What to do first questions...

nurseprnRN, BSN, RN · Sep 26, 2012

2. You are caring for a client on a ventilator who is exhibiting respiratory distress. The ventilator alarms are going off. Which intervention should you do first?

a. Notify the respiratory therapist immediately.

b. Ventilate with a manual resuscitation bag.

c. Check the ventilator to resolve the problem.

d. Auscultate the client’s lung sounds.

RATIONALE: You need to assess patient first. RT doesn’t need to be notified and you wouldn’t ventilate unless needed AFTER you assess patient.

Yes, safety first; if that's not a choice, then assessment should come first, if it's indicated. (Can't seem to turn off the bold here, will have to italicize)

18. The elderly client diagnosed with deep vein thrombosis is complaining of chest pain during inhalation. Which intervention should you implement first?

a. Ask the health care provider to order a stat lung scan.

b. Place oxygen on the client via nasal cannula.

c. Prepare to administer intravenous heparin.

d. Tell the client not to ambulate and remain in bed.

RATIONALE: I would want to keep the patient in bed so I can then administer oxygen per nasal cannula, have someone contact physician/rapid response team to assist/evaluate patient. The heparin drip would be started after evaluation from rapid response team.

You'd want her to stay in bed because she might (maybe not) have thrown a deep vein thrombosis to her lung, could have more, and could get in worse trouble, and then it's so inconvenient to try to do rapid-response on somebody who's not in bed. Seriously, though, safety is always first, and this keeps her safest. YOu call the provider and describe the symptoms, but you don't do O2 or prepare heparin without an order.

19. The client is 1 week postoperative for right below the knee amputation secondary to arterial occlusive disease. The rehabilitation nurse is unable to assess a pedal pulse in the left foot. Which intervention should the nurse implement first?

a. Assess for paresthesia and paralysis.

b. Utilize the Doppler device to auscultate the pulse.

c. Place the client's leg in the dependent position.

d. Wrap the client’s left leg in a warm blanket.

RATIONALE: I would want to finish the neurovascular assessment pulse, temperature, sensation, movement and then do the other choices after that.

If this person has already lost a leg to peripheral arterial disease, you have to know that if you have lousy arteries in one place, you have them in lots of places. She probably doesn't have pulses in that foot, and maybe hasn't had for a long time. It is very likely that she already has paresthesia, since the #1 cause of PAD is DM and #1 cause of nontraumatic amputation is PAD r/t DM. Therefore your INTERVENTION (not assessment-- you already did that, and found no pulses)(and incidentally, this nurse is in rehab, not acute care; she ought to have read the chart to see if those pulses were there before transfer) is to do what you can to improve blood flow. For peripheral arterial disease, the classic intervention is to put the leg in the dependent position, not elevated, so gravity can help arterial pressure distally. Warm applications are contraindicated due to the risk of injury.

24. You are returning phone messages from clients. Which would you call first?

a. The client who called reporting being dizzy when getting up.

b. The client who has been having abdominal cramping.

c. The client who is complaining of nausea and vomiting.

d. The client who has not had a bowel movement in 3 days.

RATIONALE: I do not know which one, but I feel that the first one is more important due to loss of consciousness, falls, poor perfusion are possible complications.

Exactly right. Risk of falls are worse than all the rest. You're going to call all of them, because they could all have something bad wrong, but the risk of fall is real and present NOW.

26. You are the home health nurse visiting a client diagnosed with end stage congestive heart failure. You find the client lying in bed, short of breath, unable to talk and with buccal cyanosis. Which intervention would you implement first?

a. Assist the client to a sitting position.

b. Assess the patient's vital signs.

c. Call 911 for the ambulance.

d. Auscultate the client’s lung sounds.

RATIONALE: I am all about assessing the patient first, but I feel like sitting the position up would help with breathing.

Sit her/him up (will improve what ventilation s/he has), listen to the chest, take the VS, then you have info with which to call 911 (if the patient consents) and/or provider.

laceym · Sep 26, 2012

What about these questions? Bold are what I think

1. You are on a critical care unit caring for clients with a spinal cord injury. Which client should you assess first after receiving the following information in the change of shift report?

a. The client with a C-6 spinal cord injury who is complaining of dyspnea and has a respiratory rate of 12 breaths/minute.

b. The client with an L-4 spinal cord injury who is frightened about being transferred to the rehabilitation unit.

c. The client with an L-2 spinal cord injury who is complaining of a headache and feeling very hot all of a sudden.

d. The client with a C-4 spinal cord injury who is on a ventilator and has a pulse oximeter reading of 98%.

RATIONALE: This sounds like possible autonomic dysreflexia or increased intracranial pressure and needs to be treated as a neurological emergency to prevent hyptertensive stoke. The C-6 spinal cord injury has within range respiratory rate and they are expected to have decreased respiratory reserve.

13. You are caring for clients in a long term care facility. Which client should you assess first after receiving morning report?

a. The client diagnosed with Parkinson’s disease who began to hallucinate during the night.

b. The client diagnosed with congestive heart failure who has 3_ pitting edema of both feet.

c. The client diagnosed with Alzheimer’s disease who was found wandering in the hall at 0200 this morning.

d. The client diagnosed with terminal cancer who has lost 8 pounds since the last weight 4 weeks ago.

RATIONALE: I would assess CHF patient first because he/she is someone that may need a diuretic or his/her physician contacted for orders. Hallucination is a possibility in late stages of Parkinson’s disease, Alzheimer’s patients are known to wander, and the terminal cancer patient is expected to have weight loss.

25. You are evaluating vital signs for client being seen in the outpatient clinic. Which client would warrant intervention?

a. The 10 month old infant who has a pulse rate of 140.

b. The 3 year old toddler who has a respiratory rate of 28.

c. The 24 week gestational woman who has a blood pressure of 142/96.

d. The 42 year old client who has a temperature of 100.2 degrees F.

RATIONALE: Per resources, infant's pulse is in range, respiratory rate of toddler is in range, and the client with a slight temperature is not as serious as a pregnant woman with a blood pressure of 142/96 because this could mean pre-eclampsia.

Thanks for the feedback

flora_932 · Oct 1, 2012

1. You are on a critical care unit caring for clients with a spinal cord injury. Which client should you assess first after receiving the following information in the change of shift report?

a. The client with a C-6 spinal cord injury who is complaining of dyspnea and has a respiratory rate of 12 breaths/minute.

b. The client with an L-4 spinal cord injury who is frightened about being transferred to the rehabilitation unit.

c. The client with an L-2 spinal cord injury who is complaining of a headache and feeling very hot all of a sudden.

d. The client with a C-4 spinal cord injury who is on a ventilator and has a pulse oximeter reading of 98%.

RATIONALE: This sounds like possible autonomic dysreflexia or increased intracranial pressure and needs to be treated as a neurological emergency to prevent hyptertensive stoke. The C-6 spinal cord injury has within range respiratory rate and they are expected to have decreased respiratory reserve.

nope, the C-6 client should be assessed first due to dyspnea (shortness of breath, which is not normal) based on Airway, Breathing, Circulation [ABC]. You're starting to diagnose like a doctor, as nurses we only diagnose to responses of health problems, not the health problem itself.

13. You are caring for clients in a long term care facility. Which client should you assess first after receiving morning report?

a. The client diagnosed with Parkinson's disease who began to hallucinate during the night.

b. The client diagnosed with congestive heart failure who has 3_ pitting edema of both feet.

c. The client diagnosed with Alzheimer's disease who was found wandering in the hall at 0200 this morning.

d. The client diagnosed with terminal cancer who has lost 8 pounds since the last weight 4 weeks ago.

RATIONALE: I would assess CHF patient first because he/she is someone that may need a diuretic or his/her physician contacted for orders. Hallucination is a possibility in late stages of Parkinson's disease, Alzheimer's patients are known to wander, and the terminal cancer patient is expected to have weight loss.

nope, its the hallucinating Parkinson's disease patient. you want to assess their safety. these questions are mostly based on safety and Airway, Breathing, Circulation [ABC]. I had picked the CHF patient too with the same logic, but its not the most important since hallucination can cause suicides. And hallucination is a symptom of Parkinson's disease (you would think that the one with the abnormal symptom/result would be the one here, but its not)