Prioritization 1
The nurse just received reports on the following four clients: Which client should the nurse see first?
A. 54 year old female with a blood pressure of 140/90 mmHg
B. 89 year old male with a heart rate of 110
C. 40 year old female with a respiration rate of 30 breaths per minute
D. 91 year old who needs to use the bathroom
C. 40 year old female with a respiration rate of 30 breaths per minute
After the respiratory therapist performs suctioning on a patient who is intubated, the nursing assistant measures vital signs for the patient. Which vital sign value should the nursing assistant report to the RN immediately?
A.Heart rate of 98 beats/min
B.Respiratory rate of 24 breaths/min
C.Blood pressure of 168/90 mm Hg
D.Tympanic temperature of 101.4 F (38.6 C)
D.Tympanic temperature of 101.4 F (38.6 C)
As the shift begins, you are assigned to care for the following patients. Which patient should you assess first?
A.38-year-old with Graves disease and a heart rate of 94 beats/ min
B.63-year-old with type 2 diabetes and fingerstick glucose level of 230
C.58-year-old with hypothyroidism and a heart rate of 40 beats/ min
D.49-year-old with Cushing's disease and dependent edema rated as 3 +
C.58-year-old with hypothyroidism and a heart rate of 40 beats/ min
A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a non-rebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient’s care, you would anticipate a physician order for what action?
A.Perform endotracheal intubation and initiate mechanical ventilation
B.Immediately begin continuous positive airway pressure (CPAP) via the patient’s nose and mouth
C.Administer furosemide (Lasix) 100 mg IV push stat
D.Call a code for respiratory arrest
A.Perform endotracheal intubation and initiate mechanical ventilation
The nurse just received reports on the following four clients: Which client should the nurse see first?
A. 77 year old with the diagnosis of sepsis with vasopressors infusing
B. 71 year old with the diagnosis of respiratory distress with Normal Saline infusing and respirations of 20
C. 75 year old with the diagnosis of Non-ST Elevated MI (NSTEMI) with heparin infusing
D. 70 year old with the diagnosis of Urinary Tract Infection with Antibiotics infusing
A. 77 year old with the diagnosis of sepsis with vasopressors infusing
When assessing a 22-year-old patient who required emergency abdominal surgery and received multiple blood transfusions 3 days ago, you notice the patient is restless and anxious, with labored respirations at 38 breaths/min, use of accessory muscles, and oxygen saturation of 90% despite 6 L/min via nasal cannula. Which action is most appropriate?
A.Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes
B.Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs
C.Administer the ordered morphine sulfate to the patient and recheck vitals in 15 minutes
D.Switch the patient to a non-rebreather mask at 95% to 100% oxygen and call the physician to discuss the patient’s status
D.Switch the patient to a non-rebreather mask at 95% to 100% oxygen and call the physician to discuss the patient’s status.
After change of shift, you are assigned to care for the following patients. Which patient should you assess first?
A. A 62-year-old receiving a blood transfusion who reports mild itching at the IV site
B. A 70-year-old with heart failure whose morning weight increased by 2 lbs since yesterday
C. A 55-year-old post-op patient who needs pain medication before ambulation
D. A 48-year-old with a history of AAA who is now complaining of sudden back pain
D.A 48-year-old with a history of AAA who is now complaining of sudden back pain
A 60-year-old client arrives in the ER with crushing chest pain radiating to the left arm, BP 92/60, HR 110, RR 24, and is diaphoretic and nauseated. The ECG shows ST elevation in leads II, III, and aVF. Which action should the nurse implement first?
A. Administer sublingual nitroglycerin.
B. Administer 325 mg aspirin to chew.
C. Administer IV morphine for pain relief.
D. Administer metoprolol 25mg by mouth.
B. Administer 325 mg aspirin to chew.
The nurse just received report from the night shift. Which patient would the nurse see second?
A. 50 year old with chest pain and a BP of 120/76
B. 89 year old with Type II DM whose blood sugar is 250 and just had their breakfast tray delivered
C. 62 year old COPD patient who has become increasingly somnolent over the shift, and is now unarousable
D. 80 year old with hx of dementia that is beginning to pull off their telemetry wires
A. 50 year old with chest pain and BP of 120/76
You are evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient has been receiving oxygen at a flow rate of 5 L/min by nasal cannula overnight, and has and 02 sat of 100%. Which finding concerns you immediately?
A.The patient has fine bi-basilar crackles
B.The patient’s respiratory rate is 8 breaths/min.
C.The patient sits up and leans over the night table.
D.The patient has a large barrel chest.
B.The patient’s respiratory rate is 8 breaths/min.