Priority Action
A nurse is preparing to care for a child being admitted to the hospital with infectious gastroenteritis. Which is the priority nursing intervention?
Instructing the parents in home care measures to prevent infection
Assembling the equipment for the RN to start an intravenous (IV) line
Obtaining a stool sample for culture
Administering prescribed antimicrobials
Assembling the equipment for the RN to start an intravenous (IV) line
Rationale: Infectious gastroenteritis is caused by a variety of communicable viruses, bacteria, and parasites capable of causing serious diarrhea, massive fluid and electrolyte loss, sepsis, and death. The priority therapy in a child with infectious gastroenteritis is the replacement of water and correction of acid-base or fluid and electrolyte disturbances with the use of IV fluids or oral electrolyte-replacement preparations. A stool culture and antimicrobial drugs may be prescribed, but these are not the priority interventions. Instructions to the parents may be necessary but are not the priority on admission of the child to the hospital.
A nurse on the day shift (7 a.m.–3 p.m.) is assigned to care for four clients. In planning care, which client does the nurse attend to first?
A client scheduled for a barium enema at 9 a.m.
A client who has undergone angioplasty and is preparing to be discharged at 10 a.m.
A client requiring a daily dressing change on an amputation stump
A client with emphysema who is receiving oxygen at a rate of 2 L/min
A client with emphysema who is receiving oxygen at a rate of 2 L/min
Rationale: Airway is always the priority, so the nurse would first attend to the client who has emphysema and is receiving oxygen. The client scheduled for a barium enema today, the client requiring the daily dressing change on an amputation stump, and a client who has undergone angioplasty and is preparing for discharge are all intermediate priorities.
The nurse is working with a nursing student who will be assisting the nurse with tracheal suction. Which is a priority instruction to provide the nursing student?
Dip the tip of the suction catheter into sterile water.
Lubricate the tip of the catheter generously with water soluble lubricant.
Administer 100% oxygen for several breaths before suctioning.
Leave the catheter tip inside the tracheostomy for about 20 seconds.
Administer 100% oxygen for several breaths before suctioning.
Rationale: The priority instruction would be to administer 100% oxygen for several breaths before suctioning. Suctioning can deplete the client’s oxygen supply, and adequate preoxygenation prevents this. Dipping the catheter tip into sterile water helps lubricate the tube; however, this is not the priority. The catheter tip should not occlude the airway longer than 10 seconds. Using water soluble lubricant, or any other lubricant, is contraindicated due to risk of aspiration.
A nurse reviews the laboratory values of a client with bipolar disorder who is taking lithium carbonate and notes that the serum lithium level is 2.0 mEq/L. On the basis of this laboratory value, the nurse first takes which action?
Calls the health care provider
Places the client in the seclusion room
Administers the prescribed dose of lithium carbonate
Documents the laboratory report in the client’s record
DOUBLE JEOPARDY: What electrolyte is essential when taking Lithium?
Calls the health care provider
DJ: SODIUM
Rationale: A serum lithium level of 2.0 mEq/L indicates toxicity, and the health care provider must be notified. The nurse would monitor the client for signs of toxicity, which include coarse hand tremors, persistent gastrointestinal upset, mental confusion, muscle hyperirritability, and incoordination. Administering the prescribed dose of lithium carbonate is incorrect, because the lithium level indicates toxicity. Placing the client in the seclusion room is also inappropriate. Although the laboratory report will be documented in the client’s record, this is not the priority action.
Inner maxillary fixation (IMF) is performed on a client who sustained a mandibular fracture in a motor vehicle accident. During examination of the surgical site, the client begins to vomit. The nurse suctions the client but is unsuccessful, and the client exhibits signs of hypoxia. The nurse immediately takes which action?
Places the client is a supine position
Cuts the mouth wires
Contacts the anesthesiologist
Administers an antiemetic
Cuts the mouth wires
Rationale: IMF is a common means of securing a mandibular fracture. The bones are realigned and then wired is placed with the bite closed. After surgery, the client is at risk for aspiration if he or she vomits because of the impossibility of opening the jaws to allow ejection of the emesis. If vomiting occurs, the nurse would attempt to suction the client. If suctioning is unsuccessful, the wires are cut. Wire cutters are kept with the client at all times in readiness for this emergency. Antiemetics may be prescribed to prevent nausea and subsequent vomiting; however, this is not the immediate action if the client is vomiting. Placing the client in a supine position increases the risk of aspiration. The client is placed in an upright position and turned to the side. There is no helpful reason to contact the anesthesiologist.
A nurse on the day shift has been assigned to care for four clients. Once the nurse has made initial rounds and checked all of the assigned clients, which client will the nurse care for first?
A client who is scheduled for occupational therapy at 10 a.m.
A client with metastatic carcinoma who has just received pain medication
A client scheduled for an ultrasound at 11 a.m. who is on nothing-by-mouth (NPO) status
A client who is scheduled for surgery at 1 p.m.
A client who is scheduled for surgery at 1 p.m.
Rationale: The nurse would care for the client who is scheduled for surgery at 1 p.m. first. Several issues, including client preparation (physical and emotional) and health care provider prescriptions, must be addressed before the surgery, and this preparation takes time. Additionally, the operating often makes late changes in the schedule, depending on room and health care provider availability, and may request an earlier surgery time. Therefore it is best to ensure that this client is prepared. It is best to wait for pain medication to take effect before providing care to a client in pain. The client scheduled for an ultrasound and the client scheduled for occupational therapy later in the morning do not have priority needs.
A nurse monitoring a client undergoing peritoneal dialysis notes that the client is experiencing problems with inflow of the dialysate. The nurse first takes which action?
Places the client in a supine low Fowler position
Asks the client about recent problems with constipation
Repositions the client
Milks the peritoneal dialysis tube
Asks the client about recent problems with constipation
Rationale: Constipation is the primary cause of problems with inflow and outflow of peritoneal dialysate. Therefore the nurse would first question the client about recent problems with constipation. The nurse would next check the dialysis tubing for kinks and change the client’s position. Placing the client in a supine low Fowler position minimizes intraabdominal pressure and promotes adequate inflow and outflow of dialysate. Milking of the peritoneal dialysis tube could dislodge a fibrin clot obstructing the tubing.
A nurse is performing closed suctioning through a tracheostomy for a ventilator-dependent client. During the procedure, the alarm on the cardiac monitor sounds and the nurse notes severe bradycardia. The nurse stops suctioning the client and immediately takes which action?
Oxygenates the client manually with 100% oxygen
Contacts the respiratory therapist
Increases the degree of positive end-expiratory pressure (PEEP) the client is receiving
Rechecks all ventilator connections
Oxygenates the client manually with 100% oxygen
Rationale: Suctioning is associated with several complications, including hypoxia, tissue (mucosal) trauma, infection, vagal stimulation, and bronchospasm. Vagal stimulation may result in severe bradycardia, hypotension, heart block, ventricular tachycardia, or asystole. If vagal stimulation occurs, the nurse stops suctioning immediately and oxygenates the client manually with 100% oxygen. Contacting the respiratory therapist will delay the required and immediate intervention. Although regular checks of the ventilator connections are the standard of care for a client undergoing mechanical ventilation, doing so will not alleviate the client’s problem in this situation. An increase in PEEP is not indicated at this time.
A home health nurse is assigned to three client visits today. One client requires twice-daily irrigation of an abdominal wound. Another client was discharged from the hospital 2 days ago after cardiac catheterization and will require assistance with the scheduling of medications. The last client has diabetes mellitus and requires a fasting blood specimen for serum glucose testing to be drawn. The nurse will schedule the assignment by visiting the clients in which order?
A- The client needing wound irrigation first, the client with diabetes mellitus second, and the client requiring medication scheduling last
B- The client with diabetes mellitus first, the client with the wound irrigation second, and the client requiring medication scheduling last
C- The client requiring medication scheduling first, the client with diabetes mellitus second, and the client needing wound irrigation last
D- The client with diabetes mellitus first, the client requiring medication scheduling second, and the client needing wound irrigation last
The client with diabetes mellitus first, the client with the wound irrigation second, and the client requiring medication scheduling last
Rationale: The client with diabetes mellitus must remain on nothing-by-mouth (NPO) status until the blood specimen is drawn and so should be seen first. Because the client requiring wound irrigations will need to be visited twice, that client should be seen next. The client requiring help with medication scheduling would be visited third, after which the nurse would make the second return visit to the client requiring wound irrigation.
A client is brought to the emergency department after a motor vehicle crash in which the client sustained a blunt chest injury when his chest struck the steering wheel. The client is complaining of sharp pain on inspiration and dyspnea. The nurse notes the absence of breath sounds on the affected side. The nurse would immediately take which intervention?
Prepare a thoracentesis tray and chest drainage equipment.
Place the client in a semi-Fowler position.
Notify the health care provider
Obtain a chest x-ray.
Place the client in a semi-Fowler position.
Rationale: The client is exhibiting signs of a closed pneumothorax. If a closed chest injury is suspected, the nurse must immediately place the client in a semi-Fowler position. Because this is a medical emergency, the nurse then notifies the health care provider. A chest x-ray, computed tomography, or ultrasonography would be used to confirm the diagnosis of pneumothorax. Because treatment involves thoracentesis and placement of a chest drainage system, the nurse then prepares a thoracentesis tray and chest drainage equipment.
An emergency department nurse is assisting with data collection of a client who has sustained a circumferential burn to the right arm. What should the nurse check first?
Heart rate
Temperature
Radial pulse
Blood pressure (BP)
Radial pulse
Rationale: The client who sustains circumferential burns to an extremity is at risk for altered peripheral circulation. The priority is to check for the presence of the peripheral pulse to ensure that circulation is adequate. Although the temperature, heart rate, and BP would also be a measured, the priority with a circumferential burn is checking for the presence of a peripheral pulse.
A registered nurse (RN) on the 7 a.m. to 3 p.m. shift is planning client assignments for the day. Which clients would be appropriate for the licensed practical nurse (LPN) to accept? Select all that apply.
A- A client with type 1 diabetes mellitus who has a foot ulcer
B- A client who had a mastectomy 2 days ago
C- A newly admitted client with chronic obstructive pulmonary disease (COPD)
D- A client with left-side weakness who will need assistance with personal care
E- A client being transferred in from the intensive care unit with a deep vein thrombosis and a heparin drip
A,B,D
Rationale: When a nurse delegates aspects of a client’s care to another staff member, the nurse assigning the task is responsible for ensuring that each task is appropriately assigned on the basis of the educational level and competency of the staff member. The client with COPD who was admitted during the night will need close monitoring of the respiratory status. An LPN may not administer most high-risk intravenous medications, including heparin. The client who has had a mastectomy and the client with a foot ulcer will likely require dressing changes, an activity that is within the scope of practice of the LPN. The client with left-side weakness requiring personal care assistance could also be assigned to the LPN.