PRIORITIZATION PRACTICE TEST - Achievers Path Consult

Welcome to your PRIORITIZATION PRACTICE TEST

QUESTION 1: The pediatric nurse receives report on 4 clients. Which client should the nurse see FIRST?

1. A 2-month-old awaiting evaluation for possible hip dislocation; parents are at the bedside

2. A 6-year-old just returned from a bronchoscopy; a parent is at the bedside

3. A 7-year-old just returned from a noncontrast abdominal CT scan; no parents are at the bedside

4. An 11-year-old scheduled for ear surgery today; no parents are at the bedside

QUESTION 2: After receiving report on four clients the emergency room nurse should see the client with which of the following diagnosis FIRST?

1.Liver failure and now has petechiae

2.Cellulitis that is now itchy

3.Ovarian cyst

4.Chronic back pain 8/10

QUESTION 3: A 10-year-old weighs 99 lb (44.9 kg) and has a BMI of 24.8 kg/m2 (>95th percentile). Which is the most important assessment for the nurse to make before initiating a weight loss plan?

1. Child’s pattern of daily physical activity

2. Family’s eating habits

3. Family’s financial resources for purchasing healthy foods

4. Family’s readiness for change

QUESTION 4: The nurse in the emergency department assesses an older adult client. The client's family member states that the client has glaucoma, is hard of hearing, and has been experiencing abdominal pain for the past 24 hours. Which action by the nurse is the most appropriate?

1. Assess the intensity of the client’s pain using a numeric rating scale.

2. Ask if the client wears hearing aids.

3. Administer the prescribed pain medication to the client.

4. Determine when the client last saw a health care provider.

QUESTION 5: The nurse provides care for an infant immediately after a surgical procedure. Which nursing action is the most important?

1. Minimize stimuli for the infant.

2. Restrain all extremities.

3. Encourage the parents to stroke the infant.

4. Explain to the parent how to assist with the infant’s care.

QUESTION 6: The nurse cares for clients on the medical/surgical unit. After receiving report, which of the following clients should the nurse see FIRST?

1. An elderly client 2 days postop after a total hip replacement who slipped out of bed when trying to stand.

2. An elderly client with a history of cardiomyopathy who aspirated cooked cereal at breakfast.

3. An elderly client diagnosed with a right-sided CVA who requires assistance going to the bathroom.

4. An elderly client diagnosed with heart failure (HF) who has been vomiting for 3 days.

QUESTION 7: The nurse receives report on the medical-surgical unit. Which client does the nurse see first?

1.A client newly diagnosed with type 1 diabetes and who had a myocardial infarction 2 days ago.

2.A client diagnosed with right-sided heart failure and glaucoma.

3.A client diagnosed with chronic obstructive pulmonary disease (COPD) and psoriasis.

4.A client diagnosed with rheumatoid arthritis and malnutrition.

QUESTION 8: An LPN/LVN from a different team approaches the nurse. The LPN/LVN expresses concern because the RN (a new graduate) administers oxygen at 2 L/min to a client diagnosed with COPD. Which response by the nurse is best?

1.”I will assess the client for oxygen toxicity.”

2.”Are you concerned about the oxygen or the new graduate’s competency?”2.”Are you concerned about the oxygen or the new graduate’s competency?”

3.”Please tell me more about your concerns.”

4.”Leave the oxygen in place.”

QUESTION 9: The nurse receives report from the previous shift. Which client does the nurse see first?

1.A client with myocardial infarction whose monitoring shows four to six premature ventricular beats per hour.

2.A client with dementia who is confused, agitated, and incontinent of urine and feces.

3.A client with pneumonia who is increasingly confused and has a temperature of 104 °F (40 °C).

4.A client with diabetes who is restless during the night and whose fasting blood glucose is 170 g/dL (9.4 mmol/L).

QUESTION 10: Four clients arrive in the emergency department within a 5-minute period. Which client does the nurse see first?

1. A client, pale and diaphoretic, who reports sudden and severe pain radiating from the flank to the scrotum.

2. A client with right lower quadrant abdominal pain of 24 hours’ duration and which is relieved by flexing the legs.

3. A client, jaundiced and nauseated, who reports pain in the right shoulder and has a temperature of 100°F (37.8°C).

4. A client with sudden epigastric pain and nausea who is vomiting blood and has an odor of alcohol on the breath.

QUESTION 11. A nurse invites a friend home one evening. On arrival, the friend sees the nurse's large, white, long-haired cat sitting on the couch and begins to experience palpitations, trembling, nausea, shortness of breath, and a feeling of losing control. What should the nurse do first?

1. Stay with the friend until the friend feels better.

2. Have the friend breathe into a paper bag.

3. Remove the cat from the room.

4. Dim the lights in the room.

QUESTION 12. Question: A 72 year old client admitted with a diagnosis of bleeding ulcers has been prescribed ranitidine 50 mg IVPB every 8 hours and omeprazole 10 mg po every morning. Based on this data what intervention should the nurse take first? Exhibit: Nursing Notes at (0900): Client alert and oriented. Denies abdominal pain, discomfort, or nausea and vomiting. Active bowel sounds in all quadrants. Abdomen soft, non-tender to palpation. Ranitidine 50 mg IVPB hung to IV line of NS at 100 mL per hour. No redness or edema noted at IV site. At 0930: Client confused to place and time. Oxygen sat 95%. Lungs clear bilaterally. Denies pain. BP 118/78, HR 84/min, RR – 20/min, Temp. – 97.8 F (36.55 C).

1. Stop the infusion of ranitidine.

2. Send the client for a CT scan of the head.

3. Provide oxygen at 2L/NC.

4. Notify the primary healthcare provider.

QUESTION 13. Question: The oncoming nurse has just received report and is preparing to make initial rounds. Which postpartum client should the nurse see first?

1. A primipara 6 hours postpartum saturating one peripad every two hours

2. A multigravida 1 hour postpartum and reporting intense perineal pain

3. A primigravida 12 hours postpartum with the uterine fundus at the umbilicus

4. A multigravida 72 hours postpartum with a brownish pink lochia discharge.

QUESTION 14: Which pediatric client should the nurse see first?

1. Six year old with a femur fracture.

2. Two year old with a fever of 102 ° F (38.8 ° C)

3. Three year old with wheezes in right lower lobe.

4. Two year old whose gastrostomy tube came out.

QUESTION 15: The nurse has received the shift report. Which client should the nurse assess first?

1. The client diagnosed with a DVT who is complaining of dyspnea and coughing.

2. The client diagnosed with gallbladder ulcer disease who refuses to eat the food served.

3. The client diagnosed with pancreatitis who wants the nasogastric tube removed.

4. The client diagnosed with osteoarthritis who is complaining of stiff joints.

QUESTION 16: The nurse is developing the plan of care for a newly admitted client diagnosed with schizophrenia. What goal would the nurse consider a priority for this client?

1. Schedule alone time for client to relax.

2. Frequently reorient the client to surroundings.

3. Encourage participation in all social activities.

4. Assign same staff to provide client care daily.

QUESTION 17: The nurse sees the following rhythm on the cardiac monitor for a client recovering from a myocardial infarction. What would be the nurse's first action upon entering the client's room? Exhibit Cardiac Strip:

1. Attempt defibrillation

2. Begin CPR

3. Assess for carotid pulse

4. Administer lidocaine

QUESTION 18: An elderly client with a history of coronary artery disease (CAD) has just been admitted to the telemetry unit following a syncopal episode at home. The admitting nurse places EKG leads on the client and notes the following rhythm on the monitor. When the client indicates the need to void, the nurse knows that what would be the safest action? Exhibit ECG Monitor:

1. Request order for a foley catheter.

2. Assist client with the use of a bedpan.

3. Provide a bedside commode chair.

4. Perform in and out straight catheterization.

QUESTION 19: A small community has experienced a mudslide that hit a restaurant causing mass casualties. What would the nurse do first?

1. Assess the immediate area for electrical wires on the ground.

2. Attend to victim injuries as they are encountered.

3. Activate the community emergency response team.

4. Triage and tag victims according to injury.

QUESTION 20: A home health nurse is educating a client about home care considerations for clean intermittent catheterization. Which statement made by the client would indicate to the nurse that teaching was successful?

1. “After insertion, I will tape the tubing to my lower abdomen.”

2. “I will discard the catheter after use.”

3. “It is important that I keep the drainage bag below the level of my bladder.”

4. “Catheterization should be done when I feel the need to void.”

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