NURSING
Priority Setting CBT
Review Exam
Q&A
2024
,1. A nurse is caring for four patients in a medical-surgical unit. The
patients have the following conditions: a) a post-operative patient who had
a cholecystectomy yesterday and has a low-grade fever, b) a patient with
chronic obstructive pulmonary disease (COPD) who is experiencing
dyspnea and wheezes, c) a patient with diabetes mellitus who has a blood
glucose level of 250 mg/dL and is scheduled for insulin administration,
and d) a patient with hypertension who has a blood pressure of 160/90
mmHg and is due for an antihypertensive medication. Which patient
should the nurse attend to first?
a) The post-operative patient
b) The patient with COPD
c) The patient with diabetes
d) The patient with hypertension
*Answer: b) The patient with COPD*
Rationale: The patient with COPD has the most urgent problem that
requires immediate intervention. Dyspnea and wheezes indicate
respiratory distress that can lead to hypoxia and respiratory failure. The
other patients have less acute problems that can be managed later.
2. A nurse is working in an emergency department and receives four
patients at the same time. The patients have the following conditions: a) a
25-year-old male who was involved in a motor vehicle accident and has an
open fracture of the left femur, b) a 50-year-old female who has chest pain
radiating to the left arm and jaw, c) a 35-year-old male who has abdominal
pain, nausea, and vomiting, and d) a 40-year-old female who has a severe
headache, blurred vision, and slurred speech. Using the ABCDE (airway,
breathing, circulation, disability, exposure) principle, which patient should
the nurse prioritize?
a) The 25-year-old male
b) The 50-year-old female
c) The 35-year-old male
d) The 40-year-old female
*Answer: b) The 50-year-old female*
Rationale: The 50-year-old female has the most life-threatening condition
that could indicate a myocardial infarction (heart attack). Chest pain
radiating to the left arm and jaw is a classic sign of cardiac ischemia. The
, nurse should prioritize this patient to prevent cardiac arrest and
irreversible damage to the heart muscle. The other patients have serious
but less critical conditions that can be assessed later.
3. A nurse is assigned to care for five patients in a pediatric unit. The
patients have the following conditions: a) a 2-year-old child who has
pneumonia and is receiving oxygen therapy, b) a 4-year-old child who has
gastroenteritis and is dehydrated, c) a 6-year-old child who has
appendicitis and is scheduled for surgery, d) an 8-year-old child who has
asthma and is on nebulizer treatments, and e) a 10-year-old child who has
a fractured arm and is in pain. Using Maslow's hierarchy of needs, which
patient should the nurse prioritize?
a) The 2-year-old child
b) The 4-year-old child
c) The 6-year-old child
d) The 8-year-old child
e) The 10-year-old child
*Answer: a) The 2-year-old child*
Rationale: According to Maslow's hierarchy of needs, physiological needs
are the most basic and essential for survival. The 2-year-old child has the
most compromised physiological need of oxygenation due to pneumonia.
Oxygen therapy is vital to maintain adequate oxygen saturation and
prevent respiratory failure. The other patients have less urgent
physiological needs that can be addressed later.
4. A nurse is working in a psychiatric unit and has four patients to care
for. The patients have the following conditions: a) a patient with
schizophrenia who is experiencing auditory hallucinations and is agitated,
b) a patient with bipolar disorder who is in a manic episode and is
spending money impulsively, c) a patient with major depressive disorder
who is suicidal and has a plan to overdose on pills, and d) a patient with
generalized anxiety disorder who is having panic attacks and is
hyperventilating. Using the nursing process, which patient should the
nurse assess first?
a) The patient with schizophrenia
b) The patient with bipolar disorder
c) The patient with major depressive disorder
d) The patient with generalized anxiety disorder
Priority Setting CBT
Review Exam
Q&A
2024
,1. A nurse is caring for four patients in a medical-surgical unit. The
patients have the following conditions: a) a post-operative patient who had
a cholecystectomy yesterday and has a low-grade fever, b) a patient with
chronic obstructive pulmonary disease (COPD) who is experiencing
dyspnea and wheezes, c) a patient with diabetes mellitus who has a blood
glucose level of 250 mg/dL and is scheduled for insulin administration,
and d) a patient with hypertension who has a blood pressure of 160/90
mmHg and is due for an antihypertensive medication. Which patient
should the nurse attend to first?
a) The post-operative patient
b) The patient with COPD
c) The patient with diabetes
d) The patient with hypertension
*Answer: b) The patient with COPD*
Rationale: The patient with COPD has the most urgent problem that
requires immediate intervention. Dyspnea and wheezes indicate
respiratory distress that can lead to hypoxia and respiratory failure. The
other patients have less acute problems that can be managed later.
2. A nurse is working in an emergency department and receives four
patients at the same time. The patients have the following conditions: a) a
25-year-old male who was involved in a motor vehicle accident and has an
open fracture of the left femur, b) a 50-year-old female who has chest pain
radiating to the left arm and jaw, c) a 35-year-old male who has abdominal
pain, nausea, and vomiting, and d) a 40-year-old female who has a severe
headache, blurred vision, and slurred speech. Using the ABCDE (airway,
breathing, circulation, disability, exposure) principle, which patient should
the nurse prioritize?
a) The 25-year-old male
b) The 50-year-old female
c) The 35-year-old male
d) The 40-year-old female
*Answer: b) The 50-year-old female*
Rationale: The 50-year-old female has the most life-threatening condition
that could indicate a myocardial infarction (heart attack). Chest pain
radiating to the left arm and jaw is a classic sign of cardiac ischemia. The
, nurse should prioritize this patient to prevent cardiac arrest and
irreversible damage to the heart muscle. The other patients have serious
but less critical conditions that can be assessed later.
3. A nurse is assigned to care for five patients in a pediatric unit. The
patients have the following conditions: a) a 2-year-old child who has
pneumonia and is receiving oxygen therapy, b) a 4-year-old child who has
gastroenteritis and is dehydrated, c) a 6-year-old child who has
appendicitis and is scheduled for surgery, d) an 8-year-old child who has
asthma and is on nebulizer treatments, and e) a 10-year-old child who has
a fractured arm and is in pain. Using Maslow's hierarchy of needs, which
patient should the nurse prioritize?
a) The 2-year-old child
b) The 4-year-old child
c) The 6-year-old child
d) The 8-year-old child
e) The 10-year-old child
*Answer: a) The 2-year-old child*
Rationale: According to Maslow's hierarchy of needs, physiological needs
are the most basic and essential for survival. The 2-year-old child has the
most compromised physiological need of oxygenation due to pneumonia.
Oxygen therapy is vital to maintain adequate oxygen saturation and
prevent respiratory failure. The other patients have less urgent
physiological needs that can be addressed later.
4. A nurse is working in a psychiatric unit and has four patients to care
for. The patients have the following conditions: a) a patient with
schizophrenia who is experiencing auditory hallucinations and is agitated,
b) a patient with bipolar disorder who is in a manic episode and is
spending money impulsively, c) a patient with major depressive disorder
who is suicidal and has a plan to overdose on pills, and d) a patient with
generalized anxiety disorder who is having panic attacks and is
hyperventilating. Using the nursing process, which patient should the
nurse assess first?
a) The patient with schizophrenia
b) The patient with bipolar disorder
c) The patient with major depressive disorder
d) The patient with generalized anxiety disorder
