ArcherReview uct cree essa Achieve your NCLEX or 0 == a= USMLE target score with eS ArcherReview! statisti nee aes een eRe UE eo ue Nea eosArcherReview NCLEX - BOOK JELLY F MARK For LATER Pore Pe ASS) QID: 6965 The emergency department (ED) nurse cares for a client who presents with irritability, nuchal rigidity, and a fever. Which of the following actions should the nurse take first? X © A. Administer prescribed ibuprofen. 8. Place the client on droplet precautions. vv * C. Notify the public health department x oo00o°o D. Obtain prescribed blood cultures. © Omitted 78% a¢ of peers have answered correctly [5%] [78%] [2%] [14%] Correct Answer(s): B poy 19-09-2022 Last Updated Explanation Choice B is correct. Initiating droplet precautions is a high priority for this client. The classic bacterial meningitis triad is fever, neck stiffness, and altered mental status. Protecting the other clients and staff from disease transmission is essential for the nurse. Thus, the nurse should initiate droplet precautions by placing the client in a room with all visitors and staff wearing a surgical mask in the client's presence. Choices A, C, and D are incorrect. Medications to lower fever, such as acetaminophen or ibuprofen, would be helpful for a client with bacterial meningitis. If bacterial meningitis is confirmed, the public health department must be notified to initiate contact tracing. However, these do not prioritize the safety and infection control of the clients and staff within the ED. @ Additional Info Neisseria meningitidis is a common cause of bacterial meningitis in children and adolescents. symptoms classically have an abrupt onset and include headache, fever, nuchal rigidity, photophobia, and myalgias. The nurse's immediate concern is to protect the safety of the staff and the other clients by placing the client in isolation with droplet precautions. The other actions do not reflect an immediate priority. Treatment for N. meningitidis includes prompt initiation of antibiotics such as ceftriaxone Subject Lesson Client Need Area Leadership & Management Prioritization Safety & Infection Control Client Need Topic Question Type Standard ‘Application Precautions/Transmission-ArcherReview NCLEX - BOOK JELLY F MARK For LATER Pore Pe AU SS)) (oP iE v4 The nurse is caring for the following assigned clients. It would be a priority for the nurse to assess the client Y © Avbeing evaluated for chest pain and requesting an antacid for indigestion. [74%] X © B. reporting nervousness following the administration of albuterol. [21%] X © C.requesting pain medication for their chronic knee and back pain 13%] X © D. awaiting discharge teaching on their insulin pump and glucometer. [2%] © Omitted Correct Answer(s): A 31s aa 29-08-2022 Time Spent seals A Last Updated answered correctly Explanation Choice A is correct. Reports of indigestion could be a symptom associated with myocardial infarction. This atypical sign is concerning because the client is already being evaluated for chest pain. Thus, the nurse needs to follow up with this client Choices A, B, and D are incorrect. Nervousness following the administration of albuterol is an expected finding because albuterol stimulates beta-adrenergic receptors. Pain medication for chronic pain is a priority but not the initial priority because the nurse should always prioritize acute needs over chronic needs. Discharge teaching is a low-priority task for the nurse. ® additional info When prioritizing client care, the nurse should always see clients who report acute changes, appear unstable, or have imminent safety concerns. Unstable patients will have abnormal vital signs or exhibit signs such as restlessness which is a non-reassuring finding in any client as it could be hypoxia, increased intracranial pressure, etc. Subject Leadership & Management Lesson Prioritization Client Need Area Reduction of Risk Potential Client Need Topic Potential for Alterations in Body systems Question Type AnalysisArcherReview NCLEX - BOOK JELLY eae uamestU sas The nurse walks into the room and finds her Explanation client complaining of severe shortness of breath and chest pain. She suspects a Choice D is correct. The first action following the notification of the rapid response team when a pulmonary embolism is suspected is “elevating pulmonary embolism, After notifying the rapid the head of the bed’ to about 30 degrees. This is a quick action that does not require a doctor's order. A pulmonary embolism causes ventilation response team, the nurse's priority action is and perfusion mismatch. In a position with the head of the bed elevated, gravity pulls the diaphragm downward, allowing for lung expansion bIChIGTebettaltowvigg? and improved ventilation. X © A. Obtain vitalsigns and place — [41%] Please note that an embolus may refer to a blood clot (pulmonary embolism, arterial thromboembolism), air bubble (air embolism), or a piece of the client in left-sided, fatty deposit (fat embolism) that can be carried into the bloodstream to lodge in a vessel and cause an embolism. Many students make a knee-jerk Trendelenburg position. selection of Trendelenburg's position the moment they see the word embolism in the question. Please note that the Trendelenburg's position X OB Administer heparin [496] or left lateral position is used in patients with "air" embolism. This is because air is 2 gas and it will float in the upper part of the right ventricle/right atrium when patients are placed in such a position. Pulmonary embolism (PE) is a blood clot. Often, it travels from the lower * © ©. Check lung sounds. [9%] extremities to the lungs. You do not want to keep a patient with acute PE in Trendelenburg's position because that may facilitate further Y © D. Elevate the head of the [46%] embolism in an acute thromboembolism scenario. Deed Choice A is incorrect. The patient is short of breath and is clearly in distress. Vital signs should be taken after the patient's head of the bed is elevated and oxygen has been initiated Choice B is incorrect. While this patient may receive heparin, a doctor's order will be needed to initiate heparin. © Omitted Correct Answer(s): D i - ; Choice € Is incorrect. The patient is in distress. The rapid response team needs to be notified and the head end of the bed needs to be elevated prior to proceeding with further assessment. The nurse may assess lung sounds after the head of the bed is elevated and oxygen has been initiated. 46% a ot peers ce NCSBN client need Topic: Physiological Integrity, Reduction of Risk Potential s Timespane 1% bee CE) Last ae Updated Subject Lesson Client Need Area Leadership & Management Prioritization Reduction of Risk Potential Client Need Topic Question Type system Specific Assessments ApplicationPeereacunad (ated sole) @[a tng ‘The charge nurse is observing a newly hired nurse care for a patient who sustained a closed head injury, is receiving mechanical ventilation, and is at risk for developing increased ‘intracranial pressure (ICP). Which of the following actions, if performed by the newly hired nurse, would require intervention by the charge nurse? X © A.Suctioning the patient 129%] when the high-pressure alarm sounds X © B.Hyperventilating with 100% [4%] FiO2 prior to suctioning. X © C.Performs oral care with a (8%) chlorhexidine solution. Y © D. Maintaining the head of 159%] the patient's bed more than 90 degrees. © omitted oboe Aec B 2s ig Le tae GY 202 ime spent ered 8 correctly pe Explanation Choice D is correct. Maintaining a patient's head of the bed more than 90 degrees is detrimental for a patient with a traumatic brain injury ( TBI). The patient should avoid hip and neck flexion as this raises intracranial pressure ( ICP). While elevating the head end of the bed beyond 30 degrees may drop the ICP further, it can also cause an unwanted drop in the mean arterial pressure ( MAP). A decrease in MAP reciuces cerebral perfusion pressuire | CPP). A fall in CPP is detrimental to the patient with a TBI. Therefore, the head of the bed recommendation for a patient with a risk for increased ICP is 30 to 45 degrees, Such an angle decreases the ICP while maintaining adequate CPP around 70 to 80 mm Hg. Such head of the bed elevation is also necessary to prevent the patient from developing ventilator-acquired pneumonia Choices A, B, and C are incorrect. Suctioning is a necessary procedure for patients with artificial airways. Suctioning the patient when the high-pressure alarm sounds is an appropriate intervention. A high-pressure alarm is triggered when an obstruction is evident in the tubing. Not intervening immediately may cause airway compromise and put the client at risk of death, While suctioning may cause an increase in the ICP, one should use the ABC prioritization method and address the airway first. There is no absolute contraindication to suctioning when clinical indicators indicate the need for it. When clinically warranted, a patient should be hyperventilated with 100% oxygen before suctioning, Oral care with chlorhexidine or hydrogen peroxide is recommended to prevent ventilator acquired pneumonia. © Learning Objective When considering head elevation in patients with increased ICP, one should also ensure adequate CPP is maintained. A 30-45 degree elevation decreases ICP while also maintaining the CPP. Elevating the head of the bed beyond 45 degrees may drop the CPP. @ Additional info When caring for a patient with a TBI, the nurse should maintain a low stimulating environment. The patient should be positioned with the neck midline with their body. The earliest indicator of a patient having increased ICP is alterations in level of consciousness. Subject Lesson Client Need Area Leadership & Management Prioritization Reduction of Risk Patential Client Need Topic Question Type Potential for Complications from Surgical Procedures and Application Heaith Alterations,Nrontacv aVaN ee es\o1e).@ 4223245 (Timed) he] Pe) FP MARK FOR LATER Which of the following clients should the nurse assess first when preparing to do Explanation initial rounds? Choice B is correct. The patient with airway compromise should always be given the © A The client with diabetes who is being discharged today. (196) highest priority. Remember ABC (Airway, Breathing, Circulation). ¥ © 8.A32-year-old female with a tracheostomy experiencing [9796] Choices A, C, and D are incorrect. None of the patients in these answer options indicate copious secretions. a priority for the initial assessment. x © C.A 16-year-old scheduled for physical therapy this morning. (196) NCSBN Client Need Topic: Safe and Effective Care Environment - Coordinated Care, X © D.An 80-year-old male with a decubitus ulcer that needs a [2%] Subtopic: Prioritizing Patient Care dressing change. Subject Lesson Client Need Area Leadership &Management Prioritization Management of Care © Omitted Correct Answer(s): B Client Need Topic Question Type Establishing Priorities Analysis 24 27% 16-07-2022 s =» i€-07- Time Spent [x ofppeers have Last Updated answered correctly IW mtcnetmsNrontacv aVaN ee es\o1e).@ 4223245 (Timed) QID: 3427 FP MARK FOR LATER The nurse is taking care of a client two days post lobectomy. He is complaining of Explanation difficulty breathing. He is restless, lethargic, and has bilateral crackles. What is the nurse's most appropriate initial intervention? Choice B is correct. The client is in obvious respiratory distress. The nurse needs help with initiating life-saving procedures such as endotracheal intubation. The nurse need * © A Check the client’s oxygen saturation. [5296] not call a “Code Blue” since the client is still breathing. However, a Rapid Response Team Y © BiNotify the rapid response team (RAT). 134%) (RRT) can be called for help. The RRT is a team of healthcare professionals who respond to client emergencies even when they are still breathing and/or have a pulse. Since the * © G.Place the client in Trendelenburg position. [8%] client is in obvious respiratory distress, no additional assessment is needed prior to X © D.Check the client's surgical dressing, 6%) ae ac Choice A is incorrect. The client is in obvious respiratory distress, even without the oxygen saturation reading. The nurse should initiate a nursing intervention to help the client. RRT needs to be contacted right away. Please note, "When in distress do not @ Omitted Correct Answer(s): B assess!" Choice C is incorrect. The Trendelenburg position is appropriate for clients in shock, but it is inappropriate for clients in respiratory distress 34% |x. of peers have answered correctly 24s Time Spent 4 19-09-2022 Last Updated Choice D is incorrect. The client is already in respiratory distress. Checking the dressing of the client is inappropriate and causes an unnecessary delay of priority interventions. Subject Lesson Client Need Area Leadership & Management —_ Prioritization Physiological Adaptation Client Need Topic Question Type Alterations in Body Systems Analysis IW mtcnetmsPVA chet ore) g 0nd Sev) ‘While working in the pediatric emergency department, you receive a 2-year-old patient from EMS who has ingested an unknovin amount of a household chemical. You will be the nurse caring for this patient. Place the Following interventions in order from highest priority to lowest priority. Assess the client Ensure no further exposure to poison = Admmnister the antidote if available Identify the specific type of poison Correct Answer is: = Assess the client Ensure no further exposure to poison = laentity the specitc type of poison = Administer the antidote if available Incorrect 1% a ve. oi peets nie 19-09-2022 Time Spent ie Last Updated answered correctly Explanation Assess the client is the first action. Poisoning is a frequent cause of admission to pediatric emergency departments. The priority of nursing action will always be to assess the client. Follow the "ABCs" (airway, breathing, and circulation) and intervene as appropriate. IF the child does not have an airway, establish one. If they are not breathing, manuelly ventilate them. If circulation is inadequate, provide fluid boluses or vasopressors for support as prescribed by the health care provider. The next priority nursing action is to ensure there is no further exposure to the poison. Is the chemical present near their mouth? Is the poison on their skin? Ensure that itis completely removed before proceeding, Next, the nurse needs to take action to identify the specific type of poison. This could mean asking the parents or whoever witnessed what happened, or looking at the chemical bottle themselves if the parents or EMS brought it along, The last priority action is to administer the antidote if available. |f an antidote is available, correctly administer this medication to the client to prevent ongoing tissue damage from the poison that was ingested © Learning Objective Prioritize the order of emergency Department care based on assessment of the affected pediatric client, @ Additional info The nurse should be able to recognize that the most significant risk to the victim of an accidental poisoning is airway compromise and respiratory failure. The nurse should response by assessing their client and ensuring there is no further poison risk to the client or staff caring for the client who ingested the polson. The nurse should further respond by placing an IV line and ensuring patency of the established IV and ensure that there is emergency resuscitation equipment readily available. The nurse should contact poison control in collaboration with the healthcare provider to receive guidance for possible antidotes that may be administered along with further guidelines on patient management Subject Lesson Client Need Area Leadership & Management Prioritization Safety & infection Control client Need Topic question Type Handling Hazardous and infectious Application MaterialsPeereacunad (ated sole) @[a tng The nurse is caring for a client receiving prescribed diltiazem. The client has the following tracing on the electrocardiogram shovmn in the exhibit. The nurse should perform which priority action? See the exhibit. Y © A.Discontinue the diltiazem infusion. [38%] X © B. Notify the primary healthcare physician (PHCP). [19%] * © C.Assess the client's oxygen saturation and respiratory rate (RR). 124%) X © _D.Prepare a prescription of intravenous (IV) atropine. 19%) © omitted Correct Answer(s): A a= sa een som Time Spent p Last Updated answered correctly Explanation Choice A is correct. The tracing shows sinus bradycardia, The priority action would be to discontinue the diltiazem infusion as this medication is a calcium channel blocker that lowers heart rate and blood pressure. If the infusion were to continue, it would lower the heart rate further. Choices B, C, and D are incorrect. The physician should be notified, and oxygen saturation should be assessed. However, the priority action is to discontinue the offending agent first, the diltiazem. 'V atropine is inappropriate as the offending agent (diltiazem) must be discontinued. jonal Info @ Ad Diltiazem is a calcium channel blocker prescribed to treat hypertension and atrial fibrillation. When given continuously in an infusion, the nurse must elesely monitor the client's blood pressure and heart rate. Diltiazem may cause dangerously low blood pressure and bradycardia Other calcium channel blackers include amlodipine, nifedipine, and verapamil. Only verapamil and diltiazem lower both the blood pressure and heart rate. subject Lesson Client Need Area Leadership & Management Prioritization Reduction of Risk Potential Client Need Topic Question Type Changes/Abnormalities in vital Signs ApplicationNrontacv aVaN ee es\o1e).@ FP MARK FOR LATER QID: 3795 4223245 (Timed) While ambulating a patient who has an infusion running through their peripherally inserted central catheter (PICC) in the right arm, they suddenly complain of dyspnea and chest pain. You immediately sit them down in the closest chair and assess them. Their BP is 72/38 mmHg and their heart rate is 186. What is the priority nursing action? Select all that apply. (0 A.Clamp the catheter [20%] v Y (J B.Notify the health care provider [36%] X © CLaythe patient flat [10%] v (0 «~ODz« Administer oxygen [34%] © Omitted Correct Answer(s): A,B,D 36% 32s 24-06-2022 of hi Time Spent ESN eae aks Last Updated answered correctly IW mtcnetms Explanation Choices A, B, and D are correct. The nurse suspects that the patient has an air embolism related to their PICC line. This is a potential complication of central venous catheters and the nurse is expected to monitor for it. Signs and symptoms include tachycardia, hypotension, chest pain, dyspnea, tachypnea, and hypoxia. Since the nurse suspects an air embolism, she should clamp the catheter immediately to prevent any further air entry. This is a medical emergency, and the health care provider should be notified promptly. Hypoxia is a symptom of an air embolism; therefore the patient should immediately begin receiving oxygen to prevent tissue ischemia and further complications. Choice C is incorrect. Laying the client supine could cause air embolism to exit the right atrium of the heart and travel to the brain or lungs, causing complications such as a stroke or pulmonary embolism (PE). The patient should be positioned on their left side with their head lower than their feet. This will trap the embolism in the right atrium of the heart and prevent further complications. Lesson Client Need Area Reduction of Risk Potential Subject Leadership & Management Prioritization Client Need Topic Potential for Complications of Diagnostic Tests/Treatments/Procedure Question Type ApplicationNrontacv aVaN ee es\o1e).@ 4223245 (Timed) fe] |e eke) FP MARK FOR LATER The client has just been given an IV dose of morphine 6 mg for neuropathic pain. A few minutes later, the nurse notes that the client's respirations are now 8, and his blood pressure has dropped from 122/83 mmHg to 88/67 mmHg. Which nursing action is the most appropriate? X © A Prepare for intubation. 1796] © 8B. Prepare to administer a dopamine infusion. (3%) Y © ©.Administer naloxone. [80%] X © D.Start an IV infusion of normal saline. [10%] © Omitted Correct Answer(s}: C 80% 27s 25-07-2022 © |x. of peers have fel Time Spent Last Updated answered correctly IW mtcnetms Explanation Choice C is correct. The client is suffering from morphine toxicity. The nurse needs to administer the antidote, which is naloxone (Narcan). Choice A is incorrect. The client is in morphine toxicity. The nurse needs to administer an antidote to reverse the symptoms of respiratory depression. Preparing for intubation should not be the nurse's initial action. Choice B is incorrect. The drop in blood pressure is a result of morphine toxicity. Dopamine infusion is not yet necessary as of the moment. Choice D is incorrect. Starting an IV infusion may be necessary; however, in this case, the first action of the nurse would be to administer an antidote to morphine. Subject Lesson Client Need Area Leadership & Management _ Prioritization Redluction of Risk Potential Client Need Topic Question Type Potential for Complications Application of Diagnostic Tests/Treatments/Procedure sArcherReview NCLEX - BOOK JELLY F MARK For LATER Pore Pe AS.) QID: 8389 The nurse is caring for assigned clients. The nurse should initially assess the client who Y © Avis recovering from a femoral angioplasty and reports their foot as falling [70%] asleep. X © _B-has diabetes mellitus and refused their prescribed glargine insulin 15%] X © C.received alteplase three hours ago for a stroke and has a Glasgow Coma [7] Scale of 14. X © _D. hada T6 spinal cord injury and has not had a bowel movement since 117%] yesterday. © Omitted Correct Answer(s): A 70% © ®: lav Encerstave -<4 10-09-2022 Time Spent ee KE Last Updated answered correctly Explanation Choice A Is correct. Following a femoral angioplasty, the affected extremity should be assessed for @ pulse, and the client should be instructed to report any decreased sensation. A common complication following this procedure is arterial occlusion which causes a decreased pulse and the client to experience a reduced sensation (or paresthesias). Choices B, C, and D are incorrect, Any client who refuses a medication should receive follow-up as the nurse is instrumental in explaining the purpose of the medication. However, this is not the priority because the client would adversely face hyperglycemia which is not immediately life- threatening. A GCS of 14 (with the highest score of 15) is optimal and does not require immediate follow-up. Finally, bowel and bladder function disturbances are commonly seen with a thoracic spinal cord injury. However, this is not of immediate concern, considering the last bowl movement was one day ago. ® Additional nfo The neurovascular assessment is a priority following a femoral angioplasty. This includes assessing the affected extremities’ distal pulse and temperature. Additionally, the client should report any signs of decreased sensation or paresthesia. Antiplatelets are commonly prescribed following this procedure to prevent occlusion: Subject Lesson Client Need Area Leadership & Management Prioritization Management of Care Client Need Topic Question Type Establishing Priorities, AnalysisArcherReview NCLEX - BOOK JELLY F MARK For LATER Pore re AU SS)) Ql ETE The patient has a history of chronic venous insufficiency, atrial fibrillation, and varicose veins. Upon assessment, the RN finds the patient to be afebrile with left calf edema, pain, and erythema that is warm to the touch. What Is the RN‘s most urgent concern? Y © A.Deep vein thrombosis (DVT) 190%] x © B.Cellulitis (8%] Xx © Osteomyelitis 1194] X © D.Lymphedema [2%] © Omitted Correct Answer(s): A 90% of peers have answered correctly 44s Time Spent 21-07-2022 Last Updated Explanation Choice A is correct. The patient has a history of chronic venous insufficiency, atrial fibrillation, and varicose veins, which are all risk factors for developing blood clots. The patient is also presenting with hallmark signs of deep vein thrombosis (unilateral lower leg pain, swelling, and redness). DVT is an emergency because a clot may dislodge and travel, causing a stroke or myocardial infarction. OF the choices, DVT is the most emergent situation. Choice incorrect. Cellulitis is an infection in the soft tissue. Although it is typically unilateral, it would not be as urgent as a blood clot. The patient's history of venous problems would not be a relevant risk factor for developing cellulitis. Choice correct. Osteomyelitis is an infection of the bone, caused by an external pathogen that usually enters the blood or tissue via an open wound. The patient's history of venous problems would not bea relevant risk factor for developing osteomyelitis. Choice D is incorrect. lymphedema would cause bilateral swelling that is not warm to the touch. NCSBN Client Need Topic: Prioritization, Subtopic: Potential for complications from health alterations, pathophysiology, illness management, medical emergencies Client Need Area Reduction of Risk Potential Subject Leadership & Management Lesson Prioritization Client Need Topic Potential for Alterations in Body Systems, Question Type AnalysisArcherReview NCLEX - BOOK JELLY F MARK For LATER 5 (Timed) The nurse is preparing medications for the shift. Which of the following clients should be prioritized for immediate medication administration? X © A. Digoxin to a client with an apical pulse of 50 (8%) x Oo 8. Furosemide to a client with a serum potassium level of 3.0 mEq/L [8%] Y © C.Magnesium sulfate to a client with Torsades de pointes 181%] X © D. Verapamil to a client with blood pressure af 100/60 mmHg [2%] © Omitted 81% of peers have answered correctly Correct Answer(s): C po 16-07-2022 Last Updated Explanation Choice € is correct. Torsades de pointes, a form of ventricular tachycardia, is a life-threatening condition. The nurse should immediately administer the medication to the client to prevent the disease from progressing into ventricular fibrillation. Choice B Is incorrect. Furosemide is a loop diuretic used to treat congestive heart failure and edema. The drug predisposes the client to hypokalemia. In this case, the client already has a low serum potassium level. Therefore, the nurse needs to notify and question the prescribing physician whether he/she should still proceed with administering the medication. Choice A Is incorrect. When the nurse is administering digoxin, she should check the patient's apical pulse and withhold the dose if the pulse falls below 60 beats per minute. Choice D is incorrect. The blood pressure of the client is at 100/60 mmHg. Verapamil is a calcium channel blocker and is often used to treat high blood pressure and angina. It can be administered as ordered, Typically, physicians order blood pressure medications to be held at a systolic blood pressure of 90 mmHg or below. However, in this case, the nurse should prioritize administering magnesium to the client with Torsades de pointes, Subject Lesson Client Need Area Leadership & Management Prioritization Management of Care Client Need Topic Question Type Establishing Priorities AnalysisNrontacv aVaN ee es\o1e).@ 4223245 (Timed) QID: 5015, FP MARK FOR LATER A nursing assistant tells the nurse that her patient with COPD reports he did not get his annual flu shot this year and has not had a pneumonia vaccination. The nurse should instruct the CNA that which of the following is the priority? X © A.Blood pressure 150/80 mmHg, [5%] * © 8B. Respiratory rate 26 breaths/min [2596] * © C.Heart rate 92 beats/min [1%] Y © D.Oral temperature of 101.4 degrees F [69%] © Omitted Correct Answer(s): D 5 245 ie ne h jx 16-07-2022 Time Spent Ae) St beets Tavs Last Updated answered correctly IW mtcnetms Explanation Choice D is correct. An elevated temperature indicates some form of infection which may be respiratory in origin. A patient who did not receive pneumonia or influenza vaccines is at increased risk of developing pneumonia and influenza. Monitoring for signs/symptoms of infection is a crucial nursing intervention. Choices A, B, and C are incorrect. Although all of the vital signs in these answer options are slightly elevated, they do not represent a cause for immediate concern NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control - Oxygenation and Perfusion Subject Lesson Client Need Area Leadership & Management _Prioritization Reduction of Risk Potential Client Need Topic Question Type Chenges/Abnormalities in Application Vital SignsNrontacv aVaN ee es\o1e).@ FP MARK FOR LATER fel aa 4223245 (Timed) You are the Registered Nurse working a night shift with a Certified Nursing Assistant. It is your first night back after a vacation, so you are not familiar with the patients. The CNA reports that Mrs. Smith has a headache, Mrs. Jones cannot stop coughing, Mr. Peters has an oxygen saturation of 88%, and Mr. White's IV is beeping. The patient you should see first is: * © AMrs. Smith [2%] X © B.Mrs. Jones [13%] ¥ © CMr. Peters [80%] * © D.Mr. White [5%] © Omitted Correct Answers): C 23s 80% 20-07-2022 [x of peers have answered correctly Time Spent Last Updated IW mtcnetms Explanation Choice C is correct. You should see Mr. Peters first since his oxygen saturation is below 949. The prioritization for patient care should first be based on the "ABCs - Airway, Breathing, Circulation”. An oxygen saturation reading below 94% should be investigated since this would indicate that the patient may have an airway or breathing problem. You should ask the CNA to sit with Mrs. Jones until you can get in to evaluate her coughing. Mrs. Smith's headache should be assessed third. Finally, you should look at Mr. White's IV to determine why it is beeping. NCSBN Client Need Topic: Management of Care, Sub-Topic: Establishing Priorities, Prioritization Subject Lesson Client Need Area Leadership & Management Prioritization Management of Care Client Need Topic Question Type Establishing Priorities AnalysisArcherReview NCLEX - BOOK JELLY 5 (Timed) QID: 4296 eae uamestU sas The nurse receives a report on four patients at the start of shift change. Which patient should Explanation the nurse see first? Choice € is correct. This patient may be developing autonomic dysrefiexia, a medical emergency. X © A.Apatient with a right femur fracture who complains of right leg pain. 115%] One of the first signs/symptoms of autonomic dysreflexia is a severe, throbbing headache following spinal cord injury (most common in T6 and above). Patients usually develop autonomic dysrefiexia X © B.Apatient being treated for pneumonia with scheduled IV antibiotics due. [79% © Bap e P ve) tite month’to one year ater thelr injury. Howevels it has also been described innthe first daysor Y © .Apatient with a history of 76 spinal injury 6 months ago, now presents 159%] weeks after the original trauma. Objectively, an episode is defined as an increase in systolic blood with a headache. pressure of 25 mmHg, Patients with this condition will develop dangerously high blood pressure that MO. DsApaencihstis ay posteperatneaBertcoeCpEtSmyNaNiETEEN ION can result in severe, fatal diseases such as seizures, pulmonary edema, and myocardial infarction. aieeae [Assessing this patient would be the nurse’s highest priority. Choice A is incorrect. Right leg pain is expected in a patient with an acute right femur fracture. The nurse needs to address this patient's pain, but expected outcomes would not be the highest priority. © Ching Gueenenic Choice B is incorrect. Scheduled medications would not be a higher priority than the patient showing symptoms of a life-threatening complication Choice D is incorrect. Green drainage is expected in a patient with an open cholecystectomy due to ae 59% aaa the green color of bile in the common bile duct. The nurse should assess this patient's drainage and oe of : : i q Taupe of peers have Lat Upaated progression of healing, but it would not be the highest priority. answered correctly NCSBN Client Need Topic: Establishing priorities, medical emergencies, Subtopic: Priorities Subject Lesson Client Need Area Leadership & Management Prioritization Management of Care Client Need Topic Question Type Establishing Priorities Analysiseeiueuouaeloed ole) ging PULAU} Tear QID: 2376 Explanation iM EER eR EEE pa _CEOER Choice Ais correct. You should include Maslow’s Hierarchy of Needs theory in this class about priority setting. theory should you include in this class? Maslow’s approach is the most popular and most frequently used theory to determine priorities from the mast basic physical needs to the most advanced self-actualization needs. The argument is often presented as a five-level Y © A.Maslow's theory [90%] pyramid. When answering NCLEX questions, it is important to note that basic/lower-level needs are of "HIGHEST" riority. X © B.Piaget’s theory 13%] RNS X © C.Orem's theory (5%1 XO D.Skinners theory (2%) Maslow's Hierarchy of Basic Human Needs Omitted Correct Answer(s): A 90% ) ’v_ of peers have qe Rane +Higher-level needs ‘Slfestecm YD Time Spent Last Updated answered correctly Love and belonging. Safety and security Lower-level needs Physteloge enchecRevinPeer Eyer Tura) QID: 2376 Pace Menias You have been asked to present a class about priority setting to a group of new graduate nurses. Whose theory should you include in this class? Y © A.Maslow’s theory [90%] X © B.Piaget’s theory 1%] x © C.Orem’s theory (5%) X © _D.Skinner’s theory [2] © Omitted Correct Answer(s): A enretec Ravin Maslow’s “hierarchy of needs" is typically presented as a five-level pyramid, with higher needs coming into focus only once lower, more basic needs are met. 90% ~ 24s 25-07-2022 Therefore, when answering questions, note that basic needs are the "HIGHEST" priority. © oe of peers have ee, answered correctly ts Time Spent Choice 8 is incorrect. Piaget's theory addresses the cognitive development of infants and children along the life span and would not be included in a class about priority setting. Choice C is incorrect. Orem's theory addresses the self-care needs of clients and would not be included in a class about priority setting Choice D is incorrect. Skinner's theory addresses operant conditioning and would not be included in a class about priority setting, Subject Lesson Client Need Area Leadership & Management Prioritization Management of Care Client Neod Topic Question Type Establishing Priorities ApplicationPeereacunad (ated sole) @[a tng ‘The nurse is caring for a client who intentionally overdosed on ami iptyline. What action should the nurse Explanation prioritize? Choice A is correct. Amitriptylineis a tricyclic antidepressant (TCA) and, when taken in excess, may cause cardiac Y © A.Obtain a 12lead electrocardiogram (75%) dysrhythmias. TCA toxicity’s most severe cardiac effects include QT interval prolongation, torsade de paintes, and RG laa oesahlonneanee ea ise sudden cardiac death. The essential action is to address the patient's physiological needs by assessing if the x x patient has catastrophic dysrhythmias. © C.Determine the reasoning for the overdose 1 Choices B, C, and D are incorrect. & consultation with psychiatry is highly likely considering the intentionality of © 0. Establish a therapeutic relationship [14%] the overdose. However, the priority is the patient's physiological needs. Determining the reasoning for the overdose and establishing a therapeutic relationship is not a priority over the patient’s physical needs. © Omitted Correct Answer(s): A @ Additional info TCAs are indicated for depressive and absessive disorders. Considering they are profoundly anticholinergic, ise the toxicity of these medications may be fatal. Drugs in this class include amitriptyline, nortriptyline, and 325 cae) (OE SRA HEN 29-08-2022 imipramine. Clinical features of an overdose include dysrhythmias, hypotension, confusion, and ahawereaeoreaty Last Updated hyperthermia, The nurse should immediately determine hemodynamic stability through continuous cardiac and blood pressure monitoring. Time Spent Subject Lesson Client Need Area Leadership & Management Prioritization Pharmacological and Parenteral Therapies Client Need Topic Question Type Adverse Application Effects/Contraindications/Side Effects/interactions PearyPeereacunad (ated sole) @[a tng (deena: You are the nurse manager of the surgical acute care unit. You have noticed that several clients have almost been sent to the preoperative suite when they are not scheduled for a planned surgical procedure. Fortunately, no clients have gotten a “wrong surgery” because this possible error was caught in time. What is your priority action as the nurse manager? * © A.Praise the staff for catching these near misses before a surgical error occurs. 15%] Y¥ © Bulnvestigate and explore this near miss. (70%) X © C.lnvestigate and explore this medical error. [21%] % © D.Report the nature and frequency of these medical errors to the State Department of 14%] Health. © Omitted Correct Answer(s): B 47s ae 25-07-2022 22 of peers have answered correctly Time Spent Last Updated rere Explanation Choice 8 is correct. You, as the nurse manager of this surgical unit, should investigate and explore this near miss to prevent further medical errors in the future. This is your priority action. It’s important to conduct near-miss investigations within 24 to 48 hours of the incident while memories are fresh about what happened and how the incident could have been prevented. Know these definitions: Near miss: A near miss is defined as “any event that could have had adverse consequences but did not and was indistinguishable from fully-fledged adverse events in all but outcome." In a near miss, an errar was committed, but the patient did not experience clinical harm, either through early detection or sheer luck. In the above question, the clients have not undergone the wrong surgery and therefore, it's a near miss. Sentinel event: An unexpected occurrence involving death or serious physical/psychological injury. These events are called “sentinel” because they signal the need for immediate investigation and response. In the above question, the harm has not occurred. Therefore, it’s not a sentinel event. Note that the terms “sentinel event” and ‘error’ are not synonymous. Not all sentinel events occur because of an error and not ail errors result in sentinel events. Choice A is incorrect. Aithough you should praise the staff for catching these near misses before a surgical error occurs, the priority is to investigate what led to the near miss. Choice Cis incorrect. These near misses are not an actual medical error. Choice D is incorrect. These near misses are not an actual medical error, so it does not have to be reported to the State Department of Health. Subject Lesson lient Need Area Leadership & Management Prioritization Management of Care Client Need Topic Question Type Performance Improvement (Quality Application Improvement) PearyArcherReview NCLEX - BOOK JELLY F MARK For LATER Pore re AUS.) Ce) ) The nurse enters the room of a 5-year-old client and finds the client lying on the floor. The fall was unwitnessed. What is the priority nursing action? X © AFilean incident report [0%] X © B.Assist the child back to bed 2%) X © C.Call forhelp (8%) Y © D.Assess the child for any injuries [89%] © Omitted Correct Answer(s): D 23s beet! 12-07-2022 Time Spent seals A Last Updated answered correctly Explanation Choice D is correct. The priority nursing action is to assess the client. The nurse should assess the child for any injury and/or loss of consciousness. Following the assessment, the nurse can determine a further course of action. Choice € is incorrect. While itis likely that the nurse will need to call for help, this is not the priority nursing action. The nurse should first assess the fallen child. Choice A is incorrect. Following any fall event, the nurse must file an incident report. Incident reports help evaluate the cause of falls and help take steps to prevent future unwanted incidents. However, the patient is the utmost priority, and the nurse must assess the patient first before proceeding to other actions. Choice B is incorrect. Before assisting the child back to the bed, the nurse must complete her assessment. This includes assessing for an injury (fractured bones, etc). if the child is injured, the nurse should take appropriate actions to move them safely. Inappropriate handling of an injured limb (example: hip fracture) may inflict further distress to the child and/or aggravate the injury. NCSBN Client Need: Topic: Effective, safe care environment; Subtopic: Infection control and safety Subject Leadership & Management Lesson Client Need Area Prioritization Reduction of Risk Potential Client Need Topic Potential for Alterations in Body Systems, Question Type Knowledge/ComprehensionArcherReview NCLEX - BO 4223245 (Timed) QID: 3905 FP MARK FOR LATER An emergency response nurse has just arrived on the scene of a 911 call. The patient is unconscious and without a pulse. The nurse's priority action is to: Xx © A Administer two rescue breaths. [196] Y © B. Begin chest compressions. [69%] X © C.Check the patient for a patent airway. [30%] * © D.Ask another health care professional to check the carotid [1%] artery. © Omitted Correct Answer(s): B 69% 27s 22-07-2022 |x. of peers have Time Spent answered correctly Last Updated IW mtcnetms Explanation Choice B is correct. If the nurse has found an unconscious and pulseless patient, they should begin chest compressions. Immediate chest compressions are the most effective way to maintain total body oxygenation. Choice A is incorrect. Rescue breaths, while important, should not be initiated at this point. Instead, rescue breaths should be started if the patient is apneic and after chest compressions have been undertaken. Choice C is incorrect. While checking a pulseless patient for a patent airway is a reasonable step, it is not the best action at this point. Choice D is incorrect. Asking another health care professional to check for pulselessness delays necessary treatment. NCSBN client need Topic: Safety and Infection Control: Emergency Response Plan Subject Lesson Client Need Area Leadership & Management Prioritization Physiological Adaptation Client Need Topic Question Type Medical Emergencies Knowledge/ComprehensionArcherReview NCLEX - BOOK JELLY F MARK For LATER Pore re ASD) QID: 6895 ations. The nurse should first follow The nurse has become aware of the following client up with which client? X © A.Aclient with a chest tube that has tidaling in the water seal chamber. (2) X © B.Aclient that is receiving mechanical ventilation and is occasionally biting on [8%] the tube. X © C.Aclient that is receiving albuterol via a nebulizer and reports headache and [4%] nervousness. Y © D.Aclient with pneumonia that has become restless and confused 185%] © Omitted Correct Answer(s): D 25s Bove 03-08-2022 A of peers hi Time Spent Reicneeiegeal Last Updated answered correctly Explanation Choice D is correct. One of the dreaded complications of pneumonia is acute respiratory distress syndrome (ARDS) which is manifested by hypoxia. The client demonstrating confusion and restlessness is quite concerning for hypoxia. The nurse should quickly assess the client and intervene by calling a rapid response if this should occur in the acute care setting. Choices A, B, and C are incorrect. Tidaling in the water seal chamber is a normal finding when a client has a chest tube. Biting on an endotracheal tube is a common finding and does require follow- up as the client could be in pain. Headache and nervousness are common effects associated with albuterol treatments. ® Additional info For a client with pneumonia, the nurse must constantly monitor for ARDS since this syndrome is characterized by an inflammatory injury to the lungs. Classic findings include hypoxemia, progressive dyspnea, and adventitious lung sounds. Medical treatment includes positive airway pressure with oxygen, prone position, glucocorticoids, glucose control, and antimicrobials or antivirals. The prone position is preferred because this position improves ventilation in the dorsal region of the lung, therefore improving oxygenation. Subject Leadership & Management Lesson Client Need Area Prioritization Physiological Adaptation Client Need Topic Illness Management Question Type AnalysisArcherReview NCLEX - BOOK JELLY F MARK For LATER Pore re AUS.) Ce) or EE) The patient with history of right mastectomy is receiving maintenance IV fluids via peripherally inserted intravenous line in the left cephalic vein. The patient complains of pain at the IV site, and the nurse notes that the Infusion has slowed and assesses swelling and erythema at the IV site. Which action should the nurse take first? Y © A.Stop the infusion and remove the IV catheter [93%] X © B. Insert new IV in left intermediate basilic vein. [2%] X © C. Prepare the patient for PICC line placement. [1%] X © D. Elevate the right arm to reduce swelling, [4%] © Omitted Correct Answer(s): A 93% 26s =) 12-07-2022 Time Spent Ee eae Last Updated answered correctly Explanation Choice A is correct. This patient's IV site shows signs of phlebitis: redness, swelling, pain, and ‘slowed infusion rate. The first priority action is to remove the current IV catheter to reduce the risk of further complications. Localized symptoms of phlebitis typically resolve after discontinuation of the catheter. Choice B is incorrect. Since this patient is not a candidate for IV access in the opposite arm due to a history of right mastectomy, the nurse should remove the current IV, and then attempt to insert a new IV proximal from the original site, but the current IV site should be discontinued first, prior to initiating any other interventions. Choice correct. This patient may be a candidate for PIC line placement if attempts to insert IVs at new sites are unsuccessful, but the current IV site shauld be discontinued first, prior to initiating any other interventions. Choice D is incorrect. Although phlebitis symptoms can be relieved by elevating the affected limb, applying a warm compress application, and administering analgesics, the current IV site should be discontinued first, prior to initiating any other interventions. NCSBN Client need: Topic: Physiological integrity, Sub-topic: Pharmacological and Parenteral Therapies Subject Lesson Client Need Area Leadership & Management Prioritization Reduction of Risk Potential Client Need Topic Question Type Knowledge/Comprehension Potential for Complications of Diagnostic Tests/Treatments/ProceduresArcherReview NCLEX - BOOK JELLY F MARK For LATER Po Pere AUS.) Ce) Por EP The nursing student inserts an indwelling urinary catheter for a female patient prior to surgery. Which of the following would require Immediate intervention by the RN? X © A The patient states she feels the need to urinate 111%] X © B. Patient reports a pinching sensation as the catheter is advanced 117%] Y © C.The student nurse notes resistance when inflating the balloon. [68%] % © D. The student separates the labia majora and labia minora with non- B%] dominant hand. © Omitted Correct Answer(s): C 26s | oe xs have ey 12-07-2022 Time Spent noi EE) Last Updated answered correctly Explanation Choice correct. This may indicate the balloon is within the urethra, not the bladder. If inflated within the urethra, the balloon may cause significant damage. Any complaints or nonverbal signs of discomfort or resistance is noted by the nurse during balloon inflation, are indications to stop this procedure immediately. Choice A is incorrect. The patient may feel the urge to void as the catheter is advanced through the internal urethral sphincter, this would not be a reason to stop the procedure Choice B Is Incorrect. The student nurse should explain to the patient that she may feel pressure upon catheter insertion. A brief pinching sensation indicates the catheter is passing through the internal urethral sphincter and would not be a reason to stop the procedure. Choice D is incorrect. This action is appropriate. The student should use the non-dominant hand to position the patient and the dominant hand should remain sterile for insertion. NCSBN Client need: Topic: Physiological integrity, Sub-topic: Reduction of Risk Potential Lesson Client Need Area Reduction of Risk Potential Subject Leadership & Management Prioritization Client Need Topic Question Type Potential for Complications of Application Diagnostic Tests/Treatments/ProceduresPeereacunad (ated sole) @[a tng xa) ‘The emergency department (ED) nurse is triaging clients in the ED. It would be appropriate for the nurse to Explanation triage which client as nonurgent? 4 client Select all that apply. Choices A, D, and E are correct. These client situations require a triage of non-urgent. The non-urgent triage Y © A.with a localized abscess on the right leg. [29%] category signifies that the client can be placed in the waiting area for a set of times without risking clinical X (© B.reporting that they have chest pressure. [1%] eSies % () C.with nausea, vomiting, and! painful urination, (5%) Choices B and C are incorrect. A client reporting chest pressure should be triaged as emergent as they need to be evaluated by a primary healthcare provider (PHCP) immediately. Nausea, vomiting, and pain with urination are Y 1 D.requesting a refill of their prescribed antidepressant. [32%] suggestive of renal colic, which should be triaged as urgent Y ©) Ewitha single laceration to the left hand. [29%] @ Additional Info Sonne Gere hee ADE The emergent triage category implies that a condition exists that poses an immediate threat to life or limb. Conditions that should be triaged as emergent include: active hemorrhage, unstable vital signs, significant trauma, chest pain, and manifestations of a stroke. The urgent triage category indicates that the client should be treated quickly but that an immediate — 47% x 1S! threat to life does not exist at the moment, Conditions that typically fall into the urgent category are Time Spent [x ofpeers have C2) cast updated those with a new onset of pneumonia (as long as respiratory failure does not appear imminent), renal answered correctly colic, abdominal pain, complex lacerations not associated with majar hemorrhage, displaced fractures or dislocations, and temperature higher than 101°F (38.3°C). Those triaged as non-urgent can generally tolerate waiting several hours for health care services without a significant risk for clinical deterioration. Conditions within this classification include clients with sprains and strains, simple fractures, general skin rashes, and uncomplicated urinary tract, infections. Subject Lesson nt Need Area Leadership & Management Prioritization Management of Care Client Need Topic Question Type Establishing Priorities Analysis PearyArcherReview NCLEX - BOOK JELLY F MARK For LATER The nurse is triaging phone calls for the primary healthcare provider (PHCP). Which client situation requires immediate notification to the PHCP? Y © A.Adlent with heart failure that reports an overnight weight gain of three [79%] pounds. X © _B.Aclient with peritoneal dialysis who has net had a bowel movement in two [7%] days. X © C.Aclient with irritable bowel syndrome (IBS) that reports frequent diarrhea. [2%] X © _D.Adient with nephrolithiasis that reports bloody urine and flank pain. 112%) © Omitted Correct Answer(s): A 27s ae h 22-10-2022 Time Spent ae ee Last Updated answered correctly Explanation Choice A is correct. The PHCP should be immediately notified about the client who gained three pounds overnight. Two pounds convert to one kilogram, and that converts to one liter of fluid. Thus, this client is retaining a significant amount of fluid and requires immediate follow-up to ensure they do not develop complications such as pulmonary edema. Choices B, C, and D are incorrect. A client with peritoneal jis should be evaluated for their complaints of constipation because it is a major cause of poor outflow. A client with IBS reporting frequent diarrhea is an expected finding, as this condition is manifested by constipation, diarrhea, and abdominal spasms. Nephrolithiasis characteristically presents with hematuria and flank pain. Each client calls about symptoms expected with the corresponding disease process; thus, they do not need to be reported immediately to the PHCP. @ Additional info Itis essential for a client with heart failure to weigh themselves daily. This weight should be completed first thing in the morning and after the morning void. The weight should be obtained with the same amount of clothing each day. The client should report a weight gain of 1-2 pounds overnight or 3-5 pounds in a week. Subject Lesson Client Need Area Leadership & Management Prioritization Management of Care Client Need Topic Question Type Establishing Priorities AnalysisArcherReview NCLEX - BOOK JELLY F MARK For LATER Pore re ASS) Col] sI-r 74 The nurse is assessing a patient who reports intermittent tingling and numbness in bilateral lower extremities. Which intervention by the nurse would be most important to prevent Injury for this patient? X © A.Perform Semmes-Weinstein monofilament test [28%] X © B. Refer the patient for a diabetic diet consult [8%] X © C. Obtain an order for Gabapentin [8%] Y © D.Teach the patient about appropriate footwear [57%] © Omitted Correct Answer(s): D 57% of peers have answered correctly 34s Time Spent 12-07-2022 Last Updated Explanation Choice D is correct. Peripheral neuropathy puts the patient at increased risk for traumatic injury and tissue breakdown since the patient may not notice early skin damage due to altered sensation. Of the options provided, educating the patient on proper footwear is the only action that aims to prevent injury related to the patient's altered sensation in the feet. Choice A is incorrect. The Semmes-Weinstein monofilament test is an appropriate way to test for sensation in the feet and is used to identify risk for neuropathic ulceration, but this assessment tool is not a preventative action. Choice B Is incorrect. Diabetes is ¢ common cause of peripheral neuropathy, but the question does not provide any information that indicates this patient is diabetic, and would not specifically address promoting the patient's safety. Choice € is incorrect. Gabapentin is used to improve neuropathic pain and may be appropriate for this patient, but would not directly prevent injury. NCSBN Client need: Topic: Safe and Effective Care Environment, Sub-topic: Safety and Infection Control Client Need Area Basic Care and Comfort Subject Lesson Leadership & Management Prioritization Client Need Topic Non-Pharmacological Comfort Interventions Question Type ApplicationPeereacunad (ated sole) @[a tng ‘The nurse has become aware of the following client situations. The nurse should first follow up with which client? X © A.Adlent with an irregular pulse that is receiving treatment for atrial fibrillation. [10%] X* © B.Aclientwith pneumonia who had an increase in temperature to 102.3° F. [23%] Y © C.Adlient receiving nebulizer treatments for asthma that suddenly stops wheezing. (58%) % © _D.Aclient that has active pulmonary tuberculosis (TB) and refuses prescribed medications. [9%] © Omitted Correct Answerts}: € 30s a 08-07-2022 ne of v of peers have Last Updated answered correctly Time Spent Explanation Choice Cis correct. Wheezing, tachypnea, and dyspnea are all expected findings during an acute asthma exacerbation, The sudden cessation of wheezing highly concerns the nurse, indicating that the client is no longer oxygenating because they are not moving air. This warrants immediate follow-up as it is a sudden change. A gradual improvement in symptoms is expected. Choices A, 8, and D are incorrect. An irregular pulse is an expected finding associated with atrial fibrillation as this is an irregular arrhythmia. Pyrexia, a productive cough, and chest discomfort are common features of pneumonia and do not require follow-up. A client refusing medications is concerning but does not override a physical threat to a client's breathing. @ Additional info Clinical features of an asthma exacerbation include the following: Tachypnea Dyspnea Persistent cough Use of accessory muscles for breathing Tachycardia Wheezing in the lung fields The priority treatment is administering oxygen followed by prescribed albutercl via nebulizer. A client may be prescribed adjunctive agents such as systemic glucocorticoids or magnesium sulfate. The nurse should avoid the administration of beta-adrenergic blockers as this may worsen or induce an exacerbation, subject Lesson Cliont Nood Ara Leadership & Management Prioritization Physiological Adaptation Client Need Topic Question Type lliness Management Analysis PearyNrontacv aVaN ee es\o1e).@ 4223245 (Timed) QID: 6047 FP MARK FOR LATER The nurse is caring for a client diagnosed with multiple myeloma. The nurse Explanation reviews the client's lab values and notes a serum calcium level of 14 mg/dL. What is the priority action the nurse should take? Choice A is correct. The normal range for serum calcium is 9-10.5 mg/dL. This client's serum calcium level is above 10.5 mg/dL; therefore, the client is experiencing ¥ O A.Notify the physician [86%] hypercalcemia. Ata calcium level of 14 mg/dL, most clients may experience symptoms. % © B.Document the finding (5961 Often, these may include polyuria, polydipsia, and dehydration. If not addressed, clients may develop renal failure and altered mental status. The nurse must notify the physician * © ©. Continue to monitor the patient [8%] regarding this abnormal lab value. * © D.Remove the patient from the telemetry monitor (196) Choices B and C are incorrect. It is inappropriate for the nurse to document the finding or just continue to monitor. The nurse has correctly identified that this lab value is out of the normal range and must report the finding to the attending physician. © omitted Cone aeRO Choice D is incorrect. Itis inappropriate for the nurse to remove the client from the telemetry monitor. Not only has the nurse identified that this finding falls outside of normal limits and needs to notify the attending physician, but the nurse should also be aware that a client experiencing hypercalcemia may have EKG changes such as a Whe 86% on 16-10-2099 shortened QT interval and a prolonged PR interval. Cardiac monitoring is essential for |x. of peers have answered correctly Time Spent Last Updated this client. @ Additional Info TOI MUR eer leceiee) em sie) alot hy € Previous | > Nextrent v aan ee es) 223245 (Timed) (el) FP MARK FOR LATER The nurse is caring for a client diagnosed with multiple myeloma. The nurse reviews the client's lab values and notes a serum calcium level of 14 mg/dL. What is the priority action the nurse should take? 5 4 rcal Y © ANotify the physician [86%] : saat * © 8B. Document the finding [5%] x ‘ [ x ~ Absorbed in Gl system, excreted by kidneys © ©. Continue to monitor the patient [8%] = Important in bones, nerves, muscle, & coagulationfctotting tactore Regulated by PTH and vitamin D * © D.Remove the patient from the telemetry monitor [1%] = Has an inverse relationship with phosphorus ‘caueesil Neuromuscular ~ Excessive intake of clelum = Weakness Hyperparathyroiaism Facey een COE RTT oe revemionse ieee ~ Cancer ofthe bones = Bradyend = Immabilty ~Cyanwosie ~ Geep veln tnrombosis Neurological 86% ye 485 4 18-10-2022 | Treatment See nse Time Spent Last Updated Gastrointestinal answered correctly eae ee Decreaced peristalsis IV fluids - NS preferred - Loop curetics ae ee ee ~ Nausea & Vomiting Beha ~~ Constipation Cardiac monitoring ~eoberae ~p ArcherReview ———__ | Couses of a Book Jelly 2 Se ele | ® Close Follow us on FacebookArcherReview NCLEX - BOOK JELLY F MARK For LATER The nurse is caring for a client diagnosed with multiple myeloma. The nurse reviews the client's lab values and notes a serum calcium level of 14 mg/dL. What is the priority action the nurse should take? Y © A.Notify the physician X © B. Document the finding X © C.Continue to monitor the patient X © D. Remove the patient from the telemetry monitor © Omitted 86% 48 ee oe |~v of peers have answered correctly [86%] (5%) [8%] (1%) Correct Answer(s): A 4 18-10-2022 Last Updated Causes of Hypercalcemia "MD SPIED" Malignancy Diuretics Steroids P arathyroid (hyperparathyroidism) T mmobilization Endocrine (Addison's) D vitamin D archerreview.com Subject Lesson Leadership & Management Prioritization Client Need Topic Question Type Lab Values Analysis Client Need Area Reduction of Risk PotentialNrontacv aVaN ee es\o1e).@ FP MARK FOR LATER QID: 6418 4223245 (Timed) The nurse is caring for a patient with a jejunostomy tube receiving intermittent enteral feedings. Which intervention would be the highest priority to reduce the risk of aspiration for this patient? * © A-Flush tubing with 20 mL water after feeding is completed [796] * © 8B. Position patient in left-lying position after feedings. [8%] X © C.Assess blood glucose every 6 hours. 11%] Y © D.Place the patient in semi-Fowler's following feedings. [85%] @ Omitted Correct Answer(s): D 85% |x. of peers have answered correctly 27s Time Spent 12-07-2022 Last Updated IW mtcnetms Explanation Choice D is correct. The nurse should assist this patient to position in semi-Fowler's or to lay on the right side following feedings, as these positions will reduce the risk of leakage, gastric reflux, and aspiration. Choice A is incorrect. This action would not reduce the patient's risk of aspiration. The nurse should use 50-60mL to flush the remaining formula, maintain patency, and reduce the risk of bacterial growth from any formula still remaining in the tubing. Choice B is incorrect. Laying on the right side (not left) would support digestion/gastric emptying and reduce the risk of reflux and aspiration. Choice C is incorrect. The nurse should assess and record blood glucose levels every 6 hours during the initiation of continuous feedings until levels are maintained within the ordered range for a 24-hour period at the maximum flow rate. However, this patient is receiving intermittent feedings, and this action would not reduce the patient's risk of aspiration. NCSBN Client need: Topic: Physiological Integrity, Sub-topic: Pharmacological and Parenteral Therapies Client Need Area Basic Care and Comfort Subject Leadership & Management Lesson Prioritization Client Need Topic Nutrition and Oral Hydration Question Type Knowledge/ComprehensionNrontacv aVaN ee es\o1e).@ FP MARK FOR LATER QID: 8 4223245 (Timed) Correct Answer is: Call for help and stay with the patient. = Cover the wound with a sterile normal saline dressing. = Take vital signs and monitor for signs of shock. Prepare the patient for immediate surgery. = Document the incident. X Incorrect 41% |x. of peers have answered correctly 47s Time Spent © = 25-07-2022 Last Updated IW mtcnetms Explanation The priority of nursing action is to call for help but stay with the patient. The nurse should tell the person who responds to notify the surgeon immediately. This is a surgical emergency, therefore the surgeon must be notified STAT. After help has been called, the nurse needs to cover the wound with a sterile 0.9% sodium chloride dressing. This helps prevent infection and keep the protruding organ moist and hydrated before surgery. The nurse should instruct the patient not to strain or cough, and keep the client in low Fowler's position (no more than 20 degrees of bed elevation) with his/her knees flexed. This position relaxes abdominal muscles and reduces abdominal muscle tension. After this, the next nursing action is to check the patient's vital signs and monitor for shock while waiting for the health care providers. If signs of shock such as tachycardia and hypotension are note, this is a medical emergency, and the health care provider/rapid response team needs to be called to the bedside immediately. After taking vital signs, the nurse should begin preparing the patient for immediate surgery. Lastly, after the patient has been taken to surgery, the nurse needs to document the incident. Subject Leadership & Management Lesson Client Need Area Prioritization Reduction of Risk Potential Client Need Topic Potential for Complications from Surgical Procedures and Health Alterations Question Type ApplicationArcherReview NCLEX - BOOK JELLY F MARK For LATER Pore re ASS) Anurse receives laboratory results for several clients under her care. Which client result would the nurse report to the health care provider (HCP) immediately? X © A.Anelevated amylase result in a client diagnosed with acute pancreatitis [8%] X © 8. Anelevated white blood cell (WBC) countin a client with a septic leg 12% wound Y © ©.Aurinalysis positive for leukocytes and nitrites ina chemotherapy client [57%] X © D.Aserum glucose of 235 mg/dL in a client with type 1 diabetes mellitus [23%] © Omitted Correct Answer(s): C 25s | or” os have e+ 08-10-2022 Time Spent noi EI Last Updated answered correctly Explanation Choice € is correct. Chemotherapy agents place clients at increased risk of infection due to immune suppression of the medication(s), specifically by decreasing neutrophils. Neutropenia, a reduction in the blood neutrophil count, is common in chemotherapy clients. As the neutropenia increases, so does the client's risk (and severity of) bacterial and fungal infections. If a bacterial or fungal infection does occur, the likelihood of the infection spreading to other parts of the body increases. In a urinalysis, the presence of leukocytes and nitrites is indicative of a urinary tract infection. This result should indicate to the nurse that a urinary tract infection is present in this immunocompromised client, warranting the nurse to notify the HCP of the result so antibiotic therapy may be initiated immediately. Choice A Is incorrect. An elevated amylase result in a client diagnosed with acute pancreatitis is an anticipated finding and would not warrant reporting the result to the HCP. Choice B is incorrect. In a client diagnosed with a septic leg wound, an elevated white blood cell count (also known as leukocytosis) is an anticipated finding. Leukocytosis usually occurs in response to infection, trauma, or inflammation. Since this client is known to be septic, the leukocytosis is an anticipated finding and, therefore, does not warrant the nurse immediately reporting this lab result to the HCP. Choice D is incorrect. The client's serum glucose level of 235 mg/dL is above the normal range of 70-110 mg/dL, but this isa relatively common finding in clients with type | diabetes mellitus and does not necessitate immediate reporting to the HCP. @ Learning Objective Identify the chemotherapy client's urinalysis as the result which requires reporting to the health care provider due to the immunacompromised state of the client.ArcherReview NCLEX - BOOK JELLY F MARK For LATER 5 (Timed) Anurse receives laboratory results for several clients under her care. Which client result would the nurse report to the health care provider (HCP) immediately? X © A.Anelevated amylase result in a client diagnosed with acute pancreatitis (8%) X © B.Anelevated white blood cell (WBC) count in a client with a septic leg [12%] wound Y © .Aurinalysis positive for leukocytes and nitrites ina chemotherapy client [579%] X © D.Aserum glucose of 235 mg/dL ina client with type 1 diabetes mellitus [23%] © Omitted Correct Answer(s): C © 25s Time Spent bee 57% |x of peers have fel answered correctly 08-10-2022 Last Updated to the HCP. Choice D is incorrect. The client's serum glucose level of 235 mg/dL is above the normal range of 70-110 mg/dL, but this is a relatively common finding in clients with type | diabetes mellitus and does not necessitate immediate reporting to the HCP, @ Learning objective Identify the chemotherapy client's urinalysis as the result which requires reporting to the health care provider due to the immunacompromised state of the client. ® Additional info Neutropenia predisposes the client to bacterial and fungal infections The risk of infection is proportional to the severity of neutropenia, with clients with neutrophil counts < 500/meL (< 0.5 x 10°/L) at the most significant risk. Febrile neutropenic clients are typically treated with broad-spectrum antibiotics pending definitive identification of the infection. Antibiotic prophylaxis may be indicated for some high-risk clients. Subject Lesson Client Need Area Leadership & Management Prioritization Management of Care Client Need Topic Question Type Establishing Priorities AnalysisArcherReview NCLEX - BOOK JELLY F MARK For LATER Pore re AUS.) QID: 6909 The nurse has received the following prescriptions for newly admitted clients. The nurse should first X © Av irrigate a wound for a client with a stage Ill pressure ulcer. [2%] © B. complete pin care for a client with a halo fixation device. [4%] Y © C.administer diazepam for a client with delirium tremens (DTS). 173%) X © D. insert an indwelling urinary catheter for a client with retention [21%] © Omitted Correct Answer(s}: C 36s ee 27-07-2022 nv of peers hi Time Spent See Last Updated answered correctly Explanation Choice correct. Delirium tremens (DTs) is a severe form of alcohol withdrawal. This prescription should be implemented immediately as the risk of seizure activity is quite significant. Choices A, B, and D are incorrect. These prescriptions require quite a bit of time and are low priority compared to the client experiencing an acute threat of a seizure. The nurse must prioritize actions based on acuity and time necessary to complete each task. Activities related to discharge are low priority and any dressing changes are also a low priority. @ Additional info Delirium tremens (DTS) is the most severe form of alcohol withdrawal. Manifestations of DTs include disorientation, hyperthermia, psychomotor agitation, hypovolemia, hallucinations, hypertension, and seizure activity. To prevent seizure activity and mitigate agitation, benzodiazepines are commonly used. Maintenance dosing of benzodiazepines may be used along with PRN dosing for additional mitigation of symptoms. DTs occur within 48 to 96 hours following the last alcoholic drink Subject Leadership & Management Lesson Client Need Area Prioritization Management of Care Client Need Topic Establishing Priorities Question Type ApplicationNrontacv aVaN ee es\o1e).@ 4223245 (Timed) QID: 3513 FP MARK FOR LATER The nurse is about to lift a 350-pound patient using an electric lift attached to the bed and transfer him to a stretcher. What should be the priority nursing action? © A.Call for assistance from two staff members. [33%] Y © 8B. Make sure the client is correctly positioned in the lift priorto [4196] operating the lift. X © C.Slowly lift the client off the bed (0%) X © D.Make sure the stretcher is locked. [26%] © Omitted Correct Answer(s): B 236 Aue 25-07-2022 a -07- f peers hi Time Spent |v ofppeers have Last Updated answered correctly IW mtcnetms Explanation Choice B is correct. The safety of the client should take priority. The nurse must ensure that the client is safely secured and adequately attached to the lift. Incorrect positioning of the client in the lift’s sleeves might put the client at risk for falls. Choice A is incorrect. The lift can be handled by two people, the nurse plus one other staff; there is no need to call for two additional staff members. Moreover, the priority action is to ensure safety by securing the patient on the lift and ensuring proper positioning. Choices C and D are incorrect. The nurse should ensure that the stretcher is locked and then slowly lift the client. However, the priority action is to make sure the client is, correctly positioned. Subject Lesson Client Need Area Leadership & Management _Prioritization Safety & Infection Control Client Need Topic Question Type Safe Use of Equipment Knowledge/ComprehensionArcherReview NCLEX - BO FP MARK FOR LATER The nurse is caring for the following assigned patients. The nurse should prioritize follow-up with which patient first? X © A The patient repeatedly washing their hands (5%) X © B. The patient talking over others during group therapy [196] ¥ © .The patient yelling and shouting at other patients [8696] * © D.The patient voluntarily admitted and requesting discharge [8%] © Omitted Correct Answer(s): C 86% 345 12-07-2022 [x of peers have answered correctly Time Spent Last Updated Follow Explanation Choice C is correct. The patient yelling and shouting at other patients requires immediate intervention because this situation is hostile and requires the nurse to deescalate the situation before it intensifies. Under Maslow's Hierarchy of Needs framework, safety and security are how this question may be answered. Choices A, B, and D are incorrect. A patient repeatedly washing their hands is a feature of obsessive-compulsive disorder, and the nurse should not intervene unless the act is threatening the patient or others. Further, a patient talking over others in therapy will require intervention, but this is not the immediate need as it is not a hostile situation. Finally, voluntarily admitted patients might request discharge, but this is a low priority item compared to the patient yelling at others. Additional information: When prioritizing patient needs, focus on ensuring that physiological, safety, and security needs are met first. In this question, the patient's safety and security needs are prioritized over the other needs. Subject Lesson Client Need Area Leadership & Management —_ Prioritization Management of Care Client Need Topic Question Type Establishing Priorities ApplicationPeereacunad (ated sole) @[a tng ‘The nurse is caring for a patient with a percutaneous Explanation endoscopic gastrostomy tube, Prior to starting the scheduled bolus feeding, the nurse is unable to auscultate the patient's Choice Cis correct. According to current American Society for Parenteral and Enteral Nutrition ( ASPEN) guidelines for nutrition support, enteral nutrition bowel sounds and notes 80 mL gastric residual volume. Of the should not be stopped for a gastric residual volume (GRY) of less than 500 mL unless there are other signs of feeding intolerance. Signs/symptoms of following, which action would be the nurse's priority? feeding intolerance include nausea, vomiting, abdominal distention, constipation, and abdominal pain. If no bowel sounds are present, the nurse should . assess the patient's abdomen for changes from the baseline, such as tenderness or distension. If no changes from the baseline, the feeding bolus may be * © A.Notify physician (17%) administered as ordered sO aoe bolusemtrecnechrestaualyolerme ds iLO] Choice A is incorrect. Assessment data of the absence of bowel sounds and a gastric resiciual volume less than 200 mL would not warrant immediately notifying the physician. The nurse should first assess the signs of feeding intolerance. In the absence of signs of feeding intolerance, the feeding can be ~ © ©.Check for abdominal distension (51%) continued as long as the GAVis less than 500 mL. However, the providers should implement methods to reduce aspiration risk for the GRVs ranging from 200 % (© DiRépodition the patient in semb-rowier’s 2% to 500 mLs. Such measures include administering prokinetic agents such as metoclopramide and erythromycin ( to stimulate gastric motility), optimizing penal glucose control (hyperglycemia can delay gastric emptying), and using continuous rather than bolus feeding for high-risk patients. Choice B is incorrect. The absence of bowel sounds and a gastric residual volume less than 500 mL would not be a contraindication for administering scheduled feedings, but an additional assessment of the abdomen should first be performed and compared to the patient's baseline. In patients who are not critically ill, GRV should be checked every four haurs during the first 48 hours of gastric feeding and, after that, every six ta eight hours. © Omitted Correct Answer(s): C Choice D is incorrect. Prior to administering bolus feedings, the patient should be positioned with the head of the bed elevated (semi-Fowler's or high- Fowler's position) to reduce the risk of aspiration, but this intervention would not impact the gastric residual volume or the lack of bowel sounds. 51% Learning objective: Understand that the in the absence of signs of feeding intolerance, enteral feedings can be continued as long as the GRV is less than 500 ml. Signs 2as Ine peat gas 12-07-2022 of feeding intolerance such as emesis, abdominal distension, and tenderness must be assessed before calling the physician and/or before stopping the scheduled Time Spent answered Last Updated feeding. correctly NCSBN Client need: Topic: Physiological Integrity, Sub-topic: Reduction of Risk Potential Subject Lesson Client Need Area Leadership & Management Prioritization Basic Care and Comfort Client Need Topic Question Type Nutrition and Oral Hydration ApplicationArcherReview NCLEX - BOOK JELLY F MARK For LATER 5 (Timed) Co) ster) The nurse is reassessing her female patient diagnosed with appendicitis. At her last assessment, the patient expressed 8/10 pain but now states that she has no pain. The nurse did not administer any pain medication. What Is the priority nursing action? © A. Document the pain score and continue monitoring © 8. Check the WBC count © C.Notify the healthcare provider x £ xX xX CO D. Palpate McBurney’s point © Omitted 83% [Av of peers have answered correctly 31s Time Spent ed @ Close [6%] (2%) [83%] (9%) Correct Answer(s): C 14-10-2022 Last Updated OW us on Explanation Choice € is correct. The nurse should immediately notify the healthcare provider of this change in the patient's status. A sudden change of 8/10 pain to 0/10 pain in a patient diagnosed with appendicitis could indicate rupture, so the healthcare provider needs to be immediately notified. This sudden pain relief is usually followed by a gradual increase in pain once again and guarding in the right lower quadrant. A ruptured appendix may result in infection, peritonitis, and abscess. Tachycardia, tachypnea, fever, restlessness, and irritability may follow. Choice A Is incorrect. When a patient with appendicitis has sudden pain relief, it isa sign of a possible appendix rupture. Appendiceal rupture is a surgical emergency, and the patient must be taken to the operating room quickly. Without taking further action, it is inappropriate for the nurse to document just the pain score. Choice B Is incorrect. W8C count can be checked to look for signs of infection, such as leukocytosis; however, this is not the priority action. Sudden relief of pain is concerning for rupture of the appendix. The physician must be notified right away. Choice D is incorrect. The patient with appendicitis will likely have tenderness at McHurney's point, but this patient is already expressing a sudden relief of pain. She needs to be evaluated for possible rupture, so the nurse should immediately notify the healthcare provider. The provider may order CT imaging to confirm the diagnosis. @ Learning Objective Understand that sudden pain relief in a patient with acute appendicitis may suggest an appendiceal rupture. ) Additional info re aay 30C 178 A € Previous | > Nextesti ars Erte a eth @ Additional info ‘The nurse is reassessing hor female patient diagnosed vith appendicitis. At her last assessment, the patient expressed £/70 pain but now states that she has no pain. The nurse did not administer any pain medication. Whats the priority nursing action? X © A-Decument the pain score and continue monitoring om Append Pain XO Bicheckthe waC count pm wedi A postive MeBumey's son's ©. E Nott the heaincare provider team Begins as dull, steady eerste ware gene iG! baSeEEEieEENE oy periumbilical pain pols Gaon palenen ation oeaa the right lower quacrant. * Over 4-6 hours, pain progresses and localizes to Correct Answers): right lower quadrant (RLQ) MeBumey's Point of the way from the Uumnateus rome Asis, * Sudden relief of pain may oe indicate appendix rupture uss ol [xe of pects nave fey Pea {which can lead to peritonitis) D Fine Spent See FD ast Updatea Appendicitis Assessment: PAINS Pain ({RLQ) Arorexia T creased temperature & WECs Nausea S sans eaumey's Psoas) Subject Lesson Client Need Arce Leadership & Management Pracnization Physiclagis Acapeation Client Need Topic Question Type [Algerationsin Bacy Sysrem= AnalysisNrontacv aVaN ee es\o1e).@ FP MARK FOR LATER 4223245 (Timed) QID: 2382 Which of the following is a priority that must be considered and critically thought about by the nurse before referring a client to a healthcare setting or service external to their current healthcare setting? * © A The external healthcare setting’s or service's cultural values [25%] and beliefs. Y © B.The external healthcare setting's or service's admission [55%] criteria, © CG. The current healthcare facility's actual and potential census. [10%] X © D. The current healthcare facility's actual and potential case mix. [10%] © Omitted Correct Answer(s): B 55% 29s 3 ‘ ae ~v_ of peers have Time Spent [te AER Last Updated answered correctly Explanation Choice B is correct. The external healthcare setting's or service's admission criteria is the priority that must be considered and critically thought about by the nurse before referring a client to a healthcare setting or service external to their current healthcare setting. Choice A is incorrect. Although the external healthcare setting’s or service's cultural values and beliefs should be considered, it is not the priority that must be found and critically thought about by the nurse before referring a client to a healthcare setting or service external to their current healthcare setting. Choice C and D are incorrect. The current healthcare facility's actual and potential census is not a consideration that the nurse should think about before referring a client to a healthcare setting or service external to their current healthcare setting; it is the client's needs that must be considered. Client Need Area Management of Care Subject Lesson Leadership & Management —_ Prioritization Client Need Topic Referrals Question Type ApplicationNrontacv aVaN ee es\o1e).@ 4223245 (Timed) kelley eye FP MARK FOR LATER 56-year-old female client presents to the emergency department (ED) who Explanation reports dyspnea, fatigue, and indigestion. The nurse should take which priority action? Choice A is correct. Obtaining a 12-lead electrocardiogram is the priority as the client is exhibiting classic symptoms of acute coronary syndrome (ACS). Women over the age of ¥ © A Obtain a 12-4ead electrocardiogram [35%] 50 are ata higher risk of developing this potentially fatal syndrome. Women may exhibit X © _B. Provide supplemental nasal cannula oxygen [42%] manifestations other than substernal chest pain. The ECG will help determine if the client has a STEMI or an NSTEMI. * © C. Established intravenous (IV) access [5%] Choices B, C, and D are incorrect. Supplemental oxygen, establishing intravenous * © D.Auscultate lung sounds (1796) access, and a respiratory assessment will need to occur. However, they do not prioritize establishing the severity of the ACS as the ECG will determine if the client has a STEMI. Additionally, the client reported difficulty with breathing, which does not necessarily indicate that she is hypoxic. The standard of care is to obtain a 12-lead © Omitted Correct Answer(s): A electrocardiogram within ten minutes of symptom presentation. See 36% on 105 0 @ Additional info Time Spent Ly ofpeers have Last Updated anewered correctly Unstable ACS (STEMI) may present with typical and atypical clinical features. Typical clinical features of ACS include: Substernal chest pain with a gradual onset Pain that radiates to the arm or jaw. Chest pain that is not relieved with rest. Diaphoresis and pallor may be additional findings. Atypical clinical features of ACS include: IW mtcnetmsrer USN Agn (ole e004 |g 4223245 (Timed) Sea e (oly Zire FP MARK FOR LATER oO) &) @ Additional info A 56-year-old female client presents to the emergency department (ED) who reports dyspnea, fatigue, and indigestion. The nurse should take which priority Unstable ACS (STEMI) may present with typical and atypical clinical features. astont Typical clinical features of ACS include: ¥ © A Obtain a 12-Iead electrocardiogram [35%] Substernal chest pain with a gradual onset, X © 8B. Provide supplemental nasal cannula oxygen [42%] Rairithaltradiates:to tievartn oF, jaw. Chest pain that is not relieved with rest. * © © Established intravenous (IV) access 15%] Diaphoresis and pallor may be additional findings. * © D. Auscultate lung sounds 11796) Atypical clinical features of ACS include Nausea and vomiting Dyspnea © Omitted Correct Answer(s): A Significant fatigue Epigastric pain Atypical features are found in women and individuals with diabetes mellitus. 36% Individuals with diabetes mellitus have attenuated chest pain because of 26s ie ree px 14-09-2022 epee Time Spent Ae) St beets Tavs Last Updated i answered correctly Subject Lesson Client Need Area Leadership & Management _ Prioritization Physiological Adaptation Client Need Topic Question Type Illness Management Analysis DIC tee)Nrontacv aVaN ee es\o1e).@ FP MARK FOR LATER io] ey eee 4223245 (Timed) The registered nurse is on a shift in the emergency department of a pediatric hospital. There are four patients in the ED; which patient would the nurse see first? ¥ © A.At-month-old infant that is crying with retractions during [79%] inspiration. X © 8B. A5-year-old with pneumonia with 95% pulse oxygen saturation. [296] X © CA 10-year-old with diarrhea and vomiting with a potassium level [796] of 3.6 mEq/L. X © D.A 15-year-old diabetic with a blood glucose level of 190 mg/dL. [11%] © Omitted Correct Answer(s): A 9 27s pote 21-07-2022 ~’_ of peers have fl Time Spent ae Last Updated answered correctly IW mtcnetms Explanation Choice A is correct. The child with inspiratory retractions indicates respiratory distress in the child and should be assessed first. Choice B is incorrect. The child with pneumonia is stable. The nurse does not need to assess this patient urgently. Choice C is incorrect. The child still has an average potassium level even though he is having diarrhea and vomiting. The nurse does not need to assess this child first. Choice D is incorrect. A glucose level of 190 mg/dL is not threatening. The nurse does not need to assess this child first. Subject Lesson Client Need Area Leadership & Management _ Prioritization Management of Care Client Need Topic Question Type Establishing Priorities AnalysisNrontacv aVaN ee es\o1e).@ 4223245 (Timed) he] pe sud FP MARK FOR LATER Which potential nursing problem is the highest priority for a patient who is in the Explanation immediate postoperative stage? Choice C is correct. Patients are at risk of illness during the post-operative stage. Of the x © ARiskfor infection (11%) answer choices listed, this potential problem would be the highest priority and would X © B Risk for fluid volume deficit [5%] result in the most severe complications. Y O CRisk for hemorrhage 184%] Choice A is incorrect. This patient would be at risk for infection due to new surgical procedures, but this would not be as high of a priority as the risk for bleeding. * © D.Risk for altered body image [0%] Choice B is incorrect. This patient would be at risk for dehydration and fluid volume deficit due to blood loss and decreased oral intake, but this would not be as high of a priority as the risk for illness. © Omitted Correct Answer(s): C Choice D is incorrect. This patient may be at risk for altered body image due to this surgical procedure. Still, this psychosocial problem would not be as high of a priority as the physiological problem of risk for illness. 26s a h 21-07-2022 NCSBN Client Need Topic: Prioritization, Subtopic: Potential for complications from Time Spent [x of peers have Last Updated surgical procedures answered correctly Subject Lesson Client Need Area Leadership & Management Prioritization Reduction of Risk Potential Client Need Topic Question Type Potential for Complications Application from Surgical Procedures and Health Alterations IW mtcnetmsArcherReview NCLEX - BOOK JELLY F MARK For LATER Pore re ASS) QID: 8342 The emergency department (ED) nurse is caring for a group of clients following an industrial accident. It would be a priority for the nurse to follow up on the client who * © A-hasa fracture to the lower extremity and increasing pain X © Bis crying because they cannot locate their child. Y © Chas singed eyebrows and a hoarse voice. X © D.isdiabetic, and their insulin pump has been lost. © Omitted 76% 32s of peers have Time Spent LA ssnesniare correctly [14%] [2%] [76%] [8%] Correct Answer(s): C 24-08-2022 Last Updated Explanation Choice € is correct. Singed eyebrows and @ hoarse voice are suggestive of a smoke inhalation injury. Considering this is an airway concern, this client should be prioritized. Choices A, B, and D are incorrect. Pain is associated with a fracture and would be expected. This client will not be prioritized over a client who has sustained an insult to their airway. Additionally, the other two client situations of not being able to locate a child or insulin pump are not of immediate physiological concern. @ Additional info The emergent triage category implies that a condition exists that poses an immediate threat to life or limb. Conditions that should be triaged as emergent include: active hemorrhage, unstable vital signs. significant trauma, chest pain, and manifestations of a stroke. The urgent triage category indicates that the client should be treated quickly but that an immediate threat to life does not exist at the moment. Conditions that typically fall into the urgent category are those with a new onset of pneumonia (as long as. respiratory failure does not appear imminent), renal colic, abdominal pain, complex lacerations not associated with major hemorrhage, displaced fractures or dislocations, and temperature higher than 101°F (38.3°C) Those triaged as non-urgent can generally tolerate waiting several hours for health care services without a significant risk for dlinical deterioration. Conditions within this classification include clients with sprains and strains, simple fractures, general skin rashes, and uncomplicated urinary tract infections. Subject Lesson Client Need Area Leadership & Management Prioritization Physiological Adaptation Client Need Topic Question Type Medical Emergencies ApplicationArcherReview NCLEX - BOOK JELLY F MARK For LATER Pore Pe AUS.) Ql : 3907 The nurse has received word that their patient is leaving the postoperative unit and being transferred to the medical-surgical floor. Upon arrival, the nurse would be correct to perform which of the following priority actions? Y © A.Assess the patient for a patent airway. 174%] X © B. Check the patient's abdomen far bowel sounds. 2%] X © ©. Order laboratory draws to check hemoglobin levels. [1%] X © D. Compare preoperative vital signs with current vital signs. [23%] © Omitted Correct Answer(s): A 74% of peers have answered correctly 31s Time Spent 22-07-2022 Last Updated Explanation Choice A is correct. Upon receiving 2 patient from the post-operative unit, the priority action is to assess the patient for a patent airway and respiratory status. The nurse would be correct in performing this action immediately. By using ABC ( airway, breathing, circulation) prioritization strategy, one can answer these questions by first focusing on the airway options. Choice B is incorrect. While appropriate during the initial post-operative assessment, checking for bowel sounds is not the necessary action in this situation. Choice € Is incorrect. Ordering labs is a job for the primary health care provider. Tracking down labs and their associated results takes away prime time to assess the patient's airway, thus putting them at risk for respiratory complications. Choice D is incorrect. While vital signs should be taken and compared to the preoperative measurements, this should be performed after the patient's airway status has been established. Counting respiratory rate alone does not give information regarding impending airway obstruction or respiration pattern. NCSBN client need Topic: Reduction of Risk Potential: Potential far Complications for Surgical Procedures and Health Alterations Subject Lesson Client Need Area Leadership & Management Prioritization Reduction of Risk Potential Client Need Topic Question Type Potential for Complications from Application Surgical Procedures and Health AlterationsArcherReview NCLEX - BOOK JELLY 4223245 (Timed) (elp ey 4 color codes are the highest priority for medical and nursing care? See exhibit. A. The yellow color code B. The green color code G The red color code x KR oooo D. The black color code © Omitted 97% of peers have answered correctly ~ 36s ) Time Spent (1% 1%] 196%] ca) Correct Answer(s): C Last Updated Explanation Choice C is correct. Clients designated with a red triage color code have been deemed to possess one or more serious, life- threatening injuries. Therefore, this group of clients is the highest priority for medical and nursing care Choice A is incorrect. Clients designated with a yellow triage color code have been deemed to possess injuries that are not life-threatening, This group of clients is not the highest priority for medical or nursing care. Choice B is incorrect. Clients designated with a green triage color code have been deemed to possess only minor injuries. This group of clients is not high priority for medical or nursing care. Choice Dis incorrect. Clients designated with a black triage color code have been deemed to have suffered significant, Injuries to the point that death is inevitable and will occur shortly. Here, staff will provide palliative pain medication as the only intervention until expiration. No other resources are provided. @ Learning Objective Recognize that in a mass casualty situation, you have limited resources and cannot utilize those resources on clients whose expiration is impending. @ Additional info This color coding is similar to a triage you would see in a mass casualty situation. The Colors of Triage LS Re Ua ed