#2 Flashcards
(30 cards)
The home care nurse visits a client in a large apartment complex. During the visit, the area experiences a major earthquake. Which of the following clients should the nurse see FIRST?
1. A restless client with a rigid abdomen and absent bowel sounds. 2. An unconscious client with left-sided tracheal shift from midline. 3. A client complaining of excruciating pain with an obvious deformity of the left leg. 4. A client clutching her chest and complaining of severe chest pain.
Show/hide explanation
Strategy: Determine the most unstable client.
(1) likely has injuries to abdominal organs, resulting in hemorrhage and severe circulatory compromise and requires emergent evaluation; airway and breathing take priority
(2) CORRECT—first sign of a tension pneumothorax; airway and breathing take priority
(3) assess for neurovascular compromise; client with breathing difficulties takes priority
(4) circulatory problem; airway/breathing problems take priority
The nurse cares for clients in the outpatient clinic. The nurse returns to the desk to find four phone messages. Which of the following messages should the nurse respond to FIRST?
1. The mother of a 15-year-old reports her son is threatening to jump off a bridge and has access to a gun. 2. A 20-year-old female reports she has lost 2 lb this week and eats only two meals a day. 3. A 45-year-old male with a history of depression who is out of Prozac. 4. A 75-year-old male complains of insomnia and irritability after the death of his wife.
Show/hide explanation
Strategy: Determine the most unstable client.
(1) CORRECT— using Maslow Hierarchy of Needs theory to prioritize, physiological issues take priority over psychological issues; patient is at risk for self harm and must be seen first; observe for safety
(2) does not require immediate attention
(3) does not require immediate attention
(4) may be a normal part of grieving; nurse should assess but is not the priority
The nurse receives report on the medical/surgical unit. Which of the following clients should the nurse see FIRST?
1. A client with an IV of normal saline infusing at 125 ml per hour complaining of slight swelling at the IV insertion site. 2. A client 3 days post right knee replacement complaining of right calf pain with movement. 3. A client with a respiratory rate of 24 and an oxygen saturation of 94% on room air. 4. A client 12 hours after a hysterectomy complaining of nausea.
Show/hide explanation
Strategy: Determine the most unstable client.
(1) assess site for client’s comfort and to prevent complications associated with IV infusion, probable DVT takes priority
(2) CORRECT—assessment for possible DVT should be performed and reported to the physician immediately
(3) respiratory status is stable at present
(4) administer antiemetics; client with calf pain takes priority
The triage nurse at an urgent care center notes that four clients have signed in, each complaining of a sore throat. Which of the following clients should the nurse see FIRST?
1. A 7-year-old whose sibling was recently treated for "strep throat." 2. A 10-year-old with a history of chronic allergies. 3. A 21-year-old with a history of chronic sinus infections. 4. A 55-year-old receiving 5-fluorouracil (5-FU).
Show/hide explanation
Strategy: Determine the most unstable client.
(1) child has likely contracted strep from his sibling; treatment should begin as soon as possible; does not take priority
(2) likely experiencing irritation as a result of sinus drainage; does not take priority
(3) likely experiencing irritation as a result of sinus drainage; does not take priority
(4) CORRECT— because many chemotherapy agents may result in neutropenia, clients receiving drugs are more susceptible to infection, less likely to be able to fight the infection; symptomatic clients require immediate evaluation and treatment
The nurse cares for clients on the pain management unit. Which of the following clients should the nurse see FIRST?
1. A client receiving intraspinal anesthesia for pain control with a heart rate of 76 bpm and a respiratory rate of 8. 2. A client receiving patient-controlled analgesia (PCA) with a heart rate of 112 bpm and a respiratory rate of 24. 3. A client requesting PRN IV medication for severe chronic back pain. 4. A client requesting PRN IV medication for acute abdominal pain.
Show/hide explanation
Strategy: Determine the most unstable client.
(1) CORRECT— clients receiving intraspinal anesthesia must be closely monitored for signs of CNS depression
(2) should be assessed for adequate pain control; does not take priority
(3) pain should be addressed; chronic condition that does not take priority
(4) though the client’s pain should be addressed, it does not take priority
A nurse working in an emergency department performs a yearly ride-along with a local ambulance service. Responding to the scene of a motor vehicle collision (MVC), which of the following clients should the nurse see FIRST?
1. A client with an obvious deformity of the right humerus with neurovascular systems intact distal to the site. 2. An unconscious client with a crushing chest wound. 3. An unconscious client with a regular heart rhythm at 64 bpm with even and unlabored respirations. 4. An alert client with multiple scalp lacerations.
Show/hide explanation
Strategy: Determine the most unstable client.
(1) client likely has a fracture that will require further stabilization; there is no evidence of neurovascular compromise at present
(2) CORRECT— clients with crushing chest wounds are at risk for a number of injuries that may compromise airway, breathing, circulation, cervical spine, and the nervous system; immediate evaluation is required
(3) though the client is unconscious, cardiopulmonary assessment is stable
(4) client has circulatory compromise but is alert and able to hold pressure to any areas where bleeding is not well controlled; requires further evaluation but does not take priority at this time
The nurse cares for patients in the pediatric clinic. Which of the following patients should the nurse see FIRST?
1. A 5-year-old diagnosed with autistic disorder demonstrating finger flapping. 2. A 6-year-old with enuresis who often urinates in his underwear. 3. A 7-year-old who is shy and has difficulty reading. 4. A 9-year-old who has used a weapon toward his mother and caused physical harm to others.
Show/hide explanation
Strategy: Determine the most unstable patient.
(1) commonly seen in autistic disorder; has stereotypical and repetitive motor mannerisms; does not require immediate attention
(2) repeated voiding of urine into bed or clothes may be involuntary or intentional; does not require immediate attention
(3) does not require immediate attention
(4) CORRECT— unstable patient; at risk for harm to self and others
The nurse learns that patients from a motor vehicle accident are being transferred to the emergency department (ED). The nurse performs triage in the ED. Which of the following patients should the nurse see FIRST?
1. A patient with ecchymosis and lacerations to the facial area. 2. A patient complaining of shortness of breath and pressure in the chest. 3. A patient with blood pressure of 90/60 and apical pulse of 120 bpm. 4. A patient complaining of dizziness and nervousness.
Show/hide explanation
Strategy: Determine the most unstable patient.
(1) does not require immediate attention
(2) potential problems; not the most unstable
(3) CORRECT— vital signs indicate shock; most unstable patient
(4) most stable patient of the four; use Maslow hierarchy of needs theory to prioritize; physiological needs take priority; use ABCs
After receiving report from the night shift, the nurse plans assignments for the day. Which of the following patients should the nurse see FIRST?
1. A patient who took 10 methylphenidate (Ritalin) and has a blood pressure of 160/100. 2. A patient who requires a metered-dose inhaler. 3. A patient with a short arm cast on the left arm. 4. A patient diagnosed with hypothyroidism requiring TSH level.
Show/hide explanation
Strategy: Determine the most unstable patient.
(1) CORRECT— most unstable patient; assess for restlessness, dilated pupils, tremors, and seizures
(2) potential problem; not priority
(3) no indications of complications; will check for complications such as circulatory impairment and peripheral nerve damage
(4) symptoms include decreased activity level, sensitivity to cold, obesity, and weight gain
The nurse cares for clients in a gynecological clinic. Which of the following clients should the nurse see FIRST?
1. A 60-year-old complaining of dry vaginal walls and painful intercourse. 2. A 35-year-old who had a hysterosalpingogram is experiencing tachycardia, and has a generalized rash. 3. A 30-year-old who requires preparation for a cervical biopsy. 4. A 25-year-old scheduled for a Pap smear.
Show/hide explanation
Strategy: Determine the most unstable client.
(1) does not require immediate attention; instruct about estrogen replacement therapy and water-soluble lubricants
(2) CORRECT— x-ray of the cervix, uterus, and fallopian tubes performed after the injection of a contrast medium; assess for allergy to shellfish or iodine; requires immediate attention because patient having an allergic reaction
(3) does not require immediate attention; physician usually performs a biopsy as a follow-up to suspicious Pap test findings
(4) exam to detect precancerous and cancerous cells from the cervix; does not require immediate attention
Children from a school-bus accident are transferred to the hospital. The nurse performs triage in the emergency department (ED). Which of the following patients should the nurse see FIRST?
1. An 8-year-old with a superficial burn to the arm. 2. A 7-year-old with burns on the face. 3. A 6-year-old with small lacerations to the arms and legs. 4. A 5-year-old complaining of elbow pain.
Show/hide explanation
Strategy: Determine the most unstable patient.
(1) does not require immediate attention
(2) CORRECT— burns can be life-threatening to children; airway, breathing, and circulation are major concerns; cardiopulmonary complications may result from exposure to electrical current, inhalation of toxic fumes, hypovolemia, and shock
(3) does not require immediate attention
(4) does not require immediate attention
After receiving report from the night shift, the nurse plans assignments for the day on the endocrinology unit. Which of the following patients should the nurse see FIRST?
1. A patient who requires a fasting blood glucose test in the morning before breakfast. 2. A patient who requires a urine test for ketone bodies. 3. A patient who will be discharged this afternoon. 4. A patient with a fasting blood glucose of 517 mg/dL.
Show/hide explanation
Strategy: Determine the most unstable patient.
(1) does not require immediate attention; normal fasting is 60 to 110 mg/dL
(2) does not require immediate attention; presence of ketones may indicate ketoacidosis; check during illness, stress, or pregnancy
(3) does not require immediate attention
(4) CORRECT— normal is 60 to 110 mg/dL; requires immediate attention; administer regular insulin
The nurse cares for patients in the psychiatric ER. Which of the following patients should the nurse see FIRST?
1. A patient receiving haloperidol (Haldol) experiencing an oculogyric crisis. 2. A patient receiving thioridazine (Mellaril) experiencing akathisia. 3. A patient receiving risperidone (Risperdal) experiencing blurred vision. 4. A patient receiving fluphenazine (Prolixin) experiencing sedation.
Show/hide explanation
Strategy: Determine the most unstable patient.
(1) CORRECT— eyes are locked upward; acute dystonic reaction; notify physician and physician will order an anticholinergic agent to correct this reaction
(2) inability to sit or stand still; foot tap, pace; does not require immediate attention; physician will change antipsychotic medication or give antiparkinsonian agent
(3) does not require immediate attention; physician will change antipsychotic medication
(4) common during first few weeks of therapy; does not require immediate attention
After receiving report from the night shift, the nurse plans assignments for the day on the pediatric unit. Which of the following patients should the nurse see FIRST?
1. A patient diagnosed with leukemia complaining of fatigue. 2. A patient diagnosed with Wilms tumor complaining of thirst. 3. A patient diagnosed with hemophilia complaining of joint pain. 4. A patient diagnosed with gastroesophageal reflux complaining of abdominal pain.
Show/hide explanation
Strategy: Determine the most unstable patient.
(1) expected because of diagnosis and treatment; balance rest and activity
(2) does not require immediate attention; Wilms tumor is a malignant neoplasm of the kidney; most common intra-abdominal tumor in children
(3) CORRECT— joint pain indicates bleeding; treatment includes factor VIII, RICE ( r est, i ce, c ompression, and e levation)
(4) backflow of gastric contents into the esophagus resulting from relaxation of the lower esophageal sphincter
The community health nurse plans visits for the day. Which of the following clients should the nurse see FIRST?
1. A client diagnosed with type 2 diabetes who is complaining of GI upset after taking chlorpropamide (Diabinese). 2. A client who is complaining of vomiting after chemotherapy. 3. A client with a tonometer reading of 21 mm Hg. 4. A client with a laryngectomy who is complaining of a greenish-yellow discharge.
The community health nurse plans visits for the day. Which of the following clients should the nurse see FIRST?
1. A client diagnosed with type 2 diabetes who is complaining of GI upset after taking chlorpropamide (Diabinese). 2. A client who is complaining of vomiting after chemotherapy. 3. A client with a tonometer reading of 21 mm Hg. 4. A client with a laryngectomy who is complaining of a greenish-yellow discharge.
The nurse is seeing patients in the medical/surgical unit. Which of the following patients should the nurse see FIRST?
1. A patient diagnosed with heart failure who has received 800 ml of IV fluids in 2 hours. 2. A patient diagnosed with lung cancer with a blood calcium level of 10.5 mg/dL. 3. A patient diagnosed with hypertension requiring the 9 A.M. dose of captopril (Capoten). 4. A patient postoperative after a laminectomy who requires supervision when ambulating.
Show/hide explanation
Strategy: Determine the most unstable patient.
(1) CORRECT— assess for circulatory overload
(2) normal range is 8.5 to 10.5 mg/dL
(3) can give 30 min before or after prescribed time; ACE inhibitor
(4) nothing to indicate patient is unstable
The nurse cares for clients in the emergency department. Four clients present complaining of side effects from prescribed medication. Which of the following clients should the nurse see FIRST?
1. A client receiving clozapine (Clozaril) and experiencing flu-like symptoms, fever, sore throat, and lethargy. 2. A client receiving valproic acid (Depakene) and experiencing tremors. 3. A client receiving lorazepam (Ativan) and experiencing abdominal discomfort. 4. A client receiving methylphenidate hydrochloride (Ritalin) who lost 5 lb in 4 weeks.
Show/hide explanation
Strategy: Determine the most unstable client.
(1) CORRECT— unstable client; may have agranulocytosis; Clozaril is an antipsychotic; pregnancy risk B
(2) physician will order valproic acid level to assess for toxicity; anticonvulsant; pregnancy risk D; does not require immediate attention
(3) does not require immediate attention; antianxiety, sedative-hypnotic
(4) may cause decreased appetite; monitor weight; does not require immediate attention
The nurse sees patients in the gastrointestinal clinic. Which of the following patients should the nurse see FIRST?
1. A middle-aged adult diagnosed with irritable bowel syndrome and complaining of cramping and loose stools. 2. A young adult complaining of not having a bowel movement in 2 days. 3. A child diagnosed with gastroenteritis with five diarrheal stools in the last 3 days. 4. A newborn experiencing projectile vomiting and irritability.
Show/hide explanation
Strategy: Determine the most unstable patient.
(1) symptoms of irritable bowel syndrome; encourage patient to eat meals at regular intervals, chew food slowly, and do not drink fluids with meals
(2) determine normal bowel pattern; encourage fluids, foods high in roughage
(3) does not require immediate attention but has potential for dehydration; real problems take priority over potential problems
(4) CORRECT— indicates pyloric stenosis; at risk for fluid and electrolyte imbalance
A nurse working in an emergency department performs a yearly ride-along with a local ambulance service. Upon responding to the scene of a motor vehicle collision (MVC), which of the following clients should the nurse see FIRST?
1. An infant who is strapped in a car seat and crying uncontrollably. 2. A child who is crying that her leg is broken. 3. A restless client with pale, cool, clammy skin and a rigid abdomen with absent bowel sounds. 4. An alert but mildly disoriented client with a scalp laceration with well-controlled bleeding.
Show/hide explanation
Strategy: Determine the most unstable client.
(1) nothing to indicate infant is unstable
(2) priority is the client who has indications of shock
(3) CORRECT— client likely has injuries to abdominal organs, resulting in hemorrhage and severe circulatory compromise; requires immediate evaluation
(4) though the client has circulatory compromise, the bleeding is well controlled; requires further evaluation but does not take priority at this time
A triage nurse in a busy urgent care center is prioritizing patients for evaluation. Which of the following patients should the nurse see FIRST?
1. A 2-month-old infant. The mother states that the child is very sleepy and has refused to nurse for 8 hours. 2. A crying 2-year-old. The father states that the toddler fell against the fireplace and continuously touches the right elbow. 3. A 5-year-old who is flushed. The grandmother states that the child has a temperature of 101.9°F (39°C). 4. A 6-year-old who complains of a sore throat. The caretaker reports the child has had two episodes of vomiting.
Show/hide explanation
Strategy: Determine the most unstable patient.
(1) CORRECT— significant risk for dehydration and acidosis; an infant’s rate of fluid exchange is significantly higher than an adult’s, and the infant’s metabolism rate is nearly twice that of an adult’s; acid forms more rapidly in infants and may lead to acidosis; kidneys are not mature at this age, cannot adequately concentrate urine to conserve water
(2) may have dislocation or fracture; evaluate neurovascular status of the affected extremity and ask the patient’s caregiver to report changes while awaiting further evaluation
(3) likely flushed as a result of the fever; request an order for Tylenol or Motrin if the child had not received either before arrival and ask the caregiver to report changes in the patient’s condition while awaiting further evaluation
(4) vomiting may pose a risk for dehydration; symptoms are likely a result of strep throat or a virus; requires urgent evaluation, but with greater body mass and more mature organ systems, this patient is not as acute as the infant
The nurse receives report on the following patients on the medicine unit. Which patient should the nurse see FIRST?
1. A patient who just arrived as a transfer from the ER with an oxygen saturation of 93% and is receiving 2 liters oxygen per nasal cannula. 2. A patient who complains of nausea while drinking contrast in preparation for a CT scan. 3. A patient who just arrived from the physician's office as a direct admission with a hemoglobin of 6.9 g/dL. 4. A patient who complains of abdominal pain and is requesting pain medication.
Show/hide explanation
Strategy: Determine the most unstable patient.
(1) respiratory status is stable at present, though additional interventions may be required if the patient’s oxygen saturation decreases further; continue to monitor the patient closely
(2) symptom management is important for patient comfort and to insure the patient’s ability to drink the contrast in preparation for the test; respiratory status takes precedence
(3) CORRECT— assessment of respiratory status is required; acute onset of anemia and/or disease may cause SOB, dyspnea, and/or chest pain; oxygen supplementation often indicated prophylactically even if asymptomatic
(4) symptom management is important for patient comfort; respiratory status takes precedence
The nurse sees patients in the adolescent psychiatric unit. Which of the following patients should the nurse see FIRST?
1. A 13-year-old who complains of impulsivity and poor attention span. 2. A 14-year-old who frequently loses his temper and argues with his teachers. 3. A 15-year-old who wants to be a model and only drinks water and eats vegetables. 4. A 16-year-old who bullies, threatens, and intimidates others and initiates physical fights.
Show/hide explanation
Strategy: Determine the most unstable patient.
(1) assess further for attention deficit disorder; not an immediate concern
(2) assess for oppositional-defiant disorder
(3) CORRECT— most unstable; assess nutritional status and monitor for eating disorder
(4) assess for conduct disorder
The nurse receives report about clients on the medical/surgical unit. Which of the following clients should the nurse see FIRST?
1. A client who is scheduled to receive verapamil (Calan). 2. A client who is scheduled to receive the prescribed metered dose inhaler (MDI). 3. Family members of a client who threaten to sue the hospital if the nurse doesn't talk to them immediately. 4. A client who is verbally abusive to staff and becomes increasingly more agitated.
Show/hide explanation
Strategy: Determine the most unstable client.
(1) Calan is an antihypertensive; safety takes precedence over administration of routine, nonemergent medications
(2) safety takes precedence over administration of routine, nonemergent medications
(3) although angry, the family members do not pose an immediate physical threat to the patient, staff, or other visitors
(4) CORRECT— poses a potentially immediate physical threat to himself, staff members, and/or other patients and visitors if the situation is allowed to escalate further; nurse must attempt to intervene and initiate protocols prescribed by the individual facility to maintain a safe environment
The nurse cares for patients in the pediatric clinic. Which of the following patients should the nurse see FIRST?
1. A 9-month-old infant with failure to gain weight and a lead level of 70 g/dL. 2. A 4-year-old child scheduled for surgery who fears body mutilation. 3. A 6-year-old who has repeated, involuntary urination at night. 4. A 7-year-old with a persistent fear of attending school.
Show/hide explanation
Strategy: Determine the most unstable patient.
(1) CORRECT— high risk for injury; requires immediate attention; provide medical treatment and chelation therapy, begin coordination of care, clinical management, environmental investigation, and lead hazard control
(2) common fear during preschool years, does not require immediate attention
(3) describes enuresis; does not require immediate attention
(4) does not require immediate attention
