Prioritization and Delegation
A client with no history of cardiovascular disease comes to the ambulatory clinic with flulike symptoms and a report of chest pain. What question should the nurse ask this client first?
"How would you describe the pain?"
A client is admitted with an eating disorder. Which client response should the nurse address first?
"I feel dizzy and light-headed when I get up."
The nurse is making assignments for the next shift. Which client can be assigned to a licensed practical nurse/licensed vocational nurse (LPN/LVN)? Select all that apply.
-A client who needs assistance with colostomy irrigation -A client who is receiving glargine subcutaneously
A client with dissociative identity disorder was admitted to the unit after a suicide attempt. Place the nursing interventions in priority order. All options must be used.
-Assess suicide risk and implement a safety plan, to include a follow-up assessment. -Initiate a therapeutic relationship, establish trust, and develop rapport. -Explain unit policies and expectations, activity schedule, and therapeutic interventions. -Teach the client specific aspects of the illness including symptoms and the treatment plan. -Educate the client on medication usage, including therapeutic benefit, administration protocol, and possible side effects. -Assist the client to develop a schedule allowing the client to manage this disorder in daily life.
The nurse is making assignments for the unlicensed assistive personnel (UAP). Which tasks can be safely assigned to UAP? Select all that apply.
-Bathing a client with Alzheimer's disease -Turning a client who is poorly nourished
Which client is most at risk for developing acute lymphocytic leukemia?
A 4-year-old white female
A nurse, working in a rural county's public health department, has been alerted that there is an outbreak of tuberculosis (TB) in the area. Which client is at highest risk for developing TB?
A 43-year-old homeless man with a history of alcoholism
The nurse is assigned to care for four clients. Which client should the nurse assess first?
A client admitted one hour ago with new-onset atrial fibrillation who is receiving IV diltiazem
Which client would benefit most from information explaining the importance of receiving an annual Papanicolaou (PAP) test?
A client infected with the human papillomavirus (HPV)
A nurse is caring for clients who have a history of genital herpes infection. Which client is most at risk for an outbreak of genital herpes?
A client who reports genital pruritus and paresthesia
A client ingested a large amount of acetaminophen at 1:00 am. Two hours later, the client comes to the emergency department, and is diagnosed with acetaminophen poisoning. What is the priority intervention for this client?
Administer acetylcysteine.
The nurse is planning interventions for a client who is having an acute gout attack. What is the priority nursing intervention for this client?
Administer prescribed analgesics
A client with pneumonia has developed dyspnea, has a respiratory rate of 32 breaths/min, and is having difficulty expelling secretions. The nurse auscultates the lung fields and hears bronchial sounds in the lower left lobe. Which action should the nurse take first?
Apply oxygen
A male neonate has just been circumcised. Which nursing intervention is part of the initial care of a circumcised neonate?
Apply petroleum jelly to the site for 24 to 48 hours.
The nurse is concerned that a client admitted with major depressive disorder may be suicidal. What is the most important action by the nurse?
Ask a direct question such as, "Do you ever think about killing yourself?"
A staff nurse receives a phone call and is told there is a bomb in a client's room. What is the nurse's priority action?
Ask the caller for details about the bomb placement.
A nurse suspects a client is experiencing alcohol withdrawal syndrome. What is the nurse's priority action?
Ask the client about the client's drinking.
A client with an uncomplicated term pregnancy arrives at the labor-and-delivery unit in early labor saying that she thinks her water has broken. What is the nurse's best action?
Ask what time this happened and note the color, amount, and odor of the fluid.
A client is brought to the emergency department after a house fire. What is the priority assessment by the nurse?
Assess oxygen saturation and the client's ability to speak.
The nurse is planning care for an infant with bronchiolitis. What is the nurse's priority intervention for this child?
Assess respiratory status frequently.
Parents bring a preschool-age client to the emergency department with suspected ingestion of an unknown toxic substance. What intervention should the nurse perform first?
Assess the child's vital signs and neurological status.
The nurse is assessing a client who has been experiencing black stools for the past month. The client suddenly reports chest and stomach pain. What is the most important action by the nurse?
Assess the client's vital signs
After undergoing a cardiac catheterization, a client has a large puddle of blood under his buttocks. What is the nurse's priority action?
Assess the groin site
A 40-year-old client with schizophrenia lives in a rooming house. The client scratches vigorously and reports creatures eating at the skin. Which intervention should be done first?
Assess the physical problems.
What is the priority nursing action for a client with generalized anxiety disorder who is working to develop coping skills?
Assist the client to identify coping mechanisms used in the past
What is the nurse's priority to regulate the temperature of a neonate?
Block radiant, convective, conductive, and evaporative losses.
A new mother states, "My baby spits up after every feeding." Which interventions should the nurse teach to this mother first?
Burp the infant more frequently during each feeding.
Which nursing intervention is a priority for an infant during the first 24 hours following surgery for cleft lip repair?
Carefully clean the suture line after feedings to reduce the risk of infection.
What is the most important intervention for the nurse to implement while caring for a neonate with an omphalocele?
Carefully position and handle the omphalocele.
A local chemical plant has had an environmental leak requiring the mass evacuation of its employees and neighbors in the surrounding area. The emergency room nurse is in the triage area when the first client is brought to the hospital. What should the nurse do first?
Determine what decontamination measures took place in the field before approaching the client.
While assessing a 2-hour-old neonate, a nurse observes the neonate to have acrocyanosis. Which nursing action should be performed first?
Do nothing different because acrocyanosis is normal in the early neonatal period.
An adolescent girl is being treated for anogenital warts caused by the human papillomavirus (HPV). What is the nurse's priority intervention for this client?
Educate the client about the accompanying risk of cervical cancer.
A child with hemophilia is hospitalized with bleeding into the knee. Which action should the nurse take first?
Elevate the affected part.
A client with venous insufficiency reports swelling in the feet and ankles. What is the most appropriate intervention for the nurse to recommend?
Elevate the feet several times a day.
A child is newly diagnosed with neonatal bronchopulmonary dysplasia (chronic lung disease). Which intervention should the nurse perform first to help the parents?
Evaluate and assess parents' stress and anxiety levels.
A nurse is making a home visit and finds an older adult client who requires immediate treatment for exposure to carbon monoxide. What priority action would the nurse take prior to the arrival of the paramedics?
Expose the client to fresh air
A 10-month-old child is found choking. The child is conscious but is not coughing or making other sounds. What is the nurse's priority intervention?
Give five back blows and five chest thrusts.
An order has been written to discontinue an infusion of total parenteral nutrition (TPN) for a child. What is the priority nursing action?
Gradually reduce the rate of the TPN per health care provider order.
A client is scheduled for amniocentesis. What priority intervention should the nurse implement?
Have the client void.
What is the most important information for a nurse to teach a client with chronic obstructive pulmonary disease (COPD)?
How to recognize the signs of an impending respiratory infection
While performing an assessment of a 75-year-old client in the emergency department, a nurse notes several areas of ecchymosis in various stages of healing on the client's body. What is the nurse's priority action?
Inquire how these bruises occurred.
A nurse is preparing a client for cardiac catheterization. What is the nurse's priority assessment?
Known allergies
While performing a cervical examination on a client in labor, a nurse's fingertips feel pulsating tissue. What is the most appropriate nursing intervention?
Leave the fingers in place and press the nurse call light.
A school-age client with a diagnosis of epilepsy is admitted to the pediatric unit of a local hospital for evaluation of anticonvulsant medications. As the nurse enters the client's room, the client begins to have a seizure. What is the priority nursing action?
Loosen any restrictive clothing.
A client has received an infusion of antibiotics and is now experiencing an anaphylactic reaction. What is the most important intervention by the nurse?
Maintain a patent airway.
The nurse is caring for a client with diabetes insipidus (DI). What is the nurse's priority intervention?
Maintaining adequate hydration
A nurse caring for an infant with neonatal bronchopulmonary dysplasia (chronic lung disease) administers furosemide. What is the priority intervention following the administration of this medication?
Monitor electrolyte status.
An adolescent client is admitted for treatment of anorexia nervosa with a body mass index (BMI) of 13. What is the nurse's priority in planning the care?
Monitor the client's urine output and vital signs.
The nurse is monitoring a client, who is six hours post embolectomy, for an acute arterial occlusion of the left leg. When a Doppler ultrasound fails to detect a pedal pulse, the nurse notifies the surgeon who requests that the client be prepared for immediate surgery. The client refuses to consider additional surgery. What is the nurse's initial intervention?
Notify the provider immediately
The nurse is preparing to discharge a school-age child with asthma. Which intervention is most important for the nurse to perform prior to discharge?
Obtain additional equipment and medication that can be provided at the school.
The nurse is caring for a child with acute glomerulonephritis. What action is most important for the nurse to do?
Obtain and monitor daily weight.
A 79-year-old client has been admitted to the unit. The client is diagnosed with a left hip fracture secondary to a fall, and is scheduled for a left total hip replacement (LTHR). The client's comorbidities are hypertension and diabetes. The client is a full code with no known allergies (NKA). What is the nurse's priority action for this client?
Pain management
A child has just returned to the pediatric unit following placement of a ventriculoperitoneal shunt for hydrocephalus. The child is placed in a supine position. What is the nurse's priority intervention?
Place the child on the side opposite the shunt.
A nurse is caring for a full-term pregnant client in active labor. The electronic fetal monitor reveals a fetal heart rate (FHR) of less than 70 beats for 1 minute. What is the nurse's priority intervention?
Place the client on her left side and apply oxygen.
A nurse is caring for a client exhibiting mild contractions and a cervical dilation of 4 cm. Using an external fetal monitor, the nurse observes variable decelerations. Which action should the nurse take first?
Place the client on her left side.
A client displays signs associated with a possible ruptured aortic aneurysm. What is the priority nursing intervention?
Prepare the client for surgical intervention
Which nursing intervention is a priority for a child with hemophilia, who has fallen, and has an acutely bruised leg?
Pressure on the site and administration of the required clotting factor
The nurse is caring for a client admitted with Addisonian crisis. Which outcome is the priority?
Preventing irreversible shock
A client with type 1 diabetes mellitus is conscious but confused, weak, diaphoretic, and having heart palpitations. What is the nurse's priority action?
Provide 15 to 20 grams of a fast-acting oral carbohydrate.
A client is admitted to the labor and delivery unit for birth of a known anencephalic fetus. What is the most appropriate intervention by the nurse?
Provide privacy and emotional support.
The nurse is caring for a recently circumcised newborn. Based on the progress note, what would be the most appropriate nursing intervention?
Provide routine care to the circumcised area.
A 22-year-old client with quadriplegia in supine position is apprehensive and flushed, with a blood pressure of 210/100 mmHg and heart rate of 50 bpm. Which nursing intervention should be done first?
Raise the head of the bed immediately to 90 degrees
Which nursing intervention is a priority for a pregnant adolescent during her first trimester?
Refer the client to a dietitian for nutritional counseling.
A client, who underwent femoral-popliteal (fem-pop) bypass surgery, is scheduled to return from the post-anesthesia care unit. Which staff member should receive this client?
Registered nurse with one year of experience
A nurse administers incorrect medication to a client. After assessing the client, and completing an incident report, which is the priority action by the nurse?
Report the incident to risk management.
A nurse suspects an infant may have a tracheoesophageal fistula or esophageal atresia. What is the most important intervention by the nurse?
Report the suspicion to the health care provider.
The nurse is preparing a client with atrial fibrillation for cardioversion. What is the nurse's priority action?
Set the defibirillator on SYNC and charge at 200 joules.
A 17-year-old primigravida with severe hypertension of pregnancy has been receiving magnesium sulfate I.V. for 3 hr. The latest assessment reveals deep tendon reflexes (DTR) of +1, flushing, blood pressure of 150/100 mm Hg, a pulse of 92 beats/min, a respiratory rate of 10 breaths/min, and urine output of 20 ml/hr. Which action would be most appropriate?
Stop the magnesium sulfate infusion.
The nurse is caring for a client diagnosed with postoperative atelectasis. What intervention performed by the nurse best addresses the underlying pathophysiology that leads to atelectasis?
Teach deep breathing, coughing, and incentive spirometry exercises.
A client with a panic disorder is having difficulty falling asleep. Which nursing intervention should be performed first?
Teach the client progressive relaxation.
A registered nurse (RN) is supervising an unlicensed assistive personnel (UAP). Which principle would the nurse follow when delegating tasks?
The RN delegates a task based on the UAP's skill set.
A nurse is instructing an unlicensed assistive personnel (UAP) on the proper care of a client in Buck's extension traction following a fracture of the left fibula. Which observation would indicate that teaching has been effective?
The weights are allowed to hang freely over the end of the bed.
The nurse is developing a plan of care for a hospitalized client who is at risk for suicide. What is the most important intervention for the nurse to include?
Use a caring approach to maintain close observation of the client
The nurse is assessing a child one hour after a cardiac catheterization. For which finding would the nurse immediately alert the provider?
Weak, thready, unequal dorsalis pedis pulses
A nurse working in the triage area of an emergency department sees several pediatric clients arrive simultaneously. Which client should be treated first?
a 2-year-old child with stridorous breath sounds, sitting up and drooling
The nurse is examining charts to identify clients at risk for developing multiple myeloma. Which client is most at risk?
a 60-year-old Black man
The nurse is planning care for several clients. Which client does the nurse prioritize as being at highest risk for developing a pulmonary embolism?
a client who has fractures of the pelvis and right femur
An older adult client with pneumonia is admitted with prescriptions for intravenous antibiotics, supplemental oxygen as needed, and antipyretics. The nurse should immediately notify the health care provider for which assessment finding?
acute onset delirium
The nurse is reviewing the interventions listed in the plan of care for a child in vaso-occlusive crisis. Which intervention should the nurse implement first?
administering analgesics
The nurse is providing community education to a group of clients about the prevention of type 2 diabetes mellitus. Which client would be at highest risk for the development of diabetes mellitus?
an older adult female client who is sedentary
A client at term arrives in the labor and delivery unit experiencing contractions every 4 minutes. After a brief assessment, the client is admitted, and an electronic fetal monitor is applied. Which assessment finding would be most concerning to the nurse?
blood pressure of 146/90 mm Hg
A child has ingested a bottle of over-the-counter medication and is brought into the emergency department by the parents. The nurse expedites rapid first aid for poisoning by immediately accessing what resource?
contacting the Poison Control Center by phone
The nurse is planning care for an infant with bronchiolitis who requires monitoring for fluid balance. What is the most accurate assessment the nurse can perform to determine the total body water volume of the infant?
daily weight
A 30-year-old multiparous client in active labor is admitted to the labor and delivery unit. She has received no prenatal care for this pregnancy. Which data would the nurse obtain first?
date of last menstrual period (LMP)
The nurse is caring for an 8-year-old child who arrived at the emergency department with chemical burns to both legs. What is the priority intervention for this child?
diluting the chemicals
A two-year-old child comes to the emergency department with inspiratory stridor and a barking cough. A preliminary diagnosis of croup has been made. What is the nurse's most important intervention?
establish and maintain the airway
There has been a large disaster, and nurses from various units have been assigned to help with the large influx of clients. To which client would it be most appropriate to assign an obstetric-postpartum nurse?
female in pelvic traction who is three months pregnant
What is the most important intervention for the nurse to include in the care plan for a male infant following surgical repair of hypospadias?
frequent assessment of the tip of the penis
A two-month-old infant arrives with a heart rate of 180 bpm and a temperature of 103.1° F (39.5° C) rectally. What is the most appropriate initial nursing intervention?
give acetaminophen
A nurse is teaching a group of parents about urinary tract infections (UTIs) in children. What is the priority educational topic for this group of parents?
interventions to prevent UTIs
The nurse in the emergency department is caring for an adolescent client with full-thickness, circumferential burns to the chest who has difficulty breathing. What is the priority intervention?
intubation
What is the priority nursing assessment of a client with an eating disorder?
level of danger to self
What is the nurse's priority when caring for a 10-month-old infant with meningitis?
maintaining an adequate airway
An 18-month-old child is experiencing supraventricular tachycardia (SVT). What should be the nurse's first intervention?
placement of a bag of ice over the child's face
A client's laboratory results indicate hypokalemia, hyperglycemia, and increased white blood cell (WBC) count. Which newly prescribed medication should the nurse associate as most likely to contribute to these changes?
prednisone
A nurse is caring for a child with pheochromocytoma. What is the most important intervention by the nurse?
promoting an environment free from emotional distress
Which nursing assessment data would be given priority for a child with clinical findings related to tubercular meningitis?
signs of increased intracranial pressure (ICP)
A client with schizophrenia has been stable for some time. What action is most important for preventing relapse?
taking prescribed medications consistently
A breastfeeding mother who is experiencing breast engorgement asks the nurse if there is anything she can do to get relief. What is the best intervention for the nurse to implement?
teaching how to express the breasts
