Leadership Management - Prioritizing

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?
1. A client scheduled for a chest x-ray
2. A client requiring daily dressing changes
3. A postoperative client preparing for discharge
4. A client receiving nasal oxygen who had difficulty breathing during the previous shift

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?
1. A client who is ambulatory
2. A client scheduled for physical therapy at 1 pm
3. A client with a fever who is diaphoretic and restless
4. A postoperative client who has just received pain medication

The nurse is giving a bed bath to an assigned client when an unlicensed assistive personnel (UAP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action?
1. Finish the bed bath and then administer the pain medication to the other client.
2. Ask the UAP to find out when the last pain medication was given to the client.
3. Ask the UAP to tell the client in pain that medication will be administered as soon as the bed bath is complete.
4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 3 pm. The nurse making rounds at 3:45 pm finds that the client is complaining of a pounding headache and is dyspneic, is experiencing chills, and is apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first?
1. Slow the IV infusion.
2. Sit the client up in bed.
3. Remove the IV catheter.
4. Call the health care provider (HCP).

The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next?
1. Remove the intravenous (IV) line.
2. Run a solution of 5% dextrose in water.
3. Run normal saline at a keep-vein-open rate.
4. Obtain a culture of the tip of the catheter device removed from the client.

Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement first?
1. Maintain bed rest with legs elevated.
2. Place the client in high-Fowler's position.
3. Increase the rate of infusion of intravenous fluids.
4. Consult with the health care provider (HCP) regarding initiation of oxygen therapy.

The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first priority intervention in the event of this occurrence is which action?
1. Immobilize the affected extremity.
2. Remove jewelry and constricting clothing from the victim.
3. Place the extremity in a position so that it is below the level of the heart.
4. Move the victim to a safe area away from the snake and encourage the victim to rest.

The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. Which statement indicates that the student correctly identifies the priority client needs?
1. Actual or life-threatening concerns are the priority.
2. Completing care in a reasonable time frame is the priority.
3. Time constraints related to the client's needs are the priority.
4. Obtaining needed supplies to care for the client is the priority.

A child with autism is being admitted to the hospital for diagnostic tests. To which type of room should the nurse assign the child?
1. Private room
2. Semiprivate room
3. Four-bed ward room
4. Contact isolation room

The labor and delivery room nurse has just received report on four clients. After reviewing the client data, the nurse should assess which client first?
1. A primigravida client in the active stage of labor
2. A multigravida client who was admitted for induction of labor
3. A client who is not contracting, but has suspected premature rupture of the membranes
4. A client who has just received an intravenous loading dose of magnesium sulfate to stop preterm labor

The nurse has developed a teaching plan for a client with hypertension regarding the administration of prescribed medications. What is the initial nursing action?
1. Set priorities for the client.
2. Assess the client's readiness to learn.
3. Find out whether anyone lives with the client.
4. Use only one teaching method to prevent confusion.

A client with cancer is receiving intravenous (IV) morphine sulfate for pain. When writing the plan of care for this client, the nurse should include which action as a priority action?
1. Monitor temperature.
2. Monitor urine output.
3. Monitor respiratory status.
4. Encourage increased fluids.

The nurse is preparing to suction the airway of a client who has a tracheostomy tube and gathers the supplies needed for the procedure. In order of priority, which actions should the nurse take to perform this procedure? Arrange the actions in the order that they should be performed. All options must be used.
1. Apply gloves and attach the suction tubing to the suction catheter.
2. Place the client in semi-Fowler's position.
3. Apply intermittent suction and slowly withdraw the catheter while rotating it back and forth.
4. Insert the catheter into the tracheostomy until resistance is met, and then pull it back 1 cm.
5. Turn on the suction device and set the regulator at 80 mm Hg.
6. Hyperoxygenate the client.

The nurse notes blanching, coolness, and edema at a client's peripheral intravenous (IV) site. Which nursing action is the priority?
1. Remove the IV catheter.
2. Apply a warm compress.
3. Check for a blood return.
4. Measure the area of infiltration.

A client has a prescription to begin an infusion of 1000 mL of 5% dextrose in lactated Ringer's solution. The client has an intravenous (IV) cannula inserted, and the nurse prepares the solution and IV tubing. Arrange the actions in the order that they should be performed. All options must be used.
1. Uncap the distal end of the tubing.
2. Attach the distal end of the tubing to the client.
3. Close the roller clamp on the IV tubing.
4. Open the roller clamp and fill the tubing.
5. Spike the IV bag and half-fill the drip chamber.

The nurse is caring for four pediatric clients. After receiving reports from the nightshift, which child should the nurse assess first?
1. A 6-year-old child being treated for bacterial meningitis and on the 10th day of antibiotic treatment
2. A 6-week-old infant admitted to the hospital for decreased level of consciousness; shaken baby syndrome is suspected
3. A 2-year-old child with cerebral palsy being admitted to the hospital for surgical placement of a gastrostomy feeding tube the next day
4. A 16-year-old child with a ventriculoperitoneal shunt that was placed at birth for hydrocephalus; possible shunt malfunction is suspected, and the child is scheduled and ready for a computed tomography (CT) scan of the head

The nurse is assigned to four clients on a postoperative surgical unit at a rural hospital. When prioritizing the care, the nurse recognizes the highest priority is focused on which client?
1. The client who lacks knowledge regarding postoperative home care
2. The client with tissue perfusion alterations related to postoperative venous stasis
3. The client with problems clearing the airway related to abdominal incision pain
4. The client who is at risk for infection related to a history of smoking for 20 years

The emergency department nurse is caring for a child with suspected epiglottitis and has ensured that the child has a patent airway. Which action is the next priority in the care of this child?
1. Prepare the child for tracheotomy.
2. Prepare to administer epinephrine.
3. Prepare the child for a chest radiograph.
4. Assist the health care provider with intubation.

The nursing instructor asks the nursing student to identify the priorities of care for an assigned client. The nursing instructor determines that the nursing student understands the client's needs when which statement is made?
1. "Actual or life-threatening concerns are the priority."
2. "Completing care in a reasonable time frame is the priority."
3. "Time constraints related to the client's needs are the priority."
4. "Obtaining the needed supplies to care for the client is the priority."

A hospitalized client with type 1 diabetes mellitus received Humulin N and Humulin R insulin 2 hours ago (at 7:30 am). The client calls the nurse and reports that he is feeling hungry, shaky, and weak. The client ate breakfast at 8 am and is due to eat lunch at noon. Arrange the actions that the nurse will take in order that they should be performed. All options must be used.
1. Take the client's vital signs.
2. Retest the blood glucose level.
3. Check the client's blood glucose level.
4. Give the client ½ cup of fruit juice to drink.
5. Give the client a small snack of carbohydrate and protein.
6. Document the client's complaints, actions taken, and outcome.

An emergency department nurse is preparing to receive four clients as a result of a motor vehicle crash. Which victim should the nurse attend to first?
1. A child with a bleeding laceration
2. A 54-year-old woman with a fractured wrist
3. A 67-year-old woman with first-degree burns on her hands and arms
4. A 45-year-old man with chest pain, shortness of breath, and diaphoresis

The nurse is assigned to care for four clients. Which client should the nurse assess first?
1. A client who has a tympanic temperature of 99.8° F
2. A client who has a regular radial pulse of 96 beats/min
3. A client who has a supine resting blood pressure of 148/90 mm Hg
4. A client who has a peripheral (index finger) oxygen saturation percentage of 85%

The nurse has received her client assignment for the day. Which client should the nurse care for first?
1. A client requiring a preoperative intravenous antibiotic
2. Shortness of breath in a client with emphysema who just ambulated
3. A client with serous drainage on an incisional spinal wound postlaminectomy
4. A client with postoperative pain reported at 7 out of 10, with 10 being the worst

The nurse has received the client assignment for the day. Which client should the nurse care for first?
1. The client receiving chemotherapy who is on day 3 of a 5-day regimen and has a question about nutrition
2. The client receiving external radiation who has complaints of dryness and itching skin at the treatment area
3. The client who had a radical mastectomy 36 hours ago and is complaining of tightness and pulling at the incision site
4. The client admitted with the medical diagnosis of neutropenia who is afebrile and is complaining of pain with urination

The nurse is the first responder at the scene of a six-car crash on a highway. Which victim should the nurse attend to first?
1. A victim experiencing dyspnea
2. A victim experiencing confusion
3. A victim experiencing tachycardia
4. A victim experiencing intense pain

The nurse in charge of a nursing unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply.
1. A client with chest pain
2. A client with a Holter monitor
3. A client receiving oral antibiotics
4. A client experiencing sinus rhythm
5. A client newly diagnosed with atrial fibrillation
6. A client experiencing third-degree heart block and requires a pacemaker

The nurse has received her client assignment for the day. Which client should the nurse care for first?
1. A client experiencing severe pain
2. A client who is hearing voices in his head
3. A client who has just returned from surgery
4. A client who is in four-point leather restraints

The nurse is a responder at the scene of a building collapse. Which victim should the nurse tend to first?
1. Victim with an open fracture of the left lower extremity
2. Victim who is crying hysterically and complaining of pain in the right ankle
3. Victim with an apparent chest wall defect and asymmetrical chest wall movement
4. Victim who is unresponsive, not breathing, and the left pupil is fixed and dilated

The nurse manager of a medical-surgical unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply.
1. Client postoperative day 1 inguinal herniorrhaphy, vital signs stable
2. Client 5 days after a myocardial infarction, vital signs stable, absence of dysrhythmias
3. Client 1 day after cardiac catheterization, normal study results, groin site free of hematoma
4.Client on nasal oxygen at 3 L/min, bibasilar crackles, and pulse oximetry readings of 88% to 92%
5.Client who is vomiting, unable to take oral fluids, and receiving intravenous fluids at 125 mL/hr
6.Client with white blood cell count of 2200 cells/mm³, temperature of 102° F and blood pressure of 90/40 mm Hg

A nurse is preparing to perform a general survey of a client who was admitted to the hospital a few hours ago. Which components of the general survey may be delegated to the unlicensed assistive personnel (UAP)? Select all that apply.
1. Inspecting skin surfaces
2. Observing the client's behavior
3. Measuring the client's height and weight
4. Assessing the client's general appearance
5. Monitoring oral intake and urinary output

A nurse is the first responder at the scene of an accident in which a tire blowout caused a bus to roll over several times. Which victim should the nurse attend to first?
1. The 11-year-old with burns to 10% of both legs
2. The sobbing 10-year-old with an obvious fracture of the forearm
3. The unconscious 14-year-old whose breathing is shallow at 12 respirations per minute
4. The confused 12-year-old with bright red blood pulsing from an open fracture of the femur

The nurse in charge of a nursing unit is asked to select those hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply.
1. The client with heart failure (HF) who has bilateral rhonchi
2. The client who 24 hours earlier gave birth to her second child by caesarean delivery
3. The 48-hour postoperative client who has undergone an ileostomy because of ulcerative colitis
4. The client with peritonitis caused by a ruptured appendix who is febrile with a temperature of 102° F
5. The 2-day postoperative client who has undergone total knee replacement and is ambulating with a walker
6. The 3-day postoperative client who has undergone coronary artery bypass grafting and is ready for rehabilitation

A nurse has received her client assignment for the day. Which client should the nurse care for first?
1. The 43-year-old client admitted for observation who has absence of bowel sounds
2. The 53-year-old client with heart failure who has gained 4 pounds since yesterday and is short of breath
3. The 49-year-old client who is scheduled for surgery within the next 2 hours and will undergo a hysterectomy
4. The 12-hour postoperative client who has undergone pneumonectomy and is completing a blood transfusion

During morning report, the day nurse is given information on the assigned clients. Which client should the nurse assess first?
1. The 80-year-old client with metastatic cancer to the brain who is confused and on one-to-one observation with a sitter in the room
2. The 55-year-old client with breast cancer who is scheduled for a computed tomographic (CT) scan of the brain at 0900 to rule out metastasis
3. The 60-year-old client with leukemia who is receiving the first round of chemotherapy, which was started at 0630 and is scheduled to end at noon
4. The 70-year-old client who was admitted at 0500 with the medical diagnosis of pneumonia and a temperature of 102.6° F. This client received (acetaminophen) Tylenol at 0600 and now has a temperature of 100.0° F

The nurse determines that which client has the highest priority needs?
1. The client who has a rectal temperature of 99.8° F
2. The client who has a blood pressure of 110/70 mm Hg
3. The client who has an oxygen saturation percentage of 95%
4. The client who has an irregular apical pulse of 120 beats per minute

When planning care, which client should the nurse assess first?
1. The client who is on contact isolation for methicillin-resistant Staphylococcus aureus (MRSA)
2. The client who is receiving total parental nutrition and lipids
3. The client who had a cholecystectomy 2 days earlier
4. The client with a chest tube for a pneumothorax

A nurse assigned to four clients reviews client data at the beginning of the shift. To which information should the nurse give highest priority?
1. Hemoglobin 12.2 g/dL
2. Urine output 240 mL/8 hr
3. Potassium level 3.6 mEq/L
4. Pulse oximetry reading 89%

A home health care nurse is planning client visits and nursing activities for the day. The nurse begins the visits at 9 am. All clients live within a 5-mile radius. In order of priority, how the nurse should plan the assignments for the day? All options must be used.
1. A client requiring supervision of a dressing change
2. A client being visited by the home health aide at 1030 am
3. A client requiring an admission assessment to home health care
4. The first dressing change for a client requiring twice daily dressing changes
5. A client with diabetes mellitus who needs a fasting blood glucose level drawn
6. The second dressing change for a client requiring twice-daily dressing changes

A nurse is monitoring a client receiving total parenteral nutrition (TPN). The client suddenly develops respiratory distress, dyspnea, and chest pain, and the nurse suspects air embolism. In order of priority, how should the nurse plan the actions to take? Arrange the actions in the order that they should be performed. All options must be used.
1. Administer oxygen.
2. Document the occurrence.
3. Take the client's vital signs.
4. Contact the health care provider (HCP).
5. Clamp the intravenous (IV) catheter.
6. Position the client in left Trendelenburg's position.

A unit of packed red blood cells has been prescribed for a client with low hemoglobin and hematocrit levels. The nurse notifies the blood bank of the prescription, and a blood specimen is drawn from the client for typing and crossmatching. The nurse receives a telephone call from the blood bank and is informed that the unit of blood is ready for administration. In order of priority, how should the nurse plan the actions to take? Arrange the actions in the order that they should be performed. All options must be used.
1. Hang the bag of blood.
2. Obtain the unit of blood from the blood bank.
3. Ensure that an informed consent has been signed.
4. Insert an 18- or 19-gauge intravenous catheter into the client.
5. Verify the health care provider's (HCP) prescription for the blood transfusion.
6. Ask a licensed nurse to assist in confirming blood compatibility and verifying client identity.

A nurse is monitoring a client in labor who is receiving oxytocin (Pitocin) and notes that the client is experiencing hypertonic uterine contractions. In order of priority, how should the nurse plan the actions to take? Arrange the actions in the order that they should be performed. All options must be used.
1. Reposition the client.
2. Stop the oxytocin infusion.
3. Perform a vaginal examination.
4. Check the client's blood pressure.
5. Administer oxygen by face mask at 8 to 10 L/min.
6. Administer medication as prescribed to reduce uterine activity.

After correctly completing the rights of medication administration, performing hand hygiene, and ensuring the correct position of the client, which steps should the nurse take to administer medication via a volume control container? Arrange the actions in the order that they should be performed. All options must be used.
1. Clean injection port on top of volume control container with an antiseptic swab.
2. Fill volume control container with desired amount of intravenous (IV) fluid by opening clamp between volume control container and main IV bag.
3. Remove the needle cap and insert the needleless syringe tip through port, then inject the medication and label volume control container with name of medication, dosage, total volume including diluents, and time of administration.
4. Dispose the syringe in puncture proof and leakproof container. Discard supplies and perform hand hygiene.
5. Close the clamp and check to be sure clamp on air vent volume control container is open.
6. Regulate IV infusion rate to allow medication to infuse in time recommended by institutional policies.