Prioritizing Client Care: NCLEX Practice Test-2

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:

• 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 recovering from a minor surgical procedure: While postoperative monitoring is crucial for all patients, immediate attention is required for a patient with breathing difficulties and a history of asthma due to the potential for respiratory compromise.
• A client with difficulty breathing and a history of asthma: This client should be prioritized because difficulty breathing in a client with asthma can indicate an exacerbation or other serious respiratory issue requiring immediate intervention to prevent respiratory distress or failure.
• A client with controlled hypertension who needs discharge instructions: While discharge instructions are important, they are not as urgent as addressing acute respiratory distress.
• A client requesting water after surgery: While providing fluids after surgery is important for hydration, it is not as urgent as addressing acute respiratory symptoms.

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

Rationale:

• preterm infant, phototherapy: Phototherapy is a common treatment for mild to moderate jaundice in preterm infants but is not as critical as severe jaundice requiring an exchange transfusion.
• term infant, blood transfusion: While a blood transfusion can be critical in certain situations, it is not specifically the standard treatment for severe jaundice.
• newborn, vitamin K injection: Vitamin K injections are given to prevent bleeding disorders in newborns and are not a treatment for jaundice.
• premature infant, exchange transfusion: Exchange transfusion is a critical and life-saving procedure for treating severe jaundice, especially in premature infants, to prevent bilirubin encephalopathy.

Therefore, the nurse should prioritize the premature infant with severe jaundice requiring exchange transfusion due to the urgency and seriousness of the condition.

Rationale:

In the emergency department, clients should be prioritized based on the severity and potentially life-threatening nature of their conditions. According to the principles of triage, the nurse should prioritize clients who require immediate intervention to prevent significant harm or death. Given this, the clients who should be prioritized for immediate care are:

• A client with chest pain and diaphoresis: This client could be experiencing a myocardial infarction (heart attack) or another serious cardiac event. Chest pain accompanied by diaphoresis (sweating) is a red flag that warrants immediate evaluation and intervention.
• A client with shortness of breath and cyanosis: This client is showing signs of respiratory distress and hypoxia, which are potentially life-threatening conditions. Immediate assessment and treatment are crucial to ensure adequate oxygenation and to address the underlying cause.
• A client with severe abdominal pain: While the exact cause is not specified, severe abdominal pain can indicate serious conditions such as appendicitis, bowel obstruction, or a ruptured aneurysm, which require prompt evaluation and treatment.

These clients present with symptoms that could indicate serious, potentially life-threatening conditions and should be prioritized for immediate care. The other clients, while they may still require medical attention, do not exhibit symptoms that suggest immediate life-threatening conditions:

• A client with a mild headache: Typically not life-threatening and can often be managed with standard analgesics and further evaluation if necessary.
• A client with a broken arm and controlled pain: Although painful, a broken arm with controlled pain is generally not life-threatening and can be managed with proper splinting and analgesia.
• A client with a small laceration on the hand: This is typically a minor injury that can be managed with cleaning, suturing, or bandaging and is not immediately life-threatening.

Rationale:

• A client postoperative day 1 after appendectomy with signs of infection: This client should be prioritized as signs of infection following surgery require immediate assessment and intervention to prevent further complications.
• A client with a history of heart disease complaining of chest discomfort: While chest discomfort in a client with a history of heart disease is concerning, it is not as urgent as addressing signs of infection post-surgery.
• A client with a surgical wound infection needing wound care: While wound care for a surgical wound infection is important, it is not as urgent as addressing signs of infection in a postoperative client.
• A client with controlled pain requesting pain medication: While managing pain is important for client comfort, it is not as urgent as addressing signs of infection post-surgery.

Therefore, the client postoperative day 1 after appendectomy with signs of infection should be the nurse's top priority in a surgical unit.

Rationale:

• A client post-chemotherapy infusion with nausea and vomiting: This client should be prioritized because nausea and vomiting following chemotherapy infusion can indicate chemotherapy-induced nausea and vomiting (CINV), which requires prompt assessment and intervention to alleviate symptoms and prevent dehydration.
• A client with controlled pain requesting pain medication: While addressing pain management is important, it is not as urgent as addressing potential complications of chemotherapy, such as CINV.
• A client with a history of hypertension needing blood pressure monitoring: While blood pressure monitoring is important for clients with hypertension, it is not as urgent as addressing symptoms related to chemotherapy.
• A client with a fever of unknown origin awaiting diagnostic workup: While a fever of unknown origin requires investigation, addressing symptoms related to chemotherapy takes precedence due to the potential for serious complications such as dehydration and electrolyte imbalances.

Therefore, the client's post-chemotherapy infusion with nausea and vomiting should be the nurse's top priority in an oncology unit.

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 who needs assistance with ambulation: While important for the client's mobility and well-being, ambulation assistance is not as urgent as addressing post-operative pain management.
• A client who requires pain medication post-surgery: This client should be prioritized because pain management is essential for post-operative recovery and comfort. Uncontrolled pain can lead to complications and hinder the client's ability to participate in activities necessary for recovery.
• A client with controlled hypertension: This client's condition is stable and does not require immediate intervention.
• A client with a urinary tract infection: While urinary tract infections require treatment, they are generally not as immediately critical as post-operative pain management.

Therefore, the client who requires pain medication post-surgery should be the nurse's top priority.

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 premature infant with respiratory distress syndrome requiring surfactant replacement therapy: This client should be prioritized as respiratory distress syndrome in premature infants can quickly progress to respiratory failure, and surfactant replacement therapy is essential for improving lung function and preventing complications.
• A term infant with jaundice awaiting phototherapy: While jaundice in a term infant may require intervention, it is not as urgent as addressing respiratory distress syndrome in a premature infant.
• An infant with congenital heart disease needing preoperative evaluation: While preoperative evaluation for congenital heart disease is important, it is not as urgent as addressing respiratory distress in a premature infant.
• An infant with a feeding tube requiring formula supplementation: While ensuring adequate nutrition is important, it is not as urgent as addressing respiratory distress in a premature infant.

Therefore, the premature infant with respiratory distress syndrome requiring surfactant replacement therapy should be the nurse's top priority in a neonatal intensive care unit (NICU).

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:

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:

• An infant with bronchiolitis requiring continuous positive airway pressure (CPAP): This client should be prioritized because bronchiolitis can lead to respiratory distress and hypoxia, and the need for CPAP indicates significant respiratory compromise requiring immediate intervention.
• A child with a history of diabetes experiencing hypoglycemic symptoms: While hypoglycemia in a child with diabetes is concerning, addressing respiratory distress in an infant takes precedence due to the immediate threat to airway and oxygenation.
• A toddler with a foreign body aspiration requiring bronchoscopy: While foreign body aspiration is serious, the need for immediate intervention is less urgent compared to the respiratory distress of bronchiolitis.
• A school-aged child with a fractured femur awaiting surgery: While a fractured femur is significant, it is not as urgent as addressing respiratory distress in an infant.

Therefore, the infant with bronchiolitis requiring continuous positive airway pressure (CPAP) should be the nurse's top priority in a pediatric ICU.

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 postpartum client requesting assistance with breastfeeding: While breastfeeding support is important, addressing decreased fetal movement in a client in active labor takes precedence as it could indicate fetal distress and requires immediate assessment and intervention.
• A client in active labor with decreased fetal movement: This client should be prioritized because decreased fetal movement may indicate fetal compromise and timely assessment is critical to ensure the safety of the mother and the child.
• A client requesting pain medication after vaginal delivery: While pain management is important for client comfort, it is not as urgent as addressing fetal well-being during labor.
• A client needing discharge teaching after cesarean section: Discharge teaching can be postponed until the immediate concern of fetal well-being is addressed.

Therefore, the client in active labor with decreased fetal movement should be the nurse's top priority in a maternity unit.

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:

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:

In a pediatric 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 care are:

• A child with a high fever and suspected sepsis: Sepsis is a life-threatening condition that requires immediate intervention to manage the infection, stabilize vital signs, and prevent organ failure.
• A child with severe dehydration and electrolyte imbalance: Severe dehydration and electrolyte imbalance can lead to shock, cardiac arrhythmias, and other critical conditions. Immediate intervention is necessary to rehydrate and correct electrolyte imbalances.
• A child with a new onset of seizures: A new onset of seizures requires immediate assessment and intervention to determine the cause and prevent further seizures and potential complications.

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 child with a mild asthma exacerbation: This child needs monitoring and treatment but is not in immediate danger compared to those with more severe or acute conditions.
• A child with stable vital signs post-appendectomy: This child is stable and does not require immediate intervention compared to those with acute life-threatening conditions.
• A child with a controlled urinary tract infection: This child is stable with the infection under control and does not require immediate intervention.

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.