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Priority Actions

by RNPRPEPBESTIE
1

A client recovering from an acute myocardial infarction becomes pale , clammy , and short of breath . Blood pressure is 82 / 48 mm Hg , heart rate 128 bpm , respirations 28 / min , and oxygen saturation 86 % on 2 L O ? . Crackles are heard at the lung bases . The nurse ? s priority action is to .

2

A post - operative client suddenly reports sharp pleuritic chest pain and severe shortness of breath . Oxygen saturation is 84 % on room air , respiratory rate 32 / min , and heart rate 122 bpm . The client is anxious and diaphoretic . The nurse ? s priority action is to .

3

A client with urosepsis has temperature 104 °F , BP 82 / 42 mm Hg , HR 136 bpm , RR 30 / min , SpO ? 88 % on 2 L O ? , and serum lactate 6 . 2 mmol / L . Two large - bore IV lines are in place . The nurse ? s priority action is to .

4

A client with a history of stroke receiving enteral tube feedings becomes increasingly drowsy and develops gurgling breath sounds . Oxygen saturation falls to 88 % , and respirations are 30 / min . The nurse ? s priority action is to .

5

A client with acute kidney injury has a serum potassium level of 6 . 8 mEq / L , heart rate 48 bpm with tall T waves , and blood pressure 94 / 60 mm Hg . Current orders include IV KCl 10 mEq , spironolactone , and furosemide 40 mg IV once . The order the nurse should question is .

6

A client with a traumatic brain injury has BP 160 / 60 mm Hg , HR 50 bpm , RR 8 / min , and unequal pupils . New orders include IV morphine 2 mg for pain , elevate HOB 30° , maintain NS at 75 mL / hr , and prepare for CT scan . The order the nurse should question is Administer .

7

A client admitted with diabetic ketoacidosis has glucose 340 mg / dL , serum K ? 2 . 9 mEq / L , arterial pH 7 . 20 , and urine output 30 mL / hr . Provider orders include : regular insulin infusion , 0 . 9 % NS at 250 mL / hr , 40 mEq KCl in IV fluids , and ABGs q 4 hr . The order the nurse should question is .

8

A client with a known peptic ulcer suddenly vomits a large amount of dark , coffee - ground emesis . Heart rate is 138 bpm , BP 84 / 46 mm Hg , and the skin is cool and pale . The nurse ? s priority action is to .

9

A laboring client receiving an oxytocin infusion develops contractions every 60 seconds lasting 90 seconds . The fetal heart rate shows repetitive late decelerations with minimal variability . The nurse ? s priority action is to .

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