Focus on Delegating Prioritizing Triage Disaster 2023/2024
Questions and Answers with complete solution
A home care nurse is assigned to visit a prenatal client with a diagnosis of
hyperemesis gravidarum (HEG). During physical assessment of the client, the
nurse should first:
Assess the client's intake and output
Rationale: HEG is persistent, uncontrolled vomiting that begins before the 20th week of
pregnancy. It can have serious consequence, including loss of 5% of prepregnancy
weight, dehydration, ketosis, acid-base imbalance, and electrolyte imbalances. Physical
assessment begins with determining the client's intake and output, because these data
provide information regarding hydration and the nutritional status of the client. The
client's weight would be obtained and the baseline value compared with previous and
subsequent values. Additionally, the nurse would instruct the client in how to accurately
check and monitor her weight. Laboratory data may need to be evaluated; increased
hemoglobin and hematocrit values may occur as a result of dehydration. Encouraging
the client to verbalize her feelings about the diagnosis is a component of the plan of
care but is not the first intervention during physical assessment.
A nurse is monitoring a client with preeclampsia who is receiving intravenous
magnesium sulfate to prevent seizures. The nurse notes that the client's
respiratory rate is 10 breaths/min. On the basis of this finding, the nurse first:
Discontinues the magnesium sulfate
Rationale: A respiratory rate slower than 12 breaths/min is a sign of magnesium toxicity.
Other signs include the absence of deep tendon reflexes, altered sensorium,
hypotension, and a serum magnesium level above the therapeutic range of 5 to 8 mg/dL
(2.05 to 3.29 mmol/L). In this situation, the nurse would first discontinue the magnesium
sulfate. The nurse would then take the client's vital signs and contact the health care
provider health care providerThe most recent serum magnesium level may be checked;
however, a current serum level would provide more useful data.
A client who has just undergone abdominal surgery calls the nurse and states, "I
feel as if I just split open." The nurse checks the abdominal incision and finds
wound evisceration. The nurse immediately:
Contacts the health care provider
Rationale: Wound evisceration is the total separation of a surgical incision or wound
with extrusion of the internal organs or viscera through the open wound. When
evisceration occurs, the nurse immediately calls for help and has the health care
provider notified. The nurse stays with the client and positions the client with the hips
and knees bent. The nurse then covers the abdominal wound with a sterile dressing
moistened with sterile saline solution. The nurse would then take the client's vital signs
and document the occurrence. Since this is a surgical emergency, the operating room
would be notified but this would not be done until directed to do so by the surgeon.
,A client is receiving an intravenous (IV) infusion of 1000 mL of normal saline
solution at a rate of 125 mL/hr. The client suddenly complains of shortness of
breath, and the nurse notes the presence of dependent edema and puffiness
around the client's eyes. The nurse suspects circulatory overload and
immediately:
Slows the IV rate
Rationale: Signs of circulatory overload include shortness of breath, cough, increased
blood pressure, puffiness around the eyes, and edema in dependent areas. The client's
neck veins may be engorged, and the nurse may hear moist breath sounds on
auscultation of the lungs. If circulatory overload occurs, the nurse must immediately
slow the IV rate and then notify the health care provider. The client would be placed in
an upright position. The nurse would monitor the client's vital signs and administer
oxygen and diuretics as prescribed.
A nurse is performing closed suctioning through a tracheostomy for a ventilator-
dependent client. During the procedure, the alarm on the cardiac monitor sounds
and the nurse notes severe bradycardia. The nurse stops suctioning the client
and immediately:
Oxygenates the client manually with 100% oxygen
Rationale: Suctioning is associated with several complications, including hypoxia, tissue
(mucosal) trauma, infection, vagal stimulation, and bronchospasm. Vagal stimulation
may result in severe bradycardia, hypotension, heart block, ventricular tachycardia, or
asystole. If vagal stimulation occurs, the nurse stops suctioning immediately and
oxygenates the client manually with 100% oxygen. Contacting the respiratory therapist
will delay the required and immediate intervention. Although regular checks of the
ventilator connections are the standard of care for a client undergoing mechanical
ventilation, doing so will not alleviate the client's problem in this situation. An increase in
PEEP is not indicated at this time.
Inner maxillary fixation (IMF) is performed on a client who sustained a mandibular
fracture in a motor vehicle crash. During an assessment, the client begins to
vomit. The nurse suctions the client but is unsuccessful, and the client exhibits
signs of hypoxia. The nurse immediately:
Cuts the mouth wires
Rationale: IMF is a common means of securing a mandibular fracture. The bones are
realigned and then wired in place with the bite closed. After surgery, the client is at risk
for aspiration if he or she vomits because of the impossibility of opening the jaws to
allow ejection of the emesis. If vomiting occurs, the nurse would attempt to suction the
client. If suctioning is unsuccessful, the wires are cut. Wire cutters are kept with the
client at all times in readiness for this emergency. Antiemetics may be prescribed to
prevent nausea and subsequent vomiting; however, this is not the immediate action if
the client is vomiting. Placing the client in a supine position increases the risk of
aspiration. The client is placed in an upright position and turned to the side. There is no
helpful reason to contact the anesthesiologist.
, A child arrives at the emergency department experiencing anaphylaxis after being
stung by a bee on the right arm. The nurse should first:
Place a tourniquet proximal to the site of the insect sting
Rationale: Anaphylaxis is a severe immediate hypersensitivity reaction to an excessive
release of chemical mediators. Treatment of anaphylaxis must be started immediately,
because it may be only a matter of minutes before the child experiences shock. The
nurse would immediately take steps to ensure an adequate airway, place a tourniquet
just proximal to the site of the insect sting to help confine the allergen, administer
epinephrine (medication of choice) as prescribed, administer oxygen, administer
corticosteroids and antihistamines as prescribed, keep the child warm and lying flat or
with the feet slightly elevated, and start an IV line.
A nurse is preparing to care for a child being admitted to the hospital with
infectious gastroenteritis. The priority nursing intervention is:
Starting an intravenous (IV) line as prescribed
Rationale: Infectious gastroenteritis is caused by a variety of communicable viruses,
bacteria, and parasites capable of causing serious diarrhea, massive fluid and
electrolyte loss, sepsis, and death. The priority therapy in a child with infectious
gastroenteritis is the replacement of water and correction of acid-base or fluid and
electrolyte disturbances with the use of IV fluids or oral electrolyte-replacement
preparations. A stool culture and antimicrobial drugs may be prescribed, but these are
not the priority interventions. Instructions to the parents may be necessary but are not
the priority on admission of the child to the hospital.
A client is brought to the emergency department after a motor vehicle crash in
which the client sustained a blunt chest injury when his chest struck the steering
wheel. The client is complaining of sharp pain on inspiration and dyspnea. The
nurse notes the absence of breath sounds on the affected side. The nurse would
immediately:
Place the client in a semi-Fowler position
Rationale: The client is exhibiting signs of a closed pneumothorax. If a closed chest
injury is suspected, the nurse must immediately place the client in a semi-Fowler
position. Because this is a medical emergency, the nurse then notifies the health care
provider. A chest x-ray, computed tomography, or ultrasonography would be used to
confirm the diagnosis of pneumothorax. Because treatment involves thoracentesis and
placement of a chest drainage system, the nurse then prepares a thoracentesis tray and
chest drainage equipment.
A registered nurse (RN) is planning the client assignments for the day. To which
nurse does the RN appropriately assign care of a woman undergoing
brachytherapy with a sealed radiation source for cervical cancer?
A nurse who has worked with clients undergoing brachytherapy in the past
Rationale: Brachytherapy involves the use of radioactive isotopes in solid form or within
body fluids. Because the radiation source is within the client, the client emits radiation
for some time and may pose a hazard to others. A pregnant nurse should not care for a
Questions and Answers with complete solution
A home care nurse is assigned to visit a prenatal client with a diagnosis of
hyperemesis gravidarum (HEG). During physical assessment of the client, the
nurse should first:
Assess the client's intake and output
Rationale: HEG is persistent, uncontrolled vomiting that begins before the 20th week of
pregnancy. It can have serious consequence, including loss of 5% of prepregnancy
weight, dehydration, ketosis, acid-base imbalance, and electrolyte imbalances. Physical
assessment begins with determining the client's intake and output, because these data
provide information regarding hydration and the nutritional status of the client. The
client's weight would be obtained and the baseline value compared with previous and
subsequent values. Additionally, the nurse would instruct the client in how to accurately
check and monitor her weight. Laboratory data may need to be evaluated; increased
hemoglobin and hematocrit values may occur as a result of dehydration. Encouraging
the client to verbalize her feelings about the diagnosis is a component of the plan of
care but is not the first intervention during physical assessment.
A nurse is monitoring a client with preeclampsia who is receiving intravenous
magnesium sulfate to prevent seizures. The nurse notes that the client's
respiratory rate is 10 breaths/min. On the basis of this finding, the nurse first:
Discontinues the magnesium sulfate
Rationale: A respiratory rate slower than 12 breaths/min is a sign of magnesium toxicity.
Other signs include the absence of deep tendon reflexes, altered sensorium,
hypotension, and a serum magnesium level above the therapeutic range of 5 to 8 mg/dL
(2.05 to 3.29 mmol/L). In this situation, the nurse would first discontinue the magnesium
sulfate. The nurse would then take the client's vital signs and contact the health care
provider health care providerThe most recent serum magnesium level may be checked;
however, a current serum level would provide more useful data.
A client who has just undergone abdominal surgery calls the nurse and states, "I
feel as if I just split open." The nurse checks the abdominal incision and finds
wound evisceration. The nurse immediately:
Contacts the health care provider
Rationale: Wound evisceration is the total separation of a surgical incision or wound
with extrusion of the internal organs or viscera through the open wound. When
evisceration occurs, the nurse immediately calls for help and has the health care
provider notified. The nurse stays with the client and positions the client with the hips
and knees bent. The nurse then covers the abdominal wound with a sterile dressing
moistened with sterile saline solution. The nurse would then take the client's vital signs
and document the occurrence. Since this is a surgical emergency, the operating room
would be notified but this would not be done until directed to do so by the surgeon.
,A client is receiving an intravenous (IV) infusion of 1000 mL of normal saline
solution at a rate of 125 mL/hr. The client suddenly complains of shortness of
breath, and the nurse notes the presence of dependent edema and puffiness
around the client's eyes. The nurse suspects circulatory overload and
immediately:
Slows the IV rate
Rationale: Signs of circulatory overload include shortness of breath, cough, increased
blood pressure, puffiness around the eyes, and edema in dependent areas. The client's
neck veins may be engorged, and the nurse may hear moist breath sounds on
auscultation of the lungs. If circulatory overload occurs, the nurse must immediately
slow the IV rate and then notify the health care provider. The client would be placed in
an upright position. The nurse would monitor the client's vital signs and administer
oxygen and diuretics as prescribed.
A nurse is performing closed suctioning through a tracheostomy for a ventilator-
dependent client. During the procedure, the alarm on the cardiac monitor sounds
and the nurse notes severe bradycardia. The nurse stops suctioning the client
and immediately:
Oxygenates the client manually with 100% oxygen
Rationale: Suctioning is associated with several complications, including hypoxia, tissue
(mucosal) trauma, infection, vagal stimulation, and bronchospasm. Vagal stimulation
may result in severe bradycardia, hypotension, heart block, ventricular tachycardia, or
asystole. If vagal stimulation occurs, the nurse stops suctioning immediately and
oxygenates the client manually with 100% oxygen. Contacting the respiratory therapist
will delay the required and immediate intervention. Although regular checks of the
ventilator connections are the standard of care for a client undergoing mechanical
ventilation, doing so will not alleviate the client's problem in this situation. An increase in
PEEP is not indicated at this time.
Inner maxillary fixation (IMF) is performed on a client who sustained a mandibular
fracture in a motor vehicle crash. During an assessment, the client begins to
vomit. The nurse suctions the client but is unsuccessful, and the client exhibits
signs of hypoxia. The nurse immediately:
Cuts the mouth wires
Rationale: IMF is a common means of securing a mandibular fracture. The bones are
realigned and then wired in place with the bite closed. After surgery, the client is at risk
for aspiration if he or she vomits because of the impossibility of opening the jaws to
allow ejection of the emesis. If vomiting occurs, the nurse would attempt to suction the
client. If suctioning is unsuccessful, the wires are cut. Wire cutters are kept with the
client at all times in readiness for this emergency. Antiemetics may be prescribed to
prevent nausea and subsequent vomiting; however, this is not the immediate action if
the client is vomiting. Placing the client in a supine position increases the risk of
aspiration. The client is placed in an upright position and turned to the side. There is no
helpful reason to contact the anesthesiologist.
, A child arrives at the emergency department experiencing anaphylaxis after being
stung by a bee on the right arm. The nurse should first:
Place a tourniquet proximal to the site of the insect sting
Rationale: Anaphylaxis is a severe immediate hypersensitivity reaction to an excessive
release of chemical mediators. Treatment of anaphylaxis must be started immediately,
because it may be only a matter of minutes before the child experiences shock. The
nurse would immediately take steps to ensure an adequate airway, place a tourniquet
just proximal to the site of the insect sting to help confine the allergen, administer
epinephrine (medication of choice) as prescribed, administer oxygen, administer
corticosteroids and antihistamines as prescribed, keep the child warm and lying flat or
with the feet slightly elevated, and start an IV line.
A nurse is preparing to care for a child being admitted to the hospital with
infectious gastroenteritis. The priority nursing intervention is:
Starting an intravenous (IV) line as prescribed
Rationale: Infectious gastroenteritis is caused by a variety of communicable viruses,
bacteria, and parasites capable of causing serious diarrhea, massive fluid and
electrolyte loss, sepsis, and death. The priority therapy in a child with infectious
gastroenteritis is the replacement of water and correction of acid-base or fluid and
electrolyte disturbances with the use of IV fluids or oral electrolyte-replacement
preparations. A stool culture and antimicrobial drugs may be prescribed, but these are
not the priority interventions. Instructions to the parents may be necessary but are not
the priority on admission of the child to the hospital.
A client is brought to the emergency department after a motor vehicle crash in
which the client sustained a blunt chest injury when his chest struck the steering
wheel. The client is complaining of sharp pain on inspiration and dyspnea. The
nurse notes the absence of breath sounds on the affected side. The nurse would
immediately:
Place the client in a semi-Fowler position
Rationale: The client is exhibiting signs of a closed pneumothorax. If a closed chest
injury is suspected, the nurse must immediately place the client in a semi-Fowler
position. Because this is a medical emergency, the nurse then notifies the health care
provider. A chest x-ray, computed tomography, or ultrasonography would be used to
confirm the diagnosis of pneumothorax. Because treatment involves thoracentesis and
placement of a chest drainage system, the nurse then prepares a thoracentesis tray and
chest drainage equipment.
A registered nurse (RN) is planning the client assignments for the day. To which
nurse does the RN appropriately assign care of a woman undergoing
brachytherapy with a sealed radiation source for cervical cancer?
A nurse who has worked with clients undergoing brachytherapy in the past
Rationale: Brachytherapy involves the use of radioactive isotopes in solid form or within
body fluids. Because the radiation source is within the client, the client emits radiation
for some time and may pose a hazard to others. A pregnant nurse should not care for a
