A client presents to the emergency room with dyspnea, chest pain, and syncope. The nurse assesses the client and notes that the following assessment cues: pale, diaphoretic, blood pressure of 90/60, respirations of 33. The client is also anxious and fearing death. Which action should the nurse take first?
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Solution
Promotion of adequate oxygenation is the most vital to life and therefore should be given highest priority by the nurse.
Nurse Paul is developing a care plan for a client after bariatric surgery for morbid obesity. The nurse should include which of the following on the care plan as the priority complication to prevent:
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Solution
Wound infection is the most common complication among obese clients who had undergone surgery. This is due to their poor blood supply in their adipose tissues.
Paige is a nurse preceptor who is working with a new nurse Joyce. She notes that the Joyce is reluctant to delegate tasks to members of the care team. Paige recognizes that this reluctance is mostly likely due to:
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Solution
Lack of trust is the common reason for reluctance in delegation of tasks.
Nurse Janus enters a room and finds a client lying on the floor. Which of the following actions should the nurse perform first?
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Solution
Assess first for responsiveness.
Nurse Channing is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first?
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Solution
The patient with problem of the airway should be given highest priority. Remember Airway, Breathing, and Circulation (ABC) is a priority.
Nurse Joriz of Nurseslabs Medical Center is planning care for a client who will undergo a colposcopy. Which of the following actions should Joriz take first?
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Solution
The priority nursing action when caring for a client who underwent colposcopy is to assist in controlling potential bleeding by applying silver nitrate to the cervix.
Nurse Jackie is reviewing the diet of a 28-year-old female who reports several months of intermittent abdominal pain, abdominal bloating, and flatulence. The nurse should tell the client to avoid:
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Solution
Broccoli are gas forming and therefore, should be avoided.
The nurse plans care for a client in the post anesthesia care unit. The nurse should assess first the client’s:
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Solution
Assessing respiratory status is the first priority. Remember ABC.
Sally is a nurse working in an emergency department and receives a client after a radiological incident. Which task is utmost priority for the nurse to do first?
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Solution
Decontaminating an open wound is the first priority for the client. This minimizes absorption of radiation in the client’s body.
Jenna is a nurse from the medical-surgical unit of a tertiary hospital. She was asked to float on the orthopedic in which she has no prior experience on working on. Which client should be assigned to her?
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Solution
A nurse from the medical-surgical floor floated to the orthopedic unit should be given clients with stable condition as those have care similar to her training and experience. A client who is in postoperative state is more likely to be on a stable condition.