Prioritization NCLEX questions

Who first, Priority- NCLEX ScienceMedicineNursing rtaba Save Prioritization NCLEX questions 28 terms madisoncastello Preview 75 Free NCLEX Questions - c/o Brilli...75 terms carey47Preview 25Qw/exp Delegation and Prioritiza...25 terms Preview NCLEX 110 term kan See first?

• A NAP enters the room of the client diagnosed with Pneumocycstis cariniipnneumoia wearing gown, mask, gloves
• The client who has just returned from a right pneumonectomy is placed in a room with the client diagnosed with COPD
• toilet overflowing
• TB patient ready for discharge

see #2 first because postop clients are considered "clean" and should not be placed with a client that is considered "dirty" #1 the NAP should be counseled for wrong PPE, standard precaution #3 is a problem but not most important #4 psychosocial need; physical needs take priority See first?

• A 22 yr old admitted with viral gastroenteritis complaining of nausea, vomiting and diarrhea
• 42 year old 24 hours post thyroidectomy who is complaining of headache and pain at the incision site
• 50 year old admitted 72 hours ago for ckd with uop of 220mL in 8 hours and hands and feet are edematous
• A 64 year old admitted yesterday for hypertension, hf, digitalis toxicity with frequent PVCs (premature ventricular complexes)
• indicated potassium imbalance; hypokalemia, dysrhythmias can rapidly deteriorate to ventricular tachycardia or sudden death.
• potential E-lyte imbalance; monitor
• expected outcome; headache needs further investigation but is not most concerning
• indicates sodium retention=expected finding in CKD; output needs to be evaluated but is not most concerning

See first?

• A client who is breastfeeding 2 day old
• discharged client with IV hep therapy for DVT
• Elderly client discharged 3 days ago with pneumonia
• elderly client who used all the diuretic medication and is expectorating pink-tinged mucous
• symptoms of pulmonary edema; requires immediate attention
• stable
• assess for bleeding gums and hematuria; not a priority
• assess for breath sounds, encourage fluids, cough and deep breathe

See First at diabetic specialty unit?

• 17 yr old with irritability complaining of fatigue
• 28 yr old woman with fruity breath smell complaining of thirst
• 38 yr old with bp of 120/50 complaining of frequent urination and thirst
• 45 yr old woman with bp of 90/60 and skin is hot and dry to touch
• indicated DKA, increased risk of injury to client
• Hypoglycemia
• Diabetes
• dehydration; first stage of DKA

Note: All have to do with diabetes because in a diabetes specialty unit.

Psych unit admission, seen first?

• A police officer with PTSD history who was admitted with agoraphobia after two of his co-officers were shot and killed in a drug raid
• A college student admitted for depression and anxiety after his younger sibling committed suicide. His mother was recently diagnosed with

lung cancer.

• high potential for violence to self &/or others; male; easy access to weapons, and has knowledge of how to use them; needs assessment

orientation to the physical surroundings, staff, unit schedules and expectations, rules and procedures for asking for help; any visitors would need to be particularly monitored for potential weapons, especially if they are other police officers and accustomed to carrying their guns.

• Should be the 2nd patient seen; siblings of a person who committed suicide often feel despair and survivor guilt, putting themselves at risk for

suicide; this patient has experienced 2 serious losses, 1 actual and 1 potential.See first on oncology floor?

• The client diagnosed with breast cancer with extensive bone metastasis who is irritable and confused
• The client with a WBC of 1.600/mm3 who reports burning with urination
• Hypercalcemia may occur as a result of bone destruction by the tumors; elevated levels affect mental status and can negatively affect multiple

organ systems.

• UTI eval needed but not most concerning.

First ACTION?

• place client on droplet precautions
• Monitor for increased ICP
• Prepare the client for a lumbar puncture
• Set up seizure precautions
• symptoms of meninitis; haemophilus influenzae and Neisseria meningitidis = droplet precautions until confirmed or eliminated
• spread of infection first then protect client
• important to assess but not priority
• culture, not priority

Seen first?

• a lethargic 2 month old who refuses to nurse for 8 hours
• A 2 year old complaining of elbow pain and deformity
• A 5 year old who is flushed and has a temp of 101.9
• A 6 yr old with 2 episodes of vomiting and a sore throat

First see 2 month old due to dehydration and acidosis, kidneys can't concentrate urine, metabolism 2x as fast as an adult Although temp is high, nurse can request antipyretic Vomiting is a risk for dehydration but age of child can withstand more than an infant Assign to RN?

• A child recovering from surgical repair of a hypospadias.
• A client recovering from excisionof a malignant melanoma
• A client diagnosed with a MI requiring assistance to the bathroom
• A client diagnosed with urolithiasis recovering from lithotripsy
• may require a wide excision that requires nurse to anticipate the need for analgesic medications; psychological support is also necessary

because of diagnosis of cancer; requires assessment, teaching and nursing judgment.

• ensure patency of urinary diversin after surgery; assign to LPN
• standard unchanging procedure, assign to NAP
• observe for obstruction and infection, strain urine; assign to LPN.

See First when all patients receiving blood transfusions

• A client complaining of a headache
• A client vomiting
• A client complaining of itching
• A client with neck vein distention
• Hemolytic reaction; most dangerous type of transfusion reaction; symptoms include nausea, vomiting, pain in lower back, hematuria;

treatment is to stop blood, obtain urine specimen and maintain blood volume and kidney perfusion.

• febrile reaction; symptoms include fever, chills, nausea, headache; treatment is to stop blood and administer aspirin
• allergic reaction; symptoms include urticaria or hives, pruritus, fever; treatment is to stop blood, give diphenhydramine and administer oxygen
• circulatory overload, treatment is to stop blood, position in an upright position and administer oxygen.

Room accommodations?

• A semiprivate with an infant diagnosed with the flu
• A semiprivate room with an infant diagnosed with kawasaki syndrome
• A private room with sleeping accommodations
• a private room without sleeping accommodations
• RSV causes bronchiolitis and requires contact precautions; parents are best providers of care for their children, sleeping accommodations are

appropriate

• requires droplet
• acute systemic vasculitis of unknown cause; treated with IV immune globulin and aslicylate therapy; requires standard precautions
• provide sleeping accommodations

See First?

• A client post CABG having the AV wires removed later in the day
• A client with type 1 diabetes scheduled for a cardiac cath later today
• A client 1 day postop with an epidural cath in place
• A client diagnosed with cardiomyopathy being evaluated for a heart transplant
• Epidural used fro pain relief, monitor for urinary incontinence, hypotension, respiratory depression and nausea and vomiting
• Although client requires a high level of nursing, no indication that the client is unstable.
• Client requires preop assessment and teaching, no indication that the client is unstable.
• requires monitoring but client with epidural takes priority

Assign to LPN?

• A client 2 days postop after abdominal hysterectomy asking to ambulate in the hall
• A client with a colostomy requiring assistance with an irrigation
• A client with a right-sided CVA requiring assistance with bathing
• A client refusing medication for treatment of cancer of the colon
• Stable client with an expected outcome; sigmoid colostomy may require irrigation
• NAP; give clear directions and should report back to RN
• NAP; standard unchanging; ADLs within UAP's scope
• RN; requires assessment and judgment

First action?Nurse notes many has flu but accompanied client to the clinic.

• Inform the family members they should stay home if they have a cough
• Instruct the coughing family members to sit at least 3 feet from each other
• the Flu spreads by droplet; nurse should offer masks to people who are coughing as well as enforce separation
• family shouldn't have gone out but they are in the clinic therefore nurse's priority is to prevent spread of the flu.

reassigned RN?

• a client diagnosed with spinal cord injury requiring assistance with meals.
• a client diagnosed with MI complaining of burning on urination
• a client diagnosed with terminal cancer exhibiting Cheyne-stokes
• a client diagnosed with a head injury with a glasgow coma score of 7
• like an LPN, assign to stable client with expected outcome; burning on urination is indicative of UTI
• assign to CNA
• RN; periodic breathing characterized by rhythmic waxing and waning of the depth of respirations; client may be dying
• 8 or less indicates severe brain damage

See First?

• multigravida at 12 weeks experiencing white vaginal discharge
• Primigravida at 17 weeks has not felt baby move
• primigravida at 22 weeks complains of feeling dizzy and clammy when lying on her back
• multigravida at 32 weeks experiencing malaise and bilateral dependent and facial edema
• symptoms of pre-eclampsia that require evaluation
• leukorrhea caused by hyperplasia of vaginal mucosa, normal finding
• normal
• vena cava syndrome-obstruction or compression of blood flow; instruct client to lie on side