Prioritization

Question 1

Tools to help with prioritization

Answer 1

ABC then MAAUAR

Question 2

What does ABC stand for

Answer 2

Airway
Breathing
Circulization

Question 3

What does MAAUAR stand for

Answer 3

• Mental status change
• Acute pain
• Acute urinary elimination concerns
• Unaddressed and untreated problems (immediate attention)
• Abnormal lab fingings or other diagnostic data outside normal
• Risks (saftey, skin breakdown, infection, other medical conditions)

Question 4

Of the patients listed below, which should the nurse see first at the beginning of the shift?

a. 89-year old with COPD on 2Liters O2 who needs vital signs.
b. 77-year-old admitted with a GI bleed the previous shift.
c. 55-year-old diabetic with a fasting blood sugar of 110 who ate 80 % of their breakfast.
d. 49-year-old with rheumatoid arthritis who needs splints reapplied to both hands.

Answer 4

b.77-year-old admitted with a GI bleed the previous shift.

Question 5

Which of the following nursing diagnosis groups are in the correct order for a patient newly admitted in a critical care unit?

1. Anxiety, decreased cardiac output, impaired gas exchange, impaired airway
2. Decreased cardiac output, impaired airway, anxiety, impaired gas exchange
3. Impaired airway, impaired gas exchange, decreased cardiac output, anxiety.
4. Impaired gas exchange, anxiety, impaired airway, decreased cardiac output.

Answer 5

3.Impaired airway, impaired gas exchange, decreased cardiac output, anxiety.

Question 6

A 62-year old male has been admitted with diabetic ketoacidosis (DKA). He is awake but listless and his initial blood glucose is found to be 650 mg/dl. Put the following interventions in their priority order.

1. Insulin administration
2. Electrolyte replacement
3. Fluid resuscitation

a. 1, 2, 3
b. 3, 1, 2
c. 1, 3, 2

Answer 6

b. 3, 1, 2

Question 7

A nurse enters a room and finds a client lying on the floor. Which action should the nurse perform first?

a. call for help to get the client back in bed
b. establish whether the client is responsive
c. assist the client back to bed
d. ask the client what happened

Answer 7

b. establish whether the client is responsive

Question 8

You are caring for a patient in the CCU who came into the ER with a myocardial infarction (MI) 4 hours ago. Which activity is the most important to perform for a common complication of an MI at this time?

a. Auscultate heart sounds
b. Monitor cardiac rate and rhythm
c. Monitor renal function (BUN, Creat)
d. Assess neurological status

Answer 8

b. Monitor cardiac rate and rhythm

Question 9

You are caring for a patient with pancreatic cancer. When you enter the room the patient is complaining of abdominal pain at 9 out of 10, has a respiratory rate of 22/min, blood pressure of 142/90. What is your first priority activity?

a. control environmental factors that may influence the patient’s response to discomfort.
b. administer analgesic care promptly
c. Explore the patient’s beliefs/knowledge about the pain.
d. Provide information about the causes of pain and how long it may last.

Answer 9

b. administer analgesic care promptly

Question 10

Ms. M., with a history of asthma, presents to the ED. She complains of dyspnea and has a respiratory rate of 32/min with use of accessory muscles. Auscultation reveals inspiratory and expiratory wheezes. Blood pressure is 156/86 and pulse 110/minute. You have implemented the NIC Asthma Management.

Identify the correctly prioritized sequence of activities.

1. Coach in breathing/relaxation techniques;
2. Administer a bronchodilator medication as appropriate and/or per policy and procedural guidelines;
3. Apply supplemental oxygen;
4. Determine compliance with prescribed treatments

a. 1, 2, 3, 4
b. 3, 2, 1, 4
c. 4, 2, 1, 3
d. 2, 1, 3, 4

Answer 10

b. 3, 2, 1, 4

supplemental O2 will increase saturation, conserve myocardium. Improve neuro function. Next would be bronchodilator.
Why not bronchodilator first? O2 may actually improve situation and allow for more effective delivery of bronchodilator.

Question 11

You are caring for a patient who just returned to the unit following hemodialysis. You are implementing the following activities from the NIC intervention Fluid Monitoring:

a. monitor weight;
b. monitor BP, heart rate, and respiratory status;
c. assess neurological status.

What is the correct order of implementation?
A. a, b, c
B. b, c, a
C. c, b, a

Answer 11

B. b, c, a

VS should be checked immediately. Volume changes have a dramatic effect on post-dialysis patients also many are anemic due to low EPO levels.

Question 12

You are making your first home visit to a hospice patient with terminal pancreatic cancer. When you arrive at the home, the patient is complaining of abdominal pain rated at 9/10.

You are implementing the NIC Intervention Pain Management.

1. Ensure that the patient receives attentive analgesic care
2. Control environmental factors that may influence the patient’s response to discomfort
3. Explore the patient’s knowledge/beliefs about the pain
4. Provide information about the pain such as causes and how long it will last
5. Teach the use of non-pharmacological techniques of pain relief

Select the three priority activities.

a. 1, 2, 4
b. 1, 3, 5
c. 2, 3, 5
d. 3, 4, 5

Answer 12

a. 1, 2, 4

all focus should be on immediate pain relief. Once you achieve relief you will be able to do more effective teaching.

Question 13

You are a triage nurse in ER expecting several victims from a motor vehicle accident (MVA). Utilizing the NIC Intervention Triage: Emergency Care what would be the three priority activities?

1. Order diagnostic tests, as appropriate
2. Obtain a pertinent medical history
3. Check for signs of bleeding
4. Check vital signs
5. Check level of consciousness
6. Check ECG

a. 2, 5, 6
b. 1, 3, 6
c. 3, 4, 5
d. 1, 4, 6

Answer 13

c. 3, 4, 5

assess injuries first! Assess for obvious bleeding, VS may have already been done at the scene along with splinting, and pressure dressings applied etc.

Question 14

Del Thomas has been admitted with diabetic ketoacidosis (DKA). His initial blood glucose is found to be 950 mg/dl. Put the following interventions in their priority order.

1. Insulin administration
2. Electrolyte replacement
3. Fluid resuscitation

a. 1, 2, 3
b. 3, 1, 2
c. 1, 3, 2

Answer 14

b. 3, 1, 2

fluids must be replaced lost through urination, vomiting because this could precipitate kidney failure, compromised myocardial integrity due to hypotension.

Question 15

An MVA victim arrives at the emergency department (E.D.), primary assessment reveals increasing respiratory distress, absent breath sounds over the upper third of the right lung, tachycardia, and probable fracture of the right humerus.

Select three of the following activities that would receive priority.

1. Apply oxygen
2. Prepare for chest tube insertion
3. Suction airway
4. Ensure the humerus is stabilized
5. Start IV

a. 1, 3, 5
b. 1, 3, 4
c. 2, 4, 5
d. 1, 2, 5

Answer 15

d. 1, 2, 5

This type of injury has caused air to enter the pleural space and is an emergency, if this is not treated quickly the patient can have a respiratory arrest

Question 16

A boy was riding his bike to school when he hit the curb. He fell and injured his leg. The school nurse was called and found him alert and conscious, but in severe pain with a possible fracture of the right femur. Which of the following is the FIRST action that the nurse should take?

A. Immobilize the affected limb with a splint and ask him not to move.
B. Make a thorough assessment of the circumstances surrounding the accident.
C. Put him in semi-Fowler’s position for comfort.
D. Check the pedal pulse and blanching sign in both legs.

Answer 16

A. Immobilize the affected limb with a splint and ask him not to move.

Do not move the limb until other emergency help arrives to secure a proper splint. While waiting you could check the pulse to help out the EMT’s when they arrive.

Question 17

A client is admitted with a diagnosis of dementia. He attempts several times to pull out his nasogastric tube. An order for cloth wrist restraints is received by the nurse. Which of the following actions by the nurse is MOST appropriate?

A. Attach the ties of the restraints to the bed frame.
B. Perform range of motion to the restrained extremities once a shift.
C. Remove the restraints when the client is up in a wheelchair.
D. Explain the need for restraints only to the family because the client is confused.

Answer 17

A. Attach the ties of the restraints to the bed frame.

The bedframe doesn’t move so restraints will not tighten or loosen with movement of the bed such as railing.

Question 18

A nurse is caring for four clients and is preparing to do her initial rounds. Which client should the nurse assess first?

a. A client with diabetes being discharged today.
b. A client with a tracheostomy and copious secretions.
c. A client scheduled for physical therapy this morning.
d. A client with a pressure ulcer that needs a dressing change.

Answer 18

b. A client with a tracheostomy and copious secretions.

ABC

Question 19

A nurse enters a room and finds a client lying on the floor. Which action should the nurse perform first?

a. Call for help to get the client back in bed.
b. Establish whether the client is responsive
c. Assist the client back to bed.
d. Ask the client what happened.

Answer 19

b. Establish whether the client is responsive

If the patient is not breathing you, the ABC’s of BLS, if no breathing you it may lead to respiratory arrest and you may be calling a code.

Question 20

A client with a history of bipolar disorder is admitted to the psychiatric hospital. She was found by the police attempting to climb onto the wing of a plane at the airport. Her husband reports that she has not eaten or slept in 2 days, and he suspects she has stopped taking lithium. On admission, the nurse should place the HIGHEST priority on which of the following client care needs?

A. Teaching the client about the importance of taking lithium as prescribed
B. Providing the client with a safe environment with few distractions
C. Arranging for food and rest for the client
D. Setting limits on the client’s behavior

Answer 20

B. Providing the client with a safe environment with few distractions

Safety is first in order to avoid any injuries to patient or others

Question 21

A nurse from medical-surgical unit is asked to work on the orthopedic unit. The medical-surgical nurse has no orthopedic nursing experience. Which client should be assigned to the medical-surgical nurse?

a) a client with a cast for a fractured femur and who has numbness and discoloration of the toes
b) a client with balanced skeletal traction and who needs assistance with morning care
c) a client who had an above-the-knee amputation yesterday and has a temperature of 101.4F
d) a client who had a total hip replacement 2 days ago and needs blood glucose monitoring

Answer 21

c) a client who had an above-the-knee amputation yesterday and has a temperature of 101.4F

This is not orthopedic specific in terms of proper ROM and activity allowed to prevent injury. An amputee may appear as a patient on any unit.