Think First: Nursing Priority Decisions

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RNPREPBESTIE MEMBERSHIP

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Think First: Nursing Priority Decisions


Froggy Jumps Think First: Nursing Priority DecisionsOnline version RNPREPBESTIE MEMBERSHIP by RNPRPEPBESTIE 1 A nurse beginning the morning shift reviews several overnight updates and patient requests. Which situation requires the nurse’s immediate assessment? a Client with new colostomy tearful and refusing to allow spouse to see the surgical site b COPD client restless, RR 30, using accessory muscles, SpO2 89% on 2 L nasal cannula c Post-op client reports incision pain 7/10 and states pain medication barely helped overnight 2 A nurse on a postpartum unit receives report on several mother–newborn pairs and begins initial rounds. Which situation requires the nurse’s immediate assessment? a Postpartum client tearful and states she feels like a bad mother and unsure she can care for baby b Postpartum client reports perineal pain 6/10 and requests stronger pain medication c Newborn 2 hr old jittery with high-pitched cry, glucose 38 mg/dL, mother had gestational diabetes 3 A nurse assessing a client with type 1 diabetes finds the client confused, diaphoretic, and shaky. Fingerstick glucose reads 42 mg/dL. The client is awake and able to swallow. What is the priority nursing action? a Prepare IV regular insulin to lower blood glucose quickly b Encourage the client to eat a full meal with protein and complex carbohydrates c Administer 15 g rapid-acting carbohydrate such as juice or glucose tablets 4 A nurse prepares to administer morning medications to several clients. Which finding requires the nurse to hold the medication and notify the provider? a Client receiving levothyroxine asks if medication should be taken with breakfast b Client scheduled for metoprolol has HR 48/min and reports dizziness when standing c Client prescribed furosemide reports frequent urination overnight 5 A nurse reviews new assessment findings for several clients on a medical unit. Which finding is most concerning and requires immediate follow-up? a Client with chronic anemia reports fatigue after walking to the bathroom b Client receiving IV heparin develops sudden severe headache and confusion c Client with heart failure reports gaining 2 lb in 3 days and mild ankle swelling 6 A nurse reviews laboratory results before morning care. Which finding requires immediate nursing follow-up? a Client with chronic kidney disease has creatinine 2.2 mg/dL consistent with baseline labs b Client receiving digoxin reports nausea and blurred yellow vision, potassium 2.9 mEq/L c Client with iron deficiency anemia has hemoglobin 10.2 g/dL and feels tired after walking 7 A nurse working on an inpatient mental health unit observes several client behaviors during evening rounds. Which behavior requires the nurse’s immediate intervention? a Client giving belongings to peers and stating, “They won’t matter soon.” b Client refusing dinner and remaining quietly in the room most of the afternoon c Client pacing the hallway and repeatedly asking when visiting hours begin 8 What is the priority nursing action when a patient with pneumonia removes the nasal cannula and says they don’t want family to see them this way? a Reapply oxygen and explain it supports breathing before discussing concerns b Encourage family support to improve the client’s confidence c Respect the request and remove oxygen to preserve the client’s dignity 9 A nurse caring for a client with a new ileostomy plans hallway ambulation. The client refuses and states, “Everyone will stare at the bag.” The nurse notes SpO₂ 88% on room air. What is the priority nursing action? a Provide reassurance and discuss feelings about body image b Apply oxygen and assess respiratory status before addressing body image concerns c Offer clothing to help cover the ostomy pouch during ambulation 10 A nurse is caring for a hospitalized teen being treated for severe anorexia nervosa. The teen asks to use the gym and states, “I feel fine and need to keep my body in shape.” What is the priority response? a Encourage discussion about body image and self-esteem concerns b Allow light exercise since the teen reports feeling stronger c Explain exercise is restricted and ensure the teen completes the scheduled meal plan 11 A nurse caring for a child with hemophilia notices the child guarding the knee and refusing to walk after playing. The knee appears swollen and warm. What is the priority nursing action? a Apply ice, immobilize the joint, and notify the provider to evaluate bleeding b Massage the knee to improve circulation and reduce discomfort c Encourage gentle walking so the joint does not become stiff

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Think First: Nursing Priority Decisions

Froggy Jumps

About this activity

Created by

Download the paper version to play

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Think First: Nursing Priority DecisionsOnline version

by RNPRPEPBESTIE

A nurse beginning the morning shift reviews several overnight updates and patient requests. Which situation requires the nurse’s immediate assessment?

A nurse on a postpartum unit receives report on several mother–newborn pairs and begins initial rounds. Which situation requires the nurse’s immediate assessment?

A nurse assessing a client with type 1 diabetes finds the client confused, diaphoretic, and shaky. Fingerstick glucose reads 42 mg/dL. The client is awake and able to swallow. What is the priority nursing action?

A nurse prepares to administer morning medications to several clients. Which finding requires the nurse to hold the medication and notify the provider?

A nurse reviews new assessment findings for several clients on a medical unit. Which finding is most concerning and requires immediate follow-up?

A nurse reviews laboratory results before morning care. Which finding requires immediate nursing follow-up?

A nurse working on an inpatient mental health unit observes several client behaviors during evening rounds. Which behavior requires the nurse’s immediate intervention?

What is the priority nursing action when a patient with pneumonia removes the nasal cannula and says they don’t want family to see them this way?

A nurse caring for a client with a new ileostomy plans hallway ambulation. The client refuses and states, “Everyone will stare at the bag.” The nurse notes SpO₂ 88% on room air. What is the priority nursing action?

A nurse is caring for a hospitalized teen being treated for severe anorexia nervosa. The teen asks to use the gym and states, “I feel fine and need to keep my body in shape.” What is the priority response?

A nurse caring for a child with hemophilia notices the child guarding the knee and refusing to walk after playing. The knee appears swollen and warm. What is the priority nursing action?