Prioritizing Client Care: NCLEX Practice Test-2

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 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:

• 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 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:

In an orthopedic 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 postoperative day 1 after total hip replacement with signs of DVT: Deep vein thrombosis (DVT) can lead to serious complications such as pulmonary embolism. Immediate intervention is necessary to assess and treat the DVT to prevent life-threatening complications.
• A client with a new onset of compartment syndrome symptoms: Compartment syndrome is a medical emergency that can lead to permanent muscle and nerve damage if not promptly treated. Immediate intervention is required to relieve the pressure and restore circulation.
• A client with a cast reporting severe pain and numbness: Severe pain and numbness in a client with a cast can indicate compartment syndrome or compromised circulation. Immediate assessment and intervention are crucial to prevent permanent damage.

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 stable femur fracture in traction: This client is stable and does not have an acute condition requiring immediate intervention.
• A client with controlled pain from a fractured arm: This client is stable with managed pain and does not require urgent intervention.
• A client with mild pain and swelling in the ankle: This client has a relatively minor issue that does not require immediate intervention compared to those with more acute and severe symptoms.

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 who needs assistance with bathing: While important for hygiene and comfort, assistance with bathing is not as urgent as addressing acute medical issues.
• A client who requires pain medication post-surgery: While pain management is important for post-operative recovery, it is not as urgent as treating an active infection.
• A client with controlled hypertension requesting dietary advice: While dietary advice is important for managing hypertension, it is not as urgent as treating an active infection.
• A patient presenting with a urinary tract infection: This client should be prioritized because urinary tract infections can lead to complications such as pyelonephritis or sepsis if not promptly treated. Immediate assessment and initiation of appropriate antibiotic therapy are necessary to prevent the spread of infection and alleviate discomfort.

Therefore, the client with a urinary tract infection should be the nurse's top priority in a medical-surgical unit.

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:

• anticoagulation therapy: Deep vein thrombosis (DVT) is a serious complication after orthopedic surgery, especially total hip replacement. Anticoagulation therapy is essential for preventing the progression of the thrombus and reducing the risk of pulmonary embolism.
• compression stockings: While compression stockings can aid in preventing DVT, they are not sufficient treatment for established DVT.
• ambulation: Ambulation is important for preventing DVT, but in this scenario, the client already has signs of DVT, indicating the need for immediate treatment rather than preventive measures.
• pain management: Pain management is important postoperatively, but it is not the priority when the client presents with signs of DVT, which requires urgent intervention to prevent complications.

Therefore, the nurse should prioritize care for the client postoperative day 1 after total hip replacement with signs of DVT requiring anticoagulation therapy to prevent further complications.

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:

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 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 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:

• 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 intracranial hemorrhage requiring urgent surgical intervention: This client should be prioritized as intracranial hemorrhage is a life-threatening condition requiring immediate surgical intervention to prevent further neurological damage.
• A client with epilepsy requesting a refill on antiepileptic medication: While medication management for epilepsy is important, it is not as urgent as addressing intracranial hemorrhage.
• A client with migraine headache requesting pain medication: While pain management for migraines is necessary, it is not as urgent as addressing intracranial hemorrhage.
• A client with a history of stroke needing speech therapy evaluation: While speech therapy evaluation is important for stroke rehabilitation, it is not as urgent as addressing intracranial hemorrhage.

Therefore, the client with intracranial hemorrhage requiring urgent surgical intervention should be the nurse's top priority in a neurological ICU.

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 who needs assistance with physical therapy: While physical therapy is important for rehabilitation, the need for pain management post-exercise takes precedence to ensure the client's comfort and ability to participate effectively in therapy.
• A client who requires pain medication post-exercise: This client should be prioritized to address their immediate need for pain relief, which is crucial for optimizing participation in therapy and promoting rehabilitation progress.
• A client who needs help with meal preparation: While assistance with activities of daily living is important, it is generally not as urgent as addressing pain management needs.
• A client who wants to talk about discharge planning: Discharge planning discussions are important but are typically addressed after immediate care needs have been met.

Therefore, the client who requires pain medication post-exercise should be the nurse's top priority, ensuring their comfort and ability to participate in rehabilitation activities effectively.

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.

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:

• 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.