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Prioritizing nursing actions
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31 cards
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1
A nurse plans care for an assigned group of clients. Which intervention is the priority?
1. Reinforce dietary teaching for a client who has a peptic ulcer
1. Provide emotional support to a client who has breast cancer
1. Administer insulin to a client who has hyperglycemia
1. Suction a tracheostomy for a client who has pneumonia
2
A nurse performs cord care for a newborn. Which action should be included?
1. Administer acetaminophen prior to cord care
1. Keep cord clean and dry
1. Cover cord with diaper and clothing
1. Remove cord clamp within 1 hr of birth
3
A nurse reinforces teaching for a client who had a permanent pacemaker inserted. Which information should be included?
1. Maintain a clear liquid diet
1. Take pulse for 1 full minute each day
1. Apply pressure to site if dizziness occurs
1. Resume showers after 2 weeks
4
A nurse cares for a child with vasoocclusive crisis related to sickle cell anemia. What is the priority nursing care?
•Administer IV fluids
•Start oxygen
•Send type and cross-match
•Apply warm compresses
5
What year is it?
2021
2022
2020
2019
6
What is the first nursing action for an infant with Tetralogy of Fallot who is having a hypercyanotic episode?
•Prepare for intubation
•Place in a knee-chest position
•Apply pulse oximetry
•Initiate IV therapy
7
What is the appropriate PPE for an infant with respiratory syncytial virus (RSV)?
•Gloves and gown
•Gloves only
•Gloves, gown, mask and goggles
•Gloves, gown and mask
8
A nurse monitors the recovery of a client who is stable 48 hr after delivering her baby. Which finding is expected?
1. Decreased desire to eat and drink
1. Elevated pulse and respiration
1. Firm fundus and small clots
1. Moderate amount of lochia serosa and no odor
9
A nurse prepares to perform a central venous catheter dressing change for a client. Which item should be used?
1. Sterile gloves
1. Antibiotic ointment
1. Hydrogen peroxide
1. Normal saline
10
A nurse implements triage for a mass casualty. Which client should be recommended for discharge first? A client who
1. Has a long bone fracture
1. Is scheduled for elective surgery
1. Reports new onset of chest pain
1. Has a small bowel obstruction
11
A nurse prepares to administer a beta blocker to a client. Which finding indicates the medication should be withheld?
1. Pedal edema
1. Confusion
1. Pulse rate 52/min
1. Blood pressure 102/70 mm Hg
12
A nurse provides care for a client who is receiving IV therapy. Which finding indicates fluid volume excess?
1. Capillary refill less than 2 seconds
1. Presence of tactile fremitus
1. Crackles noted upon auscultation
1. Urine output of 250 mL over 8 hours
13
A nurse provides care to a preschooler who is hospitalized. Which activity is age-appropriate?
1. Arranging a coin collection
1. Shaking a colorful rattle
1. Putting a puzzle together
1. Building a model spaceship
14
A nurse provides care to a 6-month-old infant. Which observations should be reported?
1. Demonstrates head leg
1. Posterior fontanel is closed
1. Grasps objects voluntarily
1. Birth weight has doubled
15
A client who has a terminal illness decides to discontinue treatment. What is the appropriate response from the nurse?
1. “Why are you giving up?”
1. “What does your family want?”
1. “You have other available options”
1. “Tell me about your decision”
16
A nurse assists a client who is partially weight-bearing using a transfer belt. Which action is appropriate?
1. Use side rails for support
1. Place chair near foot of the bed
Position the chair on the client’s weaker side
1. Grasp under the belt along the client’s sides
17
A nurse provides care for a client who has a NG tube to intermittent suction. What should be included in the care?
1. Monitor for abdominal distension
1. Check residual every 4 hrs
1. Elevate head of bed 15 degrees
1. Clamp the air vent
18
Prior to administering sliding scale insulin, What is priority nursing care?
•Proceed with nutritional teaching
•Check a blood glucose
•Contact a dietician
•Inquire about food preferences
19
After assessment of a 28 week neonate and prior to transferring to NICU, What is the priority action?
•Repeat vital signs
•Allow mother to see and touch neonate
•Assess involution progression
•Place neonate “skin-to-skin” with mom
20
What is the priority information to document on the care plan of a toddler?
•The parent’s understanding of the child’s hospitalization
•The child’s ability to follow directions
•The child’s rituals and routines at home
•The parent’s religious practices and beliefs
21
A client receives an IV infusion of cefazolin. The nurse is most concerned about the sudden onset of which finding?
1. Hoarse voice
1. Dull headache
1. Diarrhea
1. Urticaria
22
A nurse provides care to a client who is prescribed warfarin. Which supplement is of concern?
1. Flaxseed
1. Valerian root
1. Glucosamine
1. Echinacea
23
A nurse provides care to a client who requires informed consent for an elective surgery. What is the appropriate action?
1. Identify risks involved
1. Answer client questions
1. Explain the procedure
1. Witness client signature
24
A client returns to the room following a CT scan with contrast. What should the nurse monitor?
1. Daily weight
1. Pain level
1. Urine output
1. Bowel sounds
25
A nurse plans to provide change-of-shift report for a client. Which action is appropriate?
1. Ask family to participate
1. Include past admission data
1. Give report in the hallway
1. Describe client current status
26
A nurse cares for a client experiencing symptoms of alcohol withdraw 12 hr after admission. What is the priority?
1. Offer food and fluids
1. Implement seizure precautions
1. Dim lights and reduce noise
1. Document observations
27
What is the priority care for a client with increased bloody drainage on the dressing 48 hr postop?
1. Document findings
1. Notify the provider
1. Monitor urine output
1. Obtain vital signs
28
A nurse cares for a client in a long-term care facility. What client concern is the priority?
•Cloudy appearance of the left eye
•Burning on urination
•Pain in right knee after climbing stairs
•Tearing of skin when removing adhesive bandage
29
Client’s cardiac monitor change from sinus to ventricular tachycardia. What should the nurse do first?
•Assess level of consciousness
•Administer amiodarone
•Apply oxygen
•Prepare for defibrillation
30
A nurse is caring for several clients who require medications. Which medication is the priority?
•Acetaminophen
•Ferrous Sulfate
•Albuterol
•Furosemide
31
Client is 1 hr post cardiac cath with stent via the left femoral artery. What data is the most concerning?
•1 to 2 premature ventricular contractions (PVCs) per minute
•Vital signs include HR 120 bpm, BP 88/60, RR 24
•Left pedal pulse 1+with right pedal pulse 2+
•Pain rating of 3, (scale of 0 to 10) in the left groin area
