Prioritization and Delegation - ML8

A nurse manager is delegating the revision of the unit's educational policies to a committee of staff nurses. How would the nurse manager direct the committee members to divide the work required? "Submit your suggestions directly to me so I can review them prior to instituting the changes." "The revisions should be minimal and should not take you long to complete." "Distribute the topics based on your expertise, and complete the revisions in 6 weeks." "Let me know if you have any trouble accessing the resources needed for the revisions."

"Distribute the topics based on your expertise, and complete the revisions in 6 weeks." Delegation should be done in a clear, precise manner. The nurse manager must first identify the task and then assign responsibilities to those completing it, but the delegates may have some control over this group project as appropriate. The desired outcome should be explained, and the time frame for completion defined. Telling the nurses that the revisions "should not take long" is vague and unhelpful. Though the direction of who the revisions should be submitted to is important, as is what to do if resources are not readily available, failing to identify a time frame or how the work should be divided makes these instructions less helpful.

A client is admitted with an eating disorder. Which client response should the nurse address first? "My life is over if I gain weight." "I feel dizzy and light-headed when I get up." "I cannot eat because my teeth hurt." "I do not have the same energy that I used to have."

"I feel dizzy and light-headed when I get up." The priority intervention, by the nurse, would be to assess the client's vital signs to note any alterations. A client stating "My life is over if I gain weight" is an example of catastrophizing. Dental erosion and caries are commonly found in a client with an eating disorder. Muscle weakness is also commonly found in a client with an eating disorder.

A nurse is assessing a client with bulimia nervosa for possible substance abuse. What is the most important question for the nurse to ask this client? "What drugs have you used to manage your weight and appetite?" "Do you participate in "pharm" parties?" "What drugs have you used to help control anxiety?" "How would you describe your alcohol use?"

"What drugs have you used to manage your weight and appetite?" Some clients with bulimia nervosa use, or have a history of using, amphetamines to control their weight. This is the most important question, as it asks about medications related to the eating disorder and the potential medical complications. The use of alcohol and street drugs is common. Direct questions about medications used for anxiety will likely elicit a direct response. Similarly, asking for a description of alcohol use might yield information about the pattern of drinking. Participation in "pharm" parties indicates a high-risk behavior that should be addressed during treatment.

The nurse is reviewing assessment data of clients who may be at risk for developing malignant lymphoma. Which client would be at highest risk? A 40-year-old woman with HIV A 33-year-old man with a cousin with Hodgkin's lymphoma A 22-year-old man with a history of mononucleosis A 25-year-old man who smokes a pack of cigarettes a day

A 22-year-old man with a history of mononucleosis Malignant lymphoma has a peak incidence between ages 20 and 30, and after age 50. It's more common in men than women and is associated with a history of Epstein-Barr virus (which causes mononucleosis). There is also an increased incidence of the disease among siblings. There is no reported association between malignant lymphoma and smoking or HIV infection.

A nurse is assigned four clients. Which client should the nurse see first? A 50-year-old client with diverticulitis A 50-year-old client three days post myocardial infarction A 17-year-old client 24 hours post appendectomy A 33-year-old client with a recent diagnosis of Guillain-Barré syndrome

A 33-year-old client with a recent diagnosis of Guillain-Barré syndrome Guillain-Barré syndrome is characterized by ascending paralysis and potential respiratory failure. The order of client assessment should follow client priorities, with disorders of airway, breathing, and then circulation seen first. There is no information to suggest that the client with post myocardial infarction has an arrhythmia or other complication. There is no evidence to suggest hemorrhage or perforation for the remaining clients as a priority of care.

Which client is most at risk for developing acute lymphocytic leukemia? A 51-year-old Asian female A 44-year-old white male A 4-year-old white female A 25-year-old black male

A 4-year-old white female Acute lymphocytic leukemia is most common in young children and in adults age 65 and older. It's also more common in whites than in blacks or Asians.

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 54-year-old businessman who travels worldwide A 35-year-old female day-care worker A 43-year-old homeless man with a history of alcoholism A 16-year-old female high school student

A 43-year-old homeless man with a history of alcoholism Clients who are economically disadvantaged, malnourished, and have reduced immunity, such as those with a history of alcoholism, are at extremely high risk for developing TB. A high school student, daycare worker, and a man traveling on business have a much lower risk of contracting TB.

The nurse is assigned to care for four clients. Which client should the nurse assess first? A client admitted one day ago with thrombophlebitis who is receiving IV heparin A client admitted one hour ago with new-onset atrial fibrillation who is receiving IV diltiazem A client with end-stage, right-sided heart failure, with blood pressure of 78/50 mmHg, who is on hospice care A client admitted two days ago with heart failure, blood pressure of 126/76 mmHg, and a respiratory rate of 22 breaths/min

A client admitted one hour ago with new-onset atrial fibrillation who is receiving IV diltiazem The client with atrial fibrillation has the greatest potential to become unstable, and is on IV medication that requires close monitoring. After assessing this client, the nurse should assess the client with thrombophlebitis who is receiving a heparin infusion, and then the client admitted two days ago with heart failure. The client with end-stage right-sided heart failure, who is identified as a hospice client is of lowest priority.

The nurse is assigned four clients. Which client is at highest risk for impaired skin integrity? A client with endometriosis A client with a vaginal packing in place A client taking oral contraceptives A client having reconstructive breast surgery

A client having reconstructive breast surgery Reconstructive breast surgery places the client at risk for insufficient blood supply to the muscle graft and skin, which can lead to tissue necrosis. Endometriosis and oral contraceptives aren't generally associated with altered tissue perfusion. Pressure from vaginal packing can sometimes put pressure on the bladder neck and interfere with voiding.

Which client would benefit most from information explaining the importance of receiving an annual Papanicolaou (PAP) test? A client who had her first pregnancy before the age of 20 A client infected with the human papillomavirus (HPV) A client with a history of recurrent candidiasis A client who has used oral contraceptives for 27 years

A client infected with the human papillomavirus (HPV) HPV causes genital warts, which are associated with an increased incidence of cervical cancer. Recurrent candidiasis, pregnancy before age 20, and the use of oral contraceptives have not been shown to increase the risk of cervical cancer.

Which client, diagnosed with pneumonia, is most likely to have community-acquired pneumonia? A client whose spouse recently died A client who has had multiple family visitors A client newly admitted to a long-term care facility A client who recently traveled on a cruise ship

A client newly admitted to a long-term care facility The client who is a new resident in a long term care facility is at high risk for community-acquired infections. Traveling is not likely to cause community-acquired pneumonia. Legionnaires' disease is a risk if traveling on a confined cruise ship. Receiving family visits and the death of a spouse are not typically causative factors associated with developing community-acquired pneumonia.

A nurse is assigned to four clients. Which client should the nurse see first? A client who had open reduction internal fixation (ORIF) receiving fondaparinux A client with acquired immunodeficiency syndrome receiving emtricitabine A client who is being prepared for a major surgery receiving clopidogrel A client with a low white blood cell count receiving pegfilgrastim

A client who is being prepared for a major surgery receiving clopidogrel Clopidogrel is an anti-platelet drug that should be stopped seven days prior to surgery because it can increase the risk of bleeding. All the other options are correct. Fondaparinux can be given to a client who had ORIF to prevent blood clot formation. Pegfilgrastim is given to a client with low white blood cell (WBC). Emtricitabine is a nucleoside-nucleotide reverse transcriptase inhibitor (NNRTI) drug used for clients with HIV/AIDS.

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 who reports vaginal and urethral discharge A client who reports dysuria and lymphadenopathy A client who reports headache and fever

A client who reports genital pruritus and paresthesia Pruritus and paresthesia as well as redness of the genital area are prodromal symptoms of recurrent herpes infection. These symptoms occur 30 minutes to 48 hours before the lesions appear. Headache and fever are symptoms of viremia associated with the primary infection. Vaginal and urethral discharge are also a local sign of primary infection. Dysuria and lymphadenopathy are localized symptoms of a primary infection that may also occur with recurrent infection.

Which client would be considered to be at the highest risk for respiratory failure? A client with cervical sprains A client with a fractured hip A client with Guillain-Barré syndrome A client with breast cancer

A client with Guillain-Barré syndrome Guillain-Barré syndrome is a progressive neuromuscular disorder that can affect the respiratory muscles and cause respiratory failure. The other conditions don't typically affect the respiratory system.

A nurse has been assigned to four clients. Which client should the nurse see first? A client with hemophilia who is receiving acetylsalicylic acid (ASA) for joint pain A client with Hodgkin's lymphoma complaining of fatigue and night sweats A client with systemic lupus erythematosus (SLE) with malar rash on the face A client with rheumatoid arthritis who is receiving adalimumab for inflammation

A client with hemophilia who is receiving acetylsalicylic acid (ASA) for joint pain A client with hemophilia should be seen first because ASA will increase bleeding. It should not be given to a client with hemophilia. Malar rash or "butterfly" rash is usually seen in clients with SLE. Adalimumab is a tumor necrosis factor (TNF) inhibiting anti-inflammatory drug given to clients with rheumatoid arthritis. A client with Hodgkin's lymphoma is expected to have fatigue and night sweats.

A nurse's initial client assessment indicates probable opioid overdose complicated by alcohol ingestion. What intervention should the nurse perform first? Continue monitoring of vital signs Administer IV fluids Draw blood for a drug screen Administer IV naloxone

Administer IV naloxone If a client has ingested opioids, naloxone would reverse the effects and rouse the client, confirming the assessment of opioid overdose. Intravenous fluids would most likely be administered, but giving IV fluids is not the first action the nurse should take. This client would be closely monitored over a period of several hours to several days. The client should be screened for drugs, but there is not as much urgency around drawing the blood for the drug screen as for administering the naloxone.

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? Perform gastric lavage. Obtain blood work. Administer acetylcysteine. Administer I.V. fluid.

Administer acetylcysteine. If the client is seen within 1 hour of ingestion, activated charcoal can be given to prevent absorption, or gastric lavage can be used. Blood work would be obtained but wouldn't be the first priority. Intravenous fluids would also be administered, but administering ?-acetylcysteine, the specific antidote for acetaminophen poisoning, is the priority.

A client receiving hemodialysis treatments arrives at the hospital with a blood pressure of 200/100 mmHg, a heart rate of 110 bpm, and a respiratory rate of 36 breaths/min. Oxygen saturation on room air is 89%. The client reports shortness of breath, and has + 2 pedal edema. The last hemodialysis treatment was yesterday. Which intervention should be done first? Administer oxygen Elevate the foot of the bed Restrict the client's fluids Prepare the client for hemodialysis

Administer oxygen Airway and oxygenation are always the first priority. Because the client is reporting shortness of breath, and his oxygen saturation is only 89%, the nurse needs to try to increase the partial pressure of arterial oxygen by administering oxygen. The foot of the bed should not be elevated at this time as this may increase venous return to the heart and worsen pulmonary edema. The client is in pulmonary edema from fluid overload and will need to be dialyzed and have fluids restricted.

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 Instruct the client to change their dietary intake Encourage increased fluid intake Instruct the client about relaxation techniques

Administer prescribed analgesics Administering prescribed analgesics to relieve pain would be the priority. The other actions are appropriate measures, but aren't the priority.

A client presents with acute onset chest pain rated as 7/10 radiating to left arm and mid-scapular region, blood pressure of 155/95 mm Hg, heart rate of 98 beats/min, respiratory rate of 22 breaths/min, and an oxygen saturation of 94%. What is the nurse's priority intervention? Apply supplemental oxygen. Administer sublingual nitroglycerin. Conduct a full cardiovascular assessment. Establish intravenous access.

Administer sublingual nitroglycerin. Current best practice guidelines recommend the application of supplemental oxygen in acute coronary syndrome only if the client has an oxygen saturation less than 90% or has other evidence of hypoxia. In this case, the client does not require supplemental oxygen but should receive sublingual nitroglycerin as a priority. Nitroglycerin is a potent vasodilator with its effects greater on veins than arteries. By creating venous pooling, preload is reduced, which decreases myocardial oxygen demand and helps reduce the ischemia and myocardial damage. Once the drug is administered, the nurse can continue with other interventions, such as establishing IV access or continuing to gather assessment data. The nurse will recheck the client's response and blood pressure 5 minutes after administering the nitroglycerin and base further actions on the client's response.

A client with a pulmonary embolism is experiencing chest pain and apprehension. What is the nurse's priority intervention? Providing emotional support Administering ordered analgesic Using visual guided imagery Positioning the client on the left side

Administering ordered analgesic Once a pulmonary embolism has been diagnosed and the amount of hypoxia determined, chest pain and the accompanying apprehension can be treated with analgesics as long as respiratory status isn't compromised. Guided imagery and emotional support can be used in conjunction with pain medication. Positioning the client on his left side when a pulmonary embolism is suspected may prevent a clot from breaking off and traveling through the heart into the arterial circulation.

What is the priority nursing intervention for a client experiencing a myocardial infarction (MI)? Obtaining an electrocardiogram (ECG) Administering sublingual nitroglycerin Administering morphine Administering oxygen

Administering oxygen Administering supplemental oxygen to the client is the priority of care. The myocardium is deprived of oxygen during an infarction, so additional oxygen is administered to assist in oxygenation and prevent further damage. Morphine and sublingual nitroglycerin are also used to treat MI, but are commonly administered after oxygen. An ECG is the most common diagnostic tool used to evaluate MI.

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? A middle-age man with a basal metabolic rate within normal limits A middle-age woman who delivers mail An elderly woman who is sedentary A young adult who plays basketball regularly

An elderly woman who is sedentary The risk for developing type 2 diabetes mellitus is increased in clients over 65 years of age. Maintaining a normal weight and basal metabolic rate, along with exercise decrease the risk. The risk is increased with a lack of exercise.

A male neonate has just been circumcised. Which nursing intervention is part of the initial care of a circumcised neonate? Keep a bandage on the site for 24 to 48 hours. Change the diaper as needed. Apply petroleum jelly to the site for 24 to 48 hours. Wash the circumcised penis with warm water.

Apply petroleum jelly to the site for 24 to 48 hours. Petroleum jelly should be applied to the site for the first 24 to 48 hours to prevent the skin edges from sticking to the diaper. A gauze or other type of bandage may or may not be used. Washing the area with warm water is indicated, but is not part of the initial care.

What is the priority nursing measure for a client with von Willebrand's disease who is having epistaxis? Avoid packing the nostrils. Lay the client supine. Apply a warm cloth to the bridge of the nose. Apply pressure to the nose.

Apply pressure to the nose. Applying pressure to the nose may stop the bleeding because most bleeds occur in the anterior part of the nasal septum. Pressure should be maintained for at least 10 minutes to allow clotting to occur. Mouth breathing should be encouraged until the bleeding is under control. The child should be instructed to sit up and lean forward to avoid aspiration of blood. Packing with tissue or cotton may be used to help stop bleeding if applying pressure is unsuccessful, but care must be taken while removing packing to avoid dislodging the clot. Applying heat to the face would dilate blood vessels and increase the bleeding.

The nurse assesses a school-age child in the emergency department and finds a respiratory rate of 52 breaths/min, accessory muscle use, wheezing, and an oxygen saturation of 87% on room air. What action will the nurse take first? Ask the parents about the child's medical conditions. Apply supplemental oxygen. Give albuterol (salbutamol) by nebulizer as prescribed. Initiate continuous cardiac monitoring.

Apply supplemental oxygen. A client in respiratory distress with a saturation lower than 90% needs to have supplemental oxygen placed immediately, followed by initiation of cardiac monitoring. The other interventions follow these actions.

During assessment, a client verbally rates pain as 9 out of 10 on a 0-10 pain scale. There is no indication of pain relief, even though the previous nurse signed for an opioid for this client one hour prior. The client denies receiving anything for pain since the previous night. Which action should the nurse take next? Approach the nurse who signed for the opioid to seek clarification about the missing drug. Notify the supervisor that the client did not receive the prescribed pain medication. Notify the health care provider that the client is confused and pain is poorly controlled. Notify the pharmacist that the client did not receive the prescribed pain medication.

Approach the nurse who signed for the opioid to seek clarification about the missing drug. The nurse should not assume the client is confused but should instead investigate why the pain is poorly controlled. Given the scenario, the nurse needs to rule out the possibility that the other nurse has signed for a medication that was not administered. This requires asking the other nurse directly about the situation. Neither the supervisor nor pharmacist should be involved until after the situation is investigated with the nurse in question.

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?" Arrange for the client to be placed on immediate suicidal precautions Talk to the client to determine whether the client is an attention seeker Speak to family members to ascertain whether the client is suicidal

Ask a direct question such as, "Do you ever think about killing yourself?" The best approach is to ask about thoughts of suicide in a direct and caring manner. Assessing for attention-seeking behaviors doesn't deal directly with the problem. The client should be assessed directly, not through family members. Assessment must be performed before determining whether suicide precautions are necessary.

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? Put the call on hold and find the charge nurse. Signal to staff to close the client's doors. Transfer the call to security. Ask the caller for details about the bomb placement.

Ask the caller for details about the bomb placement. With imminent danger, it is important to determine as much information as possible, as quickly as possible. Transferring the call, or placing the caller on hold could result in a disconnection and loss of information. Clients may need to be evacuated.

A client who developed gestational diabetes mellitus during the pregnancy has just been admitted in the labor and delivery unit. What is the priority nursing action for this client? Prepare the client for cesarean birth. Prepare oral hypoglycemic medications for administration during labor. Notify the neonatal intensive care unit that a client with diabetes has been admitted. Ask the client about her most recent blood glucose levels.

Ask the client about her most recent blood glucose levels. Asking about the client's most recent blood glucose levels will indicate how well her diabetes has been controlled. Oral hypoglycemic drugs are never used during pregnancy because they cross the placental barrier, stimulate fetal insulin production, and are potentially teratogenic. Plans to admit the infant to the neonatal intensive care unit are premature. Cesarean is not the preferred birth method for clients with diabetes. Vaginal birth is preferred and presents a lower risk to the mother and fetus.

A nurse suspects a client is experiencing alcohol withdrawal syndrome. What is the nurse's priority action? Verify the symptoms with family. Tell the client everything will be all right. Ask the client about the client's drinking. Inform social services.

Ask the client about the client's drinking. Confirming suspicions directly with the client is the most reliable way to diagnosis and treat withdrawal symptoms. If the client isn't cooperative, verification can be sought from the family. Social services aren't required at this time, but may be helpful in discharge planning. Giving false reassurance isn't therapeutic for the client.

While performing the morning postpartum assessment, the nurse notices that a client's perineal pad is completely saturated with lochia rubra. What is the nurse's best action? Call the health care provider immediately. Have the charge nurse review the assessment. Ask the client when she last changed her perineal pad. Vigorously massage the fundus.

Ask the client when she last changed her perineal pad. If the morning assessment is done relatively early, it's possible that the client hasn't yet been to the bathroom, and the perineal pad may have been in place all night. In addition, her lochia may have pooled during the night, resulting in a heavy flow in the morning. Vigorous massage of the fundus isn't recommended if heavy bleeding or hemorrhage is present. If the nurse were uncertain, and wanted a second opinion, it would be appropriate to call the health care provider or ask another qualified nurse after doing a complete assessment of the client's status.

The parent of a 2-year-old with epiglottitis states a need to pick up the older child from school. The 2-year-old child begins to cry and appears more stridorous. What is the nurse's priority action? Ask how long the parent will be gone. Tell the 2-year-old child everything will be all right. Tell the 2-year-old child the nurse will stay. Ask the parent if there's anyone else who can meet the older child.

Ask the parent if there's anyone else who can meet the older child. Increased anxiety and agitation should be avoided to prevent airway obstruction. A 2-year-old child fears separation from parents, and the parent should be encouraged to stay. Other means of picking up the older child should be found. Telling the child that everything will be all right may not decrease agitation. The parent is the primary caregiver and important to the child for emotional and security reasons.

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? Immediately contact the provider. Prepare the woman for birth. Ask what time this happened and note the color, amount, and odor of the fluid. Collect a sample of the fluid for microbial analysis.

Ask what time this happened and note the color, amount, and odor of the fluid. Gather more information. Noting the color, amount, and odor of the fluid, as well as the time of rupture, will help guide the nurse in the next action. There's no need to immediately call the client's provider or prepare this client for birth if the fluid is clear and birth isn't imminent. Rupture of membranes isn't unusual in the early stages of labor. Fluid collection for microbial analysis is not routine if there's no concern for infection.

The nurse is assessing a laboring client. The client suddenly screams and exclaims, "My baby is coming." What is the priority action by the nurse? Administer pain medication. Calm the mother. Assess for crowning. Take the fetal heart tones.

Assess for crowning. The priority nursing action is to assess for crowning of the fetus's head, and prepare for an imminent delivery. The other actions do not respond to the possible spontaneous delivery of the fetus.

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. Collect a full set of vital signs and spheres of orientation. Assess the depth and total surface area of burns. Assess the level of pain and medication allergies.

Assess oxygen saturation and the client's ability to speak. The nurse's priority is to make sure the airway is open and that the client is breathing, which would be best accomplished by seeing if the client can speak and what the oxygen saturation is. Vital signs, degree of burns, and the client's pain can all be assessed once the nurse establishes that the client has a patent airway.

The nurse is planning care for an infant with bronchiolitis. What is the nurse's priority intervention for this child? Monitor intake and output. Assess respiratory status frequently. Position the infant with the head elevated. Incorporate parents into the child's care.

Assess respiratory status frequently. Infants with bronchiolitis will have impaired gas exchange related to bronchiolar obstruction, atelectasis, and hyperinflation. Changes in respiratory status may occur quickly as energy reserves are depleted; therefore, close monitoring is essential. Positioning the infant, monitoring fluid status, and including parents in care plan are necessary, but not the priority.

A client is undergoing peritoneal dialysis. The dialysate dwell time is completed, and the clamp is opened to allow the dialysate to drain. The nurse notes 1,500 ml was instilled, but only 500 ml has drained. Which intervention should be done first? Call the health care provider. Clamp the catheter and instill more dialysate at the next exchange time. Change the client's position. Assess the catheter for kinks or obstruction.

Assess the catheter for kinks or obstruction. The first intervention should be to check for kinks or obstructions because that could be preventing drainage. After checking for kinks, the client should change position to promote drainage. Don't give the next scheduled exchange until the dialysate is drained because abdominal distention will occur, unless the output is within the parameters set by the health care provider. If unable to get more output despite checking for kinks and changing the client's position, the nurse should then call the health care provider to determine another intervention.

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? Establish intravenous access, and provide supplemental oxygen. Interview the parents about the initial onset of symptoms. Ask the parents what they think the child ingested. Assess the child's vital signs and neurological status.

Assess the child's vital signs and neurological status. The nurse must assess the child to determine if life-saving intervention such as cardiopulmonary resuscitation is needed. This assessment will direct all the subsequent actions, such as the application of oxygen and intravenous fluids. The parents have indicated the source of suspected poisoning is unknown, so although interviewing them to try to determine the possible source and the initial symptoms should be done, the nurse must first assess and stabilize the child.

An adolescent female client reports a low-grade fever; lower abdominal pain; and frequent, painful urination. What is the nurse's priority action? Educate the client about the prevention of sexually transmitted infections (STIs). Refer the client to be assessed for HIV. Inspect the client's vulva for the presence of chancres. Assess the client for additional signs and symptoms of pelvic inflammatory disease (PID).

Assess the client for additional signs and symptoms of pelvic inflammatory disease (PID). PID is an infection of the upper female genital tract, most commonly caused by STIs. Chancres are associated with syphilis, which is not a common cause of PID. Similarly, HIV does not normally cause PID. Education is important, but assessment and treatment are short-term priorities.

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? Draw blood for laboratory analysis Initiate cardiac monitoring Administer oxygen via nasal cannula Assess the client's vital signs

Assess the client's vital signs Assessing vital signs would determine this client's hemodynamic stability. Monitoring the heart rhythm may be indicated based on assessment findings. Administering oxygen and drawing blood require a health care provider's order, and would not be part of a screening evaluation.

After undergoing a cardiac catheterization, a client has a large puddle of blood under his buttocks. What is the nurse's priority action? Ask the client to "lift up" Assess the groin site Call for help Obtain vital signs

Assess the groin site Assessment of the groin site is the priority. This establishes the source of the blood, and determines how much blood has been lost. The goal is to stop the bleeding. The nurse would call for help if needed after the assessment of the situation. After determining the extent of the bleeding, vital sign assessment is important. The nurse should never move the client, in case a clot has formed. Moving can disturb the clot and cause re-bleeding.

A 49-year-old client is admitted to the emergency department frightened and reporting hearing voices telling the client to do bad things. Which intervention should be the nurse's priority? Assess the nature of the commands by asking what the voices are saying. Provide reassurance that the client is safe and promise the staff will protect the client. Administer a neuroleptic medication before speaking with the client. Provide reassurance that the client is safe and the voices are not real.

Assess the nature of the commands by asking what the voices are saying. Safety is the priority. The nurse should ask the client directly about the nature of the auditory commands to ensure the safety of the client and staff. The nurse should never make promises to the client that the nurse may not be able to fulfill. The provider may order a neuroleptic, but the nurse's priority is to address safety.

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. Encourage the client to discuss the delusions. Call the healthcare provider. Administer an anticholinergic medication.

Assess the physical problems. Clients with schizophrenia generally have poor visceral recognition because they live so fully in their fantasy world. They need to have an in-depth assessment of physical complaints that may spill over into their delusional symptoms. Talking with the client won't provide an assessment of the itching, and itching isn't an adverse reaction of antipsychotic drugs. The client's provider should be called if the assessment warrants.

The nurse is caring for a client who has just undergone electroconvulsive therapy (ECT) for the treatment of severe depression that is unresponsive to medication. What is the nurse's most important intervention immediately postprocedure? Assess vital signs. Reorient the client to the environment. Provide oral fluids. Administer analgesics.

Assess vital signs. ECT is performed under sedation, so vital signs are monitored carefully for approximately one hour after the procedure or until the client is stable. The client should not have anything by mouth and will take time to awaken enough to require orientation to the environment. Analgesia should not be needed immediately postprocedure, because the client will not yet be conscious.

The nurse is caring for a client in the post anesthesia care unit (PACU) following an adrenalectomy. What is the nurse's priority action? Administering dextrose in water Administering opioids Assessing blood pressure Assessing serum potassium

Assessing blood pressure Removing a major source of adrenal hormones may cause a state of temporary adrenal insufficiency. After an adrenalectomy, the patient is usually sent to a critical care unit. Immediately after surgery, the patient should be assessed every 15 minutes for shock due to possible insufficient glucocorticoid replacement. Assessment is a priority over interventions. Assess the blood pressure, then electrolytes, and finally assess the client for fluid replacement and pain management needs.

A client with alcohol withdrawal syndrome is pulling at the central venous catheter, saying, "I'm swatting the spiders crawling all over me." What is the nurse's priority action? Encourage the client to rest. Tell the client there are no spiders. Explain that the client is pulling the I.V. tubing. Assign a nursing assistant to stay with the client.

Assign a nursing assistant to stay with the client. During periods of alcohol withdrawal syndrome, the client needs to be protected from harm. If the client dislodges the central venous catheter, an air embolus may develop, which can be life threatening. Although reality should be presented to the client, explaining that there are no spiders and that the I.V. tubing is being pulled may not make the client stop; therefore, the client's safety is still at risk. The client may need to be restrained if continued observation during this time isn't available. The client should also be encouraged to rest; however, this intervention doesn't take priority over safety.

What is the priority nursing action for a client with generalized anxiety disorder who is working to develop coping skills? Monitor the client for overt and covert signs of anxiety Determine whether the client has fears or obsessive thinking Assist the client to identify coping mechanisms used in the past Teach the client how to use effective communications skills

Assist the client to identify coping mechanisms used in the past To help a client develop effective coping skills, the nurse must know the client's baseline functioning. Determining whether the client has fears or obsessive thinking, monitoring for signs of anxiety, and teaching about effective communications skills are later priorities.

A child with Wilms' tumor has had a kidney removed, and is now receiving chemotherapy. What priority information should the nurse share with this child's family at the time of discharge? Limit fluid intake as ordered. Decrease sodium intake. Avoid contact sports. Avoid contact with other children.

Avoid contact sports. Because the child has only one kidney, certain precautions are recommended to prevent injury to the remaining kidney. Fluid intake is essential for renal function, and should not be decreased. The child's sodium intake shouldn't be reduced. Avoiding other children is unnecessary, may make the child feel self-conscious, and may lead to regressive behavior.

What is the nurse's priority to regulate the temperature of a neonate? Block radiant, convective, conductive, and evaporative losses. Keep the ambient room temperature less than 100° F (37.8° C). Minimize the energy needed for the neonate to produce heat. Supply extra heat sources to the neonate.

Block radiant, convective, conductive, and evaporative losses. Prevention of heat loss is always the first goal in thermoregulation to avoid hypothermia. The second goal is to minimize the energy necessary for neonates to produce heat. Adding extra heat sources is a means of correcting hypothermia. The ambient room temperature should be kept at approximately 100° F (37.8° C).

The nurse is preparing to assess a child with a possible cardiac anomaly. What is the priority assessment for this nurse? Skin turgor Pupil size and reaction to light Temperature Blood pressure in all four extremities

Blood pressure in all four extremities Measuring blood pressure in all four extremities is necessary to document hypertension and the blood pressure gradient between the upper and lower extremities. Temperature, skin turgor, and pupillary assessment are also important, but are not as specific for cardiac assessment as the blood pressure.

The nurse is preparing to feed an infant diagnosed with pyloric stenosis prior to surgical repair. What is the nurse's most important intervention? Encourage parental participation. Give feedings quickly. Don't give more feedings if the infant vomits. Burp the infant frequently.

Burp the infant frequently. These infants usually swallow a lot of air from sucking on their hands and fingers because of their intense hunger. Burping frequently will reduce gastric distention, and increase the likelihood that the infant will retain the feeding. Feedings should be given slowly with the infant lying in a semi-upright position. Parental participation should be encouraged to the extent possible, but this will not increase the likelihood that the feeding will be retained. Record the type, amount, and character of the vomit, as well as its relation to the feeding. The amount of feeding volume lost is usually refed to the infant.

A new mother states, "My baby spits up after every feeding." Which interventions should the nurse teach to this mother first? Elevate the head of the crib to 30°. Feed the baby smaller, more frequent feedings. Change the infant to a soy formula. Burp the infant more frequently during each feeding.

Burp the infant more frequently during each feeding. Frequent burping decreases the amount of air the infant has in the stomach and should be the first intervention. Feeding smaller portions more frequently may help if the infant is taking large amounts. Infants should be fed every 2 to 4 hours. Elevating the head of the bed 30° may help if the cause is gastroesophageal reflux. Formula may have to be changed if it is determined that the spitting is related to milk intolerance.

A client with an arm cast reports severe pain in the affected extremity, and decreased sensation and motion. Swelling in the fingers is also increased. What is the priority nursing intervention? Give an analgesic. Elevate the arm. Remove the cast. Call the health care provider.

Call the health care provider. The cast may be too tight and may need to be split or removed by the health care provider. The arm should already be elevated. Notify the health care provider if circulation, sensation, or motion are impaired. Giving analgesics wouldn't be the first step as they may mask the signs of a serious problem.

A physical therapist has instructed the nursing staff on how to perform range-of-motion (ROM) exercises for an infant with torticollis. The nurse is uncomfortable when the infant cries and grimaces during the exercises. What is the most important action for the nurse to take? Discontinue the exercises. Call the primary health care provider. Call the physical therapist. Check the primary health care provider's orders.

Call the physical therapist. The only cure for the torticollis is exercise or surgery. The physical therapist is the expert in exercise and should be called for assistance in this situation. The primary health care provider should only be called if there is concern over the orders written, or an abnormal development in the child.

Which nursing intervention is a priority for an infant during the first 24 hours following surgery for cleft lip repair? Position the infant in the prone position after feedings to promote drainage. Encourage the infant to use a pacifier to satisfy the urge to suck. Allow the infant to cry to promote lung expansion. Carefully clean the suture line after feedings to reduce the risk of infection.

Carefully clean the suture line after feedings to reduce the risk of infection. The suture line must be carefully cleaned with a sterile solution after each feeding to reduce the risk of infection, which could adversely affect the healing and cosmetic results. The infant shouldn't be placed in the prone position, because this puts pressure on the incision and may affect healing. Anticipatory care should be provided to reduce the risk of the infant crying, which puts strain on the incision. Pacifiers and other firm objects should not be placed in the infant's mouth because they can disrupt the suture line.

What is the most important intervention for the nurse to implement while caring for a neonate with an omphalocele? Cover the omphalocele when parents visit. Keep the omphalocele dry. Gently palpate the omphalocele to assess for changes. Carefully position and handle the omphalocele.

Carefully position and handle the omphalocele. Careful positioning and handling prevents infection and rupture of the omphalocele. The omphalocele should be kept moist until the neonate is taken to the operating room. The parents can see the defect if they so choose. Palpation of the omphalocele increases the risk of rupture and infection.

The nurse is caring for a client with type 1 diabetes mellitus. At 0300, the nurse finds the client disoriented to time and place, diaphoretic, and reports palpitations. What is the nurse's priority intervention? Give 10 to15 g of carbohydrate orally. Administer 1 mg of glucagon subcutaneously. Call the healthcare provider for additional insulin order. Check blood glucose level.

Check blood glucose level. Check the blood glucose level first when symptoms arise, then proceed with treatment according to the results. If the client is hypoglycemic, administration of a simple carbohydrate is appropriate. If the client is conscious, the carbohydrate may be given orally. If consciousness is altered, subcutaneous or intramuscular glucagon is appropriate. This client is showing symptoms of hypoglycemia, additional insulin would further lower the blood glucose.

The nurse is assessing a client's chest tube and notes that it is not working properly. What is the nurse's priority action? Check for disconnection of the tubing from the drainage unit Submerge the end of the chest tube in one inch of sterile water Clean the tips of the tubing and reconnect securely Check patency of the chest tube

Check patency of the chest tube The most important action is to determine the patency of chest tube. Checking for a disconnection would be nurse's next action. Submerging the end of the chest tube in one inch of sterile water would only be necessary if the tube was disconnected and a chest drainage system was not available. Cleaning the tips of the tubing and reconnect securely would be necessary if the tube had become disconnected.

A school-age child with a dog bite is brought to the emergency department by the parents. What is the nurse's priority action? Interview the parents about the incident. Clean and irrigate the bite wounds. Determine the child's vaccination history. Notify the health care provider for antibiotic prescription.

Clean and irrigate the bite wounds. Not every dog bite requires antibiotic therapy, but cleaning the wound is necessary for all injuries involving a break in the skin. Rabies vaccine is used if there is suspicion that the dog has rabies. The infection rate for dog bites has been reported to be as high as 50%.

The nurse is delegating activities to a recently graduated licensed practical/vocational nurse (LPN/VN) at a skilled nursing facility. Which activities are appropriate to delegate to the LPN/VN? Select all that apply. Cleansing a leg wound and applying antibiotic ointment. Assisting an unlicensed assistive personnel (UAP) with a weight. Administering intravenous sedation. Completing an admission body assessment. Recording percentage of meal completion.

Cleansing a leg wound and applying antibiotic ointment. Recording percentage of meal completion. Assisting an unlicensed assistive personnel (UAP) with a weight. According to the LPN/VN scope of practice, the LPN/VN can cleanse a leg wound and apply antibiotic ointment, record percentage of meal completion, and assist a UAP with weighing a client. The scope of practice of a LPN/VN varies by state, but it usually does not include administering an intravenous medication unless the nurse has obtained a certification establishing competency with IV medication administration. Even then, administering a sedative may be outside the scope of practice. An admission body assessment must be performed by an RN.

A 9-year-old is brought to the emergency department with extensive burns sustained in a restaurant fire. What is the nurse's most important intervention? Administer liquids orally to replace lost fluid. Administer prescribed antibiotics to prevent superimposed infections. Conduct a wound assessment. Administer frequent, small meals to support nutritional requirements.

Conduct a wound assessment. The most important aspect of care for a child with burns is wound management. The goals of wound care are to speed debridement, protect granulation tissue and new grafts, and conserve body heat and fluids. Antibiotics aren't always administered prophylactically. Fluids are administered I.V. to replace fluid volume according to the child's body weight. Enteral feedings, rather than meals, are initiated within the first 24 hours after the burn to support the child's increased nutritional requirements.

The nurse is providing care to a client with Alzheimer's-type dementia. Which nursing intervention is the priority? Establish a routine that reinforces memories and supports former habits. Maintain an environment with cheerful and pleasant surroundings. Control the environment by providing structure and consistent boundaries. Structure a daily and precise routine that can be used after discharge.

Control the environment by providing structure and consistent boundaries. By controlling the environment and providing structure and consistent boundaries, the nurse is helping to keep the client safe and secure. Establishing a routine that reinforces memories, supports former habits, maintains pleasant surroundings, and structures a daily routine fosters a supportive environment; however, keeping the client safe and secure is the priority.

A preschool-age child has just been admitted to the pediatric unit with a diagnosis of bacterial meningitis. What is the nurse's priority intervention? Decrease environmental stimulation. Monitor temperature every 4 hours. Encourage the parents to hold the child. Assess LOC every 12 hours.

Decrease environmental stimulation. A child with the diagnosis of meningitis is more comfortable in an environment with decreased stimuli. Noise and bright lights would stimulate this child and cause the child to cry, in turn, increasing intracranial pressure. Vital signs should be assessed initially every hour and temperature monitored every 2 hours. Neurological signs should be assessed according to the child's condition, but more frequently that every 12 hours. Children are usually much more comfortable if allowed to lie flat because this position reduces meningeal irritation.

A postpartum mother is concerned about a noted decrease in her breast milk production. Which response by the nurse best addresses this mother's concern? Feed the infant less frequently. Have several alcoholic beverages for relaxation. Suggest the mother consume a diet high in vitamin C. Decrease supplemental feedings with formula.

Decrease supplemental feedings with formula. Routine formula supplementation may interfere with establishing an adequate milk volume because suckling the breast stimulates prolactin production. Prolactin is the hormone responsible for milk production. Vitamin C levels haven't been shown to influence milk volume. One alcoholic beverage generally tends to relax the mother, and facilitate the milk let-down reflex. Excessive consumption of alcohol may block milk let-down, though supply isn't necessarily affected. Frequent feedings are likely to increase milk production.

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? Place the fully clothed client in a shower for decontamination. Determine what decontamination measures took place in the field before approaching the client. Cut off the client's clothing and dispose of it in hazardous waste containers. Discharge or admit all current clients in the emergency department.

Determine what decontamination measures took place in the field before approaching the client. During a disaster the nurse's priority is personal safety. Determining what decontamination measures have already taken place will inform the nurse of necessary precautions. The nurse should not cut off the clothing or place the client in the shower until an assessment of the hazardous material has been completed. Containing the exposed clients in one area, free from other clients, is important, but the safety of the healthcare workers is the priority.

While assessing a 2-hour-old neonate, a nurse observes the neonate to have acrocyanosis. Which nursing action should be performed first? Give the baby a warm bath. Do nothing different because acrocyanosis is normal in the early neonatal period. Take the neonate's temperature according to facility policy. Notify the health care provider of the need for a cardiac consult.

Do nothing different because acrocyanosis is normal in the early neonatal period. Acrocyanosis, or bluish discoloration of the hands and feet in the early neonatal period is a normal finding and should not last more than 24 hours after birth. The other choices are inappropriate for this condition.

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? Assess the client's knowledge of hormonal contraceptives. Educate the client about the accompanying risk of cervical cancer. Assess the client for signs and symptoms of systemic infection. Educate the client about the need to adhere to antibiotic therapy.

Educate the client about the accompanying risk of cervical cancer. This client's external lesions should be treated, and she should receive education regarding the relationship between HPV and cervical cancer. Antibiotics would be ineffective because of the viral etiology of HPV. Hormonal contraceptives are of no benefit, and HPV is not normally the cause of systemic infection.

A client requests help developing a plan to stop drinking 10 12-ounce cups of coffee a day. Prioritize the interventions that will help this client decrease caffeine intake. All options must be used.

Educate the client about the signs and symptoms of caffeine withdrawal. Address how to handle uncomfortable feelings that may occur. Discuss how physiologic discomfort and other health conditions can increase the risk of injury. Reinforce the need to obtain assistance when a relapse is imminent. First, educate the client about the signs and symptoms of caffeine withdrawal. Next, address how to handle uncomfortable feelings that may occur. Then, discuss how physiologic discomfort and other health conditions can increase the risk of injury. Lastly, reinforce the need to obtain assistance when a relapse is imminent.

A client with acute renal failure has a serum potassium level of 7.0 mEq/L (mmol/L). What is the nurse's priority action for this client? Urine specific gravity Blood pressure Mental status Electrocardiogram (ECG) results

Electrocardiogram (ECG) results Acute renal failure can result in hyperkalemia, which can manifest in widening of the PR and QRS intervals on the ECG as well as irregular heartbeats, such as premature ventricular contractions. Urine specific gravity, mental status, and blood pressure are not a priority for this client.

A child with hemophilia is hospitalized with bleeding into the knee. Which action should the nurse take first? Elevate the affected part. Prepare to administer a whole blood transfusion. Prepare to administer a plasma transfusion. Perform active range-of-motion (ROM) exercise on the affected part.

Elevate the affected part. Bleeding into the joint is the most common type of bleeding episode in the more severe forms of hemophilia. Elevating the affected part and applying pressure and cold are indicated. The nurse should anticipate transfusing the missing clotting factor rather than whole blood or plasma, which wouldn't stop the bleeding promptly and could pose a risk of fluid overload. Active ROM exercises are contraindicated because they may cause more bleeding, injury, and pain.

The nurse is caring for a client with functional neurologic symptom disorder who has experienced pseudoseizures. What intervention is appropriate for the nurse to perform? Encourage the client to discuss feelings about the pseudoseizures. Ignore the client's pseudoseizures to prevent reinforcement. Administer a placebo as prescribed by the health care provider. Explain to the client that the pseudoseizures are not real seizures.

Encourage the client to discuss feelings about the pseudoseizures. Pseudoseizures or psychogenic nonepileptic seizures are considered a psychological symptom and are not related to electrical disturbance in the central nervous system as epileptic seizures are. However, they are a serious disorder and should not be minimized to the client by the nurse. Cognitive behavioral therapy is a primary intervention and requires open dialogue between the client and nurse so the client should be encouraged to verbalize feelings. Placebo administration is unethical, and the nurse should not participate in this intervention. While the nurse should remain calm and not draw excessive attention to the client during a pseudoseizure, the nurse should not ignore the client outright.

A married male client is admitted to the psychiatric unit. During the nurse's interview the client states, "I cannot live this lie anymore. I wish I were a woman. I cannot live one more day feeling this way." What is the nurse's priority intervention? Call the primary health care provider. Initiate suicide precautions to ensure safety. Encourage the client to talk about his feelings. Encourage the client to tell his partner.

Encourage the client to talk about his feelings. This client reveals that he is under severe stress with potential suicidal ideation that needs to be further explored. The nurse should establish if the client has a plan for self-harm that would warrant suicide precautions prior to imitating these precautions. Discussions should not focus on gender conflict issues, because these are more long term and cannot be quickly assessed or resolved. The primary health care provider should not be notified until an assessment is completed. The client should not speak to his partner until he has processed his feelings and is ready to face the associated challenges.

A child is newly diagnosed with neonatal bronchopulmonary dysplasia (chronic lung disease). Which intervention should the nurse perform first to help the parents? Teach cardiopulmonary resuscitation. Refer them to support groups. Help parents identify necessary lifestyle changes. Evaluate and assess parents' stress and anxiety levels.

Evaluate and assess parents' stress and anxiety levels. The emotional impact of neonatal bronchopulmonary dysplasia (chronic lung disease) is a crisis situation. The parents are experiencing grief and sorrow over the loss of a healthy child. In addition to evaluating the parent's current stress and anxiety level, it is also helpful to assess their previous coping strategies. The other strategies are more appropriate for long-term intervention.

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. Look inside the child's mouth for a foreign object. Perform abdominal thrusts. Attempt a blind finger sweep.

Give five back blows and five chest thrusts. Because this infant is not coughing or making sounds, the infant has a severe foreign body airway obstruction. Because the infant is still conscious, the nurse should immediately begin giving five back blows followed by five chest thrusts, in a repeated cycle, in an attempt to dislodge the object and open the airway. Abdominal thrusts should not be performed because they can damage an infant's liver. After the airway is open, the nurse should check for a foreign object and remove it with a finger sweep if it can be seen. A blind finger sweep should never be performed because it may push the object further into the airway. If the infant loses consciousness, the nurse should begin CPR.

A parent calls the health clinic and tells the nurse that the toddler was found with an open and empty bottle of acetaminophen. The parent asks the nurse what to do. What is the nurse's priority intervention? Determine whether the parent knows cardiopulmonary resuscitation (CPR). Tell the parent to get the child to drink a glass of milk. Have the parent give the child syrup of ipecac. Give the parent instructions on how to call poison control.

Give the parent instructions on how to call poison control. The parent should call poison control and ask what immediate steps should be taken to treat this ingestion. Home administration of syrup of ipecac is no longer recommended. Milk is not an antidote for acetaminophen toxicity. Asking about CPR is not appropriate since it would distract from the immediate interventions needed.

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. Prepare to administer insulin for prevention of hyperglycemia. Notify pharmacy to prevent additional preparation of the expensive fluid. Prepare to infuse a glucose solution after discontinuing the TPN.

Gradually reduce the rate of the TPN per health care provider order. Gradually reducing the rate will avoid a sudden loss of the highly concentrated solution of amino acids, glucose, and other nutrients, and allow the child's body to adapt. Infusing a glucose solution after discontinuing TPN is not necessary when the infusion rate has been tapered. A glucose solution may need to be infused if discontinuation was sudden to avoid an abrupt drop in blood glucose. Administering insulin after discontinuing TPN would result in hypoglycemia. The pharmacy should be notified so that additional TPN is not prepared, but that is not a priority nursing action.

A child with type 1 diabetes mellitus reports feeling shaky. The child's skin is pale and sweaty. What is the nurse's priority intervention? Have the child eat a glucose tablet. Offer the child a complex carbohydrate snack. Give supplemental insulin per order. Administer intravenous dextrose.

Have the child eat a glucose tablet. These symptoms are indicative of hypoglycemia. If a client is fully conscious and able to drink and swallow safely, a rapidly absorbed carbohydrate such as glucose tablets, glucose gel, table sugar, or fruit juice should be given by mouth. This will result in a rapid increase in blood glucose. Giving supplemental insulin would lower the blood glucose. Dextrose should be given only if there is a risk of aspiration with oral glucose. Complex carbohydrates should not be the initial treatment, because these take too long to be absorbed. After the symptoms of hypoglycemia have resolved, the child should be given a snack of complex carbohydrates and protein to prevent recurrence. Ideally, the nurse monitors treatment with a glucometer.

A client is scheduled for amniocentesis. What priority intervention should the nurse implement? Instruct the client to fast for 12 hours. Have the client void. Place the client on her left side. Tell the client to drink 34 oz (1 L) of water.

Have the client void. Before amniocentesis, the client should empty the bladder which reduces the risk of bladder perforation. This client doesn't need to drink fluids or fast before amniocentesis. A client would be placed in a supine position for an amniocentesis.

The nurse is caring for a 3-year-old with acute lymphocytic leukemia and notes that the child has a decreased appetite. What is the priority nursing intervention? Have the dietician meet with the child and family to provide foods the child will eat. Provide oral hygiene after eating. Encourage the child to eat all of the meal to get adequate nutrition. Refrain from serving snacks as requested.

Have the dietician meet with the child and family to provide foods the child will eat. The dietician should be involved to help determine foods appropriate for children in different age groups. The child and family should help select preferred foods and identify cultural beliefs and dining habits. Take advantage of a hungry period and serve small snacks. Encourage parents to relax pressures placed on eating by stressing the legitimate nature of loss of appetite. The other responses do not help to stimulate the child's appetite.

A nurse is working with a client on recognizing the relationship between alcohol use and interpersonal problems. What is the nurse's priority intervention for this client? Have the client identify compulsive behaviors. Encourage the client's use of defense mechanisms. Help the client recognize personal strengths. Have the client work with peers who can serve as role models.

Help the client recognize personal strengths. The client's outcomes are best promoted if the nurse engages the client from a strengths-based approach. Defense mechanisms can impede the development of healthy relationships and cause the client pain. Compulsive behavior doesn't tend to be a problem for alcoholic clients who struggle with interpersonal problems. Working with peers who are role models would be useful after the client recognizes and gains some insight into the problems.

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 How to treat respiratory infections without the use of antibiotics How to recognize when a change in his oxygen therapy is needed How to assess his own pulse and respiratory rates

How to recognize the signs of an impending respiratory infection Respiratory infection, in clients with a respiratory disorder, can be fatal. It's important that this client understands how to recognize the signs and symptoms of an impending respiratory infection. It isn't appropriate to teach this client how to listen to his own lungs or change his oxygen therapy regimen. If this client has signs and symptoms of an infection, he should contact his health care provider immediately.

The nurse notes what appears to be a ventricular fibrillation rhythm on a client's telemetry monitor. What should the nurse do first? Prepare an intravenous dose of epinephrine. Prepare for immediate cardiac defibrillation. Call for the emergency response team. Immediately assess the client's level of consciousness.

Immediately assess the client's level of consciousness. Before taking any action, the nurse needs to confirm the accuracy of the telemetry reading. The nurse first assesses the client. If in ventricular fibrillation, the cardiac output drops rapidly and the client will lose consciousness. If the client is conscious and asymptomatic, the nurse needs to assess for reasons for artifact and adjust the client's telemetry leads. The other actions may be taken once the nurse confirms accuracy of the reading, beginning with calling the emergency response team (i.e., calling a code blue). The nurse will initiate cardiopulmonary resuscitation after calling the code. Once the team arrives, interventions such as defibrillation and medications will be administered.

A client who is experiencing thoughts of self-harm is brought to the crisis response center by family members. Which action is most important for the nurse to implement? Implementing suicide precautions. Establishing trust with client. Assessing for auditory hallucinations. Teaching relaxation techniques.

Implementing suicide precautions. A client who reports thoughts of self-harm should be placed on suicide precautions. Though it is important to establish trust with the client, the nurse must prioritize client safety. Assessments and other interventions can be performed once suicide precautions are established.

A client in early labor tells the nurse that she has a thick, yellow discharge from both of her breasts. What is the nurse's most appropriate intervention? Inform the client that the discharge is colostrum, and a normal finding. Tell her that her milk is starting to come in because she's in labor. Perform a culture on the discharge, and inform the client that she might have mastitis. Complete a thorough breast examination and document the results in the chart.

Inform the client that the discharge is colostrum, and a normal finding. After the fourth month, colostrum may be expressed. The breasts normally produce colostrum for the first few days after birth. Milk production begins one to three days postpartum. A clinical breast examination isn't usually indicated in the intrapartum setting. Although a culture may be indicated, it requires advanced assessment as well as a medical order.

A client reports an inability to sleep while on the medical unit. Which intervention should the nurse perform first? Inquire about the client's sleeping habits. Offer a sedative routinely at bedtime. Give the client a backrub before bedtime. Move the client to a bed farthest from the nurses' station.

Inquire about the client's sleeping habits. Assessing the client's sleeping habits may provide information about the causes of the inability to sleep. Sedatives should be given as a last option. A backrub may promote sleep but may not address this client's problem. Moving the client may not address the client's specific problem.

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? Notify the health care provider. Inquire how these bruises occurred. Notify the nursing supervisor. Document the findings.

Inquire how these bruises occurred. The nurse should obtain more information from the client first, in order to complete the initial assessment. The nurse should not assume that the bruises are a result of abuse, and she should not notify the nursing supervisor until additional facts are obtained. The nurse should inform the provider so an examination can be completed. She should follow the facility's policy and procedure for reporting abuse and document the findings.

Which nursing intervention is essential while caring for an infant with cleft lip or palate? Choose a regular nursery nipple for feedings. Involve the parents in feeding as soon as possible. Avoid encouraging breastfeeding. Cradle the infant horizontally while feeding.

Involve the parents in feeding as soon as possible. The sooner the parents become involved, the quicker they're able to determine the method of feeding best suited for them and their infant. Breastfeeding, like bottle feeding, may be difficult but can be facilitated if the mother is supported in this decision. If the cleft isn't severe, breastfeeding may be easier than other feeding techniques because the human nipple conforms to the shape of the infant's mouth. Feedings are usually given in the upright position to prevent formula from coming through the nose. Various special nipples have been developed for infants with cleft lip or palate. A regular nursery nipple is not effective.

A nurse is preparing a client for cardiac catheterization. What is the nurse's priority assessment? Known allergies Weight and height Cardiac rhythm Apical heart rate

Known allergies Since cardiac catheterization involves the injection of a radiopaque dye. It is most important for the nurse to determine if this client has allergies to iodine or shellfish. The other three parameters are also part of the assessment, but are not the priority.

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. Put the client in a semi-Fowler's position. Ask the client to push with the next contraction. Leave the client and call the provider.

Leave the fingers in place and press the nurse call light. When the umbilical cord precedes the fetal presenting part, it's known as a prolapsed cord. Leaving the fingers in place and calling for assistance is the safest intervention for the fetus. The nurse will need to keep the fetus off the cord to reduce cord compression. The nursing staff will contact the provider, and the client will probably require a cesarean birth to decrease the risk of fetal demise during birth. Placing the client in the semi-Fowler's position would increase the pressure of the fetus on the umbilical cord. Asking the client to push with the next contraction would force the presenting part against the cord, causing severe bradycardia and possible fetal demise.

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? Push the call light and ask for help. Hold the child down to prevent injury. Loosen any restrictive clothing. Force the jaw open to maintain an open airway.

Loosen any restrictive clothing. The primary nursing goal during a seizure is to protect the client from physical injury and maintain a patent airway. Loosening clothing, especially around the neck, will allow free movement and aid in keeping the airway open. Other priority interventions to prevent injury are raising bed rails if the client is in bed or easing the client to the floor and place a soft object under the head. After making sure the client is safe from injury, the nurse should push the call light if further assistance is needed. The nurse should never forcibly hold a client down, since the force of the child's movements against restraint could cause muscle strain or even joint dislocation. The nurse also should not force the jaw open.

A client has received an infusion of antibiotics and is now experiencing an anaphylactic reaction. What is the most important intervention by the nurse? Monitor vital signs. Maintain a patent airway. Administer a bolus of normal saline solution. Administer epinephrine.

Maintain a patent airway. The first priority is to maintain a patent airway. The client will then require an epinephrine injection. If hypotension develops, a saline bolus may be given. The client's vital signs should be monitored, but not as the first action.

The nurse is caring for a client with diabetes insipidus (DI). What is the nurse's priority intervention? Watching for signs and symptoms of septic shock Monitoring urine for specific gravity >1.030 Checking weight every three days Maintaining adequate hydration

Maintaining adequate hydration Maintaining fluid intake is essential in a client with DI. The client is at risk for developing hypovolemic shock because of increased urine output. Weight should be measured daily to monitor fluid balance. Urine specific gravity should be monitored for low osmolality, generally <1.005, due to the body's inability to concentrate urine.

A 76-year-old woman, with a history of osteoporosis is 24-hours postoperative for a total right hip replacement. What is the priority nursing action for this client? Ambulating 50 feet Promoting nutrition Caring for the surgical wound Managing pain

Managing pain Adequate pain relief will enable this client to engage in initial mobility exercises and prevent potential complications. Ambulating 50 feet is a longer-term goal. Wound care and nutrition are important post-surgical priorities over the longer term to ensure wound healing, but they are not the priority with this type of procedure.

A nurse is assessing the fundus of a client who is 12 hours postpartum, and finds that the fundus is boggy. Which action should the nurse take first? Administer blood replacement products. Massage the fundus. Prepare the client for surgery. Administer methylergonovine, as ordered.

Massage the fundus. The nurse should first massage the boggy uterus to stimulate it to contract. The client may need surgery but only if other measures fail to cause the uterus to contract and control bleeding. Blood replacement products may be given if the client has a significant blood loss. Methylergonovine may be ordered if massage fails to firm the uterus.

A nurse has been voicing concerns to colleagues about unfair client assignments being assigned by the charge nurse with some nurses consistently having less complex client assignments than others. What action should the charge nurse take upon learning this information? Ask the nurse to prove that the assignments are unfair using objective evidence. Meet with the nurse privately and provide an opportunity to express concerns. Assure the staff member that client assignment are made as fair as possible. Instruct the nurse to document concerns in writing so the charge nurse can review.

Meet with the nurse privately and provide an opportunity to express concerns. The charge nurse should meet with the nurse privately to enhance communication and model problem-solving behaviors. Instructing the staff member in how to present their concerns and assuring them that the charge nurse is distributing assignments fairly are linear and directive; these responses do not give the staff member adequate opportunity to interact with the charge nurse in a productive manner. If this is the first instance, the charge nurse needs to talk with the staff nurse directly; the nurse may understand if the charge nurse takes time to talk with them immediately and not wait for a nurse manager to be involved.

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? Obtain daily weights. Obtain vital signs every 2 hours. Monitor electrolyte status. Obtain a vision screen.

Monitor electrolyte status. Furosemide is a potent diuretic. If given in excessive amounts it can lead to a profound diuresis of water and electrolyte depletion that could lead to life-threatening arrhythmias. Input and output should be monitored along with vital signs. Furosemide can be ototoxic; therefore, hearing should be evaluated.

A client is admitted to the labor and delivery unit in labor with blood flowing down her legs. What would be the priority nursing intervention? Perform a cervical examination. Monitor fetal heart tones. Place an indwelling catheter. Prepare the client for cesarean birth. SUBMIT ANSWER

Monitor fetal heart tones. Monitoring fetal heart tones would be the priority, due to a possible placenta previa or abruptio placentae. Although an indwelling catheter may be placed, it is not a priority intervention. Performing a cervical examination would be contraindicated because any agitation of the cervix with a previa can result in hemorrhage and death for the mother or fetus. Preparing the client for a cesarean birth may not be indicated. A sonogram will need to be performed to determine the cause of bleeding. If the diagnosis is a partial placenta previa, the client may still be able to deliver vaginally.

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? Keep the client on bed rest until the goal weight is achieved. Monitor the client's urine output and vital signs. Meet daily with the client to discuss manipulation and countertransference. Encourage the client to perform muscle-building exercises.

Monitor the client's urine output and vital signs. A BMI of 13 is severely underweight and poses a risk to the client's physical health, including potential cardiac dysrhythmia, hypotension, or kidney failure. Although clients with eating disorders commonly use manipulative ploys and countertransference to resist weight gain, the priority at this stage of treatment is ensuring there are no life-threatening complications. Muscle building is not appropriate when the client is this underweight, but it can be added once weight gain is acceptable. Keeping the client on bed rest until a specified weight is attained is not recommended, because this can lead to complications related to immobility.

What is the nurse's priority action in caring for a client who has just had a liver biopsy? Assess for feelings about body image. Instruct the client to avoid alcohol in the future. Monitor vital signs. Assess the level of pain.

Monitor vital signs. Internal bleeding is a potential complication following a liver biopsy. Elevated pulse and decreased blood pressure are indications that the client may be developing shock, which results in altered circulation. Physiologic needs take priority over psychological needs, Assessing feelings and teaching should be addressed after immediate needs. Pain is considered a psychological reaction unless the client is experiencing an acute episode that is causing physiologic response.

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? Reinforce the risks of not having the surgery Notify the provider immediately Record the client's refusal in the nurses' notes Notify the nursing supervisor

Notify the provider immediately The nurse should notify the health care provider. The health care provider is responsible for providing information regarding the procedure, risks, benefits and expected outcomes. After notifying the provider, the nurse should document the situation and client response in the client's record.

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? Counsel the family in making arrangements to remove the family pet. Discuss limitations on the child's participation in sports activities. Obtain additional equipment and medication that can be provided at the school. Arrange for a thorough, deep cleaning of the home.

Obtain additional equipment and medication that can be provided at the school. The child needs to have equipment and medication available at school to treat and prevent asthma attacks. This is the priority intervention at this time. Discussions should be held with the child and family to motivate the child to be involved in as many normal activities as possible; the emphasis is on the options rather than the limitations. The nurse should teach the parents that the house should be kept as clean as possible on an ongoing basis to prevent exacerbations due to dust and pet dander, but it is not the nurse's responsibility to arrange for this cleaning. If the child is allergic to the family pet, the nurse should provide counseling on ways to minimize the risks, but this does not necessarily mean removal of the pet.

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. Increase oral fluid intake. Provide sodium supplements. Monitor for signs of hypokalemia.

Obtain and monitor daily weight. The child with acute glomerulonephritis should be monitored for fluid imbalance, which is done through daily weights. Increasing oral intake and providing sodium supplements aren't part of the therapeutic management of acute glomerulonephritis. Impaired renal function is associated with increased, not decreased, potassium levels.

A young female client with a history of sickle cell disease reports abdominal pain. What is the priority intervention by the nurse? Obtaining a history of the sequence of symptoms Keeping the client nothing by mouth (NPO) Administering IV fluids Preparing the client for a computed tomography (CT) scan of the abdomen

Obtaining a history of the sequence of symptoms Although the client may be in a sickle cell crisis and experiencing acute abdominal pain caused by sickling in the mesenteric circulation, it's important to remember that clients with sickle cell disease aren't spared from other intra-abdominal events. The history obtained from the client outlining the sequence of symptoms provides crucial assessment information. Other nursing interventions would include preparing the client for possible surgery by keeping her NPO and for diagnostic studies such as CT scanning. Administering IV fluids will help replenish fluid volume. Also, obtaining a history is a part of assessment. Nursing process always starts with assessment.

A multiparous client who has been in labor for 2 hours states that she feels the urge to move her bowels. What would the nurse do first? Check the fetal heart rate (FHR). Perform a pelvic examination. Allow the client to use a bedpan. Assist the client to get up to use the toilet.

Perform a pelvic examination. A report of rectal pressure usually indicates a low presenting fetal part, and imminent birth. The nurse should perform a pelvic examination to assess the dilation of the cervix and station of the presenting fetal part. Do not let the client use the toilet or a bedpan before she's examined because she could birth on the toilet or in the bedpan. Checking the FHR is important but comes after the nurse evaluates the client's report.

A child is admitted to the pediatric unit with an unknown mass in her lower left abdomen. Which is the nurse's priority action? Place a "do not palpate abdomen" sign over the child's bed Obtain a complete set of vital signs Obtain the history of the illness Schedule a hemoglobin and hematocrit test for early morning

Place a "do not palpate abdomen" sign over the child's bed The nurse must take measures to prevent palpation of the mass, if possible. If the mass is a malignant tumor, a "do-not-palpate" warning will help prevent trauma and rupture of the suspected tumor capsule. Rupture may cause seeding of cancer cells throughout the abdomen. Obtaining the history, vital signs, and scheduling laboratory work, are important, but not the priority.

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? Assess intake and output. Place the child on the side opposite the shunt. Administer oral pain medication as ordered. Teach on ventriculoperitoneal shut location.

Place the child on the side opposite the shunt. Following shunt placement surgery, the child would be placed on the side opposite of the surgical site to prevent pressure on the shunt valve. Intake and output will also need to be assessed, but that is not the nurse's priority. The child is usually on nothing-by-mouth status until the nasogastric (NG) tube is removed and bowel sounds return. Also, pain medication should be administered by an intravenous route initially postoperatively. Teaching, if able, begins preoperatively. If not, teaching is not the first nursing intervention when returning to the pediatric unit.

What action should the nurse take first when a client is coughing up pink, frothy sputum? Start an IV line Plan to administer a diuretic Place the client in high-Fowlers position Apply supplemental oxygen

Place the client in high-Fowlers position Production of pink, frothy sputum is a classic sign of acute pulmonary edema. Pulmonary edema requires immediate emergency treatment. The priority action is to place the client placed in high-Fowler's position to facilitate air exchange and improve oxygenation. After positioning the client, application of supplemental oxygen, IV access, and drug therapy can be performed. The goal of treatment is to reduce the amount of fluid in the lungs, improve gas exchange and heart function, and, if possible, correct the underlying disease. Because this client is at high risk for decompensation, the nurse should call for help without leaving the room.

A nurse is examining a client in active labor, who has had spontaneous rupture of the amniotic membrane, and notes a protruding umbilical cord. What is the priority nursing action? Instruct the client to begin to push. Wrap the cord in a dry sterile dressing. Push the umbilical cord back into the uterus. Place the client in knee-chest position.

Place the client in knee-chest position. A Trendelenburg or knee-chest position takes the weight of the fetus off the umbilical cord, allowing blood to flow. The cord should never be pushed back into the uterus, as this could damage the cord, obstruct the flow of blood through the cord to the fetus, or introduce infection into the uterus. The client should not be instructed to push, as she is only in active labor, and emergency surgery may be necessary. The cord should be wrapped in a sterile saline-soaked gauze.

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? Slow down the client's I.V. rate. Place the client on her left side and apply oxygen. Call the client's provider. Position the client in the lithotomy position.

Place the client on her left side and apply oxygen. An FHR below 70 beats/minute is considered severe fetal bradycardia, and immediate interventions are needed. The nurse would first apply oxygen after positioning the client on her left side. Positioning the client in the lithotomy position is not indicated. Although the provider would be notified of the status change in the client, the nurse would not wait on orders from the provider to act. Slowing the I.V. rate would reduce the circulating volume of blood and worsen the problem.

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? Administer oxygen by face mask. Increase the I.V. rate. Prepare for imminent birth. Place the client on her left side.

Place the client on her left side. Variable decelerations in fetal heart rate are caused by compression of the umbilical cord. Typically, variable decelerations are corrected by placing the client in a left lateral position to alleviate cord pressure. Since variable decelerations are usually transient and correctable, the nurse would not prepare for an imminent birth. Increasing the I.V. rate is not needed or ordered. If other measures have been ineffective in correcting the variable deceleration, oxygen may be administered.

A client is admitted to the labor and delivery unit at 30 weeks' gestation. She has a history of cesarean birth, and reports severe abdominal pain that started less than one hour ago. When the nurse palpates tetanic contractions, the client again reports severe pain. After the client vomits, she states that the pain is better and then loses consciousness. The fetal heart rate is 100. What is the nurse's priority intervention? Prepare the client for immediate surgery Place the client in a left lateral position Administer IV antibiotics Assess the client's level of pain

Prepare the client for immediate surgery Uterine rupture is a medical emergency that may occur before or during labor. Signs and symptoms typically include abdominal pain that may ease after uterine rupture, vomiting, vaginal bleeding, hypovolemic shock, and fetal distress. The client should be prepared for immediate surgery to save her life and that of the fetus. While assessing and relieving pain are important, they are not priorities in this life-threatening situation. Placing the client in a left lateral position will not affect her condition. Antibiotics may be administered but aren't the highest priority in this situation.

A client displays signs associated with a possible ruptured aortic aneurysm. What is the priority nursing intervention? Administer prescribed beta-adrenergic blocker medication Prepare the client for surgical intervention Prepare the client for an aortogram Administer prescribed antihypertensive medication

Prepare the client for surgical intervention When the vessel ruptures, prompt surgery is required for it's repair. Antihypertensive medications and beta-adrenergic blockers can help control hypertension, reducing the risk of rupture. An aortogram is a diagnostic tool used to detect an aneurysm.

The nurse is assessing a child with type 1 diabetes mellitus who recently came to the emergency department with signs and symptoms consistent with diabetic ketoacidosis. What is the nurse's priority when planning care for this child? Make a referral to the pediatric diabetes nurse. Monitor the child closely in the emergency department before transfer to the medical unit. Teach the family about the prevention of this complication of diabetes. Prepare to administer intravenous fluids and insulin per order.

Prepare to administer intravenous fluids and insulin per order. Diabetic ketoacidosis, the most complete state of insulin deficiency, is a life-threatening condition. The child should be admitted to an intensive care unit for management. Treatment would consist of rapid assessment, adequate insulin to reduce the elevated blood glucose level, fluids to overcome dehydration, and electrolyte replacement. Education would be a priority after the child has stabilized.

The nurse is caring for a client admitted with Addisonian crisis. Which outcome is the priority? Preventing infection Lowering blood pressure Preventing irreversible shock Relieving anxiety

Preventing irreversible shock A client in Addisonian crisis has an uncontrolled loss of sodium in the urine, and impaired mineralocorticoid function, which results in a loss of extracellular fluid, low blood volume, and possible irreversible shock. Preventing infection isn't an appropriate goal in this life-threatening situation. Relieving anxiety is appropriate after the client is stabilized. The client in Addisonian crisis is hypotensive, and blood pressure should be raised not lowered.

A nurse is planning care for a 14-year-old client following an appendectomy. What is the most important intervention? Confirm plans for the future. Reduce conflict between the client and the parents. Encourage the development of trust. Promote the development of an identity and independence.

Promote the development of an identity and independence. Since adolescents are in Erikson's identity versus role confusion stage, planning care should include interventions that promote a sense of identity and independence. During adolescence, conflict is usually intensified, not reduced. Trust is a developmental task of infancy. Plans for the future aren't confirmed at age 14.

A client with type 1 diabetes mellitus is conscious but confused, weak, diaphoretic, and having heart palpitations. What is the nurse's priority action? Administer glucagon intramuscularly (IM) or subcutaneously. Give an intravenous (IV) bolus of dextrose 50%. Inject 10 units of fast-acting insulin subcutaneously. Provide 15 to 20 grams of a fast-acting oral carbohydrate.

Provide 15 to 20 grams of a fast-acting oral carbohydrate. The client is exhibiting signs of hypoglycemia. Since the client is conscious, the first intervention is to give a fast-acting oral carbohydrate, such as orange juice, hard candy, or honey. If the client becomes unconscious, the nurse would administer IM or subcutaneous glucagon or dextrose 50% IV if access is available. Administering insulin wouldn't be appropriate because the client is experiencing hypoglycemia.

Immediately after birth, a nurse assesses the neonate's respiratory effort as slow. The neonate is actively moving but grimaces in response to stimulation. The neonate's fingers and toes are bluish and the heart rate is 130 bpm. Which step should the nurse take next? Provide oxygen and stimulate the baby to cry. Wrap the infant in a warm blanket. Assign an Apgar score of 8. Tell the provider that the neonate appears abnormal.

Provide oxygen and stimulate the baby to cry. The nurse should stimulate the baby to cry, provide oxygen, and call the provider to evaluate reflex irritability. It would be inappropriate to tell the provider that the neonate appears abnormal. The neonate's Apgar score is 7. Of a maximum possible Apgar score of 10, the nurse deducts one point for acrocyanosis, one point for slow respiratory effort, and one point for the grimace. Although keeping the infant warm is important, the infant clearly needs more aggressive interventions such as oxygen and stimulation

The nurse is caring for a client with terminal lung cancer. What is the priority nursing intervention for this client? Provide nutritional support. Provide education about end-of-life. Provide emotional support. Provide pain control.

Provide pain control. A client with terminal lung cancer may have extreme pleuritic pain and should be treated to reduce this discomfort. Preparing the client and their family for impending death and providing emotional support are also important, but shouldn't be the primary focus until the pain is under control. Nutritional support may be provided, but as the terminal phase advances, the client's nutritional needs greatly decrease.

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. Reassure the client that she'll get pregnant again soon. Assess fetal heart tones via external monitor. Avoid talking about the baby.

Provide privacy and emotional support. Providing privacy and support is an appropriate therapeutic intervention for the client and family to grieve their loss. Fetal heart tones are rarely assessed in a client with an anencephalic fetus. Most fetuses will not survive due to a lack of cerebral function. Reassuring the client that she will get pregnant again dismisses how she feels about her current loss, and also provides false reassurance.

The nurse is caring for a recently circumcised newborn. Based on the progress note, what would be the most appropriate nursing intervention?2/10 0800Progress Note TabThree-day-old male, two days post-circumcision by Mogen clamp. Small amount of yellow-white exudate noted around glans. No bleeding or swelling noted. Axillary temp 36.4° C (97.5° F). Nursing eagerly, latching on well. Voided x4 post-circ. Take the neonate's temperature every hour for the first 24 hours. Wrap the neonate in two additional blankets. Provide routine care to the circumcised area. Give the neonate a pacifier to help soothe the pain

Provide routine care to the circumcised area. The yellow-white exudate is part of the granulation process and is a normal finding for a healing penis following circumcision. Routine vital signs and normal layering would be recommended for this neonate as this temperature is normal in a newborn. It is not necessary to increase monitoring or covering of the neonate. Pacifiers do soothe pain in the neonate; however, there is no indication in this progress note that the neonate is in pain.

A health care provider prescribes carbamazepine 1,200 mg/po/q12h for a client with trigeminal neuralgia. Which action should the nurse take first? Question the dose because it exceeds the recommended daily dose. Store the drug in a cool, dry place away from sunlight. Encourage the client to promptly report unusual bleeding. Administer the medication with meals or with a bedtime snack.

Question the dose because it exceeds the recommended daily dose. The nurse should verify the dose with the provider as it exceeds the standard prescribed dosage. Clients with trigeminal neuralgia should receive no more than 1,200 mg/po/daily. After confirming the order, the nurse should encourage the client to take the drug at the same time each day with food to avoid GI distress. The nurse should also encourage the client to promptly report unusual bleeding. The drug should be stored in a cool, dry place.

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 Place the client flat in bed Assess patency of the indwelling urinary catheter Give one sublingual nitroglycerin tablet

Raise the head of the bed immediately to 90 degrees Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia are symptoms of autonomic dysreflexia, typically caused by such noxious stimuli as a full bladder, fecal impaction, or pressure ulcer. Putting the client flat will cause the blood pressure to increase more. The indwelling urinary catheter should be assessed immediately after the head of the bed is raised. Nitroglycerin is given to relieve chest pain and reduce preload. It isn't used for hypertension or dysreflexia.

A nurse walks into the room of a client diagnosed with congestive heart failure (CHF). The client is lying supine and is diaphoretic, anxious, and dyspneic. What is the nurse's priority action? Administer 0.5 mg of lorazepam. Raise the head of the bed to 45°. Administer oxygen at 4/l/min. Draw arterial blood gases.

Raise the head of the bed to 45°. Raising the head of the bed will help the client's lungs expand and allow for deeper breaths. The nurse would need a provider's order for oxygen, and it may not be most beneficial if the head of the bed is not elevated. Lorazepam may decrease the client's anxiety, but it may also diminish respirations and increase dyspnea. Arterial blood gases are not a priority.

Which nursing intervention is a priority for a pregnant adolescent during her first trimester? Refer the client to a dietitian for nutritional counseling. Assess the client for signs and symptoms of placenta previa. Tell the client that she will most likely need a cesarean birth due to the head size of the fetus. Schedule the client for a screening glucose tolerance test.

Refer the client to a dietitian for nutritional counseling. Adolescents are at risk for delivering low-birth-weight neonates. Nutritional counseling should be a priority for these clients to ensure proper fetal development. A pregnant adolescent is not likely to deliver a macrosomic neonate. The final head size of the fetus is unknown at this time. Adolescents are not at increased risk for developing gestational diabetes or placenta previa.

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? Licensed practical nurse (LPN) with five years of experience Registered nurse with one year of experience Nursing assistant with 15 years of experience Charge nurse with 10 years of experience

Registered nurse with one year of experience Because this client requires frequent neurovascular assessments, a registered nurse should receive him. Although experienced and able to collect data, an LPN doesn't have the education to assess this client. The nursing assistant lacks the necessary assessment skills. The charge nurse needs to be available to direct the care of other clients.

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. Complete an adverse drug reaction (ADR) report. Report the incident to the nursing regulatory agency. Anticipate suspension from the facility due to the error.

Report the incident to risk management. The incident should be reported to risk management in order to evaluate care, and determine potential risks or system problems that contributed to the error. This type of error will not be reported to the nursing regulatory agency, or result in the nurse's suspension. Some facilities track the number of errors made by a nurse, or that occur on a particular unit, in order to provide appropriate education, and to improve the nursing process. Adverse drug reaction forms are used to report a client's reaction to a medication, not errors.

A nurse suspects an infant may have a tracheoesophageal fistula or esophageal atresia. What is the most important intervention by the nurse? Tell the parents. Give oxygen. Put the neonate in an isolette or on a radiant warmer. Report the suspicion to the health care provider.

Report the suspicion to the health care provider. The provider needs to be told so that immediate diagnostic tests can be done to determine a definitive diagnosis with surgical correction. Oxygen should be given only after notifying the provider, except in an emergency; a need for oxygen is based on the infant's oxygen saturation levels or arterial blood gas results. It is not the nurse's responsibility to inform the parents of the suspected finding. By the time tracheoesophageal fistula or esophageal atresia is suspected, the neonate would have already been placed in an isolette or a radiant warmer.

What is the most important nursing intervention when caring for a child with a newly applied wet hip spica cast? Reposition the child every 1 to 2 hours. Use the fingertips when handling the cast. Cover the cast in plastic to keep it clean. Use the abductor bar to help move the child.

Reposition the child every 1 to 2 hours. The child in a wet hip spica cast should be turned every 1 to 2 hours to help dry all sides of the cast and prevent skin breakdown. The abductor bar shouldn't be used for turning the child, even after the cast is dry. A wet cast shouldn't be covered with plastic because this will impede drying, reduce air circulation, and allow heat to build up in the cast. A wet cast should be handled using the palms, because fingertips may cause indentations and pressure points.

The nurse is caring for a client who has an endotracheal tube (ETT). What is the nurse's priority intervention to prevent oral ulceration related to an ETT? Suction the oral cavity with a flexible catheter every 4 hours. Use water-based lubricant on the lips every 8 hours. Provide oral care twice a day with a soft, moist oral swab. Reposition the tube from one side of mouth to the other per protocol frequency.

Reposition the tube from one side of mouth to the other per protocol frequency. Pressure causes skin breakdown or ulceration, so repositioning the ET tube can best decrease this risk for oral ulcers. Extreme care must be taken to move the tube only laterally; it must not be pushed in or pulled out. The tape securing the tube must be changed daily. Oral care, suctioning, and lubricant will help keep skin clean, intact, and reduce the risk of further infection but will not reduce the risk for ulcers like tube repositioning will.

The nurse is preparing a client with atrial fibrillation for cardioversion. What is the nurse's priority action? Set the defibrillator on DEFIB and charge at 400 joules. Set the defibirillator on SYNC and charge at 200 joules. Keep the side rails up for client safety. Keep the client awake and alert.

Set the defibirillator on SYNC and charge at 200 joules. If cardioversion is needed, the nurse should set the defibrillator on SYNC and look for a marker on each QRS complex. The nurse should anticipate that the cardioversion will be started at a low energy level and increase as needed. The client will be sedated for this procedure. Lowering the side rails will make it easier to place paddle electrodes

A nurse finds a client crying after being told by the health care provider that the client is to start hemodialysis to treat acute renal failure. What is the nurse's most important intervention? Discuss the other abilities the client has. Refer the client to the hemodialysis team. Sit quietly with the client. Remind the client this is a temporary situation.

Sit quietly with the client. Sitting with the client shows compassion and concern and may help the nurse establish therapeutic communication. Making a referral doesn't allow the client to explore feelings with the nurse. The nurse can't guarantee the acute renal failure is temporary. Discussing the client's other abilities diverts the emphasis from the client's primary issue.

The nurse is ambulating a client. The client experiences chest pain after ambulating 50 feet. What is the nurse's priority intervention? Sit the client down Obtain an electrocardiogram (ECG) Get the client back to bed Administer the ordered sublingual nitroglycerin

Sit the client down The priority is to decrease oxygen consumption by sitting this client down. When the client's condition is stabilized, he can be returned to bed. An ECG can be obtained after the client is sitting down, and the ordered sublingual nitroglycerin could be administered.

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? Continue monitoring per standards of care. Increase the infusion rate by 5 gtt/min. Decrease the infusion rate by 5 gtt/min. Stop the magnesium sulfate infusion.

Stop the magnesium sulfate infusion. Magnesium sulfate should be withheld if the client's respiratory rate or urine output falls, or if reflexes are diminished or absent, all of which are true for this client. The client also shows other signs of impending toxicity, such as flushing and feeling warm. Inaction will not resolve the client's suppressed DTRs, low respiratory rate, and urine output. The client is already showing central nervous system depression because of excessive magnesium sulfate, so increasing the infusion rate is inappropriate. Impending toxicity indicates that the infusion should be stopped rather than just slowed down.

The nurse caring for a neonate observes excessive oral secretions, and suspects a tracheoesophageal atresia. Which priority intervention should the nurse perform? Administer oxygen. Stop PO feedings. Place a nasogastric (NG) tube. Suction the secretions.

Suction the secretions. Accumulated secretions are copious in neonates with this disorder because the neonate cannot swallow. This places the neonate at risk for aspiration. Maintenance of the airway and suctioning the secretions would be the first priority. PO feedings would be withheld until further evaluation and treatment are completed. A NG tube would be placed after the initial evaluation. Oxygen would only be administered if indicated.

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. Mobilize the client in the hallway a minimum of three times per day as tolerated. Provide supplemental oxygen as prescribed, and check oxygen saturation every hour. Encourage adequate fluid intake to thin respiratory secretions.

Teach deep breathing, coughing, and incentive spirometry exercises. Atelectasis results from partial or full occlusion of bronchioles, which causes alveolar collapse. All the listed interventions can be used in these clients. Chest physiotherapy and incentive spirometry exercises work best to enhance the clearance of mucus and equalize pressure so alveoli can reinflate. While encouraging fluids can assist in thinning secretions, secretions are not the primary etiology in postoperative atelectasis. Frequent changes in position and mobilization are recommended in these clients but do not directly address the cause of atelectasis as well as deep breathing, coughing, and incentive spirometry. Administration of oxygen will not open the alveoli and only treats the effects of hypoxia.

Which health education topic is the priority when teaching parents ways to prevent urinary tract infections (UTIs) in their children? Educate parents about hand washing, and the use of alcohol-based hand sanitizers. Teach parents to limit the frequency of tub baths. Encourage parents of male infants to avoid circumcision. Teach parents to promote adequate fluid intake.

Teach parents to promote adequate fluid intake. Urinary stasis is a major cause of UTIs, and can be partially prevented by increasing fluid intake. Baths and hand hygiene are less significant factors in the development of UTIs. Urinary tract infections are increased in uncircumcised male infants under 1 year of age, but unaffected thereafter.

A client with a panic disorder is having difficulty falling asleep. Which nursing intervention should be performed first? Obtain an order for a sleeping medication as needed. Allow the client to stay up and watch television. Call the client's psychotherapist. Teach the client progressive relaxation.

Teach the client progressive relaxation. Relaxation techniques work very well with a client showing anxiety. If this doesn't work, then contacting the psychotherapist, diversionary activities, and pharmacological interventions would be in order.

A registered nurse (RN) is supervising an unlicensed assistive personnel (UAP). Which principle would the nurse follow when delegating tasks? After a task is delegated, it's no longer the RN's responsibility. The RN must directly supervise all delegated tasks. Follow-up with a delegated task is only necessary if the UAP is untrustworthy. The RN delegates a task based on the UAP's skill set.

The RN delegates a task based on the UAP's skill set. The RN must delegate tasks that are within the scope of practice of the unlicensed personnel. The RN need not directly supervise all delegated tasks, as this would negate the benefits of delegation. When a task is delegated, the RN retains responsibility for the successful completion of the task. The RN must always follow up with the UAP to ensure the task was completed appropriately.

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 UAP lifts the weights while assisting the client as he moves up in bed. The weights are allowed to hang freely over the end of the bed. The UAP instructs the client to perform ankle rotation exercises. The leg in traction is kept externally rotated.

The weights are allowed to hang freely over the end of the bed. In Buck's traction, the weights should hang freely without touching the bed or floor. Lifting the weights would break the traction. The client should be moved up in bed, allowing the weight to move freely along with the client. The leg should be kept in straight alignment. Performing ankle rotation exercises could cause the leg to go out of alignment.

During a routine prenatal examination, a client who is at 32 weeks' gestation becomes dizzy, lightheaded, and pale. After placing the client in a supine position, what is the priority nursing action? Take the client's blood pressure. Ask the client to breathe deeply. Turn the client on her left side. Listen to fetal heart tones.

Turn the client on her left side. As the uterus gets larger, it increases pressure on the inferior vena cava. This inhibits venous return causing dizziness, lightheadedness, and pallor when the client is supine. Turning the client on her left side relieves the pressure on the vena cava and restores venous return. Although they're valuable assessments, listening to fetal heart tone and measuring maternal blood pressure don't alleviate the symptoms. Deep breathing has no effect on venous return, and will not relieve this client's symptoms.

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? Obtain an order for an antianxiety medication to keep the client calm Use a caring approach to maintain close observation of the client Develop a strong and healthy relationship with the client Encourage the client to avoid over-stimulating group activities

Use a caring approach to maintain close observation of the client Close observation, using a caring and therapeutic approach, is essential in order to decide the level of suicide precautions needed. Merely developing a strong relationship with the client isn't addressing the client's potential for self harm. Although antianxiety medication is sometimes used, the efficacy of antianxiety medications in lowering suicide risk is limited. Encouraging the client to stay away from group activities could cause isolation that would be detrimental to the client's well-being.

A client is admitted to a mental health unit. While assessing the client, the nurse finds the client exhibiting signs of hyperexcitability, increasing agitation, and distractibility. Based on this assessment, which nursing intervention has priority? Involve the client in a group activity. Use a quiet room for the client away from others. Be direct and firm and set rules for the client. Channel the client's energy toward a planned activity.

Use a quiet room for the client away from others. Being in a quiet environment away from stimuli will facilitate a sense of control for this client. If the nurse attempts to be firm and set rules, it will most likely heighten the client's agitation. This client is too excited to focus at this time. Group activities or other activities may worsen the client's situation.

A health care provider has placed a stat order for a urine specimen for culture and sensitivity. What is the best way for the nurse to delegate this task to an unlicensed assistive personnel? Please get the urine for culture for the client in room 101. A stat urine has been ordered for the client in room 101. Would you get it? We need a stat urine culture on the client in room 101. We need to collect urine from the client in room 101 for a stat culture. Please tell me when you send it to the lab.

We need to collect urine from the client in room 101 for a stat culture. Please tell me when you send it to the lab. This option not only delegates the task but also provides a checkpoint. To effectively delegate, you need to follow up on what someone else is doing. The other options don't provide for feedback, which is essential for communication and delegation.

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 Slightly bloody drainage around the catheterization site dressing Oral temperature of 100° F (37.7° C) Urine output of 2 ml/kg

Weak, thready, unequal dorsalis pedis pulses The pulse below the catheterization site should be strong and equal to the unaffected extremity. A weakened pulse may indicate vessel obstruction or perfusion problems. Slightly elevated temperature and low normal urine output are relatively normal findings after catheterization, and may be the result of decreased oral fluids. A small amount of bloody drainage is normal; however, the site must be assessed frequently for increased bleeding, and the margins of the drainage should be marked on the dressing.

A nurse admits an infant diagnosed with pyloric stenosis. What is the nurse's priority intervention? Weigh the infant. Place an I.V. catheter. Change the infant and weigh the diaper. Check urine specific gravity.

Weigh the infant. Weighing the infant would be done first so a baseline weight can be established and weight changes can be evaluated. After a baseline weight is obtained, an I.V. catheter can be placed because oral feedings generally aren't given. Infants with pyloric stenosis are usually dehydrated, so weighing the diaper or checking the specific gravity, though important, are not a priority.

The nurse is preparing to administer digoxin to an infant. What is the most important intervention by the nurse? Withhold the dose if the apical pulse rate is less than 90/bpm Give the digoxin with antacids when possible Mix the digoxin with the infant's food Double the subsequent dose if a dose is missed

Withhold the dose if the apical pulse rate is less than 90/bpm Digoxin is used to decrease the heart rate; however, the apical pulse must be carefully monitored to detect a severe reduction. Administering digoxin to an infant with a heart rate of less than 90/bpm could further reduce the rate and compromise cardiac output. Mixing digoxin with food may interfere with accurate dosing. Double dosing should never be done. Antacids may decrease drug absorption.

A nurse is working on a pediatric floor with a five-client assignment. In which order should the nurse see the assigned clients, starting with the client the nurse should see first? All options must be used.

a 15-year-old client waiting for transport to the operating room a 2-month-old client with respiratory syncytial virus in an oxygen tent a 4-year-old client with nausea who vomited one hour ago a 3-day-old client with hyperbilirubinemia waiting for discharge a 5-year-old client admitted with asthma who is now in the radiology department The nurse will prioritize the 15-year-old client waiting for transport to the operating room to be sure the client is ready for surgery. Then, the 2-month-old client with respiratory syncytial virus in an oxygen tent should be assessed to be sure that oxygenation is safe. The 4-year-old client with nausea can be assessed third; since the vomiting occurred 1 hour ago, assessment of this child is not as time sensitive as it is with the 15-year-old and 2-month-old. The 3-day-old client with hyperbilirubinemia waiting for discharge is stable and can be seen fourth. Finally, the 5-year old client admitted with asthma is at radiology department, so the assessment can be done when the client returns to the unit.

A nurse working in the triage area of an emergency department sees several pediatric clients arrive simultaneously. Which client should be treated first? a 3-year-old child with a barking cough and flushed appearance a 3-year-old child with Down syndrome who's pale and asleep a crying 4-year-old child with a laceration on the scalp a 2-year-old child with stridorous breath sounds, sitting up and drooling

a 2-year-old child with stridorous breath sounds, sitting up and drooling The child with the airway emergency should be treated first because of the risk of epiglottitis. The 3-year-old with the barking cough and fever should be suspected of having croup and should be seen promptly, as should the child with the laceration. The nurse would need to gather information about the child with Down syndrome to determine the priority of care.

The nurse is examining charts to identify clients at risk for developing multiple myeloma. Which client is most at risk? a 30-year-old White man a 60-year-old Black man a 50-year-old Hispanic woman a 20-year-old Asian woman

a 60-year-old Black man Multiple myeloma is more common in middle-aged and older adult clients. The median age at diagnosis is 60 years. It is twice as common in Black clients as it is in White clients, and it occurs most often in Black men.

A nurse is caring for clients on a medical/surgical unit. Which client should the nurse see first? a 35-year-old client scheduled for a laparoscopic cholecystectomy with chills a 65-year-old client 2 days postoperative for a coronary artery bypass graft (CABG) with a temperature of 100.2° F (37.9° C) a 50-year-old client admitted for dizziness and hypertension with a blood pressure of 160/90 mm Hg a 60-year-old client admitted with partial-thickness (second-degree) burns covering the arms, chest, neck, and face

a 60-year-old client admitted with partial-thickness (second-degree) burns covering the arms, chest, neck, and face The client with partial-thickness (second-degree) burns covering the upper body is the most at risk for airway complications and should be assessed first. The postoperative client with low-grade temperature should be assessed next. Although temperature elevations are common postoperatively, the fact that this client is only 48 hours post-CABG makes this assessment the next highest priority. Third, the nurse should assess the client awaiting cholecystectomy. Chills are common when cholecystitis is present, but because the client has a procedure pending the next day, the nurse needs to ensure the client has no acute changes that need to be addressed. Finally, the client with hypertension and dizziness would be assessed. An elevated blood pressure in this range is not urgent.

A home care nurse is preparing for the next day by reviewing his/her home visit assignments. In which order should the nurse visit the clients based on priority interventions? All options must be used.

a client injecting insulin for daily blood glucose coverage, day two a client as a new admission requiring a daily morning dose of vancomycin a client requiring a laboratory study for warfarin evening dosing a client receiving a monthly injection of cobalamin a client with a final visit for ostomy teaching The nurse will need to visit the client injecting insulin for daily blood glucose coverage day two initially to be sure that the insulin is administered with breakfast. Then the nurse should visit the client as a new admission requiring a daily morning dose of vancomycin to keep the antibiotic schedule. The client requiring a laboratory study for warfarin evening dosing can be seen next so that the laboratory specimen is ready for a warfarin dose. Both the client receiving a monthly injection of cobalamin and the client with a final visit for ostomy teaching can be done at the end of the shift since neither tasks are time dependent.

A nurse is assigned five clients on the medical-surgical floor. Place in order which client the nurse will assess during the first assessment round starting with who the nurse should see first. All options must be used.

a client with a recorded episode of hypoxia earlier in the day a client with dementia requiring wrist restraints to secure medical equipment a client admitted with leg cellulitis needing an initial intravenous antibiotic a client requesting medication teaching with an insulin dose in one hour a client awaiting transport to another hospital in two hours The nurse will first assess the client with a recorded episode of hypoxia earlier in the day because of the respiratory compromise concern. Then the client with dementia requiring wrist restraints to secure medical equipment to be sure the client is safe. The client admitted with leg cellulitis needing an initial intravenous antibiotic will be assessed next to begin the antibiotic therapy. The client requesting medication teaching with insulin dose in one hour and lastly the client awaiting transport to another hospital in two hours can be seen at the end of the initial round.

A client who uses alcohol tells the nurse, "I feel so depressed about what I've done to my family that I feel like giving up." It is most important for the nurse to assess the client for: family support. a plan for self-harm. a sponsor for the client. other ambivalent feelings.

a plan for self-harm. When a client talks about giving up, the nurse must explore the potential for suicidal behavior. Although questioning the client about family support, the availability of a sponsor, or ambivalent feelings is important, the priority action is to assess for suicide.

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? temperature of 101.3°F (38.5°C) respiratory rate of 24 breaths/minute pleuritic chest pain and cough acute onset delirium

acute onset delirium The acute change in client cognition (i.e., delirium) is considered a medical emergency and should be investigated immediately. This acute change could be evidence of sepsis, electrolyte imbalances, or other organic causes that should be diagnosed and treated as soon as possible. The nurse should assess for the common symptoms of pneumonia such as fever, chills, dyspnea, pleuritic chest pain, and a productive cough. These symptoms should be monitored, but the nurse has treatments prescribed by the health care provider to address these findings.

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? monitoring fluid intake administering analgesics administering antibiotics as prescribed encouraging activity as tolerated

administering analgesics Pain management is a priority intervention when a client is in crisis. Analgesics are used to control pain. Hydration is essential to promote hemodilution and maintain electrolyte balance. Bed rest should be promoted to reduce oxygen utilization. Antibiotics will not be effective in resolving the vaso-occlusive crisis.

The nursing team consists of one RN, one LPN, and one unlicensed assistive personnel (UAP). Which assignment should the RN delegate to the LPN? suctioning a client who is 1-day postoperative following a tracheostomy emptying a Foley catheter bag administering daily am medications passing dinner trays

administering daily am medications LPNs should be assigned higher level skills in stable, predictable situations. Lower level custodial skills should be assigned to UAP. A new tracheostomy may be unstable. The task of suctioning should be retained by the RN.

A child diagnosed with bacterial meningitis has been admitted to the unit. What is the priority nursing action? providing pain control administering intravenous antibiotics reducing environmental stimuli avoiding lifting the client's head

administering intravenous antibiotics Bacterial meningitis is a medical emergency that requires immediate treatment with antibiotics. If not treated rapidly, it may lead to brain damage, deafness, stroke, and death. All the other actions are important but only secondary to administering antibiotics.

A nurse is caring for a 2-year-old client, who weighs 25 lb (11.3 kg), and has a fractured femur. What is the nurse's priority assessment for this client? length of one leg to the other affected leg proximal to the fracture affected leg anterior to the fracture affected leg distal to the fracture

affected leg distal to the fracture The nurse should focus the assessment on the area distal to the fracture. This area is most at risk for neurovascular compromise. If a fracture severs or obstructs blood vessels or nerves, blood flow is disrupted distal to the site, and may lead to nerve or tissue damage. The unaffected leg should be used for baseline comparison. This client should be assessed for the five "Ps:" pulse, pallor, paresthesia, pain, and paralysis.

A six-week-old infant is brought to the emergency department not breathing. A preliminary finding of sudden infant death syndrome (SIDS) is made to the parents. Which initial intervention should the nurse take? collect the infant's belongings and give them to the parents call their spiritual advisor explain the etiology of SIDS allow them to see their infant

allow them to see their infant The parents need time with their infant to assist with the grieving process. Calling their pastor and collecting the infant's belongings are also important steps in the plan of care, but are not priorities. The parents may be too upset to understand an explanation of SIDS at this time.

A 24-year-old client comes into the clinic reporting sudden-onset, right-sided chest pain and shortness of breath. While assessing the client, the nurse determines that the most important intervention is to: order an electrocardiogram (ECG). auscultate the breath sounds. order a chest X-ray. order an echocardiogram.

auscultate the breath sounds. Because this client is short of breath, listening to breath sounds will allow the nurse to obtain information to support care decisions and report information that will help identify the problem. Breath sounds may be decreased, abnormal or absent when a client is short of breath. The client may need a chest X-ray and an ECG, but a health care provider must order these tests. Unless a cardiac source for the client's pain is identified, an echocardiogram won't be necessary.

The nurse is caring for a client struggling with alcohol dependence. It is most important for the nurse to: confront feelings and examples of perfectionism. avoid blaming or preaching to the client. speak briefly and directly. determine if nonverbal communication will be more effective.

avoid blaming or preaching to the client. Blaming or preaching to the client causes negativity and prevents the client from hearing what the nurse has to say. Speaking briefly to the client may not allow time for adequate communication. Perfectionism doesn't tend to be an issue. Determining if nonverbal communication will be more effective is better suited to a client with cognitive impairment.

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? treatment for syphilis at 15 weeks' gestation total weight gain of 30 lb (13.6 kg) maternal age of 32 years blood pressure of 146/90 mm Hg

blood pressure of 146/90 mm Hg A blood pressure of 146/90 mm Hg may indicate gestational hypertension. Over time, gestational hypertension reduces blood flow to the placenta and can cause intrauterine growth restriction, and other problems that reduce the fetus's ability to tolerate the stress of labor. A weight gain of 30 lb (13.6 kg) is within expected parameters for a healthy pregnancy. A woman over age 30 doesn't have a greater risk of complications if her general condition is healthy before pregnancy. Syphilis that has been treated does not pose an additional risk.

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 reviewing the treatment for overdose on the medication bottle reviewing the emergency department poison control guidelines consulting the current Compendium of Pharmaceuticals and Specialties (CPS)

contacting the Poison Control Center by phone Despite having directions on the bottle or in the CPS about what to do in the event of overdose of medications, best practice dictates the nurse contact the Poison Control Center for directions. Often, medication labels are outdated and should not be followed. Written hospital guidelines may also be out of date. Although making the call takes time, it guarantees the best treatment for the poisoning.

A nurse is developing a care plan for a family with a member who has anorexia nervosa. What is the most important information for the nurse to include? coping mechanisms that have been used in the past appropriate eating habits and social behaviors centering on eating concerns about changes in lifestyle and daily activities rejection of feedback from family and significant others

coping mechanisms that have been used in the past Examination of positive and negative coping mechanisms used by the family in the past will allow the nurse to build a new care plan specific to the family's strengths and weaknesses. The way this family copes with concerns is more important than the concerns themselves. Feedback from the family and significant others is vital when building a care plan. Eating habits and behaviors are symptoms of the way people cope with problems.

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? urine specific gravity weighing each diaper daily weight serum sodium levels

daily weight The most accurate clinical assessment for total body water is weight. Weight helps assess all the water in all spaces while other assessments are dependent on renal function or movement of fluid between spaces, making them less accurate. While sodium levels are relevant, they cannot inform about total body water volume; an infant can be in fluid volume deficit and hyponatremic concurrently depending on how much sodium is lost in relation to water. Weighing diapers is a way of measuring output, but depending on the renal function of the infant, there can be very little urine output. The infant may be retaining fluids and actually be experiencing fluid volume excess or have very little urine output because of fluid volume deficit. Similarly, urine specific gravity can be altered by the kidney's ability to concentrate the urine, so it may not accurately reflect the total water volume.

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? name of insurance provider date of last menstrual period (LMP) family history of sexually transmitted infection (STIs) number of and ages of previous children

date of last menstrual period (LMP) The date of the LMP is essential to estimate the date of birth, and should be obtained first. The nursing history would also include subjective information, such as personal history of STIs, gravidity, and parity. Although beneficial to the hospital for financial reimbursement, the insurance provider has no bearing on the nursing history. The number of siblings is not pertinent to the assessment.

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? applying sterile dressings debriding and grafting the burns applying topical antibiotics diluting the chemicals

diluting the chemicals Diluting the chemical is the priority. It will help remove the chemical and stop the burning process. The remaining treatments are initiated after dilution.

The nurse is caring for an infant who is awaiting surgical repair for esophageal atresia and distal tracheoesophageal fistula (TEF). When maintaining the infant's gastrostomy tube, what is the nurse's priority action? teaching the parents how to administer gastrostomy feedings ensuring no fluids are instilled into the tube measuring residual volumes every 2 hours flushing the tube every 4 hours to maintain patency

ensuring no fluids are instilled into the tube In the most common form of the TEF, the esophagus does not communicate with the stomach and the distal segment is connected to the trachea. This means the infant cannot take in anything orally and stomach contents will reflux into the trachea. Before this defect is repaired surgically, the nurse must prevent the aspiration of stomach contents into the trachea, which is accomplished by continuous gastric drainage via a gastrostomy tube. No feedings or fluids should be instilled into the tube during the preoperative period. Though the output will be measured, this is not considered a "residual volume" but simply gastric losses. The nurse would follow facility protocol regarding how often output should be measured.

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? male client who is three days postoperative with an indwelling urinary catheter older adult woman who has been hospitalized for two days with herpes zoster female in pelvic traction who is three months pregnant male admitted for hearing voices commanding him to kill himself

female in pelvic traction who is three months pregnant A nurse's current experience should be considered when assignments are made. Obstetric nurses may have limited experience with traction but will be able to offer the most support to the pregnant client if she has questions about the well-being of the fetus. The next best client to assign to the nurse is the postoperative male client with an indwelling catheter as the nurse should have experience caring for postoperative cesarean clients and urinary catheters. This nurse should not care for infectious clients; this presents the risk of disease transmission to those on her regular unit. This nurse has no experience with psychiatric clients.

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 urethral catheterization if voiding doesn't occur over an 8-hour period sterile dressing changes every 4 hours removal of the suprapubic catheter on the second postoperative day

frequent assessment of the tip of the penis Following hypospadias repair, a pressure dressing is applied to the penis to reduce bleeding and tissue swelling. The tip of the penis should then be assessed frequently for signs of circulatory impairment. The dressing around the penis is initially changed by the surgeon, and shouldn't be changed every 4 hours thereafter. The provider will determine when the suprapubic catheter will be removed. Urethral catheterization should be avoided after repair of hypospadias to prevent trauma to the repaired urethra.

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 apply carotid massage encourage fluid intake place the infant's hands in cold water

give acetaminophen Acetaminophen should be given to decrease the temperature. A heart rate of 180/bpm is normal in an infant with a fever. A tepid sponge bath may be given to help decrease the temperature and calm the infant. Carotid massage and placing the infant's hands in cold water are attempts to decrease the heart rate through vagal maneuvers. This will not work because the source of the increased heart rate is fever. Fluid intake is encouraged after the acetaminophen is given to help replace insensible fluid losses.

The nurse can assign an unlicensed assistive personnel (UAP) to which client? A client who: was admitted to the hospital showing signs of progressive confusion. has prostate cancer undergoing radiation implant seeding. had a newly created urinary diversion 3 days ago. is 1 day postoperative following cranial surgery.

had a newly created urinary diversion 3 days ago. When delegating care, the nurse should consider the skill level of the UAP and the needs of the client. The UAP is able to assist with activities of daily living and basic care activities. The client who had surgery to establish a urinary diversion 3 days ago is the most stable of the clients and can be assigned to the UAP for basic care. The client with cranial surgery is 1 day postoperative and will require frequent neurological assessment; this client should be assigned to a registered nurse. The client with a radiation seeding is on radiation precautions and should be assigned to a registered nurse. The client showing signs of progressive confusion is the least stable and requires direct care by a nurse.

A 19-month-old child with croup is crying as a nurse tries to auscultate breath sounds. What is the nurse's most appropriate intervention? hand the stethoscope to the child to examine before auscultating the lungs tell the parents that they are upsetting the child and to wait outside the room ignore the crying and listen to breath sounds as best as possible tell the child, in a loud and firm voice, that they must sit still and cooperate

hand the stethoscope to the child to examine before auscultating the lungs Children at this age are very curious. Encouraging the child to play with the stethoscope will distract them and help gain trust so that the nurse will be able to auscultate the lungs. Ignoring the child's crying may only upset them more, and will not help the nurse gain their trust. The nurse should ask the parents to help quiet and comfort the child. Asking the parents to leave may only upset the child more. The nurse should speak to the child in a soft, comforting tone of voice.

A three-year-old child is given a preliminary diagnosis of acute epiglottitis. Which initial nursing intervention is most appropriate? place the child in a side-lying position obtain blood cultures obtain a throat culture have emergency airway equipment readily available

have emergency airway equipment readily available With acute epiglottitis, the glottal structures become edematous. Emergency airway equipment and humidified oxygen should be readily available. The nurse should not attempt to visualize the epiglottis, use tongue blades or throat culture swabs, which can cause the epiglottis to spasm, and totally occlude the airway. Throat inspection should only be attempted when immediate intubation or tracheostomy can be performed in the event of further or complete obstruction. The child should always remain in a position that provides the most comfort, security, and ease of breathing. The child will often assumes a classic tripod posture with the trunk leaning forward, neck hyperextended, and chin thrust forward.

The nurse is assessing a client 22 hours after a cesarean birth. Which assessment finding would require immediate action by the nurse? a gush of blood from the vagina when the client stands up oral temperature of 100.2° F (37.9º C) reports of abdominal pain and cramping heart rate of 132 beats/min and blood pressure of 84/60 mm Hg

heart rate of 132 beats/min and blood pressure of 84/60 mm Hg Tachycardia and hypotension may be signs of hemorrhage. An oral temperature of 100.2° F (37.9º C) may be due to dehydration, if it occurs on the first postpartum day. A gush of blood from the vagina when a client stands is a normal finding on the first postpartum day. Reports of abdominal pain and cramping are expected following cesarean birth.

The nurse is caring for a school-aged client with sickle cell anemia. The nurse would prioritize preventing what physical state to best reduce the risk for activating sickling of red blood cells in the client? fluid volume excess pain fever hypoxia

hypoxia The most critical need of a client in sickle cell crisis is to provide adequate oxygenation, hydration, and pain management until the crisis passes. States of hypoxia are most likely to trigger sickling. Hypoxia can be caused by increased oxygen consumption during stress, pain, or fever but because these conditions are only potential contributors to hypoxia, focusing on the broader goal of preventing hypoxia in general is the better nursing priority. Fluid volume deficit (dehydration) is also a contributor to sickling but fluid volume excess is not. By thinking about care in a more conceptual way, the nurse is better able to address all potential causes of hypoxia as an important trigger for sickling.

The nurse is providing care for a school-age child with hypopituitarism. What is the nurse's priority intervention? vigilant fall precautions and fracture prevention education for the child and parents about the importance of weight-bearing exercise interventions to enhance the child's self-esteem high-protein, high-calorie diet

interventions to enhance the child's self-esteem Hypopituitarism and reduced stature can have a negative effect on self-esteem and development. Interventions to address these risks are appropriate. There is no need for a high-nutrient diet, and the child is not at high risk for injury. Weight-bearing exercise has no direct effect on the course of the illness.

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? how to identify symptoms of UTI interventions to prevent UTIs how to collect a midstream urine sample risk factors for UTIs in children

interventions to prevent UTIs Prevention is the most important goal of teaching about a preventable condition such as UTIs. The most preventive measures are simple hygienic practices that should be a routine part of daily care. While some of the teaching about prevention will overlap with risk factor discussion, some risk factors, such as female gender, are not something that can be targeted for prevention. Teaching about treatment, detection, and testing is important, but this is not the priority and will not be relevant if the UTI is successfully prevented.

The nurse in the emergency department is caring for a 12-year-old child with full-thickness, circumferential burns to the chest who has difficulty breathing. What is the priority intervention? intubation escharotomy needle thoracentesis chest tube insertion

intubation Intubation is performed to maintain a patent airway. Escharotomy is a surgical incision used to relieve pressure from edema. It's needed with circumferential burns that prevent chest expansion or cause circulatory compromise. Insertion of a chest tube and needle thoracentesis are performed to relieve a pneumothorax.

What is the nurse's priority when caring for a 10-month-old infant with meningitis? controlling seizures maintaining an adequate airway maintaining fluid and electrolyte balance controlling hyperthermia

maintaining an adequate airway Maintaining an adequate airway is always a top priority. Maintaining fluid and electrolyte balance and controlling seizures and hyperthermia are all important, but not as important as an adequate airway.

A nurse is performing an assessment of a postpartum client 2 hours after birth, and notes heavy bleeding with large clots. What should be the nurse's initial action? administering ergonovine notifying the health care provider performing bi-manual uterine compressions massaging the fundus firmly

massaging the fundus firmly Initial management of excessive postpartum bleeding is firm massage of the fundus along with a rapid infusion of oxytocin or lactated Ringer's solution. Bi-manual compression is performed by a health care provider. Ergonovine should be used only if the bleeding doesn't respond to massage and oxytocin. The health care provider should be notified if the client doesn't respond to fundal massage, but other measures should be taken in the meantime.

The nurse is planning care for a neonate with a cleft lip and palate. What is the nurse's priority area of concern? operative care parental reaction pain management inadequate urinary output

parental reaction Parents typically show a strong negative response to this deformity. They may mourn the loss of a perfect child. Helping the parents cope with their child's condition is a priority. Feeding can be challenging, and can result briefly in reduced fluid intake, but inadequate urinary output is unlikely to occur. Surgical repair is usually delayed until the child is 6 to 12 weeks of age. This deformity is not painful.

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? furosemide albuterol (salbutamol) ciprofloxacin prednisone

prednisone Many of the medications listed can contribute to hypokalemia, including prednisone (a corticosteroid), albuterol (a beta-2 agonist), and furosemide (a loop diuretic). Fluoroquinolone antibiotics such as ciprofloxacin can cause hyperglycemia, as can prednisone and albuterol. However, only prednisone can be linked to hyperglycemia, hypokalemia, and increased white blood cell count. The elevation in WBC with corticosteroid use is primarily due to the anti-inflammatory effects, which result in decreased adhesion of neutrophils to endothelium and an associated increase in the number circulating in the blood; it is not an indication of infection related to immunosuppressive effects of the drug.

The nurse is caring for an infant with pyloric stenosis. Which manifestation requires priority attention? loss of appetite explosive diarrhea constipation projectile vomiting

projectile vomiting The obstruction doesn't allow food to pass through the pylorus to the duodenum. When the stomach becomes full, the infant forcefully vomits for pressure relief. This can result in dehydration, electrolyte imbalances, and nutritional deficiency. Chronic hunger is commonly seen. Because food doesn't pass the stomach, neither diarrhea nor constipation will occur.

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 advising a low-calorie, high-nutrient diet avoiding parents rooming in because they make the client less dependent on staff avoiding analgesia administration

promoting an environment free from emotional distress The child experiencing hyperfunctioning of the adrenal gland or pheochromocytoma has excessive epinephrine resulting in an accelerated metabolism. Symptoms include hypertension, headaches, hyperglycemia with weight loss, diaphoresis, and hyperventilation. Through provision of a low-stress environment, analgesia as needed, a high-calorie diet, and supportive parents, the child will be able to prepare for surgery to eliminate the tumor causing the hypersecretion of epinephrine.

A child is hospitalized with infective endocarditis. Which nursing intervention is most appropriate? provide diversional activities give small, frequent meals provide frequent toileting increase fluids

provide diversional activities Treatment for infective endocarditis requires long-term hospitalization or home care and I.V. antibiotics. During this time children may become bored or depressed, and need age-appropriate activities. Excessive fluid volume may be seen with infective endocarditis. Gastrointestinal upset and constipation may be adverse reactions related to the antibiotics. Overeating may occur due to boredom.

The nurse is planning care for a child admitted to the pediatric unit with neonatal bronchopulmonary dysplasia (chronic lung disease). Which intervention should the nurse perform first? give palivizumab vaccine keep fluids at a minimum keep ambient air temperature cooler than normal provide humidified oxygen

provide humidified oxygen Tachypnea, dyspnea, and wheezing are intermittently or chronically present, secondary to airway obstruction and increased airway resistance. Giving humidified oxygen will help keep the airways moist and liquefy secretions. Fluid restriction may be ordered to decrease secondary problems such as heart failure, but it is not in all cases. The palivizumab vaccine is recommended in children with chronic lung disease to prevent respiratory syncytial viral (RSV) infection. It is typically given during RSV season. The ambient air temperature should be kept in a neutral thermal zone to decrease oxygen consumption.

Which nursing assessment data would be given priority for a child with clinical findings related to tubercular meningitis? occurrence of urinary and fecal incontinence degree and extent of nuchal rigidity signs of increased intracranial pressure (ICP) onset and character of fever

signs of increased intracranial pressure (ICP) Assessment of fever and evaluation of nuchal rigidity are important aspects of care, but assessing for signs of increasing ICP should be the highest priority due to the life-threatening implications. Urinary and fecal incontinence can occur in a child who is ill from nearly any cause. This doesn't pose a great danger to life.

The nurse in pediatric intensive care is caring for an infant whose respiratory rate is 50 with nasal flaring, grunting and experiencing thick yellow nasal discharge. Vital signs are stable with oxygen saturation of 96% on 0.25 L of oxygen via face mask. Chest physiotherapy has been completed, and the infant is sleeping in the supine position. What should be the nurse's next intervention? call the health care provider suction the nares change the infant's position give ordered medications

suction the nares The nurse should assess the client for respiratory compromise and clear the airway. Suctioning the nares to remove the thick mucus would be the first intervention. If the infant continues to show labored breathing, the practitioner should be notified and medications given. Repositioning the infant may help but would not be the first intervention.

What is the most important action to take for a child with ineffective airway clearance? administering medications as ordered suctioning the child's secretions reducing the child's anxiety providing adequate oral fluids

suctioning the child's secretions The most important goal is to maintain a patent airway. The child with ineffective airway clearance has secretions that can obstruct the airway. Reducing anxiety and administering medications will be necessary after the airway is secure. The child should not be allowed to eat or drink anything to prevent the risk of aspiration.

A nurse is caring for a client recovering from cocaine use. Which is the priority intervention for this client? skin care suicide precautions frequent orientation nutrition consultation

suicide precautions Clients recovering from cocaine use are prone to post-coke depression, and have a likelihood of becoming suicidal if they can't take the drug. Frequent orientation and skin care are routine nursing interventions but aren't the most immediate considerations for this client. Nutrition consultation isn't the most pressing intervention for this client.

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? applying ice applying a breast binder teaching how to express the breasts administering bromocriptine

teaching how to express the breasts Teaching the client how to express her breasts will facilitate let-down, and provide temporary relief. Ice can promote comfort by decreasing blood flow, numbing, and discouraging further let-down of milk. It is not recommended because it also causes the rebound reaction of more let-down once the ice is removed. Breast binders are not effective in relieving the discomforts of engorgement. Bromocriptine is no longer recommended for lactation suppression.

A client is receiving IV magnesium sulfate for severe preeclampsia. The nurse prioritizes what assessment finding as requiring immediate notification of the health care provider? fetal heart rate of 160 beats/min respiratory rate of 14 breaths/min urine output of 20 mL/hr deep tendon reflex of +1 on a 4-point scale

urine output of 20 mL/hr Priority assessments during antepartum magnesium sulfate infusion focus on preventing adverse effects from the drug. Magnesium is dependent on renal excretion, and a low urine output (less than 30 mL/hr) warrants immediate notification of the health care provider for dose adjustment to avoid rapid accumulation to toxic levels. Magnesium infusions may cause a depression of deep tendon reflexes or hyporeflexia, but unless the reflexes are absent or hyperreflexive, the nurse can continue to monitor. Respiratory depression may occur, but a rate of 14 breaths/min is within an acceptable range to continue monitoring. A rate below 12 may warrant notification. A fetal heart rate of 160 beats/min falls within the high end of the acceptable range.

A client experiencing alcohol withdrawal reports being upset about going through detoxification. Which goal is the priority for this client? drinking plenty of fluids on a daily basis making a personal inventory of strengths working with the nurse to remain safe committing to a drug-free lifestyle

working with the nurse to remain safe The priority goal is for client safety. Symptoms of alcohol withdrawal syndrome can include delirium and seizures. Although drinking enough fluids, identifying personal strengths, and committing to a drug-free lifestyle are important goals, the nurse's priority at this time is to promote client safety.