Priority Nursing Actions
Older adult post-op denies pain but has ↑ HR, RR, BP. Priority action?
What is assess for pain/discomfort?
Stroke risk reduction (name 2)
What are stop smoking, control BP, exercise, avoid obesity?
Older adult refusing flu vaccine—best response?
What is education on increased risk of complications?
Time in bed increases, but this decreases.
What is actual sleep time?
A patient says, “I don’t want machines keeping me alive.” What is the nurse’s best response?
What is “Can you tell me more about your concerns?”
Hospice client becomes restless and agitated—FIRST action?
What is assess for causes (pain, urinary retention, hypoxia)?
Risk factors for pressure injuries (name 2)
What are immobility, malnutrition, dehydration, norepinephrine?
Family wants feeding tube for dying client.
What is explain decreased intake is normal in dying process?
Most common hearing impairment cause.
What is cerumen impaction?
Best skin care strategy for older adults
What is hydration and lubrication?
Client at home suddenly develops numbness and headache.
What is call 911?
Early signs of hypoglycemia (name 2)
What are anxiety, diaphoresis, tachycardia?
Client refuses life-prolonging treatment, family disagrees.
What is advocate for client wishes?
Condition with morning stiffness >1 hour.
What is rheumatoid arthritis?
Primary purpose of functional assessment
What is evaluate ADLs and independence?
Older adult weak cough + thick secretions—best intervention?
What is encourage fluids and suction as needed?
Neuropathic pain descriptors (name 2)
What are burning, stabbing, tingling, shooting?
Staff member verbally abusive to resident.
What is report immediately?
Snoring + daytime sleepiness =
What is obstructive sleep apnea?
Nurse’s role in chronic illness
What is promote optimal function and quality of life?
Frail older adult on multiple high-risk meds—best nursing action?
What is contact the provider to question medications?
Parkinson’s complications (name 2)
What are depression, sleep disorders, dyskinesia, dystonia?
Polypharmacy risk noted—best action?
What is contact pharmacy and/or provider to question medications?
Sudden confusion post-op =
What is delirium?
This diagnostic test is the gold standard for detecting osteoporosis and measures bone mineral density using a specialized X-ray.
What is a DEXA scan?