PRIORITY OR DIE
Which client should the nurse assess first?
A nurse receives report on four clients:
✅ The asthma patient using accessory muscles
Who can perform this task?
The RN asks someone to obtain vital signs on a stable patient.
✅ UAP
What hypothesis should the nurse prioritize?
A school nurse notes repeated unexplained injuries, frequent absences, and a child who becomes fearful whenever a parent enters the room.
✅ Possible child maltreatment or abuse
What therapeutic response is best?
A patient says, "I am scared."
✅"Tell me more about what worries you."
Select all findings indicating abnormal mental status.
Poor hygiene
Logical conversation
Flat affect
Disorganized behavior
Appropriate eye contact
✅ Poor hygiene ✅ Flat affect ✅ Disorganized behavior
❌ Logical conversation ❌ Appropriate eye contact
Who is assessed first?
Hypotensive patient (circulation problem)
Who performs this task?
A patient starts oxygen therapy. Someone must determine if it improved breathing.
✅ RN because evaluation cannot be delegated.
What nursing action takes priority?
During a clinic visit, a child reveals information suggesting they may be unsafe at home.
✅ Protecting the child's immediate safety
What comes BEFORE providing education?
A newly diagnosed cancer patient is crying.
✅ Validate feelings.
Select all CAUTI prevention interventions.
Hand hygiene
Chlorhexidine
Stabilize catheter
Closed drainage system
Shared urine containers
✅ Hand hygiene ✅ Chlorhexidine ✅ Stabilize catheter ✅ Closed drainage system
❌ Shared urine containers
Which nursing diagnosis has highest priority?
A patient has crackles, SpO₂ 89%, glucose 275 mg/dL, and anxiety.
Impaired Gas Exchange
Which task may be assigned to the PN?
A patient needs wound care, initial assessment, medication administration, and bathing.
✅ Wound care or medication administration
What CJMM action is indicated?
A grieving patient remains severely depressed and angry 8 months after a loss.
✅ Reevaluate and revise the plan of care.
How should the nurse document this finding?
A patient smiles throughout a discussion about losing their home and employment.
✅ Incongruent affect
Select all seizure precautions.
Padded rails
Oxygen available
Suction available
Tongue blade
Restraints
✅ Padded rails ✅ Oxygen available ✅ Suction available
❌ Tongue blade ❌ Restraints
What priority principle applies?
One patient has sudden confusion and diaphoresis after receiving insulin. Another needs assistance completing admission paperwork.
✅ Physiological instability takes priority over administrative needs.
What delegation principle was violated?
An RN delegates ambulation to a UAP without first assessing the patient.
✅ The RN must assess patient condition before delegating
Which interdisciplinary member should the nurse collaborate with?
The patient states, "I cannot afford medication."
✅ Pharmacist
What is the best nursing response?
A patient reports hearing voices telling them to self-harm.
✅"I don't hear the voices, but I understand they feel real to you. What are they saying?"
Select all components of quality teaching documentation.
Motivation
Ability to learn
Goals
Response to teaching
Progress toward goals
✅ Motivation ✅ Ability to learn ✅ Goals ✅ Response to teaching ✅ Progress toward goals
Which patient is first?
A patient is actively bleeding from a surgical incision while another patient has oxygen saturation of 92%.
Actively bleeding patient because circulation is immediately threatened
Who remains accountable for overall nursing care?
A UAP neglects to report dizziness during ambulation and the patient falls.
✅ The RN
What intervention best promotes self-management?
A client newly diagnosed with heart failure says, "There's no way I'll remember all of these medications when I get home."
✅Provide individualized written instructions and resources the client can reference later.
What nursing priority is indicated?
A client states, "I've decided exactly when and how I'm going to end my life, and everything is already arranged."
✅ Immediate safety intervention because the client is at extremely high suicide risk.
A hospice patient becomes increasingly lethargic and difficult to arouse over the last 24 hours.
Select all conditions the nurse should investigate before assuming the change is expected.
Medication reactions
Electrolyte or fluid imbalance
Infection
Acute delirium
Constipation
Family anxiety
✅ Medication reactions
✅ Electrolyte or fluid imbalance
✅ Infection
✅ Acute delirium
✅ Constipation
❌ Family anxiety