Prioritizing Client Care: NCLEX Practice Test-2

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.

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 pneumonia and a respiratory rate of 32: 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 a tracheostomy and thick secretions: This client is at risk for airway obstruction due to the thick secretions. Immediate intervention is needed to clear the airway and prevent respiratory compromise.
• A client with asthma and wheezing unrelieved by medication: 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 required to control the asthma attack and improve 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 chronic obstructive pulmonary disease (COPD) on home oxygen: This client is likely stable on their home oxygen regimen and does not have an immediate change in condition requiring urgent intervention.
• A client with stable pulmonary fibrosis: This client is stable and does not require immediate intervention compared to those with acute respiratory issues.
• A client with a cough and cold symptoms: This is a relatively minor condition that does not require immediate intervention in a respiratory unit setting.

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 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 a history of myocardial infarction experiencing chest pain: This client should be prioritized as chest pain in someone with a history of myocardial infarction raises concerns for recurrent ischemia or myocardial infarction, requiring immediate assessment and intervention to prevent further cardiac damage.
• A client post-cardiac catheterization needing bed rest: While bed rest post-cardiac catheterization is important for preventing complications, addressing chest pain in a client with a history of myocardial infarction takes precedence.
• A client with controlled hypertension requesting discharge instructions: While discharge instructions are important for client education, they are not as urgent as addressing chest pain.
• A client with heart failure requesting a dietary consultation: While dietary consultation is important for managing heart failure, it is not as urgent as addressing chest pain in a client with a history of myocardial infarction.

Therefore, a client with a history of myocardial infarction experiencing chest pain should be the nurse's top priority in a cardiovascular unit.

Rationale:

• A child with a temperature of 100.5°F (38.1°C): While a fever is concerning and needs to be addressed, it is not immediately life-threatening.
• A child with a minor abrasion on the knee: This is a minor injury that can wait for more urgent issues to be addressed.
• A child with a history of asthma and difficulty breathing: This client should be assessed first because difficulty breathing in a child with a history of asthma can indicate an asthma exacerbation, which can be life-threatening if not promptly treated. Immediate assessment and intervention are critical to ensure the child's airway and breathing are maintained.
• A child with a sore throat: While this needs evaluation, it is generally not as urgent as a potential asthma exacerbation.

Therefore, a child with a history of asthma and difficulty breathing should be the nurse's top priority.

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 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:

• A client postoperative day 1 after bowel resection experiencing abdominal pain: This client should be prioritized as abdominal pain in a postoperative client could indicate complications such as infection, bleeding, or bowel obstruction, requiring immediate assessment and intervention.
• A client with diabetes requesting dietary counseling: While dietary counseling is important for managing diabetes, it is not as urgent as addressing postoperative pain.
• 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 postoperative pain.
• A client with a urinary tract infection requesting antibiotic administration: While antibiotic administration is necessary for treating urinary tract infections, it is not as urgent as addressing postoperative pain.

Therefore, the client's postoperative day 1 after bowel resection experiencing abdominal pain should be the nurse's top priority in a medical-surgical unit.

Rationale:

In a labor and delivery 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 in active labor with a non-reassuring fetal heart rate pattern: Non-reassuring fetal heart rate patterns can indicate fetal distress, requiring immediate assessment and possible intervention to ensure the safety of the fetus.
• A client with severe preeclampsia: Severe preeclampsia poses significant risks to both the mother and the fetus, including the risk of eclampsia, HELLP syndrome, and placental abruption. Immediate intervention is necessary to manage blood pressure and prevent complications.
• A client with a post-term pregnancy and decreased fetal movement: Decreased fetal movement in a post-term pregnancy can indicate fetal distress or other complications. Immediate assessment and intervention are required to ensure fetal well-being.

These clients present with conditions that could rapidly deteriorate and lead to severe complications for either the mother or the fetus 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 mild contractions and stable vital signs: This client is stable and does not require immediate intervention compared to those with more severe or acute conditions.
• A client with a history of cesarean section in early labor: This client requires monitoring, but if they are stable and not in active labor with signs of uterine rupture or other complications, they do not require immediate intervention.
• A client with mild lower back pain: This is a common discomfort in pregnancy and labor that does not require immediate intervention compared to those with critical conditions.

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:

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:

• A client with a minor head injury needing observation: While observation is important for clients with head injuries to monitor for signs of deterioration, addressing a fractured femur awaiting surgery takes precedence due to the risk of further injury or complications if not managed promptly.
• A client with a fractured femur awaiting surgery: This client should be prioritized because a fractured femur can cause significant pain and disability, and surgical intervention is often required to prevent additional damage and facilitate proper healing.
• A client with controlled pain requesting pain medication: While pain management is important, it is not as urgent as addressing the needs of a client with a fractured femur awaiting surgery.
• A client with a sprained ankle requesting ice packs: While providing comfort measures for a sprained ankle is necessary, it is not as urgent as addressing the needs of a client with a fractured femur awaiting surgery.

Therefore, the client with a fractured femur awaiting surgery should be the nurse's top priority in a trauma unit.

Rationale:

• A client who is requesting to speak with the psychiatrist: While this is important for the client’s care and treatment plan, it is not immediately critical.
• A client who needs assistance with activities of daily living: This is important for the client's well-being but is not as urgent as managing a potentially dangerous situation.
• A client who is exhibiting aggressive behavior toward others: This client should be prioritized because aggressive behavior can pose an immediate threat to the safety of the client, other clients, and staff. Immediate intervention is necessary to ensure the safety and stability of the environment.
• A client who refused to attend a group therapy session: While participation in therapy is important, this is not an urgent issue compared to managing aggressive behavior.

Therefore, the client who is exhibiting aggressive behavior toward others 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:

• 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:

• In the pediatric ICU, prioritization of care should be based on the acuity of the condition and the immediate needs of the patients. While a child with a congenital heart defect may have complex care needs, a child with acute respiratory distress syndrome (ARDS) requires immediate attention due to the potential for respiratory failure and other life-threatening complications. Therefore, the nurse should prioritize the child with ARDS over the child with a congenital heart defect in this scenario.

Rationale:

• A client with a sprained ankle: This is generally a less urgent condition compared to the others listed unless there are complications not mentioned (e.g., severe pain, compromised circulation).
• A client with a fever of 102°F (38.9°C): While a fever is a concern and needs to be addressed, it might not be immediately life-threatening compared to the potential urgency of a severe hypertension-related headache.
• A client with a history of hypertension complaining of severe headache: This client should be seen first because a headache in the context of hypertension could indicate a hypertensive crisis or other serious complications such as stroke or preeclampsia (if the client is pregnant). Immediate assessment and intervention might be necessary to prevent severe outcomes.
• A client requesting pain medication after surgery: Pain management is important, but it is generally not as urgent as the potential complications related to hypertension.

Thus, the client with a history of hypertension and a headache represents the highest priority due to the potential for severe complications.

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).