Prioritization NCLEX questions
What is the priority nursing diagnosis for a client experiencing a migraine headache? 1. Acute Pain related to biologic and chemical factors 2. Anxiety related to change in or threat to health status 3. Hopelessness related to deteriorating physiologic condition 4. Risk for Injury related to side effects of medical therapy
1- The priority for interdisciplinary care for the client experiencing a migraine headache is pain management •All of the other nursing diagnoses are accurate, but none of them is urgent like the issue of pain, which is often incapacitating. Focus: Prioritization
You have just received a change-of-shift report for the burn unit. Which client should you assess first? 1. Client with deep partial-thickness burns on both legs who reports severe and continuous leg pain 2. Client who has just arrived from the emergency department with facial burns sustained in a house fire 3. Client who has just been transferred from the postanesthesia care unit after having skin grafts applied to the anterior chest 4. Client admitted 3 weeks ago with full-thickness leg and buttock burns who has been waiting for 3 hours to receive discharge teaching
2- Facial burns are frequently associated with airway inflammation and swelling, so this client requires the most immediate assessment. The other clients also require rapid assessment or interventions, but not as urgently as the client with facial burns. Focus: Prioritization
You are reviewing the complete blood count for a patient who has been admitted for knee arthroscopy. Which value is most important to report to the physician before surgery? 1. Hematocrit of 33% 2. Hemoglobin level of 10.9 g/ dL 3. Platelet count of 426,000/ mm3 4. White blood cell count of 16,000/ mm3
4- Centers for Disease Control and Prevention (CDC) guidelines for the prevention of surgical site infections indicate that surgery should be postponed when there is evidence of a pre-existing infection such as an elevation in white blood cell count. The other values are slightly abnormal, but would not be likely to cause postoperative problems for knee arthroscopy. Focus: Prioritization
You are monitoring a 53-year-old client who is undergoing a treadmill stress test. Which client-finding will require the most immediate action? 1. Blood pressure of 152/ 88 mm Hg 2. Heart rate of 134 beats/ min 3. Oxygen saturation of 91% 4. Chest pain level of 3 (on a scale of 10)
4- Chest pain in a client undergoing a stress test indicates myocardial ischemia and is an indication to stop the testing to avoid ongoing ischemia, injury, or infarction. Moderate elevations in blood pressure and heart rate and slight decreases in oxygen saturation are a normal response to exercise and are expected during stress testing. Focus: Prioritization
The nurse plans care for a client in the post-anesthesia care unit. Which of the following should the nurse assess first? • A. Respiratory status • B. Level of consciousness • C. Level of pain • D. Reflexes and movement of extremities
A- ABCs
The nurse assessed the client and noted shortness of breath and a recent trip to China. The client is strongly suspected of having Severe Acute Respiratory Syndrome (SARS). Which of these prescribed actions will the nurse take first? • A. Place the client on airborne and contact precautions • B. Introduce normal saline at 75 mL/hr • C. Give methylprednisolone (SOLU-Medrol) 1 g intravenously (IV) • D. Take blood, urine, sputum cultures
A- SARS is deadly
Nurse Channing is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first? • A. A client with diabetes is being discharged today. • B. A 35-year-old male with tracheostomy and copious secretions. • C. A teenager is scheduled for physical therapy this morning. • D. A 78-year-old female client with a pressure ulcer that needs a dressing change.
B- airway problem given highest priority
What is regarded as one of the priority actions that must be accomplished when a primary assessment of a trauma client is conveyed? • A. Taking a full set of vital sign measurements. • B. Completing a brief neurologic assessment. • C. Monitoring pulse oximetry reading. • D. Palpating and auscultating the abdomen.
B- assess consciousness and pupil reaction - VS are part of secondary survey
Nurse Paul is developing a care plan for a client after bariatric surgery for morbid obesity. The nurse should include which of the following on the care plan as the priority complication to prevent: • A. Pain • B. Wound infection • C. Depression • D. Thrombophlebitis
B- wound infection is most common in obese patients
A client with multiple injuries is rushed to the ED after a head-on car collision. Which assessment finding takes priority? • A. Irregular apical pulse • B. Ecchymosis in the flank area • C. A deviated trachea • D. Unequal pupils
C- symptom of tension pneumothorax
A newly admitted client is suspected to have avian influenza ("bird flu") due to increasing dyspnea and dehydration. Which of these prescribed actions will the nurse implement first? • A. Give first dose of oseltamivir (Tamiflu) • B. Instill 5% dextrose in water at 100 mL/hr • C. Collect blood and sputum specimens for testing • D. Start oxygen using a non-rebreather mask
D- ABCs
The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? a. A client complaining of muscle aches, a headache, and malaise b. A client who twisted her ankle when she fell while rollerblading c. A client with a minor laceration on the index finger sustained while cutting an eggplant d. A client with chest pain who states that he just ate hot wings that was made with a very spicy sauce.
D- In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits, or who have sustained chemical splashes to the eyes, are classified as emergent and are the number 1 priority.
•Nurse Vivian is reviewing immunizations with the caregiver of a 72-year-old client with a history of cerebrovascular disease. The caregiver learns which immunization is a priority for the client? A. Hepatitis A vaccine B. Lyme's disease vaccine C. Hepatitis B vaccine D. Pneumococcal vaccine
D- •Pneumococcal vaccine is a priority immunization amongst the elderly, especially those with chronic illnesses. It is administered every five (5) years. A pneumococcal vaccine, PPSV23, is indicated in the United States for all adults 65 years of age and older, as well as younger patients with conditions that increase the risk for developing pneumococcal pneumonia or invasive pneumococcal disease.
•Nurse Janus enters a room and finds a client lying on the floor. Which of the following actions should the nurse perform first? • A. Call for help to get the client back in bed • B. Establish whether the client is responsive • C. Assist the client back to bed • D. Ask the client what happened
B- after ABCs, call for help
Which action will the nurse take to most effectively reduce the incidence of hospital-related urinary tract infections (UTI)? A. Make sure that clients have an adequate fluid intake B. Educate assistive personnel on how to provide good perineal hygiene C. Restrict the use of indwelling catheters D. Perform dipstick urinalysis for clients with risk factors for UTI
C
During a class discussion, the 50-year-old professor suddenly feels left-sided chest pain, dizziness, and diaphoresis. What is the priority action when he arrives in the ED triage area? • A. Supply oxygen via nasal cannula • B. Place intravenous (IV) access • C. Notify the ED physician • D. Set the client on continuous electrocardiographic monitoring
A- increasing myocardial oxygenation is goal
A 90-year-old client is confined to the unit for two weeks. He has been receiving antibiotics for more than a week and says that he is having frequent watery stools. Which action will you take first? A. Place the client on contact precautions B. Educate the client about correct hand washing C. Notify the physician about the loose stools D. Get stool specimens for culture
A- possible C-diff based on age and antibiotic therapy
Prior to oral defense, a 21-year-old nursing student goes straight to the clinic due to tingling sensations, palpitations, and chest tightness. Deep, rapid breathing and carpal spasms are also observed. What is the nursing priority action for this situation? •A. Give supplemental oxygen •B. Allow the student to breathe into a paper bag •C. Report to the physician immediately •D. Get an order for an anxiolytic medication
B- need more CO2
You are evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns you immediately? •A. The patient has fine bibasilar crackles. •B. The patient's respiratory rate is 8 breaths/min. •C. The patient sits up and leans over the night table. •D. The patient has a large barrel chest.
B- oxygen flow is too high and is causing high serum oxygen level
A drunk driver has been in the police station for 48 hours. During the first hours, he had tremors and was feeling anxious and sweaty. Currently, he is experiencing disorientation, hallucination, and hyperactivity. It was noted that the client has a history of alcohol abuse. What is the priority nursing diagnosis? • A. Risk for Nutritional Deficit related to chronic alcohol abuse • B. Risk for Injury related to seizures • C. Risk for Situational Low Self-Esteem related to police custody • D. Risk for Other-Directed Violence related to hallucinations
B- •Client safety is the priority because the driver exhibits neurologic hyperactivity and is on the verge of a seizure. Medications such as chlordiazepoxide (Librium) are needed to decrease neurologic irritability and phenytoin (Dilantin) for seizures. Thiamine and haloperidol (Haldol) may also be ordered to treat other problems.
The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months experience) pulled from the surgical unit to the medical unit? A. A 58-year old on airborne precautions for tuberculosis (TB). B. A 68-year old just returned from a bronchoscopy and biopsy. C. A 72-year old who needs teaching about the use of incentive spirometry. D. A 69-year old with COPD who is ventilator dependent.
C- Easiest
A nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? a. A client who is ambulatory b. A client scheduled for physical therapy at 1 pm c. A client with a fever who is diaphoretic and restless d. A postoperative client who has just received pain medication
C- The nurse should plan to care for the client who has a fever and is diaphoretic and restless first because this client's needs are the priority. The client who is ambulatory and the client scheduled for physical therapy later in the day do not have priority needs related to care. Waiting for pain medication to take effect before providing care to the postoperative client is best.
Nurse Skye is assigned to the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first? • A. A client scheduled for cardiac ultrasound this morning. • B. A client with syncope being discharged today. • C. A client with chronic bronchitis on nasal oxygen. • D. A client with diabetic foot ulcer that needs a dressing change.
C- client with airway problems should be seen first
A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted sleep cycle. Which action should you delegate to the nursing assistant? A. Discuss weight-loss strategies such as diet and exercise with the patient. B. Teach the patient how to set up the BiPAP machine before sleeping. C. Remind the patient to sleep on his side instead of his back. D. Administer modafinil (Provigil) to promote daytime wakefulness.
C- reminding
•After the respiratory therapist performs suctioning on a patient who is intubated, the RN measures vital signs for the patient. Which vital sign value should the RN be most concerned about? A. Heart rate of 98 beats/min B. Respiratory rate of 24 breaths/min C. Blood pressure of 168/90 mm Hg D. Tympanic temperature of 101.4ºF (38.6ºC)
D- Infections are always a threat to the patient receiving mechanical ventilation. The endotracheal tube bypasses the body's normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower part of the respiratory system.
Two student nurses are assigned to a client with lung cancer who has received oxycodone (Roxicodone) 10 mg orally for pain. During the assessment, which finding should the student nurses report immediately? A. Decrease in pain level from 6 to 2 (on a scale of 10) B. Heart rate of 90 to 100 beats/min C. Request by the client that the room door be closed D. Respiratory rate of 8 to 10 breaths/min
D- drop indicates respiratory depression
A client presents to the emergency room with dyspnea, chest pain, and syncope. The nurse assesses the client and notes that the following assessment cues: pale, diaphoretic, blood pressure of 90/60, respirations of 33. The client is also anxious and fearing death. Which action should the nurse take first? • A. Administer pain medications • B. Administer IV fluids • C. Administer dopamine • D. Administer oxygen via nasal cannula
D- promotion of adequate oxygenation is most vital
After a change of shift, you are assigned to care for the following patients. Which patient should you assess first? • A 60-year-old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab. • B. A 55-year-old with COPD and a pulse oximetry reading from the previous shift of 90% saturation. • C. A 70-year-old with pneumonia needs to be started on intravenous (IV) antibiotics. • D. A 50-year-old with asthma who complains of shortness of breath after using a bronchodilator.
D- this pt did not achieve relief
