Nurs 465 Practice Questions on Setting Priorities 125 complete and approved solutions.

Nurs 465 Practice Questions on Setting
Priorities 125 complete and approved
solutions.
Nurs 465 Practice Questions on Setting
Priorities 125 complete and approved
solutions.
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



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



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



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



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



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



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

,Nurs 465 Practice Questions on Setting
Priorities 125 complete and approved
solutions.
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



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



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



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



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



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



A nurse is assessing a client's abdomen who reports stomach pain. Which of the following actions should
the nurse take first? - ANSWER Inspect



A nurse in a clinic is collecting a history from a client who reports that a member of his family just
received a diagnosis of pulmonary tuberculosis. The nurse should expect that the provider will prescribe
which of the following diagnostic tests first? - ANSWER Nucleic acid amplification test (NAAT)



A nurse is caring for a client who is in active labor and notes late deceleration in the FHR. Which of the
following actions should the nurse take first? - ANSWER Change the client's position

, Nurs 465 Practice Questions on Setting
Priorities 125 complete and approved
solutions.
A nurse has been reassigned from her regular area of work to a unit that is short staffed. Which of the
following actions should the nurse take first? - ANSWER Ask what she will be assigned to do



A nurse is bathing a toddler and notices that she has several bruises. Which of the following actions
should the nurse take first? - ANSWER Ask the parents what caused the bruises



A nurse is caring for a client who is vomiting. Which of the following actions should the nurse take first?
- ANSWER Prevent the client from aspirating



A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. The
client pulls out his endotracheal tube. Which of the following actions should the nurse take first? -
ANSWER Assess the client's airway



A nurse is receiving change of shift report and is delegating tasks to the assistive personnel. The nurse
should tell the AP to complete which of the following tasks first? - ANSWER Perform blood glucose
monitoring of a client who has a prescription for short acting insulin prior to breakfast



A nurse has completed care procedures for a client who requires airborne precautions. Which of the
following items of PPE should the nurse remove first? - ANSWER Gloves



A nurse is preparing to administer medications to four clients. The nurse should administer medications
to which of the following clients first? - ANSWER A client who has renal failure, a serum potassium of
5.8/mEq/L, and is prescribed sodium polystyrene sulfonate



An assistive personnel contacts a nurse manager and reports that on the last shift a nurse seemed
distracted and that a client reported that the nurse smelled of alcohol. The AP alleged that the nurse
was drinking alcohol during the shift. Which of the following actions should the nurse manager take
first? - ANSWER Perform an investigation into the facts surrounding the incident



A nurse finds radioactive pellets on the floor of the surgical unit. Which of the following actions should
the nurse take first? - ANSWER Follow safety data sheet (SDS) instructions