Prioritization NCLEX questions

Prioritization NCLEX questions ScienceMedicineNursing madisoncastelloTop creator on Quizlet Save 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 client complaining of muscle aches, a headache, and malaise
• A client who twisted her ankle when she fell while rollerblading
• A client with a minor laceration on the index finger sustained while cutting an eggplant
• 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.

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 client who is ambulatory
• A client scheduled for physical therapy at 1 pm
• A client with a fever who is diaphoretic and restless
• 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.You are monitoring a 53-year-old client who is undergoing a treadmill stress test. Which client-finding will require the most immediate action?

• Blood pressure of 152/ 88 mm Hg
• Heart rate of 134 beats/ min
• Oxygen saturation of 91%
• 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

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?

• Hematocrit of 33%
• Hemoglobin level of 10.9 g/ dL
• Platelet count of 426,000/ mm3
• 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

What is the priority nursing diagnosis for a client experiencing a migraine headache?

• Acute Pain related to biologic and chemical factors
• Anxiety related to change in or threat to health status
• Hopelessness related to deteriorating physiologic condition
• 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?

• Client with deep partial-thickness burns on both legs who reports severe and continuous

leg pain

• Client who has just arrived from the emergency department with facial burns sustained in a

house fire

• Client who has just been transferred from the postanesthesia care unit after having skin

grafts applied to the anterior chest

• 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 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.