management of care

Question 1

1. When prioritizing between clients, first eliminate
   stable and chronic issues and expected abnormal.

Answer 1

Stable: Waiting for discharge
Chronic: Dyspnea on exertion with CHF
Expected abnormal: 90% pulse oximetry with COPD

Question 2

2. Highest priorities are airway and safety issues.

Answer 2

Airway: Stridor
Safety: Suicidal ideations

Question 2

3. Next are issues related to breathing, circulation,
   or disability (neurological).

Answer 2

Breathing: Tachypnea
Circulation: Hypotension (SBP less than 90)
Disability: Altered mental status

Question 3

4. Lowest priorities are expected findings,
   psychosocial needs, and routine tasks.

Answer 3

Expected: Nausea after chemotherapy
Psychosocial: Crying client
Routine task: Scheduled lab draw

Question 4

Exceptions:

Answer 4

Exceptions:
With life-threatening bleeding during
disaster triage, prioritize circulation (C-AB)
by applying tourniquet. In cardiac arrest, prioritize circulation
(C-AB) by starting chest compressions.

Question 5

Safety

Answer 5

Suicidal ideations
Signs of aggression (psych
client pacing)

Question 5

Findings that typically require immediate follow-up:

Answer 5

COMMON WARNING SIGNS ON NCLEX

Question 6

Airway

Answer 6

Anaphylaxis (wheezing, rash)
Epiglottitis (stridor, drooling)
Inhalation injury (soot-tinged
sputum, singed nasal hair)

Question 7

Breathing

Answer 7

Increased work of breathing
(paradoxical respirations,
intercostal retractions, grunting
in infants)
Hypoxia (restlessness)

Question 8

Circulation

Answer 8

Myocardial infarction (diaphoresis,

chest or shoulder pain) Peritonitis (rigid abdomen) Limb ischemia (6 Ps)
Severe potassium imbalances Coagulopathy (PT/INR, PTT)
Late decelerations in FHR Autonomic dysreflexia
(diaphoresis, pallor) Neutropenia with fever

Question 9

Disability
(neurologic)

Answer 9

Change in mental status Hypoglycemia
(cool and clammy)

Question 10

Priority clients might have only subtle warning signs,

Answer 10

such as drooling (A), restlessness (B), abdominal
rigidity (C), or cool and clammy skin (D).