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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 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?
- Encouraging problem solving
- Promoting usefulness
- Preventing injury (correct)
- Enhancing self-esteem
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 has been assigned to care for four clients on a medical-surgical floor. Which of the following clients should the nurse evaluate first?
- A client admitted with a GI bleed receiving packed RBCs for hemoglobin of 7.8 gm/dL
- A client 48 hr following abdominal surgery with redness and swelling at the edges of the incision
- A client admitted with cholecystitis who reports frequent nausea and vomiting
- A client following knee replacement surgery complaining of pain and warmth in the calf (correct)
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 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?
- Initiate continuous ECG monitoring.
- Encourage increased fluid intake.
- Place the client on bed rest.
- Evaluate level of consciousness. (correct)
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?
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?
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?
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?
A nurse is caring for a client who is experiencing panic level anxiety. Which of the following actions should the nurse take first?
A nurse is caring for a client who is experiencing panic level anxiety. Which of the following actions should the nurse take first?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
A nurse on a medical unit has received report on four clients. Which of the following clients should the nurse evaluate first?
A nurse on a medical unit has received report on four clients. Which of the following clients should the nurse evaluate first?
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?
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?
A nurse is caring for a group of pediatric clients. Which of the following clients requires immediate intervention?
A nurse is caring for a group of pediatric clients. Which of the following clients requires immediate intervention?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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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