Promotion of adequate oxygenation is the most vital to life and therefore should be given highest priority by the nurse.
In case of injury, especially among children, it is very important that the nurse should first assess possible abuse. Abuse is one of the reporting responsibilities of the nurse.
A client with airway problems should be attended first.
Assessing the level of consciousness should be the first action when dealing with clients that might have fell over.
The nurse should use proper channel of communication. The nursing supervisor is responsible for the actions of the different members of the nursing team.
Before each use, the cap is removed and the inhaler is shaken according to the instructions in the package insert. Next the patient should tilt the head back and breathe out completely. As the patient begins to breathe in deeply through the mouth, the canister should be pressed down to release one puff (dose) of the medication. The patient should continue to breathe in slowly over 3 to 5 seconds and then hold the breath for at least 10 seconds to allow the medication to reach deep into the lungs. The patient should wait for at least 1 minute between puffs from the inhaler.
The client with heart failure who is complaining of shortness of breath should be assessed first after receiving the change-of-shift report.
Heart failure is a serious condition that can lead to fluid accumulation in the lungs, causing respiratory distress and shortness of breath. It is important for the nurse to prioritize this client because their symptoms indicate a potential worsening of their condition and the need for immediate assessment and intervention.
The adult client receiving patient-controlled administration of morphine with a respiratory rate of 9 breaths/minute would cause the nurse the most concern.
A respiratory rate of 9 breaths/minute is significantly lower than the normal range for adults, which is typically between 12 and 20 breaths per minute. This low respiratory rate indicates respiratory depression, which can be a serious adverse effect of opioid medications like morphine.
In this situation, the nurse should not allow the nursing assistant to perform the fingerstick without official training. While the nursing assistant may have some experience in performing fingersticks, it is important to prioritize patient safety and adhere to proper protocols and guidelines.
Please select 3 correct answers
Nursing interventions that originate from the physician or primary care provider orders are considered dependent interventions.
Dependent interventions are those that require an order or prescription from a healthcare provider. Nurses follow these orders to carry out specific actions or procedures for patient care. The orders may include medication administration, treatments, diagnostic tests, therapies, or other prescribed interventions.
The finding that the femoral site is soft and free of hematoma or bleeding is a positive finding and does not require immediate priority. However, the highest priority finding in this situation would be any signs or symptoms of compromised peripheral circulation.
In this scenario, the patient is in respiratory distress with a pulse oximetry reading of 88%, indicating a low oxygen level. The nurse's priority is to ensure the patient receives the necessary oxygen therapy to improve oxygenation and respiratory function.
Since the RN is currently assessing a critical patient and is unable to attend to the respiratory distress situation immediately, it would be appropriate for the nurse to delegate the task to the LPN. The LPN can obtain the patient's vital signs, including respiratory rate, heart rate, and blood pressure, to gather further information about the patient's condition. Additionally, the LPN can apply a nasal cannula at 2L/min as ordered to provide supplemental oxygen and help increase the patient's oxygen saturation.
Delegating this task to the LPN allows for timely intervention and ensures that the patient's immediate oxygenation needs are addressed. Once the LPN has initiated the oxygen therapy, the RN can continue assessing the critical patient and then reassess the patient in respiratory distress as soon as possible to determine if any further interventions or adjustments are needed.
A direct care intervention refers to a hands-on, physical act performed by the nurse to directly meet the healthcare needs of the patient. The administration of an injection involves the nurse physically administering medication to the patient through an injection route, such as intramuscular or subcutaneous. This action directly impacts the patient's health and is considered a direct care intervention.
An independent nursing intervention refers to an action that a registered nurse can initiate without requiring an order from a healthcare provider. The nurse uses their own knowledge, judgment, and skills to provide direct care to the patient.
A 75-year-old with recent cognitive decline should require more time in the schedule at a community clinic.
Cognitive decline in an older adult can have various underlying causes and may significantly impact their ability to communicate, comprehend instructions, and engage in a healthcare visit effectively. Allocating more time for this client allows the nurse to conduct a comprehensive assessment, address their specific needs, and provide appropriate support and interventions.
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NCLEX Nursing Prioritization Test #6
