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NCLEX-RN® > NCLEX-RN (2) Management of Care > Multiple Patient Priority / "Who Do You See First?" > Flashcards

Multiple Patient Priority / "Who Do You See First?" Flashcards

Review the ABCs and priority conditions.

1
Q

What is the order for assessing clients?

A
  1. Assess clients with immediate complications first such as unconscious, airway, breathing, and circulatory issues (ABCs)
  2. Then see clients with expected and moderate to severe pain
  3. See psychosocial clients that are upset next
  4. Lastly, see clients with expected or normal symptoms of a condition that are not immediate concerns
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2
Q

What type of clients are discharged first?

A

Stable clients that are not having any complications.

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3
Q

What are the ABCs?

A

Airway, Breathing, Circulation

Clients with these complications are a high priority for being seen. Chest pain and stroke symptoms are usually a higher priority than shortness of breath.

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4
Q

Unconscious clients are completely dependent on caregivers. What is the priority concern?

(Immediate Complication)

A

Make sure they have an airway.

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5
Q

At what Glasgow coma score is the client typically intubated?

(Immediate Complication)

A

“Less than 8, intubate”

8 indicates a coma.

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6
Q

Why do burns have a high risk of airway problems?

(Immediate Complication)

A

Smoke inhalation.

Always assess the airway first and give oxygen.

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7
Q

What is a pneumothorax?

(Immediate Complication)

A

A collapsed lung with air in the pleural space.

It is caused by trauma. The client will get chest tubes.

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8
Q

What is an anaphylactic reaction?

(Immediate Complication)

A

An overactive response of the immune system to substances that can cause a rash or severe difficulty with breathing.

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9
Q

What are the steps if a client has an anaphylactic reaction?

(Immediate Complication)

A
  • assess respiration status and maintain a patent airway
  • call HCP and rapid response team
  • give oxygen
  • start an IV and give normal saline
  • prepare to give diphenhydramine and epinephrine
  • possible intubation and ventilator
  • document the event
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10
Q

What is the immediate action if the tracheostomy tube dislodges?

(Immediate Complication)

A
  1. extend neck and open the tissues of the stoma
  2. pull the retention sutures to spread the opening
  3. use a tracheal dilator to hold the stoma open
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11
Q

What is the immediate action if the tracheostomy tube falls out within the first 72 hours?

(Immediate Complication)

A

Manually resuscitate using an Ambu bag and call the HCP.

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12
Q

What is an air embolism?

(Immediate Complication)

A

When air goes into the client’s IV and goes to the lungs.

Place the client in Trendelenburg position.

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13
Q

What is a major complication from the fracture of a large bone?

(Immediate Complication)

A

A fat embolism.

A fat emobolism occurs when a large bone such as a femur or pelvis gets fractured. It is a fat blob that gets released into the bloodstream and can go to the lungs causing respiratory distress.

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14
Q

What is flail chest?

(Immediate Complication)

A

Occurs when a segment of the rib cage breaks due to trauma and becomes detached from the rest of the chest wall.

There can also be rib fractures.

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15
Q

What is pulmonary edema?

(Immediate Complication)

A

When fluid gets backed up into the lungs.

It can be caused by left-sided heart failure, kidney failure or liver failure.

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16
Q

What is hypoxia?

(Immediate Complication)

A

Pulse oximetry reading < 95%.

Give oxygen.

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17
Q

What is acute respiratory failure (ARF)?

(Immediate Complication)

A

When there is not enough oxygen to get to the lungs or alveoli (air sacs) and CO2 builds up in the blood.

The client becomes hypoxic and hypercapnic.

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18
Q

What is a pulmonary embolism?

(Immediate Complication)

A

When a blood clot goes to the lungs.

It is usually caused by a DVT.

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19
Q

What is acute respiratory distress syndrome (ARDS)?

(Immediate Complication)

A

Causes inflammation and fluid to build up in the alveoli of the lungs. The client is unable to get enough oxygen.

The client will be intubated and placed on a ventilator.

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20
Q

What is Guillain-Barre Syndrome?

(Immediate Complication)

A

Occurs after an infection where the immune system overacts and destroys the myelin sheath.

The client gets ascending paralysis, eventually affecting the respiratory muscles.

The myelin sheath is the part that connects nerves.

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21
Q

What is a seizure?

(Immediate Complication)

A

A sudden, uncontrolled electrical disturbance in the brain. It can cause changes in behavior, movements or feelings, and in levels of consciousness.

Epilepsy is a seizure disorder of two or more seizures or a tendency to have recurrent seizures.

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22
Q

What is an intracerebral hemorrhage?

(Immediate Complication)

A

When a blood vessel within the brain has ruptured.

It can occur from a traumatic brain injury (TBI) or cerebral aneurysm.

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23
Q

What is a stroke?

(Immediate Complication)

A

When the brain does not get enough oxygen either caused by bleeding or a blood clot.

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24
Q

What is a hypertensive crisis?

(Immediate Complication)

A

Blood pressure greater than 200/120.

If BP is not controlled, it can cause a hypertensive stroke.

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25
Q

What is angina?

(Immediate Complication)

A

Chest pain caused by inadequate myocardial blood and oxygen supply.

Give OANM: oxygen, aspirin, nitroglycerin, and morphine.

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26
Q

What is an aortic aneurysm?

(Immediate Complication)

A

Stretching of the arterial wall in the abdomen.

If it ruptures, the client will experience pain, difficulty breathing and signs of shock.

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27
Q

What is cardiogenic shock?

(Immediate Complication)

A

Low blood pressure caused by damage to the heart that impairs pumping ability.

It can be from myocardial infarction, tamponade, or heart failure.

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28
Q

What is asystole?

(Immediate Complication)

A

Fatal dysrhythmia:

  • start CPR
  • epinephrine
  • NO defibrillation
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29
Q

What is ventricular tachycardia?

(Immediate Complication)

A

Fatal dysrhythmia:

  • Pulseless V-tach
    • CPR
    • defibrillate
    • epinephrine
    • amiodarone (or lidocaine)
  • With a pulse
    • amiodarone (or lidocaine)
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30
Q

What is ventricular fibrillation?

(Immediate Complication)

A

Fatal dysrhythmia:

  • “defib the V-fib”
  • CPR
  • epinephrine
  • amiodarone (or lidocaine)
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31
Q

What is a myocardial infarction?

(Immediate Complication)

A

Fatal heart condition:

  • give “OANM” (oxygen, aspirin, nitroglycerin, morphine)
  • “clot busters” if caused by a clot (T-PA)
  • cardiac catheterization if caused by plaque
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32
Q

What is supraventricular tachycardia?

(Immediate Complication)

A

Can be a fatal dysrhythmia:

  • vagal maneuvers (carotid sinus massage, beardown/Valsalva)
  • cardiovert with adenosine
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33
Q

What is a heart block?

(Immediate Complication)

A
  • typically less than 60 beats per minute
  • have an elongated PR interval
  • will receive atropine if showing symptoms
  • if atropine doesn’t work, client will either get cardioversion or a pacemaker.
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34
Q

What is an Addisonian crisis?

(Immediate Complication)

A

Can cause severe fluid and electrolyte imbalances.

It is caused by stress, infection, trauma, or abrupt discontinuation of steroids.

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35
Q

What is a myxedema coma?

(Immediate Complication)

A

When the client has extremely low metabolism and goes into a coma.

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36
Q

What is a thyroid storm?

(Immediate Complication)

A

When the client has an extremely high metabolism and can get elevated temperature, blood pressure, seizures and then a coma.

37
Q

What is hyperosmolar hyperglycemic syndrome (HHS) and diabetic ketone acidosis (DKA)?

(Immediate Complication)

A

Extremely high blood sugar.

If not treated, the client can go into a coma.

38
Q

What is compartment syndrome?

(Immediate Complication)

A

When there is too much pressure in a cast or enclosed space due to edema.

The client will either get a fasciotomy (cut the skin open) or the cast will be cut off.

39
Q

What is hemorrhage?

(Immediate Complication)

A

Severe bleeding that causes the client to go into hypovolemic shock.

The client gets a very low blood pressure and tachycardia.

40
Q

What major complications can occur with fluid and electrolyte imbalances?

(Immediate Complication)

A

Life-threatening complications such as:

  • dysrhythmias
  • seizures
  • respiratory depression
  • coma
41
Q

What is septic shock?

(Immediate Complication)

A

Systemic infection throughout the entire body.

It can cause very low blood pressure and tachycardia.

42
Q

What is peritonitis?

(Immediate Complication)

A

When the bowel perforates causing infection and eventually septic shock if not treated.

The client gets a rigid, hard abdomen.

43
Q

What is acute angle-closure glaucoma?

(Immediate Complication)

A

Sudden eye pain and possible nausea and vomiting, resulting in blindness.

The client will receive antiglaucoma meds to lower the pressure.

44
Q

What are the interventions if a client has a penetrating object in the eye such as sharp metal?

(Immediate Complication)

A
  • DO NOT remove the object
  • cover the eye with a cup and tape in place
  • no bending, no straining
  • surgery to remove object
45
Q

What is the intervention if a client gets chemicals splashed in the eye?

(Immediate Complication)

A

Flush eyes with water for at least 15 to 20 minutes.

46
Q

What is an acid-base imbalance?

(Immediate Complication)

A

A circulation or breathing issue where the client has a high risk of death if it becomes severe.

47
Q

What is autonomic dysreflexia?

(Immediate Complication)

A

When the client with a spinal injury overreacts to stimuli such as unable to urinate or have a bowel movement.

It can cause a hypertensive crisis if it becomes severe.

48
Q

What is a myasthenic crisis and cholinergic crisis?

(Immediate Complication)

A

When the client does not get the correct amount of medicine at the correct time.

  • myasthenic crisis is undermedicated
  • cholinergic crisis is overmedicated

This causes muscle weakness and respiratory muscle weakness if not treated.

49
Q

What life-threatening condition are clients at risk for after a head injury, stroke or brain surgery?

(Immediate Complication)

A

Increased intracranial pressure.

(ICP)

Increased pressure in the brain due to edema.

50
Q

What are Stevens-Johnson syndrome and toxic epidermal necrolysis?

(Immediate Complication)

A

Really bad adverse reactions of many meds that cause a severe rash all over the body.

Always let the HCP know if you notice a rash, especially after the client starts a new med.

51
Q

What is wound dehiscence and evisceration?

(Immediate Complication)

A
  • Dehiscence is when the surgical incision opens.
  • Evisceration is when the abdominal organ comes out of the incision.

Immediate intervention is to put a sterile, saline-soaked dressing over site.

52
Q

What are life-threatening signs and symptoms of a blood transfusion reaction?

(Immediate Complication)

A
  • respiratory distress, dyspnea, dizziness, shortness of breath
  • chills, diaphoresis
  • back or chest pain

Antibodies are attacking the red blood cells causing decreased oxygen.

53
Q

What are the steps if there’s a reaction to a blood transfusion?

(Immediate Complication)

A
  1. FIRST: stop the blood transfusion
  2. change out the tubing, but keep the IV line in
  3. start a new bag of normal saline, 0.9%
  4. tell the HCP and blood bank
  5. return the blood and tubing to the blood bank
  6. stay with the client
  7. may have to give epinephrine for severe symptoms such as difficulty breathing
54
Q

What is suicide?

(Immediate Complication)

A

A psychological disorder when the client wants to kill themselves.

It is an emergency and someone needs to stay with the client at all times.

55
Q

What is done if the chest tube comes out of the client’s chest wall?

(Immediate Complication)

A

Pinch the opening shut and apply an occlusive sterile dressing taped on 3 sides.

56
Q

When should the HCP be notified about chest tubes?

(Immediate Complication)

A
  • drainage is >70 - 100 mL/hour
  • drainage suddenly becomes bright red or increases in the amount
  • chest tube comes out of client
57
Q

What should be kept at the bedside for a client with chest tubes?

(Immediate Complication)

A
  • a clamp - to check for leaks
  • sterile occlusive dressing - in case the tube comes out of the client
  • a bottle of sterile water - in case the tube comes out of the CDU
58
Q

What is the immediate intervention if the chest tube drainage system breaks or cracks?

(Immediate Complication)

Sometimes the CDU falls over and breaks.

A

Put the chest tube in a bottle of sterile water to act as a water seal so air doesn’t go into the client.

59
Q

In what order should clients be evacuated during a fire?

(Immediate Complication)

A
  1. clients who can walk first
  2. clients in wheelchairs next
  3. bedridden clients last
60
Q

What are 3 adverse effects (reactions) of medications?

(Immediate Complication)

A
  1. anaphylactic shock or difficulty breathing
  2. rash
  3. significant changes in vital signs or level of consciousness

Notify the HCP immediately.

61
Q

What is delirium tremens?

(Immediate Complication)

A

Withdrawal of alcohol that occurs 48 - 72 hours after stopping alcohol.

62
Q

What should the nurse do immediately if a client is being violent?

(Immediate Complication)

A
  • approach the client calmly and communicate with a calm and clear tone of voice
  • maintain a safe distance away from client
  • maintain a non-aggressive posture
  • listen actively and acknowledge anger
  • determine what their need is
  • call security if client does not calm down
63
Q

What is serotonin syndrome?

(Immediate Complication)

A

When a client’s serotonin level increases to dangerous levels.

It is caused by taking too many sedatives at once.

64
Q

What is neuroleptic malignant syndrome?

(Immediate Complication)

A

A rare and fatal reaction to antipsychotics.

65
Q

What is a positive/abnormal contraction stress test?

(Immediate Complication)

A

Indicates a bad finding and that late decelerations of the fetal heart rate were noted.

Late decelerations are never a good finding.

66
Q

What is disseminated intravascular coagulation (DIC) during pregnancy?

(Immediate Complication)

A

A serious bleeding and clotting complication in a pregnant client with eclampsia, placenta abruption, a dead fetus, placenta retention or infection.

The clotting factors are becoming over or underactivated.

67
Q

What is HELLP syndrome?

(Immediate Complication)

A

A condition that can cause severe bleeding in a pregnant client.

The cause is not known but associated with gestational hypertension and preeclampsia.

68
Q

What is eclampsia?

(Immediate Complication)

A

The onset of seizures for a pregnant client with preeclampsia.

69
Q

What are the general interventions if the mom or baby is having life-threatening distress during labor?

(Immediate Complication)

A
  • put mom in Trendelenburg position
  • give oxygen 8-10 liters by mask
  • give IV fluids
  • blood transfusion if needed
  • prepare for cesarean delivery
70
Q

What is a prolapsed umbilical cord?

(Immediate Complication)

A

When the umbilical cord drops through the open cervix into the vagina ahead of the baby.

The cord can then become trapped against the baby’s body during delivery.

71
Q

What is abruptio placenta?

(Immediate Complication)

A

When the placenta has separated off the uterine wall.

72
Q

What is an amniotic fluid embolism?

(Immediate Complication)

A

When there is an escape of amniotic fluid into maternal circulation which can lead to respiratory failure and bleeding.

73
Q

What are the signs and symptoms of fetal distress?

(Immediate Complication)

A
  • fetal heart rate is < 110 or > 160 beats/minute
  • meconium-stained amniotic fluids
  • fetal hypo or hyperactivity
  • severe variable or late decelerations
74
Q

What type of fetal heart rate decelerations are these?

(Immediate Complication)

A

Late decelerations caused by placenta compression.

There is a gradual decrease in fetal heart rate. The lowest heart rate occurs after the contraction peak.

75
Q

What are two life-threatening postpartum complications of cesarean section?

(Immediate Complication)

A

Bleeding and Infection.

76
Q

How many saturated pads per hour is considered hemorrhage?

(Immediate Complication)

A
  • > than 1 pad per hour or
  • one pad that gets saturated within 15 minutes
77
Q

How much blood loss is considered hemorrhage for a vaginal delivery and a cesarean delivery?

(Immediate Complication)

A
  • Vaginal delivery: > 500 mL after delivery
  • Cesarean delivery: > 1000 mL after delivery
78
Q

What can cause respiratory distress syndrome in an infant?

(Immediate Complication)

A

The newborn unable to produce enough surfactant.

It can occur in preterm infants.

Surfactant helps open up the lungs to breathe better.

79
Q

What is pathological jaundice?

(Immediate Complication)

A

An increase in bilirubin and yellowing of the skin.

It is caused by a hemolytic disease such as Rh incompatibility or liver disease. It occurs before 24 hours and is a serious life-threatening condition.

80
Q

What is meconium aspiration syndrome?

(Immediate Complication)

A

When meconium gets into the lungs and causes respiratory distress and/or pneumonia.

81
Q

What are the steps for a choking infant?

(Immediate Complication)

A
  1. hold infant face down with head lower than feet
  2. support head and jaw
  3. give 5 back slaps
  4. then put baby face up and give 5 chest thrusts
  5. repeat until obstruction clears

Click HERE for a video on infant CPR and Choking treatment.

82
Q

What are the steps for CPR on an infant?

(Immediate Complication)

A
  1. check for pulse with brachial artery
  2. use 2 fingers or 2 thumbs for chest compressions
  3. go down 1 1/2 inches (2 cm) for compressions
    • 1 rescuer: 30 compressions then 2 breaths
    • 2 rescuers: 15 compressions and then 2 breaths

Click HERE for a video on infant CPR and choking treatment.

83
Q

What is esophageal atresia and tracheoesophageal fistula?

(Immediate Complication)

A

When the esophagus forms an unnatural connection with the trachea causing food to enter the airway.

There is a high risk of aspiration.

84
Q

What is the treatment for acetaminophen overdose?

(Immediate Complication)

A
  • give acetylcysteine
  • use activated charcoal with gastric lavage
87
Q

What is the treatment for aspirin (acetylsalicylic acid) overdose?

(Immediate Complication)

A

Give activated charcoal.

88
Q

What is the treatment for corrosive poisoning in a child, such as household cleaners, bleach, paint or batteries?

(Immediate Complication)

A
  • give water or milk
  • don’t induce vomiting as it can cause damage to the esophagus
89
Q

What is a sickle cell anemia crisis?

(Immediate Complication)

A

When RBCs clump together and block small blood vessels that carry blood to organs.

It causes severe pain.

90
Q

What is epiglottitis?

(Immediate Complication)

A

An infection of the epiglottis which can be caused by Influenza type B or Strept.

There is a high risk of airway obstruction.

91
Q

What is status asthmaticus?

(Immediate Complication)

A

A severe asthma attack that doesn’t respond to inhalers.

Intubation and ventilator may be needed.

NCLEX-RN (2) Management of Care (3 decks)

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