Prioritizing Client Care: NCLEX Practice Test-2

Rationale:

• A client who needs assistance with mobility exercises: While important for rehabilitation, mobility exercises are not as immediately critical as ensuring proper medication administration for a client with diabetes.
• A client who requests a snack: While addressing nutritional needs is important, it is not as urgent as ensuring medication administration for a client with diabetes.
• A client who wants to discuss financial planning: While addressing financial concerns may be important for the client's overall well-being, it is not as urgent as ensuring medication administration.
• A client with controlled diabetes who needs insulin administration: This client should be prioritized because timely insulin administration is crucial for managing blood sugar levels and preventing complications associated with diabetes.

Therefore, the client with controlled diabetes who needs insulin administration should be the nurse's top priority in a rehabilitation center.

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 with a minor laceration to the hand: This is a less urgent condition that can wait, as it is unlikely to be life-threatening.
• A client with chest pain and diaphoresis: This client should be assessed first because these symptoms are indicative of a possible myocardial infarction (heart attack) or other serious cardiac conditions. Immediate assessment and intervention are crucial to prevent severe outcomes.
• A client with an ankle fracture: While this client is in pain and needs medical attention, it is not as urgent as a potential cardiac emergency.
• A client with a severe headache: This condition can be serious, especially if it is indicative of a neurological issue like a hemorrhagic stroke or meningitis, but chest pain and diaphoresis take precedence due to the immediate risk of a life-threatening cardiac event.

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

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 preterm infant requiring phototherapy for jaundice: While phototherapy for jaundice is important for preterm infants, addressing bronchiolitis and the need for oxygen support takes precedence due to the potential for respiratory compromise and hypoxia.
• A newborn with stable vital signs awaiting discharge: While discharge planning is important for newborns, addressing bronchiolitis and the need for oxygen support in an infant is more urgent.
• An infant with bronchiolitis needing oxygen support: This client should be prioritized because bronchiolitis can cause respiratory distress and hypoxia, requiring immediate intervention to ensure adequate oxygenation and prevent complications.
• A neonate with a feeding tube in place requiring formula: While feeding is important for neonates, addressing respiratory distress in an infant takes precedence due to the potential for compromised oxygenation.

Therefore, the infant with bronchiolitis needing oxygen support should be the nurse's top priority in a neonatal intensive care unit (NICU).

Rationale:

• Uncontrolled hypertension poses immediate risks of cardiovascular complications such as heart attack, stroke, or organ damage. Urgent intervention, such as medication adjustment or initiation, is required to lower blood pressure and prevent these complications. On the other hand, while urinary retention can lead to discomfort and potential urinary tract complications, it is not typically considered an emergency unless it is associated with severe pain or complications like urinary tract infection or renal impairment. Therefore, in a medical-surgical unit, prioritizing the client with uncontrolled hypertension ensures timely intervention to mitigate immediate risks to health.

Rationale:

• A client with a compound fracture of the forearm awaiting reduction: While a compound fracture requires timely treatment, it is not as urgent as addressing altered mental status in a client with diabetes, which may indicate a life-threatening condition such as diabetic ketoacidosis or hypoglycemia.
• A client with diabetes presenting with altered mental status: This client should be prioritized because altered mental status in a diabetic patient can indicate a medical emergency requiring immediate assessment and intervention to stabilize blood sugar levels and prevent complications.
• A client with a minor laceration to the scalp requiring suturing: While suturing is necessary for wound closure, it is not as urgent as addressing altered mental status in a diabetic patient.
• A client with hypertension needing a refill on antihypertensive medication: While medication management is important, it is not as urgent as addressing altered mental status in a diabetic patient.

Therefore, the client with diabetes presenting with altered mental status should be the nurse's top priority in a busy emergency department.

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:

• intracranial hemorrhage, surgical evacuation: An intracranial hemorrhage can rapidly lead to increased intracranial pressure and brain herniation, making it a critical condition requiring immediate surgical intervention to prevent irreversible brain damage or death.
• seizure, antiepileptic therapy: While seizures need to be controlled promptly to prevent complications, they typically do not require the same level of immediate intervention as an intracranial hemorrhage.
• stroke, thrombolytic therapy: Thrombolytic therapy for an ischemic stroke is indeed time-sensitive, but the urgency is not as immediate as the need for surgical evacuation in a hemorrhagic stroke.
• meningitis, lumbar puncture: Meningitis requires prompt treatment, but the immediate threat to life is less severe compared to an intracranial hemorrhage needing surgical evacuation.

Thus, the nurse should prioritize the client with an intracranial hemorrhage requiring surgical evacuation due to the immediate risk to life and the potential for rapid deterioration.

Rationale:

• A client with a rash and itching: This is typically a non-urgent condition that can be addressed after more critical needs are met.
• A client with a urinary tract infection needing antibiotics: While timely administration of antibiotics is important, it is generally not immediately life-threatening compared to post-surgical complications.
• A client who needs assistance with repositioning: Repositioning is important for comfort and preventing pressure injuries, but it is not as urgent as assessing a post-surgical client.
• A client who just returned from surgery and needs pain assessment: This client should be prioritized because post-surgical patients are at risk for complications such as hemorrhage, infection, and severe pain. Immediate assessment is crucial to ensure their recovery is progressing safely and to address any complications early.

Therefore, the client who just returned from surgery and needs pain assessment should be the nurse's top priority.

Rationale:

• head injury, neurosurgical intervention: A head injury that requires neurosurgical intervention is a critical situation that needs immediate attention due to the potential for life-threatening complications such as increased intracranial pressure or bleeding.
• fracture, splinting: While fractures need prompt care, splinting can typically be managed after more life-threatening conditions are addressed.
• laceration, suturing: Suturing a laceration is important for wound care but is generally not as urgent as a severe head injury requiring neurosurgery.
• concussion, observation: Concussions require monitoring, but they do not typically require immediate intervention unless there are severe symptoms indicating a more serious injury.

Therefore, the nurse should prioritize the client with a head injury requiring immediate neurosurgical intervention due to the critical nature of the condition.

Rationale:

• A client postoperative day 1 after total hip replacement with signs of deep vein thrombosis (DVT): This client should be prioritized as signs of DVT following surgery require immediate assessment and intervention to prevent potential complications such as pulmonary embolism or further thrombus formation.
• A client with pain 7/10 requesting pain medication: While managing pain is important for client comfort, it is not as urgent as addressing signs of DVT post-surgery.
• A client with a history of osteoarthritis requesting dietary counseling: While dietary counseling may be beneficial for managing osteoarthritis, it is not as urgent as addressing signs of DVT post-surgery.
• A client with a fractured wrist awaiting cast application: While awaiting cast application is important for managing a fractured wrist, it is not as urgent as addressing signs of DVT post-surgery.

Therefore, the client postoperative day 1 after total hip replacement with signs of deep vein thrombosis (DVT) should be the nurse's top priority in an orthopedic 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 with a road accident having lacerations to the arm: While this client needs care, a laceration to the arm is generally not life-threatening and can wait unless there is severe bleeding.
• A client with a history of heart failure complaining of fatigue: This client should be seen first because fatigue in a client with a history of heart failure can indicate a worsening of their condition, such as decompensated heart failure, which requires immediate assessment and possible intervention to prevent serious complications.
• A client with a history of migraines requesting pain medication: This client needs pain relief but is not as urgent as a potential cardiac issue.
• A client with a fever of 101°F (38.3°C): While a fever needs attention, it is generally not as immediately critical as the potential for heart failure exacerbation.

Therefore, the client with a history of heart failure complaining of fatigue should be the nurse's top priority.

Rationale:

• acute respiratory distress syndrome (ARDS), mechanical ventilation: ARDS is a life-threatening condition that causes severe respiratory failure. Mechanical ventilation is critical to ensure adequate oxygenation and to prevent further respiratory compromise.
• chronic obstructive pulmonary disease (COPD), bronchodilator therapy: While bronchodilator therapy is important for managing COPD, it is generally not as immediately life-threatening as ARDS requiring mechanical ventilation.
• pneumonia, oxygen therapy: Oxygen therapy is crucial for pneumonia patients, especially those with significant hypoxia, but the need is not as urgent as mechanical ventilation for ARDS.
• asthma exacerbation, nebulizer treatment: Asthma exacerbations can be serious and require prompt nebulizer treatment, but ARDS with the need for mechanical ventilation presents a more immediate critical situation.

Therefore, the nurse should prioritize the client with ARDS requiring mechanical ventilation due to the acute and potentially life-threatening nature of the condition.

Rationale:

In a psychiatric 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 care are:

• A client with major depressive disorder expressing thoughts of self-harm: This client is at immediate risk for self-harm or suicide. Immediate intervention is necessary to ensure their safety and provide appropriate treatment.
• A client with bipolar disorder in a manic state: This client may exhibit impulsive, risky behaviors, agitation, or aggression, which can endanger themselves or others. Immediate intervention is needed to stabilize their mood and ensure safety.
• A client with a history of substance abuse and current withdrawal symptoms: Withdrawal can lead to severe and potentially life-threatening symptoms such as seizures, delirium tremens, or severe agitation. Immediate intervention is necessary to address withdrawal symptoms and prevent complications.

These clients present with conditions that could rapidly deteriorate and lead to severe complications or safety concerns 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 schizophrenia experiencing auditory hallucinations: While this client may need close monitoring and treatment, auditory hallucinations alone do not necessarily require immediate intervention unless they are commanding the client to harm themselves or others.
• A client with anxiety requesting to talk to the nurse: This client should be attended to, but their condition is not as urgent as those with immediate safety risks or severe withdrawal symptoms.
• A client with mild depression: This client requires ongoing support and treatment but does not have an immediate safety risk or severe symptoms requiring urgent intervention.

Rationale:

• A client with pain NRS 6/10 following orthopedic surgery: While pain management is important, hypoglycemic symptoms in a client with diabetes are more immediately life-threatening and require prompt intervention.
• A client with a history of diabetes exhibiting hypoglycemic symptoms: This client should be prioritized because hypoglycemia can lead to severe complications such as loss of consciousness or seizures if not promptly treated.
• A client with nausea and vomiting after general anesthesia: While nausea and vomiting are common after anesthesia, they are generally not as immediately life-threatening as hypoglycemic symptoms.
• A client with a surgical site infection needing wound care: While wound care is important for preventing complications, it is not as urgent as addressing hypoglycemic symptoms.

Therefore, the client with a history of diabetes exhibiting hypoglycemic symptoms should be the nurse's top priority in a post-anesthesia care unit (PACU).

Rationale:

• A client with chronic obstructive pulmonary disease (COPD) requesting a breathing treatment: While addressing COPD exacerbations is important, providing chest physiotherapy to a client with pneumonia is more urgent due to the risk of retained secretions and the potential for respiratory complications.
• A client with pneumonia needing chest physiotherapy: This client should be prioritized because chest physiotherapy helps to mobilize and clear secretions from the lungs, which is crucial for preventing pneumonia-related complications such as atelectasis and respiratory distress.
• A client with a history of asthma requesting a refill on inhalers: While ensuring adequate medication supply is important for managing asthma, it is not as urgent as providing chest physiotherapy to a client with pneumonia.
• A client with controlled hypertension experiencing nasal congestion: Nasal congestion in a client with controlled hypertension may indicate a minor respiratory issue or allergy but is not as urgent as providing chest physiotherapy to a client with pneumonia.

Therefore, the client with pneumonia needing chest physiotherapy should be the nurse's top priority in a respiratory unit.

Rationale:

• A client with aortic dissection requiring immediate surgical intervention: This client should be prioritized as aortic dissection is a life-threatening emergency that requires immediate surgical intervention to prevent further complications such as aortic rupture or organ ischemia.
• A client post-percutaneous coronary intervention (PCI) with controlled chest pain: While chest pain in a client post-PCI requires attention, it is not as urgent as addressing aortic dissection.
• A client with stable angina requesting nitroglycerin for chest discomfort: While addressing angina symptoms is important, it is not as urgent as managing aortic dissection.
• 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 aortic dissection.

Therefore, a client with aortic dissection requiring immediate surgical intervention should be the nurse's top priority in a cardiovascular ICU.

Rationale:

• A client who needs assistance with activities of daily living: While assistance with activities of daily living is important, it is not as urgent as addressing the safety of a client with suicidal ideation.
• A client with suicidal ideation: This client should be prioritized because suicidal ideation indicates a serious risk to the client's safety and requires immediate assessment and intervention to ensure their safety and prevent self-harm.
• A client with a history of migraines requesting pain medication: While pain management is important, it is not as urgent as addressing suicidal ideation.
• A client attending an art therapy session: While participation in therapy is important for the client's well-being, it is not as urgent as addressing a client's suicidal ideation.

Therefore, the client with suicidal ideation should be the nurse's top priority in a mental health facility.