You are the charge nurse in a busy med-surg unit. There are several patients under your care, and you are managing a group of nurses. Which patient should be prioritized for immediate intervention?

A patient with a fractured femur who is receiving a dose of opioid pain medication and reports a pain level of 8/10.

A patient who has just returned from a colonoscopy and is stable but complaining of minor bloating.

A patient with newly diagnosed Type 1 diabetes who is receiving insulin for the first time and reports confusion.

A patient with a history of heart failure who has a blood pressure of 90/60 mmHg and is lethargic.

Answer and Explanation

The Correct Answer is D

Choice A reason: Pain of 8/10 is significant, but the patient is receiving opioids, and pain is less immediately life-threatening than hypotension and lethargy. This is incorrect, as it’s lower priority than the nurse’s need to address a patient with unstable vital signs.

Choice B reason: Minor bloating post-colonoscopy is expected and stable, not requiring immediate intervention. Hypotension in heart failure is critical, making this incorrect, as it’s less urgent than the nurse’s priority to manage a patient with potential decompensation.

Choice C reason: Confusion in new Type 1 diabetes may indicate hypoglycemia, but hypotension and lethargy in heart failure suggest acute decompensation, a higher priority. This is incorrect, as it’s less critical than the nurse’s focus on the heart failure patient’s instability.

Choice D reason: Hypotension (90/60 mmHg) and lethargy in a heart failure patient indicate possible cardiogenic shock, requiring immediate intervention. This aligns with prioritization in acute care, making it the correct patient for the charge nurse to prioritize for urgent assessment and action.

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Correct Answer is B

Explanation

Choice A reason: Initiating antibiotics is critical but follows cultures to identify the causative organism. Obtaining cultures first ensures accurate treatment, making this incorrect, as it risks altering culture results if antibiotics are given before sampling in the pneumonia client.

Choice B reason: Obtaining blood and sputum cultures first identifies the pneumonia-causing organism, guiding effective antibiotic therapy. This aligns with infection management protocols, making it the correct initial order to implement for the client admitted with pneumonia to ensure accurate treatment.

Choice C reason: Airborne precautions are needed for specific pneumonias (e.g., tuberculosis), but most require droplet precautions. Cultures guide treatment, making this incorrect, as it’s less urgent than obtaining cultures first to confirm the pathogen in the client with pneumonia.

Choice D reason: An indwelling catheter is unnecessary for pneumonia unless urinary retention is present. Obtaining cultures is the priority, making this incorrect, as it’s irrelevant to the immediate management of the client’s infection compared to identifying the causative organism.

A. Palpation of a thrill over the fistula. B. Presence of a radial pulse in the left wrist. C. Visualization of enlarged blood vessels at the fistula site. D. Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand.

Correct Answer is A

Explanation

Choice A reason: Palpation of a thrill, a vibrating sensation, indicates blood flow and patency in an arteriovenous fistula. This aligns with hemodialysis access assessment, making it the correct finding the nurse would use to confirm the fistula is patent.

Choice B reason: A radial pulse in the wrist is normal but doesn’t confirm fistula patency, which requires a thrill. Palpation of a thrill is specific, making this incorrect, as it’s not a direct indicator of fistula function in hemodialysis preparation.

Choice C reason: Enlarged vessels may suggest fistula development but don’t confirm active flow. A thrill indicates patency, making this incorrect, as it’s less specific than the nurse’s assessment of a palpable thrill over the fistula site.

Choice D reason: Capillary refill less than 3 seconds assesses distal perfusion, not fistula patency. Palpation of a thrill is the standard, making this incorrect, as it’s unrelated to the nurse’s evaluation of the arteriovenous fistula for hemodialysis.

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You are the charge nurse in a busy med-surg unit. There are several patients under your care, and you are managing a group of nurses. Which patient should be prioritized for immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client with pneumonia. Which of the following orders should be implemented first?

Correct Answer is B

Explanation

The nurse is assessing the patency of a client’s left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent?

Correct Answer is A

Explanation

The nurse is caring for a client with ulcerative colitis. Which findings does the nurse determine is consistent with this diagnosis? (Select all that apply)

The nurse cares for a client with 0.9% sodium chloride infusing at 125 mL/h. 2 hours after the infusion was started, the client’s central venous pressure (CVP) reading is 16 cm H2O. It is MOST important for the nurse to take which action?

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? (Select all that apply)

Which actions are considered best practices for the nurse to use during the administration of parenteral potassium to a client with a serum potassium level of 1.9 mEq/L (mmol/L)? (Select all that apply)

A client is being treated for diabetes insipidus (DI) with synthetic vasopressin (desmopressin). What is the priority health teaching that the nurse provides regarding drug therapy?

A nurse is caring for a client who is being treated for heart failure and has a prescription for furosemide. The nurse should plan to monitor for which of the following adverse effects of the medication?

A patient’s blood pressure is 90/72 mm Hg. What is the patient’s pulse pressure?