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. - ANSWER 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 - ANSWER 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.
1
, 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) - ANSWER 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?
1. Hematocrit of 33%
2. Hemoglobin level of 10.9 g/ dL
3. Platelet count of 426,000/ mm3
4. White blood cell count of 16,000/ mm3 - ANSWER 4- Centers for Disease Control
and Prevention (CDC) guidelines for the prevention of surgical site infections indicate that
surgery should be postponed when there is evidence of a pre-existing infection such as an
elevation in white blood cell count. The other values are slightly abnormal, but would not be
likely to cause postoperative problems for knee arthroscopy. Focus: Prioritization
What is the priority nursing diagnosis for a client experiencing a migraine headache?
1. Acute Pain related to biologic and chemical factors
2. Anxiety related to change in or threat to health status
3. Hopelessness related to deteriorating physiologic condition
4. Risk for Injury related to side effects of medical therapy - ANSWER 1- The priority
for interdisciplinary care for the client experiencing a migraine headache is pain
management
•All of the other nursing diagnoses are accurate, but none of them is urgent like the issue of
pain, which is often incapacitating. Focus: Prioritization
2
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. - ANSWER 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 - ANSWER 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.
1
, 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) - ANSWER 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?
1. Hematocrit of 33%
2. Hemoglobin level of 10.9 g/ dL
3. Platelet count of 426,000/ mm3
4. White blood cell count of 16,000/ mm3 - ANSWER 4- Centers for Disease Control
and Prevention (CDC) guidelines for the prevention of surgical site infections indicate that
surgery should be postponed when there is evidence of a pre-existing infection such as an
elevation in white blood cell count. The other values are slightly abnormal, but would not be
likely to cause postoperative problems for knee arthroscopy. Focus: Prioritization
What is the priority nursing diagnosis for a client experiencing a migraine headache?
1. Acute Pain related to biologic and chemical factors
2. Anxiety related to change in or threat to health status
3. Hopelessness related to deteriorating physiologic condition
4. Risk for Injury related to side effects of medical therapy - ANSWER 1- The priority
for interdisciplinary care for the client experiencing a migraine headache is pain
management
•All of the other nursing diagnoses are accurate, but none of them is urgent like the issue of
pain, which is often incapacitating. Focus: Prioritization
2
