A nurses caring for a client who is in the immediate post operative period following a tracheotomy. Which of the following is the nurses priority action?
  • Creating meaningful social relationships
  • Move the client to room near the nurses station
  • Maintaining a patent airway
  • Obtain an ECG
A nurse is caring for a client who has a serum potassium level of 3.1 mEq/L. Which of the following actions should the nurse take first?
  • Platelets 95,000 mm3
  • Hypoxic
  • Obtain an ECG
  • Digoxin 3.0ng/mL
A nurse is caring for a newly admitted client. Which of the following client needs should the nurse address first?
  • Hypoxic
  • Place the client in the orthopneic position
  • Diarrhea
  • Obtain an ECG
A nurse in a rehabilitation facility has received report on four clients. Which of the following should the nurse evaluate first?
  • Determine the mobility status of each patient
  • A client who had abdominal surgery 10 days ago and reports feeling his incision pop
  • Place the client in the orthopneic position
  • A client who is having a nosebleed associated with hypertension
A newly hired nurse is reviewing the facilities emergency preparedness plan. Based on a review of the four triage categories, the nurse should provide power you care to clients who are in which of the following categories during a disaster?
  • Diarrhea
  • Check on the client
  • Assist client to cough effectively
  • Immediate
A nurse is collecting data on four clients. Which of the following is the highest priority finding by the nurse?
  • Hypoxic
  • Warmth and pain in the calf
  • Diarrhea
  • Obtain an ECG
A nurses caring for an older adult client who recently experienced the death of her partner. Which of the following is the priority need of the client?
  • Maintaining a patent airway
  • Move the client to room near the nurses station
  • Creating meaningful social relationships
  • Check the heart rate and blood pressure
A nurse is conducting therapeutic medication monitoring on four clients. Which of the findings should be immediately reported to the provider?
  • Diarrhea
  • Platelets 95,000 mm3
  • Digoxin 3.0ng/mL
  • Obtain an ECG
A nurses caring for a client who has a urinary track infection. The client is disoriented and found wandering on another unit. Which of the following actions should the nurse take first?
  • Maintaining a patent airway
  • Creating meaningful social relationships
  • Move the client to room near the nurses station
  • Have the client position the head with the chin down while swallowing
A nurse is reinforcing discharge teaching to a new mother regarding sudden infant death syndrome (SIDS). Which of the following is the highest priority to include in the instructions?
  • Check the heart rate and blood pressure
  • Have the client position the head with the chin down while swallowing
  • Place the client in the orthopneic position
  • Place the infant in a supine position when sleeping
A nurse is reviewing the lab results for four clients. The client with which of the following values requires immediate intervention?
  • Platelets 95,000 mm3
  • Place the client in the orthopneic position
  • Obtain an ECG
  • Digoxin 3.0ng/mL
A nurse working on the cardiac unit hears an alarm and finds one of the heart monitor screens at the nurse's station is displaying a straight line, indicating a client is in cardiac arrest. Which of the following actions should the nurse take first?
  • Check the leg for warmth and edema
  • Digoxin 3.0ng/mL
  • Check the heart rate and blood pressure
  • Check on the client
A nurse is assisting with the admission of a client who has decreased circulation in the left leg. Which of the following is the first action the nurse should take?
  • Check the heart rate and blood pressure
  • Check the leg for warmth and edema
  • Place the infant in a supine position when sleeping
  • Place the client in the orthopneic position
A nurse is caring for a client who is diagnosed with gastroenteritis. Which of the following actions should the nurse take first when evaluating for fluid volume deficit?
  • Place the infant in a supine position when sleeping
  • Check the leg for warmth and edema
  • Check the heart rate and blood pressure
  • Place the client in the orthopneic position
A nurse is collecting data on four clients. Which of the following findings is the most urgent?
  • Diarrhea
  • Place the client in the orthopneic position
  • Warmth and pain in the calf
  • Obtain an ECG
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