Prioritizing Client Care: NCLEX Practice Test-2

Rationale:

In a critical care 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 septic shock and hypotension: Septic shock is a life-threatening condition that requires immediate intervention to manage infection, restore blood pressure, and support organ function to prevent multi-organ failure.
• A client with an acute myocardial infarction: An acute myocardial infarction (heart attack) is a critical condition that requires immediate intervention to restore blood flow to the heart and prevent further cardiac damage or death.
• A client with acute pulmonary edema: Acute pulmonary edema can lead to severe respiratory distress and hypoxia. Immediate intervention is necessary to manage 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 stable chronic obstructive pulmonary disease (COPD): This client is stable and does not have an acute condition requiring immediate intervention.
• A client with a controlled seizure disorder: This client is stable with their condition under control and does not require immediate intervention compared to those with acute life-threatening conditions.
• A client with stable vital signs post-surgery: This client is stable and does not require immediate intervention compared to those with acute critical conditions.

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:

• 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:

• newborn, surfactant replacement therapy: While surfactant replacement therapy is critical for newborns with respiratory distress syndrome, it is typically more urgent in neonates rather than in a pediatric ICU setting where an adolescent with ARDS requiring mechanical ventilation would take precedence.
• toddler, bronchodilator therapy: Bronchodilator therapy is important for conditions like asthma, but it is less urgent than ARDS requiring mechanical ventilation.
• child, continuous positive airway pressure (CPAP): CPAP is significant for respiratory support, but mechanical ventilation in an adolescent with ARDS is more critical.
• adolescent, mechanical ventilation: Mechanical ventilation for ARDS is a high priority due to the severity of the condition and the immediate need for advanced respiratory support.

Thus, the client in most urgent need of prioritization is the adolescent requiring mechanical ventilation for ARDS.

Rationale:

• A neonate with hyperbilirubinemia requiring phototherapy: While hyperbilirubinemia requires monitoring and treatment, it is not as immediately life-threatening as dehydration from gastroenteritis.
• A toddler with gastroenteritis needing IV hydration: This client should be prioritized because gastroenteritis, especially in young children, can lead to rapid dehydration and electrolyte imbalances, which can be life-threatening if not promptly addressed.
• A school-aged child with a fractured arm awaiting cast application: While fracture management is important, it is not as urgent as addressing dehydration in a toddler with gastroenteritis.
• A teenager with asthma exacerbation requiring a nebulizer: While asthma exacerbation requires prompt treatment, it is not as immediately life-threatening as dehydration from gastroenteritis in a toddler.

Therefore, the toddler with gastroenteritis needing IV hydration should be the nurse's top priority in a pediatric ICU.

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:

• 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 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:

• 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 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:

• 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 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:

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:

• 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 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 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 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:

• Neutropenia, a condition characterized by abnormally low levels of neutrophils (a type of white blood cell), can significantly compromise the immune system, leaving the individual vulnerable to infections, including potentially life-threatening ones. Therefore, it requires immediate attention and intervention, such as administration of growth factors or antibiotics, to prevent or manage infections. Chemotherapy-induced nausea, while distressing, is generally manageable with antiemetic medications and supportive care. In an oncology unit, the priority would be to address the neutropenia to prevent serious complications before addressing symptoms like nausea.

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 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.