Nurs 465 Practice Questions on Setting Priorities | UPDATED Questions
with 100% Verified Answers
Question:
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?
Answer:
place a seat alarm in the client's chair
Question:
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?
Answer:
Insert a gloved hand into the vagina to relieve pressure on the cord
Question:
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?
Answer:
stridor
Question:
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?
Answer:
check the client's vital signs
Question:
,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?
Answer:
Gloves
Question:
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?
Answer:
Auscultate for wheezing
Question:
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?
Answer:
Provide the appropriate PPE to the AP
Question:
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?
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
Question:
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?
, Answer:
Set behavioral limits for the client
Question:
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?
Answer:
Place the client in a sitting position
Question:
A nurse is assessing four clients on a medical surgical unit.
Which of the following client should the nurse care for first?
Answer:
A client who has a cast on the left leg and reports numbness and paresthesia
Question:
A nurse is caring for a client who develops a pulmonary
embolism. Which of the following interventions should the
nurse implement first?
Answer:
Administer oxygen therapy
Question:
While caring for a client, the nurse experiences a needle stick
injury. Which of the following actions should the nurse take
first?
Answer:
Wash the site of the injury with soap and water
Question:
A nurse is assessing a client's abdomen who reports stomach
pain. Which of the following actions should the nurse take
first?
with 100% Verified Answers
Question:
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?
Answer:
place a seat alarm in the client's chair
Question:
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?
Answer:
Insert a gloved hand into the vagina to relieve pressure on the cord
Question:
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?
Answer:
stridor
Question:
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?
Answer:
check the client's vital signs
Question:
,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?
Answer:
Gloves
Question:
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?
Answer:
Auscultate for wheezing
Question:
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?
Answer:
Provide the appropriate PPE to the AP
Question:
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?
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
Question:
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?
, Answer:
Set behavioral limits for the client
Question:
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?
Answer:
Place the client in a sitting position
Question:
A nurse is assessing four clients on a medical surgical unit.
Which of the following client should the nurse care for first?
Answer:
A client who has a cast on the left leg and reports numbness and paresthesia
Question:
A nurse is caring for a client who develops a pulmonary
embolism. Which of the following interventions should the
nurse implement first?
Answer:
Administer oxygen therapy
Question:
While caring for a client, the nurse experiences a needle stick
injury. Which of the following actions should the nurse take
first?
Answer:
Wash the site of the injury with soap and water
Question:
A nurse is assessing a client's abdomen who reports stomach
pain. Which of the following actions should the nurse take
first?
