Prioritizing Client Care: NCLEX Practice Test-2

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 patient suffering from acute respiratory distress syndrome (ARDS) necessitating mechanical ventilation: This client should be prioritized as ARDS is a life-threatening condition requiring immediate intervention with mechanical ventilation to support oxygenation.
• A client with asthma exacerbation requesting bronchodilators: While addressing asthma exacerbation is important, it is not as urgent as managing ARDS requiring mechanical ventilation.
• A client with pneumonia needing oxygen support: While oxygen support for pneumonia is necessary, it is not as urgent as managing ARDS requiring mechanical ventilation.
• A client with chronic obstructive pulmonary disease (COPD) requesting a refill on inhalers: While ensuring medication availability for COPD is important, it is not as urgent as managing ARDS requiring mechanical ventilation.

Therefore, a patient suffering from acute respiratory distress syndrome (ARDS) necessitating mechanical ventilation should be the nurse's top priority in a respiratory unit.

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.

Rationale:

In a neurology 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 a suspected stroke presenting with sudden-onset weakness: A suspected stroke is a medical emergency. Immediate assessment and intervention are crucial to initiate treatment (such as thrombolysis) and minimize potential brain damage.
• A client with new-onset aphasia: New-onset aphasia can indicate a stroke or other acute neurological event. Immediate assessment and intervention are necessary to determine the cause and begin appropriate treatment.
• A client with transient ischemic attack (TIA) symptoms: TIAs are often warning signs of an impending stroke. Immediate evaluation and intervention are needed to prevent a full-blown stroke and address underlying risk factors.

These clients present with conditions that could rapidly deteriorate and lead to severe complications or permanent damage 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 history of migraines: While painful and requiring management, migraines are generally not immediately life-threatening and do not require urgent intervention compared to acute stroke symptoms.
• A client with a stable chronic subdural hematoma: This client is stable and does not have an acute condition requiring immediate intervention unless there are changes in their status.
• A client with a minor head injury: While this client requires monitoring, a minor head injury does not require immediate intervention unless symptoms worsen or new concerning symptoms develop.

Rationale:

• A client with dementia exhibiting aggressive behavior toward staff: This client should be prioritized as aggressive behavior can pose a safety risk to both the client and staff and requires immediate intervention to prevent harm.
• A client with urinary incontinence requesting assistance with toileting: While assisting with toileting is important, it is not as urgent as addressing aggressive behavior.
• A client with osteoarthritis requesting pain medication: While pain management is important for client comfort, it is not as urgent as addressing aggressive behavior.
• 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 aggressive behavior.

Therefore, the client with dementia exhibiting aggressive behavior toward staff should be the nurse's top priority in a geriatric unit.

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 complaining of back pain rated 6/10: While this client is in significant pain and needs attention, it is not immediately life-threatening.
• A client reporting difficulty breathing and chest pain: This client should be seen first because these symptoms can indicate a potentially life-threatening condition such as a myocardial infarction (heart attack), pulmonary embolism, or severe respiratory distress. Immediate assessment and intervention are critical to prevent severe outcomes.
• A client with a urinary catheter needing to be emptied: Although this task is important for client comfort and infection prevention, it is not an urgent priority compared to a client with chest pain and difficulty breathing.
• A client requesting a snack: This is a low-priority task that can wait until more urgent needs are addressed.

Therefore, the client reporting difficulty breathing and chest pain should be the nurse's top priority.

Rationale:

• Acute exacerbations of chronic obstructive pulmonary disease (COPD) can rapidly deteriorate respiratory function and lead to life-threatening complications. Therefore, they often require urgent intervention, such as bronchodilator therapy, corticosteroids, and oxygen therapy, to stabilize the client's condition and improve breathing. Pneumonia, while serious, may not always require immediate intervention depending on its severity and the client's overall clinical status. In a respiratory unit, prioritizing the client with acute exacerbation of COPD ensures timely management to prevent respiratory failure and other complications.

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.

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 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:

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:

• 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.

Rationale:

• A client with a seizure disorder requesting assistance with ambulation: While assistance with ambulation is important for clients with mobility issues, addressing tremors in a client with Parkinson's disease takes precedence as it may indicate inadequate medication control and can significantly impact the client's quality of life.
• A client with a new diagnosis of multiple sclerosis needing education: While education for clients with new diagnoses is important, it is not as urgent as addressing tremors in a client with Parkinson's disease.
• A client with a headache rated 8/10 requesting pain medication: While pain management is important, it is not as urgent as addressing tremors in a client with Parkinson's disease.
• A client with Parkinson's disease experiencing tremors after medication dose: This client should be prioritized because tremors in Parkinson's disease can be distressing and may indicate a need for medication adjustment or additional interventions to manage symptoms effectively.

Therefore, the client with Parkinson's disease experiencing tremors after medication dose should be the nurse's top priority in a neurology unit.

Rationale:

• A client post-cardiac surgery with a blood pressure of 110/70 mmHg: While monitoring blood pressure post-cardiac surgery is important, it is not as urgent as managing a client in septic shock requiring vasopressors.
• A client with septic shock requiring vasopressors: This client should be prioritized because septic shock is a life-threatening condition that requires immediate intervention to stabilize blood pressure and prevent organ failure.
• A client with a history of atrial fibrillation requiring telemetry monitoring: While telemetry monitoring is important for clients with cardiac arrhythmias, it is not as urgent as managing a client in septic shock.
• A client post-abdominal surgery with controlled pain: While pain management is important for post-operative recovery, it is not as urgent as managing a client in septic shock.

Therefore, the client with septic shock requiring vasopressors should be the nurse's top priority in the ICU.

Rationale:

• A client with diabetes who needs insulin: While timely administration of insulin is important, this situation is not immediately life-threatening.
• A client who just returned from surgery and needs pain medication: Postoperative pain management is essential for comfort and recovery, but it is not as immediately critical as a respiratory issue.
• A client who needs assistance with ambulation to the bathroom: This is a routine care task and does not present an immediate risk to the client.
• A client with a history of asthma complaining of shortness of breath: This client should be prioritized because shortness of breath in an asthmatic patient can indicate a potentially life-threatening asthma exacerbation. Immediate assessment and intervention are required to ensure the client's airway and breathing are maintained.

Therefore, the client with a history of asthma complaining of shortness of breath should be the nurse's top priority.

Rationale:

• In a neonatal intensive care unit (NICU), the prioritization of care is based on the severity and acuity of the conditions. Respiratory distress syndrome (RDS) in a preterm infant can lead to severe respiratory compromise and requires immediate intervention to support lung function and oxygenation. Hyperbilirubinemia in a term infant, while significant, may not pose an immediate threat to life or organ function. Therefore, the preterm infant with RDS would be prioritized over the term infant with hyperbilirubinemia in the NICU.

Rationale:

• A client with postpartum hemorrhage requiring uterine massage and assessment: This client should be prioritized as postpartum hemorrhage is a potentially life-threatening complication that requires immediate intervention to prevent further bleeding and stabilize the client's condition.
• A client requesting assistance with breastfeeding techniques: While assisting with breastfeeding techniques is important for maternal-infant bonding and breastfeeding success, it is not as urgent as addressing postpartum hemorrhage.
• 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 scheduled discharge requiring medication reconciliation: While medication reconciliation is necessary for safe discharge, it is not as urgent as addressing postpartum hemorrhage.

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

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 client with diabetes complaining of blurred vision: This client should be assessed first as blurred vision in a diabetic client may indicate hyperglycemia or other serious complications such as diabetic retinopathy, which require immediate attention to prevent further deterioration.
• A client postoperative day 1 after bowel resection needing ambulation: While ambulation is important for postoperative recovery, it is not as urgent as addressing potential complications related to diabetes.
• A client with controlled hypertension requesting dietary advice: While dietary advice is important for managing hypertension, it is not as urgent as addressing potential complications related to diabetes.
• A client with a urinary tract infection needing antibiotic administration: While urinary tract infections require timely treatment, addressing blurred vision in a diabetic client takes precedence due to the potential for vision loss and other serious complications.

Therefore, the nurse should assess the client with diabetes complaining of blurred vision first in a medical-surgical unit.