Prioritizing Client Care: NCLEX Practice Test-2

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).

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 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:

• myocardial infarction, thrombolytic: A myocardial infarction (heart attack) is a critical condition that requires immediate intervention to restore blood flow to the heart muscle. Thrombolytic therapy can dissolve clots quickly, which is vital to prevent further heart muscle damage and save the patient's life.
• heart failure, cardiac catheterization: While cardiac catheterization is important for diagnosing and treating heart conditions, it is not as immediately life-threatening as a myocardial infarction requiring thrombolytic therapy.
• atrial fibrillation, electrical cardioversion: Electrical cardioversion is used to restore normal heart rhythm in atrial fibrillation, but it is not as emergent as a thrombolytic intervention for a myocardial infarction.
• pericarditis, pericardiocentesis: Pericardiocentesis is important for relieving symptoms of pericarditis with tamponade, but it is not as immediately life-threatening as a myocardial infarction requiring thrombolytic therapy.

Therefore, the nurse should prioritize the client with a myocardial infarction requiring urgent thrombolytic intervention due to the immediacy and severity of the condition.

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:

• 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 client with a traumatic brain injury requiring immediate neurological assessment: This client should be prioritized as traumatic brain injuries can lead to life-threatening complications, and a prompt neurological assessment is crucial for the early detection and intervention of neurological issues.
• A client with a fractured clavicle requesting pain medication: While pain management is important, it is not as urgent as assessing a traumatic brain injury.
• A client with a minor abrasion on the leg needing wound care: While wound care is necessary, it is not as urgent as assessing and managing a traumatic brain injury.
• A client with a dislocated shoulder awaiting reduction: While shoulder dislocation requires intervention, it is not as urgent as assessing a traumatic brain injury.

Therefore, a client with a traumatic brain injury requiring immediate neurological assessment should be the nurse's top priority in a trauma 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:

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:

• 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 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:

• dementia, aggressive behavior management: Aggressive behavior in dementia patients poses immediate risks to the safety of the patient and others, requiring prompt intervention to ensure a safe environment.
• urinary incontinence, toileting assistance: While important for maintaining comfort and dignity, toileting assistance for urinary incontinence may not present an immediate threat to the client's safety compared to managing aggressive behavior in dementia.
• osteoarthritis, pain medication: Pain management for osteoarthritis is essential for the client's comfort but may not require urgent attention unless the pain is severe and uncontrolled.
• hypertension, blood pressure monitoring: Monitoring blood pressure in hypertensive clients is important for overall health management, but it may not be as immediately urgent as managing aggressive behavior in dementia.

Therefore, the nurse should prioritize care for the client with dementia requiring aggressive behavior management due to the potential risks associated with uncontrolled aggression.

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:

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 depression requesting to skip group therapy: While addressing the client's request is important, auditory hallucinations in a client with schizophrenia indicate a potential psychiatric crisis requiring immediate attention to ensure the client's safety and well-being.
• A client with schizophrenia experiencing auditory hallucinations: This client should be prioritized because auditory hallucinations can lead to distress and impairment in functioning, and addressing them promptly is crucial in psychiatric care.
• A client with anxiety asking for assistance with relaxation techniques: While assisting with relaxation techniques is important for managing anxiety, it is not as urgent as addressing auditory hallucinations in a client with schizophrenia.
• A client with bipolar disorder needing medication refill: While medication management is important for clients with bipolar disorder, it is not as urgent as addressing auditory hallucinations.

Therefore, the client with schizophrenia experiencing auditory hallucinations should be the nurse's top priority in a psychiatric unit.

Rationale:

• A client with a road accident having lacerations to the arm: While this client needs care, a laceration to the arm is generally not life-threatening and can wait unless there is severe bleeding.
• A client with a history of heart failure complaining of fatigue: This client should be seen first because fatigue in a client with a history of heart failure can indicate a worsening of their condition, such as decompensated heart failure, which requires immediate assessment and possible intervention to prevent serious complications.
• A client with a history of migraines requesting pain medication: This client needs pain relief but is not as urgent as a potential cardiac issue.
• A client with a fever of 101°F (38.3°C): While a fever needs attention, it is generally not as immediately critical as the potential for heart failure exacerbation.

Therefore, the client with a history of heart failure complaining of fatigue should be the nurse's top priority.

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:

• 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 postoperative day 1 after appendectomy requesting pain medication: While pain management is important for postoperative care, chest discomfort in a client with a history of heart disease raises concerns for a potential cardiac event, which requires immediate assessment and intervention.
• A client with a history of heart disease complaining of chest discomfort: This client should be assessed first as chest discomfort in someone with a history of heart disease may indicate angina or another cardiac issue requiring urgent evaluation.
• A client with controlled hypertension requesting dietary counseling: While dietary counseling is important for managing hypertension, it is not as urgent as addressing chest discomfort in a client with a history of heart disease.
• A client with a surgical wound infection needing wound care: While wound care is necessary, it is not as urgent as assessing chest discomfort in a client with a history of heart disease.

Therefore, a client with a history of heart disease complaining of chest discomfort should be the nurse's top priority in a surgical unit.