Prioritizing Client Care: NCLEX Practice Test-2

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 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:

• Acute exacerbations of chronic obstructive pulmonary disease (COPD) can rapidly deteriorate respiratory function and lead to life-threatening complications. Therefore, they often require urgent intervention, such as bronchodilator therapy, corticosteroids, and oxygen therapy, to stabilize the client's condition and improve breathing. Pneumonia, while serious, may not always require immediate intervention depending on its severity and the client's overall clinical status. In a respiratory unit, prioritizing the client with acute exacerbation of COPD ensures timely management to prevent respiratory failure and other complications.

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 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 with stable angina reporting chest tightness: While chest tightness in a client with stable angina should be assessed, managing heart failure with IV diuretics takes precedence due to the potential for acute decompensation and fluid overload.
• A client with heart failure requiring IV diuretics: This client should be prioritized because heart failure exacerbation requires immediate intervention to reduce fluid overload and improve cardiac function.
• A client with atrial fibrillation needing anticoagulation therapy adjustment: While anticoagulation therapy adjustment is important for managing atrial fibrillation, it is not as urgent as addressing heart failure exacerbation.
• A client post-percutaneous coronary intervention (PCI) with groin site discomfort: While monitoring for complications after PCI is important, addressing heart failure exacerbation takes precedence due to the potential for serious complications such as pulmonary edema.

Therefore, the client with heart failure requiring IV diuretics should be the nurse's top priority in a cardiac step-down 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 receiving a blood transfusion with a slight temperature elevation: While monitoring for signs of transfusion reaction is important, a slight temperature elevation alone may not warrant immediate attention compared to the sudden onset of chest pain.
• A client with a central line and sudden onset of chest pain: This client should be seen first because sudden onset of chest pain in a client with a central line raises concerns for potential complications such as catheter-related bloodstream infection, thrombosis, or pneumothorax, which require immediate assessment and intervention.
• A client postoperative day 1 after open-heart surgery needing ambulation: While early ambulation is important for postoperative recovery, it is not as urgent as addressing sudden onset of chest pain.
• A client with chronic obstructive pulmonary disease (COPD) requesting bronchodilators: While addressing COPD exacerbations is important, sudden onset of chest pain in a client with a central line takes precedence.

Therefore, the client with a central line and sudden onset of chest pain should be the nurse's top priority in a critical care unit.

Rationale:

• A client with a suspected stroke presenting with sudden-onset weakness on one side: This client should be prioritized as a suspected stroke is a medical emergency requiring immediate assessment and intervention to minimize potential brain damage and improve outcomes.
• A client with a history of migraines requesting pain medication: While addressing pain in clients with migraines is important, it is not as urgent as assessing and managing a suspected stroke.
• A client with epilepsy requesting a refill on antiepileptic medication: While ensuring medication compliance is important for clients with epilepsy, it is not as urgent as addressing a suspected stroke.
• A client with a minor head injury awaiting discharge instructions: While providing discharge instructions for clients with minor head injuries is important, it is not as urgent as assessing and managing a suspected stroke.

Therefore, the client with a suspected stroke presenting with sudden-onset weakness on one side should be the nurse's top priority in a neurology unit.

Rationale:

• A client with a minor cut on the right arm: While any injury requires attention, a minor cut is generally not immediately life-threatening compared to severe bleeding.
• A client with severe bleeding from a leg wound: This client should be prioritized because severe bleeding can lead to rapid blood loss and shock, which can be life-threatening if not promptly addressed.
• A client with a history of asthma requesting for an inhaler: While asthma management is important, it is not as urgent as managing severe bleeding.
• A client with a dislocated shoulder complaining of pain: While painful, a dislocated shoulder is not immediately life-threatening compared to severe bleeding.

Therefore, the client with severe bleeding from a leg wound should be the nurse's top priority in a disaster response setting. Immediate intervention is necessary to control bleeding and prevent further complications.

Rationale:

• acute respiratory distress syndrome (ARDS), mechanical ventilation: ARDS is a life-threatening condition that causes severe respiratory failure. Mechanical ventilation is critical to ensure adequate oxygenation and to prevent further respiratory compromise.
• chronic obstructive pulmonary disease (COPD), bronchodilator therapy: While bronchodilator therapy is important for managing COPD, it is generally not as immediately life-threatening as ARDS requiring mechanical ventilation.
• pneumonia, oxygen therapy: Oxygen therapy is crucial for pneumonia patients, especially those with significant hypoxia, but the need is not as urgent as mechanical ventilation for ARDS.
• asthma exacerbation, nebulizer treatment: Asthma exacerbations can be serious and require prompt nebulizer treatment, but ARDS with the need for mechanical ventilation presents a more immediate critical situation.

Therefore, the nurse should prioritize the client with ARDS requiring mechanical ventilation due to the acute and potentially life-threatening nature of the condition.

Rationale:

• neutropenia, fever: Neutropenia combined with fever is a medical emergency in oncology patients due to the high risk of severe infections. It indicates potential sepsis, which requires immediate intervention to prevent serious complications or death.
• nausea, vomiting: While nausea and vomiting are common and distressing side effects of chemotherapy, they are not as immediately life-threatening as neutropenic fever.
• anemia, fatigue: Anemia and fatigue require management and monitoring but do not pose the same immediate risk as a febrile neutropenic patient.
• thrombocytopenia, bleeding: Thrombocytopenia with bleeding is serious and requires prompt attention, but neutropenic fever takes precedence due to the rapid progression and high risk of infection-related complications.

Thus, the nurse should prioritize the client with neutropenia and fever due to the immediate risk of severe infection and potential sepsis.

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:

• A client with controlled hypertension who needs a blood pressure check: While blood pressure monitoring is important for clients with hypertension, it is not as urgent as addressing acute respiratory symptoms.
• A client with a history of migraines requesting pain medication: While pain management is important, it is not as urgent as addressing difficulty breathing and wheezing.
• A client with difficulty breathing and wheezing: This client should be seen first because difficulty breathing and wheezing indicate potential respiratory distress or exacerbation of conditions like asthma, which requires immediate assessment and intervention to ensure airway patency and oxygenation.
• A client with a minor abrasion on the arm: While abrasions should be assessed and treated, they are not as urgent as respiratory symptoms.

Therefore, the client with difficulty breathing and wheezing should be the nurse's top priority in a primary care clinic.

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 child with a central line experiencing fever and chills: This client should be prioritized as fever and chills in a child with a central line may indicate central line-associated bloodstream infection (CLABSI), which requires immediate assessment and intervention to prevent sepsis and other serious complications.
• A child with leukemia needing assistance with schoolwork: While supporting the child's educational needs is important for their overall well-being, addressing potential infection in a child with a central line takes precedence due to the risk of sepsis.
• A child with a minor abrasion on the knee requesting a bandage: While providing wound care is necessary, it is not as urgent as addressing potential signs of infection in a child with a central line.
• A child with a history of asthma requesting a nebulizer treatment: While managing asthma exacerbations is important, it is not as urgent as addressing potential complications related to the central line.

Therefore, a child with a central line experiencing fever and chills should be the nurse's top priority in a pediatric oncology unit.

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 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:

• 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:

• 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.