labeled tubing indicating that tubing was changed 48 hours ago(1%) 3. Client with a pulmonary embolus receiving continuous IV heparin infusion and warfarin who has an International Normalized Ratio of 1.9(23%) 4. Client with a resistant bacterial infection receiving IV vancomycin who reports discomfort at the peripheral IV site(47%)

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.

The nurse in the pediatric clinic is triaging telephone messages. The nurse should call the parent of which child first? 1. 2-year-old with bilateral tympanostomy tubes who has a small piece of plastic in the right outer ear(18%) 2. 4-year-old post adenotonsillectomy who is now reporting ear pain(53%) 3. 6-year-old with strep throat who needs a note to return to school 24 hours after starting antibiotics(3%) 4. 7-year-old 5 days post tonsillectomy who wants to return to soccer practice today(24%)

The child with a recent tonsillectomy is at highest safety risk. Postoperative hemorrhage from tonsillectomy is uncommon but may occur up to 14 days after surgery. During the healing process, white scabs will form at the surgical sites. Sloughing then occurs approximately 7 days after the procedure, increasing the risk for bleeding. Caregivers should be taught to observe for signs of bleeding (eg, frequent swallowing or throat clearing). The child may also experience increased pain. The nurse should instruct this parent that the child should not resume strenuous activity or contact sports for at least 7-14 days post surgery. (Option 1) Tympanostomy tubes or grommets are pressure-equalizing tubes placed in the tympanic membrane to facilitate drainage of middle ear fluid (eg, for eustachian tube dysfunction or recurrent otitis media with effusion). One of this child's tubes has most likely fallen out of the eardrum. No immediate intervention is required; however, the health care provider should be notified. (Option 2) Clients often report ear pain (otalgia) following adenotonsillectomy due to irritation of the 9th cranial nerve (glossopharyngeal) in the throat, causing referred pain to the ears. This is a normal, expected finding. (Option 3) The contagious period for strep throat starts at the onset of symptoms and lasts through the first 24 hours of beginning antibiotic treatment. This client is able to return to activities and does not require an immediate call back.

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%)

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. (Option 1) Unresolved pain should be reassessed by the nurse, but a client with a possible respiratory emergency takes priority. (Option 2) Shortness of breath with activity is expected in a client with chronic kidney disease and anemia. This is most likely due to lack of erythropoiesis (red blood cell production) related to decreased erythropoietin production in the kidney and does not require immediate attention. (Option 3) Dilutional hyponatremia (<135 mEq/L (135 mmol/L) is expected in a client with heart failure due to excess fluid and can cause fatigue and headache. Change in level of consciousness and seizures can occur with sodium <120 mEq/L (120 mmol/L), but a borderline low level does not require immediate attention.

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(63%) 2. Client who is 1 day post bowel resection with absent bowel sounds(11%) 3. Client with a pulse of 109/min who has a history of atrial fibrillation(14%) 4. Client with pancreatitis whose total parenteral nutrition is almost finished(10%)

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. (Option 2) It can take 24-48 hours for peristalsis to return after bowel surgery due to manipulation of the bowels and anesthesia. This client should be monitored for return of bowel function and should be assessed last. (Option 3) Clients with atrial fibrillation may experience tachycardia and irregular heart rhythm even with treatment. This client should be assessed after the client with an endarterectomy. (Option 4) Total parenteral nutrition (TPN) should never be discontinued abruptly (due to the risk for hypoglycemia). This client should be seen third so that TPN is not interrupted.

The nurse receives report on 4 clients. Which client should the nurse see first? 1. Client admitted 12 hours ago with acute asthma exacerbation who needs a dose of IV methylprednisolone(21%) 2. Client admitted 2 days ago with congestive heart failure who is reporting shortness of breath and had an extra dose of furosemide prescribed recently(55%) 3. Client admitted with intestinal obstruction who is reporting abdominal pain and distention and needs nasogastric tube placement(17%) 4. Client who had cardiac valve surgery 8 days ago but was readmitted with a sternal wound infection and needs antibiotics and a dressing change(6%)

Although it is not a STAT order, an extra dose of furosemide was prescribed for the client with congestive heart failure. The shortness of breath is most likely due to a change in fluid status, and this client is the priority. Furosemide works immediately and should be given urgently. (Option 1) Even though this client has asthma exacerbation, steroids (methylprednisolone [Solu-Medrol]) do not show their effect immediately. These drugs control underlying inflammation but take several hours/days to take effect. Bronchodilators such as albuterol or ipratropium work immediately. (Option 3) This client has intestinal obstruction and needs nasogastric tube placement. However, this is not a priority over a client with heart failure. (Option 4) This client with a sternal wound infection needs a dressing change and an antibiotic. Although this localized infection is important, it is not the priority.

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%(4%) 2. Healthy child with new-onset fiery-red rash on cheeks and the "flu"(25%) 3. Middle-aged client with vaginal itching and white, curdlike discharge(0%) 4. Unconscious elderly client who smells of alcohol and has fresh vomit on the face(69%)

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). (Option 1) Bacterial infection is the most common cause of COPD exacerbation. Although clients with COPD usually have cough and sputum, it becomes a concern when the sputum changes in color, consistency, or volume. This client needs antibiotics. The goal pulse oximetry reading for COPD is typically 90%-93% as many clients with COPD rely on their hypoxemic drive to breathe. Therefore, this client is stable and can wait until the unconscious elderly client is treated. (Option 2) This child has fifth disease ("slapped-cheek," erythema infectiosum), which is caused by parvovirus B19. Symptoms, in addition to a bright-red facial rash, include fever and general flulike symptoms. It is harmless unless the client has a hemolytic/immunodeficient condition. Pregnant women should avoid contact with infected individuals as the virus can be transmitted to the fetus and cause anemia. Prioritization is determined by acuity, and therefore children do not automatically receive higher priority. However, due to the potential exposure of this child to a pregnant client in the ED, the triage RN should prioritize this client ahead of the one with vaginal infection. (Option 3) This client is exhibiting a classic sign of the common Candida vaginitis (yeast) infection. Classic signs and symptoms include itching and irritation in the vulva or vagina, white cheesy vaginal discharge, and low vaginal pH. Although uncomfortable, this client is stable and can safely wait up to 2 hours for treatment.

The nurse receives report on 4 clients. Which client should be seen first? 1. Client with amyotrophic lateral sclerosis experiencing increased dysarthria(24%) 2. Client with chronic obstructive pulmonary disease reporting increasing leg edema(40%) 3. Client with strep throat and fever of 102 F (38.9 C) on antibiotics for 12 hours(11%) 4. Client with urolithiasis reporting wavelike flank pain and nausea(24%)

Amyotrophic lateral sclerosis (ALS) is characterized by the progressive loss of motor neurons in the brainstem and spinal cord. Clients have spasticity, muscle weakness, and atrophy. Neurons involved in swallowing and respiratory function are eventually impaired, leading to aspiration, respiratory failure, and death. Care of clients with ALS focuses on maintaining respiratory function, adequate nutrition, and quality of life. There is no cure, and death usually occurs within 5 years of diagnosis. The client with ALS and worsening ability to speak (dysarthria) may also have dysphagia and respiratory distress; this client should be seen first (Option 1). (Option 2) The client with chronic obstructive pulmonary disease and peripheral edema may have cor pulmonale, or right-sided heart failure, from vasoconstriction of the pulmonary vessels. Cor pulmonale is treated with long-term, low-flow oxygen; bronchodilators; and diuretics. This client should be seen second. Right-sided heart failure (peripheral edema) is not as dangerous as left-sided heart failure (pulmonary edema). (Option 3) Fever often occurs with strep throat and may persist for ≥24 hours after initiation of antibiotics. This client should be seen last and should receive an antipyretic. (Option 4) Wavelike flank pain is characteristic of urolithiasis (urinary stones). This client needs pain medication and, possibly, further treatment (eg, lithotripsy) and should be seen third.

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(54%) 2. Severe lower back pain after lifting heavy boxes(0%) 3. Sharp calf ache with ambulation that improves with rest(11%) 4. Unilateral leg swelling with 2+ pitting edema after an airplane trip(33%)

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.

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(15%) 2. Call the health care provider about the 4-year-old with leukemia who has a low-grade fever(16%) 3. Measure head circumference of the 3-month-old with ventriculoperitoneal shunt placement(10%) 4. Suction the 3-month-old with bronchiolitis who is irritable and scheduled for a feeding(57%)

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. (Option 1) Intussusception can be reduced with hydrostatic enema (nonoperative approach). This is important but is not a priority over a child with bronchiolitis and respiratory distress. (Option 2) Chemotherapy can result in neutropenia and immunosuppression. Even a low-grade fever should be taken seriously as it can result in lethal sepsis. The client needs cultures and empiric antibiotics. However, the client with bronchiolitis is the priority. (Option 3) Increased intracranial pressure will occur with shunt malfunction. The nurse should routinely measure the head circumference, but it is not a priority over a client with respiratory distress.

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(19%) 2. Client with gastroparesis who reports persistent nausea and vomiting(18%) 3. Client with intractable lower back pain who reports new urinary incontinence(44%) 4. Client with Ménière disease who reports increasing tinnitus(17%)

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 (ie, incontinence); therefore, the nurse should assess this client first. (Option 1) Clients with acute cholecystitis may experience referred pain to the right shoulder due to irritation of the diaphragm from the inflamed gallbladder. Although the client's pain should be addressed, this client is not the priority. (Option 2) Clients with gastroparesis have delayed gastric emptying and often report persistent nausea and vomiting. Treatment includes antiemetics, but this client is not the priority. (Option 4) Ménière disease is an inner ear disorder. Expected symptoms include episodic vertigo, tinnitus, and muffled hearing. Treatment during an acute attack includes antihistamines, anticholinergics, and benzodiazepines. As long as the client is safe from falling, treatment is not emergent.

The nurse is working on a busy medical-surgical unit and is responding to the client call lights. Which statement would be the priority to assess first? 1. A 65-year-old female client recently started on celecoxib says, "I am having some nausea and my upper back and shoulder are hurting quite a bit."(51%) 2. A client's child says, "My parent has been here for 2 days without anything to eat or drink."(10%) 3. A paraplegic client with multiple stage 4 pressure ulcers says, "I have had a bowel movement and need to be cleaned up."(21%) 4. A postoperative client says, "I am very nauseous and just threw up. This pain medicine is making me really sick."(17%)

Celecoxib (Celebrex), a COX-2 inhibitor, has a black box warning for increased risk of cardiovascular complications. Myocardial infarction symptoms, which can be vague in female clients, include nausea and upper back and shoulder pain. These symptoms would be the priority to assess first, and immediate testing (ie, ECG, cardiac enzymes) would be warranted. (Option 2) This client's nutritional status is concerning and needs to be addressed but would not be a priority over a client experiencing a possible acute myocardial infarction. (Option 3) This client needs cleaning as soon as possible to prevent fecal matter from entering into wounds. Cleaning the client can be delegated to a licensed practical nurse or unlicensed assistive personnel and would not be a priority over a client experiencing a possible acute myocardial infarction. The registered nurse can assess the wounds and dressings later. (Option 4) This client's nausea and pain medication need to be addressed; they would not be a priority over a client experiencing a possible acute myocardial infarction.

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(27%) 2. Client receiving intravenous antibiotics for bacterial pneumonia who reports cough with blood-tinged sputum(14%) 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(46%) 4. Client with chronic pancreatitis who reports upper abdominal pain and voluminous, foul-smelling, fatty stools(12%)

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. (Option 1) The dose of levothyroxine, a thyroid replacement drug that raises the metabolic rate, may need to be adjusted as the client is now exhibiting manifestations of hyperthyroidism (eg, nervousness, sweating, insomnia). (Option 2) Hemoptysis can sometimes be seen with pneumonia, lung abscess, tuberculosis, and lung cancer, as well as in bronchiectasis. Unless there is a significant amount of blood, this is not a concerning finding. (Option 4) Epigastric abdominal pain and steatorrhea (voluminous, foul-smelling, fatty stools) due to fat malabsorption are expected findings in chronic pancreatitis. Appropriate pain medication and pancreatic enzyme supplements (prior to each meal) are administered for prevention.

The nurse is triaging clients from the waiting room. The care of which client is a priority? 1. 2-year-old who ingested a button battery approximately 30 minutes ago and is asymptomatic(32%) 2. 4-year-old who started crying and suddenly won't use the left arm after being swung by the arms(9%) 3. Child with cerebral palsy and a baclofen pump who has increased muscular spasms(13%) 4. Child with osteogenesis imperfecta who walks in reporting being hit on the front of the head with a baseball(45%)

Foreign body aspiration can be life-threatening depending on the object's location, type, and size. Up to 50% of children with foreign body ingestion are asymptomatic at the beginning. Alkaline batteries can be corrosive to the esophageal and intestinal mucosa; if ingested, they must be removed emergently by endoscopy as perforation can occur. (Option 2) This client likely has nursemaid's elbow due to the mechanism (swinging by the arms) by which the injury occurred. This condition is common in children and characterized by a subluxation of the radial head. It can seem like an urgent condition due to the suddenness of the child's inability to use the arm. A simple reduction of the arm by a health care provider should reposition the radial head. (Option 3) Clients with cerebral palsy commonly have an implanted baclofen pump to help control muscle spasms. Increased spasms indicate a possible problem with the pump, such as infection or displacement. Baclofen should not be stopped abruptly. This client needs prompt evaluation, but the condition is not immediately life-threatening. (Option 4) Osteogenesis imperfecta (imperfect bones) is a condition in which bones are brittle and fracture easily. Head trauma indicates a possible skull fracture and alerts the need to assess for intracranial hemorrhage. This child is walking, and so bleeding is unlikely. However, the child should be examined for fracture.

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(61%) 2. Child with an abscess on the buttock that is red, swollen, and warm to the touch(0%) 3. Child with immune thrombocytopenia who fell off a bike and reports shoulder pain(14%) 4. Child with low-grade fever, barking cough, and runny nose who has mild retractions(23%)

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.

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(14%) 2. Room 2: Client and family request clergy to administer last rites(31%) 3. Room 3: Puncture-resistant sharps disposal container on the wall is full(33%) 4. Room 4: Client with diabetes mellitus has an 8 AM fingerstick glucose of 80 mg/dL (4.4 mmol/L)(20%)

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. (Option 1) If any urine is discarded by accident during a 24-hour collection test, the procedure must be restarted. A new container will need to be labeled with the appropriate times and date, but immediate intervention is not required. (Option 2) The nurse will arrange for a visit from clergy to administer the last rites (Sacrament of the Sick), a religious ceremony for Roman Catholic clients who are extremely or terminally ill. Although the situation requires prompt intervention, it does not involve a safety hazard. (Option 4) A fingerstick glucose of 80 mg/dL (4.4 mmol/L) is normal (70-110 mg/dL [3.9-6.1 mmol/L]) and requires no intervention unless the client received insulin and refuses or is unable to eat.

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(56%) 2. Hang the second unit of packed red blood cells for a client with a hemoglobin of 6 g/dL (60 g/L)(36%) 3. Replace the empty IV opioid medication syringe in a patient-controlled analgesia pump(5%) 4. Replace the heparin infusion bag that has 100 mL remaining and is infusing at 50 mL/hr(1%)

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.

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

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. (Option 2) Maintenance doses of cyanocobalamin for vitamin B12 deficiency are usually administered every 4 weeks. Although this client should receive the injection as soon as possible, postponing the home care visit for 1 or 2 days will not harm the client. (Option 4) This client can be provided with telephonic care management; the nurse can perform medication reconciliation over the phone and provide instructions regarding care. Educational objective:During a weather-related emergency, home care visits are classified as: High priority - unstable clients who need care and are at risk for hospitalization if not seen. Moderate priority - clients who are moderately stable and will suffer no harm if a visit is postponed; telephonic care management can be provided to these clients. Low priority - clients who are stable and can engage in self-care and/or have a caregiver who can provide or assist with care.

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(41%) 2. Client receiving radiation therapy who has 6-in (15.2-cm) arm laceration that is not actively bleeding(26%) 3. Client with purulent drainage and crusting of the eyelid with vision unaffected(10%) 4. New parent who is crying and overwhelmed, and denies suicidal ideation(21%)

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. (Option 2) The client receiving radiation therapy is stable, and there is 6- to 8-hour window in which to safely close the wound. This is not a high-risk client. (Option 3) Bacterial conjunctivitis (pink eye) presents with conjunctival erythema; thick, purulent drainage; and "crusted" eyelids. The client will receive antibiotic drops or ointment, warm soaks/cool compresses, and infection control. Pink eye is highly contagious but not emergent. (Option 4) The parent has postpartum blues/depression and is not emergent. This client can be counseled or provided resources later after the infant with fever is seen.

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(59%) 2. A 9-month-old with diarrhea who is refusing fluids and cries without tears(29%) 3. An 11-month-old with cold symptoms and an abdominal breathing pattern(10%) 4. An 18-month-old who cries when the caregiver leaves(0%)

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 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(15%) 2. Client who recently underwent a coronary artery bypass graft with cardiac output of 5 L/min(12%) 3. Client with a gastrointestinal bleed and mean arterial pressure of 58 mm Hg(55%) 4. Client with an adrenal gland tumor and blood pressure of 168/95 mm Hg(16%)

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. (Options 1 and 2) Central venous pressure of 6 mm Hg and cardiac output of 5 L/min are within normal limits. (Option 4) Blood pressure of 168/95 mm Hg is an elevated reading requiring further assessment. However, low MAP is the highest priority due to risk for tissue ischemia.

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(5%) 2. Client with chronic heart failure taking metoprolol and lisinopril who has dizziness when standing up(20%) 3. Client with major depressive disorder taking phenelzine and pseudoephedrine who has a headache(56%) 4. Client with type 2 diabetes taking metformin and lovastatin who has stomach upset and nausea(16%)

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). (Option 1) Buspirone, an anxiolytic medication, and diphenhydramine, an antihistamine and anticholinergic, commonly cause dry mouth. This adverse effect is inconvenient but does not pose a risk to the client. (Option 2) Beta blockers, such as metoprolol, and ACE inhibitors, such as lisinopril, are used to treat hypertension. These medications commonly cause orthostatic hypotension characterized by dizziness when rising to stand. The nurse should follow up, but this is not the priority. (Option 4) Metformin is a biguanide oral antidiabetic medication used to treat type 2 diabetes mellitus. Lovastatin is a statin medication used to treat hyperlipidemia. A common side effect of metformin is stomach upset. The nurse should assess the client's symptoms, but this is not the priority.

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(8%) 2. Client 8 days postoperative ileostomy placement who reports nausea, vomiting, and abdominal bloating(39%) 3. Client postoperative right below-the-knee amputation who is concerned about a new tingling sensation in the right foot(15%) 4. Client with a temperature of 101.2 F (38.4 C) who is scheduled for a shoulder arthroplasty the next morning(35%)

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. (Option 1) Constipation is common after abdominal surgery due to opioid usage and decreased peristalsis from bowel manipulation. Increasing food or fluids might help the client have a bowel movement. (Option 3) Phantom limb pain is a sensation of pain or tingling in the amputated body part. Wrapping the extremity or applying ice or heat might help until the client can be evaluated by the health care provider. (Option 4) Active infection is a relative contraindication for elective surgical procedures. The client should be called back for assessment and likely rescheduling of surgery but would not take priority over a client with bowel obstruction.

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(1%) 2. A 37-year-old client with Guillain-Barré syndrome who has "0" deep tendon patellar reflexes(18%) 3. A 58-year-old client with Parkinson disease who is drooling(14%) 4. A 78-year-old client with dementia who has new-onset agitation and confusion(65%)

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. (Option 1) Bowel and/or bladder incontinence or retention is an expected sign/symptom in clients with multiple sclerosis. (Option 2) Guillain-Barré syndrome is ascending bilateral paralysis from segmental demyelination (remyelination eventually occurs). Normal deep tendon reflexes are 2+. Hypotonia (muscle weakness) and areflexia (loss of reflexes) are common manifestations. The current level of paralysis is at the knees and is therefore not the priority as it has not yet reached the diaphragm. (Option 3) Drooling, lack of blinking, mask-like facial expressions, and lack of swinging arms with walking are expected findings of Parkinson disease. This loss of autonomic movements results from alterations of the basal ganglia and extrapyramidal portion of the central nervous system.

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(5%) 2. 50-year-old client who developed a smooth, red, pinpoint rash after taking sulfa (62%) 3. 60-year-old client with pain and crusted blisters along the back(27%) 4. 70-year-old client who has erythema with a small pustule at the hair follicle(4%)

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. (Option 1) Oropharyngeal candidiasis/thrush (moniliasis) is a fungal infection of skin or mucous membranes. It resembles curdled milk and can bleed when removed. The etiology may be due to not rinsing the mouth after steroid inhaler use. It is treated with antifungal suspensions (nystatin) and is nonurgent. (Option 3) Shingles (herpes zoster) is reactivation of dormant varicella virus. The lesions follow the nerve dermatome and can be quite painful. Incidence increases after age 50. Active chickenpox requires airborne and contact precautions, but not the shingles with crusted lesions, especially if the lesions are covered with clothes. It can be contagious to individuals who have not had varicella or who are immunocompromised. However, this is the second priority as this is a localized issue; the nurse can place this client in a private area. (Option 4) Folliculitis is usually due to the presence of staphylococci in moist areas where there is friction. It is most common in the scalp, beard, and extremities in men. It can be treated with medicated soap, topical antibiotics, and warm compresses. The systemic issue in Client 2 is a priority.

The nurse is reviewing new laboratory values. Which client would be the priority to report to the health care provider? 1. Client 2 days after a hip arthroplasty with a white blood cell count of 12,000/mm3 (12x109/L)(28%) 2. Client admitted for cocaine overdose with a creatine kinase of 30,000 U/L (501 µkat/L)(34%) 3. Client admitted for end-stage renal disease with a creatinine of 3.6 mg/dL (274.5 mmol/L)(8%) 4. Client in heart failure exacerbation with a brain natriuretic peptide of 600 pg/mL (600 pmol/L)(28%)

Rhabdomyolysis occurs when muscle tissue is damaged and myoglobin (protein found in muscle tissue) is released into the blood, usually after an injury from overexertion, dehydration, severe vasoconstriction (eg, cocaine use), heat stroke, or trauma. Acute kidney injury can occur when myoglobin overwhelms the kidneys' filtration ability. As myoglobin is excreted, the urine becomes very dark and is described as being a cola-brown color. Severely elevated creatine kinase levels, typically >15,000 U/L (>250 µkat/L), are observed with severe muscle damage and can be a precursor to kidney injury (Option 2). Forced saline diuresis with intravenous fluids (to prevent blockage of the renal tubules with myoglobin) is necessary to prevent permanent kidney damage. (Option 1) Postoperative leukocytosis (leukocytes >11,000 mm3 [>11X109/L]) is common in the first 48 hours after orthopedic surgery from normal inflammatory immune responses. (Option 3) Clients with end-stage renal disease commonly have elevated creatinine and blood urea nitrogen levels. These are expected findings. (Option 4) Increased brain natriuretic peptide levels can indicate stretching of the chambers of the heart in heart failure. Levels >100 pg/mL (>100 pmol/L) can indicate heart failure and would be expected in this client.

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(12%) 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(9%) 3. Student who woke from a deep sleep in an unfamiliar dormitory room and is panic-stricken with severe vaginal pain(76%) 4. Student with itchy, cottage-cheese-like vaginal discharge who is sexually active and worried about having a sexually transmitted infection(1%)

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 receives handoff of care report on four clients. Which client should the nurse assess first? 1. Client who had an appendectomy today and reports severe nausea and 8 out of 10 pain(28%) 2. Client with a diabetic foot ulcer who has current blood glucose level of 301 mg/dL (16.7 mmol/L)(13%) 3. Client with a fever of unknown origin whose arterial blood gas reveals PaCO2 30 mm Hg (4.0 kPa)(56%) 4. Client with persistent diarrhea who has continuous lactated Ringer solution IV infusing at 125 mL/hr(2%)

Systemic inflammatory response syndrome (SIRS) is a pathophysiologic response mediated by the release of large quantities of inflammatory cytokines from the inflammatory cascade. Overwhelming release of inflammatory cytokines triggers vasodilation and capillary leakage, leading to hypotension and impaired end-organ perfusion. SIRS may occur in response to trauma, tissue ischemia, infection (ie, sepsis), and shock and can rapidly progress to hemodynamic instability, respiratory failure, and multiorgan dysfunction. Clinical manifestations of SIRS include fever or hypothermia, tachycardia, leukocytosis or leukopenia, and tachypnea (often associated with a low PaCO2 value). Clients who develop multiple symptoms of SIRS require aggressive fluid resuscitation and treatment to address possible causes (eg, antibiotics for infection) as SIRS may be life-threatening (Option 3). (Options 1 and 2) Addressing a client's postoperative pain and nausea and further assessing a client with hyperglycemia and diabetes are important but are lower priorities than initiating care for SIRS. (Option 4) A client with persistent diarrhea should have both total intake and output and recent electrolyte levels assessed, but signs of SIRS should be addressed first.

After the nurse receives the change-of-shift report, which client should the nurse assess first? 1. Client with asthma who has shortness of breath and high-pitched expiratory wheezing(30%) 2. Client with diabetes and a stasis leg ulcer dressing saturated with serosanguineous drainage(1%) 3. Client with heart failure who is short of breath and coughing up pink frothy sputum(47%) 4. Client with left pleural effusion and absent breath sounds in the left base(20%)

The ABC (airway, breathing, circulation) and Maslow's hierarchy of needs frameworks are commonly used to prioritize client needs. This client with heart failure who is short of breath and coughing up pink frothy sputum has developed acute pulmonary edema (fluid filling the alveoli), a potentially life-threatening condition. This client's status has deteriorated from baseline, is potentially the most hemodynamically unstable, and should be assessed first. (Option 1) This client with shortness of breath and high-pitched expiratory wheezing is experiencing expected clinical manifestations of asthma and is the second most unstable client at this time. (Option 2) Diabetic stasis leg ulcers can be associated with large amounts of serous or serosanguineous drainage and is an expected manifestation. This client is not the most unstable at this time. (Option 4) Absent breath sounds in the lung base in this client with pleural effusion is an expected finding as the collection of fluid in the pleural space prevents the lung from expanding. This client is not the most unstable at this time.

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(16%) 2. Client 2 days post-op below-the-knee amputation (BKA) who reports same-leg foot pain rated as 7 on the pain scale(15%) 3. Client with a deep venous thrombosis (DVT) who is up to use the bathroom for the second time(41%) 4. Client with Raynaud's phenomenon who reports throbbing, tingling, and swelling of fingers in both hands(26%)

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. (Option 1) Because the bowels have been manipulated in AAA surgery, hypoactive sounds are common for several days afterward. (Option 3) Bed rest is no longer required for a client with DVT unless the client is having severe edema or leg pain. Early ambulation does not increase the short-term risk of pulmonary embolism, and it can reduce edema and leg pain. The nurse should see this client second to assess the affected limb. (Option 4) Raynaud's phenomenon is usually triggered by cold exposure. During a typical episode, digital arteries (most often in the fingers) constrict and blood flow is impaired, causing the skin to turn pale and then blue and to feel numb and cold. As blood flow returns to the affected digits, the skin turns red and a throbbing or tingling sensation is often felt. This is an expected finding; episodes usually resolve in 15-20 minutes once the trigger has been removed (eg, rewarming of the fingers).

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(67%) 2. The client 4 hours post permanent pacemaker insertion that is 100% paced(10%) 3. The client with a deep venous thrombosis (DVT) who has a dose of enoxaparin due (12%) 4. The client with coronary artery disease and atrial fibrillation who has a dose of warfarin due(9%)

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. (Option 1) Atelectasis is a common complication after heart surgery. The nurse needs to assess the client and encourage coughing, deep breathing, and use of the incentive spirometer. These interventions are important but should be done after the other client has received enoxaparin. (Option 2) At 4 hours post permanent pacemaker insertion, the client will need vital signs measured less frequently. The pacer is 100% paced, indicating that it is working appropriately. This client needs assessment by the nurse but is a lower priority than the client with DVT. (Option 4) The client with atrial fibrillation is at risk of forming left atrial clots, which can embolize and cause stroke. Warfarin and other anticoagulants (eg, dabigatran, rivaroxaban, apixaban) are given for prevention of clot formation. It is important that this client receive anticoagulants, but the client with the DVT is a higher priority due to the current clot that could mobilize and cause a PE.

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(23%) 2. Client admitted 2 hours ago with gastroenteritis who has been vomiting for 36 hours and has muscle cramps and weakness(62%) 3. Client who has received IV bumetanide for 3 days for heart failure and experiences dizziness when standing up(2%) 4. Client with acute poststreptococcal glomerulonephritis who is receiving antibiotics and has gross hematuria(11%)

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). (Option 1) A histamine-related reaction (eg, pruritus) is an expected adverse effect associated with the administration of epidural morphine (Astramorph), so this client does not need to be assessed first. An antihistamine such as IV diphenhydramine (Benadryl) may be prescribed to help alleviate itching. (Option 3) This client may have been excessively diuresed (eg, with bumetanide [Bumex]) and could have orthostatic hypotension. This client is the second priority. Because the client is in the hospital, the risk of severe hypokalemia is low (as most clients receive potassium supplements), and the client is not exhibiting symptoms of hypokalemia. (Option 4) Gross hematuria is an expected manifestation of poststreptococcal glomerulonephritis. It is usually mild and does not require urgent attention.

The nurse receives a hand-off report from the night shift nurse. Which client should the nurse assess first? 1. Client with anemia who began receiving a unit of packed red blood cells 1 hour ago(32%) 2. Client with hemoglobin of 7 g/dL (70 g/L) who needs to be started on IV iron therapy(21%) 3. Client with seizure activity who received lorazepam 20 minutes ago(38%) 4. Client with suspected leukemia scheduled for a bone marrow biopsy in 1 hour(7%)

The nurse should assess the client with seizure activity first. This client is at increased risk for injury, aspiration, and airway obstruction. The nurse should obtain baseline neurological vital signs (eg, level of consciousness, pupillary reaction, speech, hand grasps) against which to compare subsequent findings and to evaluate the client's response to lorazepam. The client requires a safe environment, so the nurse should also ensure that fall and seizure precautions (eg, full side rail pads, low bed, floor mats, suction equipment, oxygen at bedside) have been initiated. (Option 1) A serious ABO incompatibility/transfusion reaction typically occurs within the first 15 minutes or 50 mL of transfusion. The unit of packed red blood cells was hung 1 hour ago; therefore the baseline 15- and 30-minute vital signs have already been recorded. The nurse will assess the client and infusion rate and site but does not need to check on this client first. (Option 2) Hemoglobin of 7 g/dL (70 g/L) is not life-threatening and many clients can tolerate this level. IV iron administration is not a priority. (Option 4) The nurse should ensure that the consent form is signed and the client understands the bone marrow biopsy (BMB) procedure, but this client should not be assessed first. BMB is done at the bedside and usually does not have major complications.

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(43%) 2. Client with an ulcerative colitis flare-up has temperature 101 F (38.3 C) and abdominal cramping(17%) 3. Client with atrial fibrillation, on telemetry, prescribed warfarin, with an International Normalized Ratio (INR) of 3.2(23%) 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)(15%)

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) Client with chronic kidney disease scheduled for dialysis in 30 minutes - the nurse should perform a baseline assessment before dialysis is initiated. The nurse should then prepare the client by making sure the client eats breakfast, administering prescribed morning medications that are not dialyzed out, and holding those that are dialyzed out. Elevated creatinine level (eg, normal 0.6-1.3 mg/dL [53-115 µmol/L]) is an expected finding. (Option 4) Client with ulcerative colitis (UC) with elevated temperature and abdominal pain - UC is an inflammatory bowel disease; fever and lower-quadrant abdominal cramping are expected findings. After assessing the client, the nurse will administer an analgesic and an antipyretic as prescribed. (Option 2) Client with history of atrial fibrillation, prescribed warfarin (Coumadin) - the client is on telemetry; in most facilities, if dysrhythmias occur, the monitor technician/nurse will notify the primary care nurse immediately. The goal INR is 2.0 to 3.0 for atrial fibrillation. An INR of 3.2 is expected when adjusting the warfarin dose. (Option 3)

The nurse assesses 4 clients. Which assessment finding requires the nurse's priority action? 1. 26-year-old with splenectomy reports a headache and chills(52%) 2. 40-year-old with immune thrombocytopenic purpura has petechiae on the arms(19%) 3. 60-year-old with marked anemia reports shortness of breath when ambulating(12%) 4. 68-year-old with polycythemia vera has a hematocrit of 66% (0.66)(16%)

The spleen is part of the immune system and functions as a filter to purify the blood and remove specific microorganisms that cause infections (eg, pneumococcal pneumonia, meningococcal meningitis). Overwhelming postsplenectomy bacterial infection or rapid-onset sepsis are major lifelong complications in a client without a functioning spleen. A minor infection can quickly become life-threatening, and so any indicator of infection such as a low-grade fever, chills, or headache needs immediate intervention (eg, cultures, imaging, antibiotic therapy). Therefore, the client with the splenectomy who is reporting headache and chills requires immediate action. (Option 2) Immune thrombocytopenic purpura (ITP) is an autoimmune condition in which clients have abnormal platelet destruction with a count <150,000/mm3 (150 x 109/L). ITP is associated with an increased risk of bleeding. A common manifestation of ITP includes petechiae, which are pinpoint flat, red or brown microhemorrhages under the skin caused by leakage of red blood cells. Petechiae are an expected finding. (Option 3) A client with marked anemia can develop exertional dyspnea due to the body's inability to meet the metabolic demands (oxygen supply) associated with activity. This is an expected finding. (Option 4) Polycythemia vera (true primary polycythemia) is a chronic myeloproliferative disease characterized by bone marrow overproduction of red blood cells, white blood cells, and platelets. This leads to increased hematocrit (>53% [0.53]) and blood volume, enhanced blood viscosity, and abnormal clotting. A hematocrit of 66% (0.66) is an expected finding.

Tramadol (Ultram)

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.

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(47%) 2. Client scheduled for whirlpool bath in 20 minutes has the dressing on the infected foot ulcer fall off(0%) 3. Client with arteriovenous graft for hemodialysis access has new-onset pain and redness at graft site(24%) 4. Client with urinary retention and infection receiving antibiotics is confused and trying to pull out Foley catheter(26%)

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). (Option 2) The dressing on an infected foot ulcer is usually removed before the foot is placed in a whirlpool bath (hydrotherapy). The nurse can apply a new dressing or cover and wrap the foot using a sterile towel or gauze bandage to protect it from microorganisms. This client is not the priority. (Option 3) Dialysis grafts are prone to infection. This client needs to be assessed for erythema, graft tenderness, fever, and tachycardia. These are not immediately life-threatening conditions. (Option 4) Infection can cause delirium (altered mental status). This client needs one-to-one observation and repeated reorientation while antibiotics take effect. However, this client is not a priority over a client who is actively bleeding.

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%)

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. (Option 2) Cheyne-Stokes respiration is a repetitive, abnormal, irregular breathing pattern characterized by alternating deep and shallow respirations followed by periods of apnea (10-20 seconds). The pattern is usually associated with certain neurologic conditions (eg, stroke, increased intracranial pressure) and with end of life; it would be expected in this client. (Option 3) Shortness of breath and tachycardia with activity related to decreased hemoglobin level, red cells, and oxygen-carrying capacity would be expected in a client with moderate to severe anemia. (Option 4) Kussmaul breathing is characterized by regular but rapid, deep respirations and is associated with conditions that cause metabolic acidosis (eg, renal failure, diabetic ketoacidosis, shock). Kussmaul breathing would be expected in this client as it is a compensatory action by the lungs to excrete excess acid from the body by hyperventilating, thereby blowing off carbon dioxide (acid gas).

The nurse assesses and reviews the laboratory results for 4 clients. Which client's fever is of highest priority and should be reported to the health care provider immediately? 1. Client newly diagnosed with Hodgkin lymphoma scheduled for chemotherapy who has a fever of 100.9 F (38.3 C) and white blood cell count of 6,000/mm3 (6.0 × 109/L)(7%) 2. Client with acute cholecystitis scheduled for laparoscopic surgery who has a fever of 102 F (38.9 C) and white blood cell count of 13,000/mm3 (13.0 × 109/L)(34%) 3. Client with Clostridium difficile infection receiving metronidazole who has a fever of 101 F (38.3 C) and white blood cell count of 18,000/mm3 (18.0 × 109/L)(6%) 4. Client with colon cancer receiving chemotherapy who has a fever of 100.4 F (38 C) and white blood cell count of 1,500/mm3 (1.5 × 109/L)(50%)

A common adverse effect of chemotherapy is bone marrow suppression (eg, anemia, leukopenia, thrombocytopenia) and immunosuppression. A decreased neutrophil (type of white blood cell) count, termed neutropenia, increases the client's susceptibility to infection. A fever can signal an infection and, in the presence of neutropenia (ie, neutropenic fever), can rapidly develop into life-threatening sepsis. Even a low-grade fever should be taken seriously in these clients. (Option 1) Hodgkin lymphoma is a malignant cancer of the lymphatic system. Expected early manifestations include painless enlarged lymph nodes, fatigue, fever, weight loss, and drenching night sweats. The client's white blood cell count is within normal limits (4,000-11,000 mm3 [4.0-11.0 × 109/L]). (Option 2) Acute cholecystitis involves inflammation of the gallbladder. Expected manifestations include right upper quadrant pain that can radiate to the right shoulder, nausea, vomiting, fever, and leukocytosis (white blood cells count >11,000/mm3 [11.0 × 109/L]). The client is scheduled for surgery and is likely on antibiotics. Even if the client is not on antibiotics, neutropenia is a priority over acute cholecystitis. (Option 3) Clostridium difficile is a toxin-producing bacterium that proliferates in the lower gastrointestinal tract. Expected manifestations include diarrhea, fever, and leukocytosis. First-line pharmacologic treatment includes metronidazole (Flagyl) and oral vancomycin.

Four clients come to the emergency department simultaneously. Which client should the nurse see first for definitive care? 1. 6-month-old with a temperature of 101 F (38 C) who is rubbing the ears and being fussy(4%) 2. 10-day-old client with a red mark (stork bite) on the neck, the mother is concerned(1%) 3. A client who took a handful of amitriptyline pills, a tricyclic antidepressant drug(66%) 4. A client who tripped and hit the head but is alert with no loss of consciousness, currently takes warfarin (27%)

In this scenario, a client with a drug overdose (OD) is the highest priority as the actual amount taken and its effects are unknown. In addition, clients who deliberately OD often consume other substances (eg, alcohol) that can potentiate the effect of the drug. OD is especially concerning for a tricyclic antidepressant (TCA) due to the effect this can have on the cardiovascular and central nervous systems (eg, dysrhythmias, seizures). TCA use for depression is an uncommon second-line treatment, but the drug class is used for neuropathic pain and sometimes bed-wetting (enuresis). A client with head trauma (a vascular area of the body) who is currently on an anticoagulant could have potential intracranial bleeding and should be treated next. The 6-month-old client is exhibiting classic signs of otitis media (eg, fever, ear pulling/rubbing). This infection of the middle ear is a common childhood illness, often in conjunction with an upper respiratory infection. The child should be treated third and will need antibiotics, but this is nonurgent. Antipyretics can be given for comfort by protocol or direct order from the health care provider while the child is still in the triage/waiting area. The 10-day old client's mark is a salmon-colored patch (nevus simplex or angel kiss); this is a developmental vascular abnormality that will disappear within 1 year. It is at the nape of the neck but can also be seen on the eyelid, upper lip, or between the eyes. The mother needs reassurance and teaching.