Questions and Answers
A nurse is caring for a client who is newly diagnosed with bipolar disorder and is currently experiencing an acute manic episode. Which of the following is a priority concern of the nurse?
A nurse has been assigned to care for four clients on a medical-surgical floor. Which of the following clients should the nurse evaluate first?
A nurse is caring for a client who has a fractured hip and a respiratory rate of 26/min. Which of the following actions should the nurse take first?
A school nurse is reinforcing teaching regarding bicycle safety to a group of school-age children. Which of the following is the most important concept to include in the teaching?
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A nurse is caring for a client who was admitted to the unit three hours ago following a total hip arthroplasty. Which of the following findings should be the nurse's priority concern?
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A nurse is caring for a client who is experiencing panic level anxiety. Which of the following actions should the nurse take first?
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A nurse is caring for a toddler who has laryngotracheobronchitis and is having difficulty breathing. Which of the following should be the first action of the nurse?
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A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate. Which of the following client data is most important for the nurse to monitor?
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A nurse is caring for a client who has a flaccid bladder following a spinal cord injury. Which of the following actions should the nurse take first?
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A nurse is caring for a client who is 48 hr post-operative following an abdominal aortic aneurysm resection. Which of the following findings is the most urgent?
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A nurse is caring for a child who has sickle cell disease and has been admitted in a vaso-occlusive crisis. Which of the following is the nurse's priority concern?
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A nurse on a medical unit has received report on four clients. Which of the following clients should the nurse evaluate first?
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A nurse is caring for a client who has a compound fracture of the tibia and fibula and is in skin traction. The client reports pain of a 6 on a scale of 0 to 10 under the traction bandage. Which of the following actions should the nurse take first?
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A nurse is caring for a group of pediatric clients. Which of the following clients requires immediate intervention?
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Following morning report, a nurse assigns completion of several tasks to an assistive personnel (AP). Which of the following tasks should the nurse have the AP perform first?
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A nurse is caring for a client who has a radial head fracture. Which of the following should be the priority action by the nurse following application of the cast?
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A nurse in a provider's office is collecting data on a group of clients who are pregnant. Which of the following clients should be the nurse's priority concern?
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A public health nurse is triaging clients at the site of an explosion. The client with which of the following injuries should be the nurse's priority concern?
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A nurse is collecting data on a client who has a diagnosis of myasthenia gravis. For which of the following complications is it most important for the nurse to monitor?
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A nurse working the 7 PM to 7 AM shift on the pediatric unit has received report on four post-operative clients. Which of the following requires immediate intervention?
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Study Notes
Prioritization in Nursing Care
- Client with Bipolar Disorder: Priority is to prevent injury during an acute manic episode.
- Post-Surgery Client: A client post-knee replacement with calf pain and warmth requires urgent evaluation for potential thromboembolism.
- Fractured Hip: First action in a client with increased respiratory rate is to evaluate their level of consciousness for possible complications.
- Bicycle Safety for Children: Emphasize the importance of using a properly fitted helmet as a key safety measure.
Post-Operative Care
- Total Hip Arthroplasty: An oxygen saturation of 90% on 2 L oxygen is a priority concern, indicating possible respiratory issues.
- Client with Abdominal Aortic Aneurysm Resection: Absent dorsalis pedis pulses signals urgent vascular compromise.
Crisis Management
- Panic Level Anxiety: Engaging the client in physical activity is the first step to alleviate symptoms and reduce anxiety.
- Laryngotracheobronchitis in Toddler: Initial assessment should be to obtain oxygen saturation levels to monitor respiratory status.
Maternal and Fetal Monitoring
- Preterm Labor with Magnesium Sulfate: Monitoring maternal respirations is crucial due to the risk of respiratory depression from the medication.
Neurological and Urinary Concerns
- Flaccid Bladder Post-Spinal Injury: The priority action is to initiate a bladder training schedule for promoting urinary function.
- Client with Myasthenia Gravis: Monitoring for decreased respiratory effort is critical as it signifies potential respiratory failure.
Pediatric Nursing Considerations
- Sickle Cell Disease Crisis: Focus on promoting oxygenation as a priority to prevent complications from occlusive crises.
- Post-Tonsillectomy Child: Frequent swallowing may indicate bleeding and requires immediate intervention.
General Nursing Prioritization
- Digestive and Fluid Management: Monitor clients with gastrointestinal complaints for risks of complications, assessing signs like fever and abdominal tenderness.
- Client with Digoxin: Monitor clients with multiple vomiting episodes closely to prevent toxicity, as digoxin has a narrow therapeutic window.
Task Delegation and Client Care
- Assistive Personnel Assignments: The first task assigned is performing fingersticks for glucose monitoring in diabetic clients to ensure safety and management of blood sugar levels.
- Neurovascular Assessment Post-Cast Application: Evaluating neurovascular status is vital after applying a cast to prevent complications like compartment syndrome.
Emergency Triage
- Public Health Emergency Response: Prioritize clients with life-threatening injuries, such as incomplete amputations, over less severe injuries for immediate care.
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Description
This set of flashcards focuses on advanced nursing priorities in various clinical scenarios, particularly for clients with mental health concerns. Each card presents a situation requiring the nurse to decide on the priority of care to ensure patient safety and effective treatment. Perfect for nursing students and professionals preparing for exams or improving their clinical decision-making skills.
