NCLEX Archer Review delgation.

Test Strategies, Prioritization, & Delegation Archer Review Crash Course Welcome! ● If you have a question please enter it in the chat! I will do my best to answer questions as we go, but if I miss one will always circle back to you! ● We will take 1-2 breaks throughout the class ● Handouts & powerpoint slides are located in the ‘Handouts’ section of your GoToWebinar control panel. You can download and print them from here! ● If you have any technical issues or questions about streaming, handouts, etc. please email Prioritization ABC’s ● Airway ○ Foreign body in the airway ○ Obstruction ○ Edema ○ Goal is a patent airway ○ No patent airway? ■ Intubate ■ Trach ● Circulation ○ Are they getting good blood flow to their tissues. ○ Providing oxygen to organs ○ Good pulses ○ Brisk cap-refill ○ Warm skin ○ Appropriate color ○ Insufficient circulation? ■ Fluids ■ Pressors ● Breathing ○ Adequate respirations ■ RR is sufficient ■ Shallow? ○ Bilateral breath sounds ○ Good air entry ○ Breathing insufficient? Breathe for them. ■ BMV NCLEX Question A client in septic shock in the intensive care unit is receiving a Dopamine infusion. Upon assessment, the nurse notices that the client’s; blood pressure is 195/120 mm Hg. Which initial nursing action would the nurse implement? a. Discontinue dopamine. b. Notify the physician c. Administer Furosemide. d. Assess the clients’ GCS Answer: A A is correct. The initial action for the nurse is to discontinue Dopamine, which is a vasoconstrictor, the medication that causes the client’s high blood pressure. B is incorrect. The nurse needs to notify the physician in order to arrange an adjustment of the medication dosage. However, this should not be the initial action of the nurse. C is incorrect. The nurse can give Furosemide to decrease the patient's blood pressure. But the nurse should terminate the exact cause of hypertension which is Dopamine. D is incorrect. The nurse can assess the client's GCS, but the nurse should decrease the client's blood pressure. NCLEX Question A client in his early 60s is brought to the ER complaining of shortness of breath. Initial assessment findings include crackles, finger clubbing, and dry cough. The client states that he has previously worked in construction for 15 years. The ER physician suspects asbestosis. Which nursing problem should the nurse prioritize in the client? a. Impaired gas exchange b. Imbalanced nutrition: Less than body requirements c. Fatigue d. Ineffective airway clearance Answer: A A is correct. In asbestosis, there is filling and inflammation of lung spaces with asbestos fibers. These fibers move into the alveolar space and cause fibrosis, leading to increased production in secretions impairing gas exchange. This should be a priority problem for the nurse. B is incorrect. There is imbalanced nutrition on the patient because of his difficulty of breathing and intolerance to activity. However, it should not be prioritized over the gas exchange. C is incorrect. Because of the client’s impaired oxygenation, there is not enough oxygen that reaches the muscles to sustain activity. However, this problem must not take priority over the gas exchange. D is incorrect. Due to the increased secretions brought about by the asbestos fibers, there is an ineffective airway clearance. Although equally crucial with gas exchange, the nurse should prioritize impaired gas exchange over airway clearance because treatment for asbestosis is focused on the relief of symptoms. Oxygen delivery to the cells holds more importance. Stability Most stable to least stable Stable ● Chronic ● Expected findings ● Ready for discharge ● Consistent lab values ● Consistent vital signs ● Unchanging Unstable ● Changing condition ● Acute ● Unexpected ● Recently admitted ● New onset ● Newly diagnosed ● Critical lab values ● Hemorrhage NCLEX Question A nurse employed in an emergency department is doing triage on the evening shift. Which of the following clients should be assigned the highest priority? a. A client complaining of muscle aches, a headache, and malaise that has been on for 5 hours b. A client who twisted her ankle when she fell while skateboarding c. A client with a minor laceration on the index finger sustained while slicing vegetables d. A client with chest pain who claims that he just ate a very spicy pizza 2 hours ago Answer: D In the emergency department, triage involves brief client assessment to classify clients according to their need for care and includes prioritization of care. The type of illness or injury, the severity of the problem, and the resources available are considered in 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 or highest priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as a second priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are the third priority. Thus, the correct answer is D, while options A, B, and C are incorrect. NCLEX Question You are caring for a 46 year old woman who has just been diagnosed with Stage IV breast cancer. She shares with you that she was estranged from her father over a decade ago, but now that she is sick is thinking about reaching back out to him. As the nurse, you know this falls under which category in Maslow’s Hierarchy of Needs? A. Love and belonging B. Physiological C. Esteem D. Self-actualization Answer: A A is correct. Love and belonging is the level on Maslow’s hierarchy of needs where this patient’s relationship with her mother would fall. B is incorrect. Physiological needs include items such as oxygen, fluids, nutrition, shelter, and elimination. The patient’s relationship with her mother would fall under love and belonging. C is incorrect. Esteem needs include things such as self-confidence, recognition, self-worth, status, and respect. The patient’s relationship with her mother would fall under love and belonging. D is incorrect. Self-actualization needs include things such as Full potential of self, effective coping, and problem solving capabilities. The patient’s relationship with her mother would fall under love and belonging. NCLEX Question During handoff, the nurse was informed that a patient’s serum potassium is 2.8 mEq/L. During rounds, the first thing that the nurse should assess in this client should be: a. Ability to balance while walking b. Quality of peripheral pulses c. Respiratory status looking out for shallow respirations d. Frequency of bowel movement Answer: C Rationale: Hypokalemia affects the musculoskeletal, cardiovascular, neurologic, and respiratory systems. The skeletal muscles become weak, causing the patient to collapse while ambulating; the peripheral pulses are expected to be thready and weak, making palpation difficult and causes decreased peristalsis, which may lead to constipation. However, it is the respiratory system that is severely affected by hypokalemia through the weakness of the muscles needed for breathing. This may lead to shallow respirations and lead to respiratory insufficiency, being a major cause of death. Thus, respiratory status should be assessed first in any client with hypokalemia, making option C the correct answer. Options A, B, and D should also be included in the assessment but are not the utmost priority and are, therefore, incorrect.