Prioritization NCLEX Latest ,recent
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The nurse employed in an emergency department is assigned to triage clients coming to the emergency
department for treatment on the evening shift. The nurse should assign priority to which client?
, a. A client complaining of muscle aches, a headache, and malaise
b. A client who twisted her ankle when she fell while rollerblading
c. A client with a minor laceration on the index finger sustained while cutting an eggplant
d. A client with chest pain who states that he just ate hot wings that was made with a very spicy sauce. -
correct ans:D- In an emergency department, triage involves brief client assessment to classify clients
according to their need for care and includes establishing priorities of care. The type of illness or injury,
the severity of the problem, and the resources available govern the process. Clients with trauma, chest
pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits, or
who have sustained chemical splashes to the eyes, are classified as emergent and are the number 1
priority.
A nurse has received the assignment for the day shift. After making initial rounds and checking all of the
assigned clients, which client should the nurse plan to care for first?
a. A client who is ambulatory
b. A client scheduled for physical therapy at 1 pm
c. A client with a fever who is diaphoretic and restless
d. A postoperative client who has just received pain medication - correct ans:C- The nurse should plan to
care for the client who has a fever and is diaphoretic and restless first because this client's needs are the
priority. The client who is ambulatory and the client scheduled for physical therapy later in the day do
not have priority needs related to care. Waiting for pain medication to take effect before providing care
to the postoperative client is best.
You are monitoring a 53-year-old client who is undergoing a treadmill stress test. Which client-finding
will require the most immediate action?
1. Blood pressure of 152/ 88 mm Hg
2. Heart rate of 134 beats/ min
3. Oxygen saturation of 91%
4. Chest pain level of 3 (on a scale of 10) - correct ans:4- Chest pain in a client undergoing a stress test
indicates myocardial ischemia and is an indication to stop the testing to avoid ongoing ischemia, injury,
or infarction. Moderate elevations in blood pressure and heart rate and slight decreases in oxygen
saturation are a normal response to exercise and are expected during stress testing. Focus: Prioritization
You are reviewing the complete blood count for a patient who has been admitted for knee arthroscopy.
Which value is most important to report to the physician before surgery?
and frequently tested exam with
comprehensive questions and verified
accurate solution (detailed &
elaborated) GRADED A+
Professional Academic Assistance Services
Services Offered
Proctored Exam Assistance
Online Class Management (Full Course Support)
Exam Preparation & Study Materials
Assignments and Coursework Support
Essays and Research Papers
Discussion Posts and Replies
The nurse employed in an emergency department is assigned to triage clients coming to the emergency
department for treatment on the evening shift. The nurse should assign priority to which client?
, a. A client complaining of muscle aches, a headache, and malaise
b. A client who twisted her ankle when she fell while rollerblading
c. A client with a minor laceration on the index finger sustained while cutting an eggplant
d. A client with chest pain who states that he just ate hot wings that was made with a very spicy sauce. -
correct ans:D- In an emergency department, triage involves brief client assessment to classify clients
according to their need for care and includes establishing priorities of care. The type of illness or injury,
the severity of the problem, and the resources available govern the process. Clients with trauma, chest
pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits, or
who have sustained chemical splashes to the eyes, are classified as emergent and are the number 1
priority.
A nurse has received the assignment for the day shift. After making initial rounds and checking all of the
assigned clients, which client should the nurse plan to care for first?
a. A client who is ambulatory
b. A client scheduled for physical therapy at 1 pm
c. A client with a fever who is diaphoretic and restless
d. A postoperative client who has just received pain medication - correct ans:C- The nurse should plan to
care for the client who has a fever and is diaphoretic and restless first because this client's needs are the
priority. The client who is ambulatory and the client scheduled for physical therapy later in the day do
not have priority needs related to care. Waiting for pain medication to take effect before providing care
to the postoperative client is best.
You are monitoring a 53-year-old client who is undergoing a treadmill stress test. Which client-finding
will require the most immediate action?
1. Blood pressure of 152/ 88 mm Hg
2. Heart rate of 134 beats/ min
3. Oxygen saturation of 91%
4. Chest pain level of 3 (on a scale of 10) - correct ans:4- Chest pain in a client undergoing a stress test
indicates myocardial ischemia and is an indication to stop the testing to avoid ongoing ischemia, injury,
or infarction. Moderate elevations in blood pressure and heart rate and slight decreases in oxygen
saturation are a normal response to exercise and are expected during stress testing. Focus: Prioritization
You are reviewing the complete blood count for a patient who has been admitted for knee arthroscopy.
Which value is most important to report to the physician before surgery?
