Nurs 465 Practice Questions on Setting Priorities with Correct Answers

A nurse is caring for a client who has dementia. The client is agitated and is having difficulty staying in his chair. Which of the following actions should the nurse take first? Correct Answer place a seat alarm in the client's chair A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first? Correct Answer Insert a gloved hand into the vagina to relieve pressure on the cord A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client finding should the nurse intervene first? Correct Answer stridor A nurse is caring for a client who has CHF and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first? Correct Answer check the client's vital signs A nurse is removing PPE after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first? Correct Answer Gloves A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first? Correct Answer Auscultate for wheezing A nurse sees and assistive personnel (AP) entering the room of a client who requires transmission based precautions without using the appropriate PPE. Which of the following actions should the nurse take first? Correct Answer Provide the appropriate PPE to the AP A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first? Correct Answer check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate A nurse is caring for a client who attacked one of her friends and is administered to the psychiatric unit. Which of the following actions should the nurse take first? Correct Answer Set behavioral limits for the client A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first? Correct Answer Place the client in a sitting position