NURS 502 Chapter 36 and 47 Questions
Effectiveness and efficiency - ANS-A recently hired graduate nurse is having difficulty
establishing a workflow, which is affecting the quality of patient care provided. The nurse
manager discusses setting priorities, managing time, and delegating to staff as strategies the
new graduate can use. Which qualities that affect patient perception of nursing care are
supported through use of these strategies?
a. Accountability and responsibility
b. Adaptability and flexibility
c. Effectiveness and efficiency
d. Empathy and caring
Assess pulse, respiratory rate, and blood pressure. - ANS-Which action should the nurse
perform immediately upon the patient's arrival?
a. Insert a Foley catheter.
b. Insert two large-bore intravenous (IV) catheters for fluid replacement.
c. Obtain a complete medical history from those accompanying the patient.
d. Assess pulse, respiratory rate, and blood pressure.
The patient complains of shortness of breath when walking from the bed to the bathroom. -
ANS-The nurse is caring for several patients during a shift. Which data collected during a
nursing assessment should be a priority for care?
a. The patient complains of shortness of breath when walking from the bed to the bathroom.
b. The patient has a blood pressure of 96/54 mmHg, heart rate of 70 beats/min, respiration rate
of 20 breaths/min, and temperature of 97.6°F.
c. The patient begins coughing after 6 minutes of walking.
d. The patient has an oxygen saturation of 94%.
Assessing neurologic status frequently - ANS-The nurse is caring for a patient with increased
intracranial pressure. Which is a priority nursing intervention?
a. Monitoring oxygenation status
b. Assessing neurologic status frequently
c. Checking for bowel and bladder distention
d. Spacing nursing care to allow for rest periods
,Nursing process - ANS-A recently graduated nurse asks a mentor for guidance concerning how
to determine priorities when working with patients. Which process codified by the American
Nurses Association (ANA) should the mentor refer to as a useful framework?
a. Clinical decision-making process
b. Evidence-based process
c. Quality-improvement process
d. Nursing process
Obtaining an order for intravenous fluids at 100 mL/hr - ANS-A 64-year-old patient is receiving
chemotherapy for breast cancer. After the morning report, the nurse finds the patient nauseated,
vomiting light green emesis, and crying because her hair is falling out in clumps. The pulse is
110 beats/min and thready, and the blood pressure is 96/50 mmHg. Which intervention should
the nurse make priority for this patient?
a. Obtaining an order for intravenous fluids at 100 mL/hr
b. Cleansing the skin and applying a clean hospital gown
c. Premedication for nausea before the next chemotherapy dose
d. Teaching the patient some deep-breathing exercises to help her calm down
"I'll get the pain medication first because the pain level is so high, and I'll get another staff
member to refill the water pitcher." - ANS-A patient admitted for palliative care secondary to a
recent diagnosis of pancreatic cancer asks the nurse for medication for pain because the pain is
now a 9 on a 10-point scale. The family of the patient also asks if the nurse can make sure to fill
the patient's water pitcher. Which response by the nurse would best help the family to
understand the prioritization of the current needs?
a. "The medications are not near the water station. Is it okay if I bring the water later?"
b. "Right now, I'm just worried about getting the pain under control."
c. "I'll get the pain medication first because the pain level is so high, and I'll get another staff
member to refill the water pitcher."
d. "I'll see what I can do; I'll be back as soon as I can."
A 33-year-old patient admitted with a new diagnosis of hepatic cancer who is tearful and very
anxious - ANS-The nurse is assigned to four patients. In the shift report, the outgoing nurse
shares the various upcoming needs and issues that the incoming nurse will need to address.
Which patient's needs should the nurse classify as medium priority?
a. A 67-year-old patient with deep vein thrombosis who recently started coumadin therapy
b. A 52-year-old stroke patient who is dealing with severe dysphagia and impaired ability to
clear the airway of mucus
c. A 90-year-old patient who is admitted secondary to inability to care for self and awaiting
transfer to a long-term care facility
,d. A 33-year-old patient admitted with a new diagnosis of hepatic cancer who is tearful and very
anxious
Blood draw for vancomycin trough - ANS-Which nursing intervention would require priority
based on a time constraint?
a. Foley catheter change
b. Wound dressing change
c. Blood draw for vancomycin trough
d. Admission assessment for new hospice patient
A patient with stroke symptoms - ANS-The nurse is caring for several patients in the emergency
department. Which patient should the nurse prioritize for care using the urgency factor?
a. A patient with a fractured femur
b. A patient with stroke symptoms
c. A patient with sharp, continuous pain radiating from the kidney area
d. A young child with a possible arm fracture
Assisting in the ambulation of a postoperative patient - ANS-The nurse on a medical-surgical
unit has finished receiving the report on five assigned patients for the day. Which nursing
intervention should the nurse consider an acute intervention when organizing the day?
a. Assisting in the ambulation of a postoperative patient
b. Teaching a patient and family how to care for an indwelling urinary catheter
c. Sitting with a patient who is anxious about an upcoming procedure
d. Completing an activity of daily living (ADL) assessment on a patient who is being transferred
to a long-term care facility
A 36-year-old who is 32 weeks pregnant with her first child and is experiencing difficulty
breathing - ANS-An emergency department nurse is organizing care for several patients
admitted following a multiple-vehicle crash. Which patient should the nurse classify as having
critically urgent needs?
a. A 72-year-old with a small gash above the right eye that has currently stopped bleeding
b. A 36-year-old who is 32 weeks pregnant with her first child and is experiencing difficulty
breathing
c. A 5-year-old with multiple bumps and bruises who is frightened and anxious
d. A 16-year-old patient who is complaining of pain in the right wrist and has an immobilizer in
place
Imminent death - ANS-The nurse is conducting triage in a mental health facility. A family
member brings in a patient for suspected overdose. The patient's breathing is very slow and
shallow, and the patient is not responding to the nurse's questions. The nurse has several other
, patients awaiting triage. Which level of urgency in nursing intervention should the nurse
prioritize?
a. Critical
b. Acute
c. Imminent death
d. Non Acute
Priority 2: Should do - ANS-An unlicensed assistive personnel (UAP) has asked the nurse for
assistance ambulating an 87-year-old patient who is on postoperative day 3 following a knee
replacement. As which level of priority should the nurse classify this request when organizing
the activities of the day?
a. Priority 2: Should do
b. Priority 1: Must do
c. Priority 1: Vital to do
d. Priority 3: Nice to do
The patient with difficulty breathing requiring oxygenation - ANS-The nurse who is working in
the emergency department receives multiple patients. Which patient requires priority nursing
care?
a. The patient with atelectasis requiring thoracentesis
b. The patient with a laceration to the lower extremity requiring sutures
c. The patient with a distended bladder and accompanying pain requiring catheterization
d. The patient with difficulty breathing requiring oxygenation
A middle-aged adult complaining of sinus headache and possible sinus infection - ANS-The
emergency department nurse is triaging patients for the urgent or nonurgent track. Which
patient should the nurse triage into the nonurgent track?
a. A middle-aged adult complaining of sinus headache and possible sinus infection
b. An infant with severe flu symptoms
c. An older adult who fell at home and whose family is unsure if the patient experienced a head
injury from the fall
d. A school-aged child having an allergic response to a bee sting
Justice and fairness - ANS-A nurse new to the emergency department is struggling with triaging
patients and assigning priority for care because many of the individuals who present seem to
have equally significant problems. Which ethical principles should the nurse use as guides when
setting priorities?
a. Integrity and respect
b. Justice and fairness
Effectiveness and efficiency - ANS-A recently hired graduate nurse is having difficulty
establishing a workflow, which is affecting the quality of patient care provided. The nurse
manager discusses setting priorities, managing time, and delegating to staff as strategies the
new graduate can use. Which qualities that affect patient perception of nursing care are
supported through use of these strategies?
a. Accountability and responsibility
b. Adaptability and flexibility
c. Effectiveness and efficiency
d. Empathy and caring
Assess pulse, respiratory rate, and blood pressure. - ANS-Which action should the nurse
perform immediately upon the patient's arrival?
a. Insert a Foley catheter.
b. Insert two large-bore intravenous (IV) catheters for fluid replacement.
c. Obtain a complete medical history from those accompanying the patient.
d. Assess pulse, respiratory rate, and blood pressure.
The patient complains of shortness of breath when walking from the bed to the bathroom. -
ANS-The nurse is caring for several patients during a shift. Which data collected during a
nursing assessment should be a priority for care?
a. The patient complains of shortness of breath when walking from the bed to the bathroom.
b. The patient has a blood pressure of 96/54 mmHg, heart rate of 70 beats/min, respiration rate
of 20 breaths/min, and temperature of 97.6°F.
c. The patient begins coughing after 6 minutes of walking.
d. The patient has an oxygen saturation of 94%.
Assessing neurologic status frequently - ANS-The nurse is caring for a patient with increased
intracranial pressure. Which is a priority nursing intervention?
a. Monitoring oxygenation status
b. Assessing neurologic status frequently
c. Checking for bowel and bladder distention
d. Spacing nursing care to allow for rest periods
,Nursing process - ANS-A recently graduated nurse asks a mentor for guidance concerning how
to determine priorities when working with patients. Which process codified by the American
Nurses Association (ANA) should the mentor refer to as a useful framework?
a. Clinical decision-making process
b. Evidence-based process
c. Quality-improvement process
d. Nursing process
Obtaining an order for intravenous fluids at 100 mL/hr - ANS-A 64-year-old patient is receiving
chemotherapy for breast cancer. After the morning report, the nurse finds the patient nauseated,
vomiting light green emesis, and crying because her hair is falling out in clumps. The pulse is
110 beats/min and thready, and the blood pressure is 96/50 mmHg. Which intervention should
the nurse make priority for this patient?
a. Obtaining an order for intravenous fluids at 100 mL/hr
b. Cleansing the skin and applying a clean hospital gown
c. Premedication for nausea before the next chemotherapy dose
d. Teaching the patient some deep-breathing exercises to help her calm down
"I'll get the pain medication first because the pain level is so high, and I'll get another staff
member to refill the water pitcher." - ANS-A patient admitted for palliative care secondary to a
recent diagnosis of pancreatic cancer asks the nurse for medication for pain because the pain is
now a 9 on a 10-point scale. The family of the patient also asks if the nurse can make sure to fill
the patient's water pitcher. Which response by the nurse would best help the family to
understand the prioritization of the current needs?
a. "The medications are not near the water station. Is it okay if I bring the water later?"
b. "Right now, I'm just worried about getting the pain under control."
c. "I'll get the pain medication first because the pain level is so high, and I'll get another staff
member to refill the water pitcher."
d. "I'll see what I can do; I'll be back as soon as I can."
A 33-year-old patient admitted with a new diagnosis of hepatic cancer who is tearful and very
anxious - ANS-The nurse is assigned to four patients. In the shift report, the outgoing nurse
shares the various upcoming needs and issues that the incoming nurse will need to address.
Which patient's needs should the nurse classify as medium priority?
a. A 67-year-old patient with deep vein thrombosis who recently started coumadin therapy
b. A 52-year-old stroke patient who is dealing with severe dysphagia and impaired ability to
clear the airway of mucus
c. A 90-year-old patient who is admitted secondary to inability to care for self and awaiting
transfer to a long-term care facility
,d. A 33-year-old patient admitted with a new diagnosis of hepatic cancer who is tearful and very
anxious
Blood draw for vancomycin trough - ANS-Which nursing intervention would require priority
based on a time constraint?
a. Foley catheter change
b. Wound dressing change
c. Blood draw for vancomycin trough
d. Admission assessment for new hospice patient
A patient with stroke symptoms - ANS-The nurse is caring for several patients in the emergency
department. Which patient should the nurse prioritize for care using the urgency factor?
a. A patient with a fractured femur
b. A patient with stroke symptoms
c. A patient with sharp, continuous pain radiating from the kidney area
d. A young child with a possible arm fracture
Assisting in the ambulation of a postoperative patient - ANS-The nurse on a medical-surgical
unit has finished receiving the report on five assigned patients for the day. Which nursing
intervention should the nurse consider an acute intervention when organizing the day?
a. Assisting in the ambulation of a postoperative patient
b. Teaching a patient and family how to care for an indwelling urinary catheter
c. Sitting with a patient who is anxious about an upcoming procedure
d. Completing an activity of daily living (ADL) assessment on a patient who is being transferred
to a long-term care facility
A 36-year-old who is 32 weeks pregnant with her first child and is experiencing difficulty
breathing - ANS-An emergency department nurse is organizing care for several patients
admitted following a multiple-vehicle crash. Which patient should the nurse classify as having
critically urgent needs?
a. A 72-year-old with a small gash above the right eye that has currently stopped bleeding
b. A 36-year-old who is 32 weeks pregnant with her first child and is experiencing difficulty
breathing
c. A 5-year-old with multiple bumps and bruises who is frightened and anxious
d. A 16-year-old patient who is complaining of pain in the right wrist and has an immobilizer in
place
Imminent death - ANS-The nurse is conducting triage in a mental health facility. A family
member brings in a patient for suspected overdose. The patient's breathing is very slow and
shallow, and the patient is not responding to the nurse's questions. The nurse has several other
, patients awaiting triage. Which level of urgency in nursing intervention should the nurse
prioritize?
a. Critical
b. Acute
c. Imminent death
d. Non Acute
Priority 2: Should do - ANS-An unlicensed assistive personnel (UAP) has asked the nurse for
assistance ambulating an 87-year-old patient who is on postoperative day 3 following a knee
replacement. As which level of priority should the nurse classify this request when organizing
the activities of the day?
a. Priority 2: Should do
b. Priority 1: Must do
c. Priority 1: Vital to do
d. Priority 3: Nice to do
The patient with difficulty breathing requiring oxygenation - ANS-The nurse who is working in
the emergency department receives multiple patients. Which patient requires priority nursing
care?
a. The patient with atelectasis requiring thoracentesis
b. The patient with a laceration to the lower extremity requiring sutures
c. The patient with a distended bladder and accompanying pain requiring catheterization
d. The patient with difficulty breathing requiring oxygenation
A middle-aged adult complaining of sinus headache and possible sinus infection - ANS-The
emergency department nurse is triaging patients for the urgent or nonurgent track. Which
patient should the nurse triage into the nonurgent track?
a. A middle-aged adult complaining of sinus headache and possible sinus infection
b. An infant with severe flu symptoms
c. An older adult who fell at home and whose family is unsure if the patient experienced a head
injury from the fall
d. A school-aged child having an allergic response to a bee sting
Justice and fairness - ANS-A nurse new to the emergency department is struggling with triaging
patients and assigning priority for care because many of the individuals who present seem to
have equally significant problems. Which ethical principles should the nurse use as guides when
setting priorities?
a. Integrity and respect
b. Justice and fairness
