Prioritizing Client Care: NCLEX Practice Test-2

Rationale:

• A client with a scheduled routine check-up: While routine check-ups are important for preventive care, they are not as urgent as addressing acute symptoms.
• A client with a fever and productive cough: This client should be seen first because a fever and productive cough can indicate an infectious process or other serious underlying condition that requires immediate evaluation and treatment to prevent the worsening of symptoms and spreading of illness.
• A client who needs assistance with completing paperwork: While assisting clients with paperwork is important, it is not as urgent as addressing acute symptoms.
• A client who wants to discuss smoking cessation strategies: While smoking cessation is important for overall health, it is not as urgent as addressing acute symptoms.

Therefore, a client with a fever and productive cough should be the nurse's top priority in a community health center.

Rationale:

• A premature infant with respiratory distress syndrome requiring surfactant replacement therapy: This client should be prioritized as respiratory distress syndrome in premature infants can quickly progress to respiratory failure, and surfactant replacement therapy is essential for improving lung function and preventing complications.
• A term infant with jaundice awaiting phototherapy: While jaundice in a term infant may require intervention, it is not as urgent as addressing respiratory distress syndrome in a premature infant.
• An infant with congenital heart disease needing preoperative evaluation: While preoperative evaluation for congenital heart disease is important, it is not as urgent as addressing respiratory distress in a premature infant.
• An infant with a feeding tube requiring formula supplementation: While ensuring adequate nutrition is important, it is not as urgent as addressing respiratory distress in a premature infant.

Therefore, the premature infant with respiratory distress syndrome requiring surfactant replacement therapy should be the nurse's top priority in a neonatal intensive care unit (NICU).

Rationale:

• A client with a history of diabetes requesting dietary counseling: While important for diabetes management, dietary counseling is not as urgent as addressing acute symptoms like shortness of breath and chest pain.
• A client with shortness of breath and chest pain: This client should be prioritized because these symptoms can indicate a potentially life-threatening condition such as a myocardial infarction (heart attack) or pulmonary embolism. Immediate assessment and intervention are crucial to prevent severe outcomes.
• A client who needs assistance with bathing: While assistance with activities of daily living is important for patient comfort, it is not as urgent as addressing acute symptoms.
• A client who is awaiting discharge instructions: Discharge planning is important but can be addressed after immediate care needs are met.

Therefore, the client with shortness of breath and chest pain should be the nurse's top priority.

Rationale:

• A client with dementia wandering in the hallway: While wandering behavior in clients with dementia requires attention, addressing a urinary tract infection needing antibiotics is more urgent to prevent complications such as sepsis or worsening of the infection.
• A client with a urinary tract infection needing antibiotics: This client should be prioritized because urinary tract infections can lead to serious complications in the elderly, and timely administration of antibiotics is necessary to prevent progression and alleviate symptoms.
• A client with osteoarthritis requesting pain medication: While pain management is important for clients with osteoarthritis, it is not as urgent as addressing a urinary tract infection.
• A client with controlled hypertension needing blood pressure monitoring: While blood pressure monitoring is important for clients with hypertension, it is not as urgent as addressing a urinary tract infection.

Therefore, the client with a urinary tract infection needing antibiotics should be the nurse's top priority in a geriatric unit.

Rationale:

• A client post-chemotherapy infusion with nausea and vomiting: This client should be prioritized because nausea and vomiting following chemotherapy infusion can indicate chemotherapy-induced nausea and vomiting (CINV), which requires prompt assessment and intervention to alleviate symptoms and prevent dehydration.
• A client with controlled pain requesting pain medication: While addressing pain management is important, it is not as urgent as addressing potential complications of chemotherapy, such as CINV.
• A client with a history of hypertension needing blood pressure monitoring: While blood pressure monitoring is important for clients with hypertension, it is not as urgent as addressing symptoms related to chemotherapy.
• A client with a fever of unknown origin awaiting diagnostic workup: While a fever of unknown origin requires investigation, addressing symptoms related to chemotherapy takes precedence due to the potential for serious complications such as dehydration and electrolyte imbalances.

Therefore, the client's post-chemotherapy infusion with nausea and vomiting should be the nurse's top priority in an oncology unit.

Rationale:

• Unstable angina represents an acute coronary syndrome and is considered a medical emergency due to the increased risk of myocardial infarction. Therefore, a client with unstable angina requires immediate attention and intervention to prevent further cardiac complications. Atrial fibrillation, while also significant, may not be as immediately life-threatening as unstable angina. Hence, in a cardiovascular ICU, the nurse should prioritize the client with unstable angina over the client with atrial fibrillation.

Rationale:

• A client receiving chemotherapy who needs pain medication: Pain management is crucial, especially for clients undergoing chemotherapy, as they may experience pain due to the treatment's side effects or underlying conditions. Addressing pain promptly ensures the client's comfort and well-being during treatment.
• A client with controlled hypertension requesting dietary advice: While dietary advice is important for managing hypertension, it is not as urgent as addressing pain in a client undergoing chemotherapy.
• A client who needs assistance with arranging transportation for follow-up appointments: While arranging transportation is important for continuity of care, it is not as urgent as addressing pain management.
• A client with a headache: While a headache should be assessed, it is not as urgent as ensuring pain relief for a client undergoing chemotherapy.

Therefore, the client receiving chemotherapy who needs pain medication should be the nurse's top priority in an oncology unit.

Rationale:

• A client with full-thickness burns covering 30% of the body surface area requiring debridement: This client should be prioritized as full-thickness burns covering a significant body surface area requires immediate intervention to prevent complications such as infection and impaired wound healing.
• A client with partial-thickness burns on the hands needing dressing changes: While dressing changes for partial-thickness burns are important, they are not as urgent as addressing full-thickness burns requiring debridement.
• A client with superficial burns on the face requesting pain medication: While pain management for superficial burns is necessary, it is not as urgent as addressing full-thickness burns requiring debridement.
• A client with sunburn needing topical application of aloe vera gel: While providing comfort measures for sunburn is important, it is not as urgent as addressing full-thickness burns requiring debridement.

Therefore, the client with full-thickness burns covering 30% of the body surface area requiring debridement should be the nurse's top priority in a burn unit.

Rationale:

In a respiratory unit, the nurse should prioritize clients who are experiencing acute or potentially life-threatening conditions that require immediate intervention. The clients who should be prioritized for immediate intervention are:

• A client with asthma unrelieved by inhaler: This client is experiencing an asthma exacerbation that is not responding to initial treatment, which can lead to severe respiratory distress or failure. Immediate intervention is necessary to control the asthma attack and improve breathing.
• A client with pneumonia and a respiratory rate of 30: This client is experiencing tachypnea, which can indicate respiratory distress or inadequate oxygenation. Immediate intervention is necessary to manage the underlying infection and ensure adequate breathing and oxygenation.
• A client with pulmonary edema and pink frothy sputum: This is a classic sign of acute pulmonary edema, which can be life-threatening. Immediate intervention is required to manage the fluid overload, improve oxygenation, and support breathing.

These clients present with conditions that could rapidly deteriorate and lead to severe complications or death without prompt intervention.

The other clients, while they need monitoring and ongoing care, do not present with conditions that require immediate intervention:

• A client with COPD with an oxygen saturation of 92%: While this client's oxygen saturation is slightly low, it is generally acceptable for a COPD patient and does not require immediate intervention compared to more acute situations.
• A client with a stable tracheostomy: This client is stable and does not require immediate intervention unless there are changes in their status or complications arise.
• A client with mild dyspnea on exertion: This client has a relatively minor issue that does not require immediate intervention compared to those with more acute and severe symptoms.

Rationale:

In a post-anesthesia care unit (PACU), the nurse should prioritize clients who are experiencing acute or potentially life-threatening conditions that require immediate intervention. The clients who should be prioritized for immediate care are:

• A client with a respiratory rate of 8 breaths per minute: A respiratory rate of 8 breaths per minute is significantly below the normal range and may indicate respiratory depression or airway obstruction. Immediate intervention is required to assess and address the cause of hypoventilation to prevent respiratory failure.
• A client with excessive bleeding from the surgical site: Excessive bleeding can lead to hypovolemic shock and requires immediate intervention to control bleeding and stabilize the client's condition.
• A client with an oxygen saturation of 85%: Oxygen saturation of 85% is below the normal range and indicates hypoxemia. Immediate intervention is necessary to improve oxygenation and prevent complications of hypoxia.

These clients present with conditions that could rapidly deteriorate and lead to severe complications or death without prompt intervention.

The other clients, while they need monitoring and ongoing care, do not present with conditions that require immediate intervention:

• A client with a blood pressure of 90/50 mmHg post-surgery: While low blood pressure may require monitoring and assessment for potential hypotension, it does not necessarily require immediate intervention unless the client is symptomatic or showing signs of shock.
• A client with stable vital signs post-surgery: A client with stable vital signs does not require immediate intervention unless there are other concerning factors present.
• A client complaining of mild nausea: Mild nausea is a common postoperative symptom and may not require immediate intervention unless it progresses or is associated with other symptoms indicating a more serious complication.

Rationale:

• The severity of burns is determined not only by the percentage of body surface area affected but also by the depth of the burn and the presence of associated complications. Full-thickness burns, even if covering a smaller percentage of the body surface area, are considered more severe than partial-thickness burns due to the involvement of deeper layers of tissue. Therefore, a client with full-thickness burns covering 10% of the body surface area would likely require more immediate and intensive intervention compared to a client with partial-thickness burns covering 20% of the body surface area.

Rationale:

• A client with second-degree burns to the lower extremities: This client should be prioritized as second-degree burns can lead to complications such as infection and impaired wound healing, especially when located on the lower extremities where mobility can be affected. Prompt assessment and management are necessary to prevent complications and promote healing.
• A client with a history of diabetes requesting blood sugar monitoring: While blood sugar monitoring is important for clients with diabetes, it is not as urgent as addressing the acute needs of a client with second-degree burns.
• A client with a minor burn on the hand needing wound care: While wound care is necessary, it is not as urgent as attending to a client with more severe burns.
• A client with a sunburn requesting pain medication: Sunburns, while painful, are typically not as serious as second-degree burns and can usually be managed with over-the-counter pain medication and topical treatments.

Therefore, the client with second-degree burns to the lower extremities should be the nurse's top priority in a burn unit.

Rationale:

• A client with a history of diabetes requesting a prescription refill: While medication management is important, it is not as urgent as addressing acute symptoms like fever and cough.
• A client with a fever and cough: This client should be seen first because fever and cough can indicate an infectious process, possibly requiring immediate evaluation and treatment to prevent the spreading of the illness and worsening of symptoms.
• A client who needs help with scheduling a follow-up appointment: While follow-up appointments are important for continuity of care, they are not as urgent as addressing acute symptoms.
• A client who wants to discuss weight loss options: While weight loss discussions are important for overall health, they are not as urgent as addressing acute symptoms.

Therefore, the client with a fever and cough should be the nurse's top priority.

Rationale:

• A client requesting assistance with breastfeeding techniques: While breastfeeding support is important, addressing postpartum hemorrhage takes precedence due to the potential for serious complications such as hypovolemic shock.
• A client with a history of gestational diabetes needing blood sugar monitoring: While blood sugar monitoring is important for clients with gestational diabetes, it is not as urgent as addressing postpartum hemorrhage.
• A client with a scheduled discharge requiring medication reconciliation: While medication reconciliation is important for safe discharge, it is not as urgent as addressing postpartum hemorrhage.
• A client with postpartum hemorrhage requiring assessment and intervention: This client should be prioritized because postpartum hemorrhage can lead to significant maternal morbidity and mortality if not promptly addressed with appropriate assessment and intervention.

Therefore, the client with postpartum hemorrhage requiring assessment and intervention should be the nurse's top priority in a postpartum unit.

Rationale:

• A client who needs assistance with feeding: While important for the client’s nutrition and well-being, this is a routine task that is not immediately life-threatening.
• A client who wants help with grooming: Grooming assistance is important for dignity and hygiene but is not an urgent need.
• A client who requires a medication refill: While ensuring medications are refilled is important, it generally does not require immediate attention unless the medication is critically time-sensitive.
• A client who is experiencing sudden confusion and agitation: This client should be prioritized because sudden changes in mental status can be indicative of a serious underlying condition such as delirium, infection (like a urinary tract infection or sepsis), hypoxia, or other medical emergencies that require immediate assessment and intervention.

Therefore, the client experiencing sudden confusion and agitation should be the nurse's top priority.

Rationale:

In a neonatal intensive care unit (NICU), the nurse should prioritize clients who are experiencing acute or potentially life-threatening conditions that require immediate intervention. The clients who should be prioritized for immediate care are:

• A preterm infant with apnea and bradycardia: Apnea (cessation of breathing) and bradycardia (slow heart rate) in preterm infants can lead to severe hypoxia and other complications. Immediate intervention is critical to ensure adequate oxygenation and prevent further complications.
• A newborn with severe retractions and grunting: These are signs of respiratory distress, which can be life-threatening if not promptly addressed. Severe retractions and grunting indicate that the newborn is struggling to breathe and requires immediate respiratory support.

These clients present with conditions that could rapidly deteriorate and lead to severe complications or death without prompt intervention.

The other clients, while they may need monitoring and ongoing care, do not present with conditions that require immediate intervention:

• A preterm infant with a temperature of 97.0°F (36.1°C): While this temperature is slightly low, it is not immediately life-threatening and can be managed with appropriate warming measures.
• A term infant with jaundice: Jaundice is a common condition in newborns that usually requires monitoring and treatment, but it is not typically an immediate life-threatening emergency unless the bilirubin levels are extremely high.
• A neonate with a feeding tube in place: This is a stable situation where the feeding tube is providing necessary nutrition. Monitoring is important, but it does not require immediate intervention.
• A neonate awaiting a hearing test: This is a routine screening procedure and does not indicate an immediate health concern.

In the trauma unit, the nurse should prioritize clients who are experiencing potentially life-threatening or severe conditions that require immediate assessment and intervention. The clients who should be prioritized for immediate assessment and intervention are:

• A client with a suspected spinal cord injury: This client is at risk for severe complications such as paralysis, neurogenic shock, or respiratory compromise. Immediate assessment and stabilization are crucial.
• A client with a fractured femur and pallor: This client may be experiencing significant blood loss or developing compartment syndrome, both of which can be life-threatening. Immediate intervention is required to assess and manage the potential for hemorrhage or vascular compromise.
• A client with a decreased level of consciousness after a head injury: This client may have a traumatic brain injury, which can lead to increased intracranial pressure or other critical conditions. Immediate evaluation and intervention are essential to prevent further deterioration.

These clients present with conditions that could quickly deteriorate and lead to severe complications or death without prompt intervention.

The other clients, while they may need medical attention, do not present with conditions that require immediate intervention:

• A client with a minor laceration on the forehead: This is a relatively minor injury that can be addressed after more critical conditions are managed.
• A client with bruising and abrasions: These injuries, while potentially painful, are not immediately life-threatening and can be treated after more urgent cases are addressed.
• A client with a sprained ankle: This is a minor injury that does not require immediate intervention compared to the more critical conditions listed above.

Rationale:

• A client with controlled hypertension requesting a prescription refill: While medication management is important, it is not as urgent as addressing acute symptoms like fever and diarrhea.
• A client with a fever and diarrhea: This client should be seen first because fever and diarrhea can indicate an infectious process or other serious underlying condition that requires immediate evaluation and treatment to prevent dehydration, complications, and spreading of illness.
• A client who needs help scheduling an appointment for a routine check-up: While routine check-ups are important for preventive care, they are not as urgent as addressing acute symptoms.
• A client who wants to discuss stress management techniques: While stress management is important for overall well-being, it is not as urgent as addressing acute symptoms.

Therefore, the client with a fever and diarrhea should be the nurse's top priority.

Rationale:

• A client receiving a blood transfusion with a slight temperature elevation: While monitoring for signs of transfusion reaction is important, a slight temperature elevation alone may not warrant immediate attention compared to the sudden onset of chest pain.
• A client with a central line and sudden onset of chest pain: This client should be seen first because sudden onset of chest pain in a client with a central line raises concerns for potential complications such as catheter-related bloodstream infection, thrombosis, or pneumothorax, which require immediate assessment and intervention.
• A client postoperative day 1 after open-heart surgery needing ambulation: While early ambulation is important for postoperative recovery, it is not as urgent as addressing sudden onset of chest pain.
• A client with chronic obstructive pulmonary disease (COPD) requesting bronchodilators: While addressing COPD exacerbations is important, sudden onset of chest pain in a client with a central line takes precedence.

Therefore, the client with a central line and sudden onset of chest pain should be the nurse's top priority in a critical care unit.

Rationale:

In a cardiac ICU, the nurse should prioritize clients who are experiencing acute or potentially life-threatening conditions that require immediate intervention. The clients who should be prioritized for immediate intervention are:

• A client with a new onset of atrial fibrillation with rapid ventricular response: This condition can lead to hemodynamic instability and increase the risk of thromboembolism. Rapid intervention is needed to control the heart rate and prevent complications.
• A client post-MI with a BP of 90/60 mmHg: This client is hypotensive, which could indicate cardiogenic shock, ongoing ischemia, or other complications. The client needs immediate assessment and intervention to stabilize.
• A client with chest pain unrelieved by nitroglycerin: This suggests that the client may be experiencing ongoing myocardial ischemia or a potential myocardial infarction that is not being adequately managed with current treatment. Immediate intervention is required to prevent further cardiac damage.

These clients present with symptoms and conditions that could quickly deteriorate and lead to severe complications or death without prompt intervention.

The other clients, while they may need close monitoring and ongoing care, do not present with conditions that require immediate intervention:

• A client with stable angina on telemetry: This client is currently stable and does not require immediate intervention unless there is a change in their condition.
• A client with controlled hypertension: This client is stable with managed hypertension and does not require urgent intervention.
• A client scheduled for a routine echocardiogram: This client is scheduled for a diagnostic procedure and does not have an acute condition requiring immediate intervention.