Unit 6 Prioritization and Delegation questions
and answers with solutions
The nurse has just admitted a client with sickle cell crisis. What is the nurse's priority
intervention?
Increasing fluid intake and giving analgesics
The primary therapy for sickle cell crisis is to increase fluid intake according to age and to give
analgesics. Blood transfusions are given conservatively to avoid iron overload. Antibiotics are
given to clients with fever. Routine splenectomy is controversial, and not recommended.
A hospitalized client, with a productive cough, chills, and night sweats is suspected of having
active tuberculosis (TB). What is the nurse's most important intervention?
Maintain the client on respiratory isolation
This client is showing signs and symptoms of active TB and, because of the productive cough, is
highly contagious. He should be admitted to the hospital and placed in respiratory isolation.
Three sputum cultures should be obtained to confirm the diagnosis.
What is the nurse's most important intervention for a client having a tonic-clonic seizure?
Protect the client from further injury
The priority during and after a seizure is to protect the person from injury by keeping them from
falling to the floor. Furniture or other objects that be a source of injury during the seizure
should be moved out of the client's way. Timing the seizure, and noting the origin of the seizure
are important, but are not the priority. Nothing should be placed in the client's mouth during a
seizure because teeth may be dislodged or the tongue pushed back, further obstructing the
airway.
The nurse is concerned that a client admitted with major depressive disorder may be suicidal.
What is the most important action by the nurse?
Ask a direct question such as, "Do you ever think about killing yourself?"
,The best approach is to ask about thoughts of suicide in a direct and caring manner. Assessing
for attention-seeking behaviors doesn't deal directly with the problem. The client should be
assessed directly, not through family members. Assessment must be performed before
determining whether suicide precautions are necessary.
A two-month-old infant arrives with a heart rate of 180 bpm and a temperature of 103.1° F
(39.5° C) rectally. What is the most appropriate initial nursing intervention?
give acetaminophen
Acetaminophen should be given to decrease the temperature. A heart rate of 180/bpm is
normal in an infant with a fever. A tepid sponge bath may be given to help decrease the
temperature and calm the infant. Carotid massage, and placing the infant's hands in cold water
are attempts to decrease the heart rate through vagal maneuvers. This will not work because
the source of the increased heart rate is fever. Fluid intake is encouraged after the
acetaminophen is given to help replace insensible fluid losses.
A client experiencing alcohol withdrawal reports being upset about going through
detoxification. Which goal is the priority for this client?
working with the nurse to remain safe
The priority goal is for client safety. Although drinking enough fluids, identifying personal
strengths, and committing to a drug-free lifestyle are important goals, the nurse's first priority
must be to promote client safety.
A nurse is working on a pediatric floor with a five-client assignment. In which order should the
nurse see the assigned clients, starting with the client the nurse should see first? All options
must be used.
a 15-year-old client waiting for transport to the operating room
a 2-month-old client with respiratory syncytial virus in an oxygen tent
a 4-year-old client with nausea and vomited one hour ago
a 3-day-old client with hyperbilrubinemia waiting for discharge
a 5-year-old client admitted with asthma at the radiology department
The nurse will prioritize the 15-year-old client waiting for transport to the operating room to be
, sure the client is ready for surgery. Then, the 2-month-old client with respiratory syncytial virus
in an oxygen tent should be assessed to be sure that oxygenation is safe. The 4-year-old client
with nausea and who vomited one hour ago can be assessed third since the nausea and
vomiting occurred 1 hour ago. The 3-day-old client with hyperbilrubinemia waiting for discharge
is stable and can be seen next. Lastly, the 5 year old client admitted with asthma is at radiology
department so the assessment can be done when the client returns to the unit.
An older adult client with pneumonia is admitted with prescriptions for intravenous antibiotics,
supplemental oxygen as needed, and antipyretics. The nurse should immediately notify the
health care provider for which assessment finding?
acute onset delirium
The acute change in client cognition (i.e., delirium) is considered a medical emergency and
should be investigated immediately. This acute change could be evidence of sepsis, electrolyte
imbalances, or other organic causes that should be diagnosed and treated as soon as possible.
The nurse should assess for the common symptoms of pneumonia such as fever, chills, dyspnea,
pleuritic chest pain, and a productive cough. These symptoms should be monitored, but the
nurse has treatments prescribed by the health care provider to address these findings.
The nurse is caring for a client with functional neurologic symptom disorder who has
experienced pseudoseizures. What intervention is appropriate for the nurse to perform?
Encourage the client to discuss feelings about the pseudoseizures.
Pseudoseizures or psychogenic nonepileptic seizures are considered a psychological symptom
and are not related to electrical disturbance in the central nervous system as epileptic seizures
are. However, they are a serious disorder and should not be minimized to the client by the
nurse. Cognitive behavioral therapy is a primary intervention and requires open dialogue
between the client and nurse so the client should be encouraged to verbalize feelings. Placebo
administration is unethical, and the nurse should not participate in this intervention. While the
nurse should remain calm and not draw excessive attention to the client during a
pseudoseizure, the nurse should not ignore the client outright.
A primiparous client arrives for her first prenatal visit at 10 weeks' gestation. The client seems
nervous and has many questions. What is the most important intervention by the nurse?
Reassure the client that all her questions will be answered during the visit.
and answers with solutions
The nurse has just admitted a client with sickle cell crisis. What is the nurse's priority
intervention?
Increasing fluid intake and giving analgesics
The primary therapy for sickle cell crisis is to increase fluid intake according to age and to give
analgesics. Blood transfusions are given conservatively to avoid iron overload. Antibiotics are
given to clients with fever. Routine splenectomy is controversial, and not recommended.
A hospitalized client, with a productive cough, chills, and night sweats is suspected of having
active tuberculosis (TB). What is the nurse's most important intervention?
Maintain the client on respiratory isolation
This client is showing signs and symptoms of active TB and, because of the productive cough, is
highly contagious. He should be admitted to the hospital and placed in respiratory isolation.
Three sputum cultures should be obtained to confirm the diagnosis.
What is the nurse's most important intervention for a client having a tonic-clonic seizure?
Protect the client from further injury
The priority during and after a seizure is to protect the person from injury by keeping them from
falling to the floor. Furniture or other objects that be a source of injury during the seizure
should be moved out of the client's way. Timing the seizure, and noting the origin of the seizure
are important, but are not the priority. Nothing should be placed in the client's mouth during a
seizure because teeth may be dislodged or the tongue pushed back, further obstructing the
airway.
The nurse is concerned that a client admitted with major depressive disorder may be suicidal.
What is the most important action by the nurse?
Ask a direct question such as, "Do you ever think about killing yourself?"
,The best approach is to ask about thoughts of suicide in a direct and caring manner. Assessing
for attention-seeking behaviors doesn't deal directly with the problem. The client should be
assessed directly, not through family members. Assessment must be performed before
determining whether suicide precautions are necessary.
A two-month-old infant arrives with a heart rate of 180 bpm and a temperature of 103.1° F
(39.5° C) rectally. What is the most appropriate initial nursing intervention?
give acetaminophen
Acetaminophen should be given to decrease the temperature. A heart rate of 180/bpm is
normal in an infant with a fever. A tepid sponge bath may be given to help decrease the
temperature and calm the infant. Carotid massage, and placing the infant's hands in cold water
are attempts to decrease the heart rate through vagal maneuvers. This will not work because
the source of the increased heart rate is fever. Fluid intake is encouraged after the
acetaminophen is given to help replace insensible fluid losses.
A client experiencing alcohol withdrawal reports being upset about going through
detoxification. Which goal is the priority for this client?
working with the nurse to remain safe
The priority goal is for client safety. Although drinking enough fluids, identifying personal
strengths, and committing to a drug-free lifestyle are important goals, the nurse's first priority
must be to promote client safety.
A nurse is working on a pediatric floor with a five-client assignment. In which order should the
nurse see the assigned clients, starting with the client the nurse should see first? All options
must be used.
a 15-year-old client waiting for transport to the operating room
a 2-month-old client with respiratory syncytial virus in an oxygen tent
a 4-year-old client with nausea and vomited one hour ago
a 3-day-old client with hyperbilrubinemia waiting for discharge
a 5-year-old client admitted with asthma at the radiology department
The nurse will prioritize the 15-year-old client waiting for transport to the operating room to be
, sure the client is ready for surgery. Then, the 2-month-old client with respiratory syncytial virus
in an oxygen tent should be assessed to be sure that oxygenation is safe. The 4-year-old client
with nausea and who vomited one hour ago can be assessed third since the nausea and
vomiting occurred 1 hour ago. The 3-day-old client with hyperbilrubinemia waiting for discharge
is stable and can be seen next. Lastly, the 5 year old client admitted with asthma is at radiology
department so the assessment can be done when the client returns to the unit.
An older adult client with pneumonia is admitted with prescriptions for intravenous antibiotics,
supplemental oxygen as needed, and antipyretics. The nurse should immediately notify the
health care provider for which assessment finding?
acute onset delirium
The acute change in client cognition (i.e., delirium) is considered a medical emergency and
should be investigated immediately. This acute change could be evidence of sepsis, electrolyte
imbalances, or other organic causes that should be diagnosed and treated as soon as possible.
The nurse should assess for the common symptoms of pneumonia such as fever, chills, dyspnea,
pleuritic chest pain, and a productive cough. These symptoms should be monitored, but the
nurse has treatments prescribed by the health care provider to address these findings.
The nurse is caring for a client with functional neurologic symptom disorder who has
experienced pseudoseizures. What intervention is appropriate for the nurse to perform?
Encourage the client to discuss feelings about the pseudoseizures.
Pseudoseizures or psychogenic nonepileptic seizures are considered a psychological symptom
and are not related to electrical disturbance in the central nervous system as epileptic seizures
are. However, they are a serious disorder and should not be minimized to the client by the
nurse. Cognitive behavioral therapy is a primary intervention and requires open dialogue
between the client and nurse so the client should be encouraged to verbalize feelings. Placebo
administration is unethical, and the nurse should not participate in this intervention. While the
nurse should remain calm and not draw excessive attention to the client during a
pseudoseizure, the nurse should not ignore the client outright.
A primiparous client arrives for her first prenatal visit at 10 weeks' gestation. The client seems
nervous and has many questions. What is the most important intervention by the nurse?
Reassure the client that all her questions will be answered during the visit.
