NCLEX Leadership: Prioritization

NCLEX Leadership: Prioritization What is hypertensive encephalopathy? - ANS- A medical emergency caused by a sudden elevation in blood pressure (eg, hypertensive crisis) creating cerebral edema and increased intracr ...

NCLEX Leadership: Prioritization What is hypertensive encephalopathy? - ANS- A medical emergency caused by a sudden elevation in blood pressure (eg, hypertensive crisis) creating cerebral edema and increased intracranial pressure (ICP). s/s of hypertensive encephalopathy - ANS- The client may report severe headache, visual impairment, anxiety, confusion, and observed epistaxis, seizures, or coma. - HE may precipitate life-threatening complications such as myocardial infarction, hemorrhagic stroke, and acute kidney injury. The client with a history of chronic hypertension and active signs of increased ICP (eg, anxiety, epistaxis) requires immediate assessment and treatment What does petichiae and fever post valve replacement mean? - ANS- A fever of 102 F (38.8 C) and petechiae in a post valve replacement client could indicate endocarditis. This client would need to be seen second, as this is a circulation disorder. The office nurse receives 4 telephone messages. Which client should the nurse call back first? - ANS- 70 year old male patient with peripheral vascular disease who has acute onset abdominal pain radiating to the lower back - this is indicative of AAA The pediatric nurse receives report on 4 clients. Which client should the nurse see first? - ANS- A 6 year old just returned from a bronchoscopy, a parent is at the bedside - Following the procedure, the client will need to be monitored for complications such as bleeding, bronchial perforation, pneumothorax, and bronchial spasm. Follow ABC prioritization rule. What is cauda equina syndrome? - ANS- A disorder that results from injury to the lumbosacral nerve roots (L4-L5) causing motor and sensory deficits. The main symptoms are severe lower back pain, inability to walk, saddle anesthesia (ie, motor weakness/loss of sensation to inner thighs and buttocks), and bowel and bladder incontinence (late sign). Cauda equina syndrome is a medical emergency. How is cauda equina syndrome treated? - ANS- Treatment requires urgent reduction of pressure on the spinal nerves to prevent permanent damage. This client displays characteristic late signs of cauda equine syndrome (ie, incontinence); therefore, the nurse should assess this client first. The nurse cares for a group of clients in a medical surgical unit. The client with which diagnosis and condition requires the most immediate assistance by the nurse? - ANS- Patient with BG of 55 - I chose the one with BG of 250, but this is not priority because hypoglycemia is more urgent Unlicensed assistive personnel report 4 situations to the registered nurse. Which situation warrants the nurse's intervention first? - ANS- Puncture resistant container is full What does a deviated trachea indicate? - ANS- pneumothorax What is the normal range for carboxyhemoglobin level? - ANS- Normal values are <5% in nonsmokers and slightly higher (<10%) in smokers. - This client with CO poisoning is the highest priority for treatment and requires immediate administration of 100% oxygen to increase the rate at which CO dissipates from the blood to prevent tissue hypoxia and severe hypoxemia. (patient had level of 20) What type of pain is associated with diverticulitis? - ANS- Fever and left lower quadrant pain in an elderly client are usually due to acute diverticulitis. - The client needs bowel rest, antibiotics, and IV fluids. The nurse is triaging clients from the waiting room. The care of which client is a priority? - ANS- The two year old who swallowed a button battery and is asymptomatic - Children are asymptomatic in the beginning. Alkaline batteries can be corrosive to the esophageal and intestinal mucosa; if ingested, they must be removed emergently by endoscopy as perforation can occur. I chose: child with osteogenesis imperfecta who was hit in the head with a baseball What are the manifestations of septic arthritis? - ANS- (eg, pain, limited range of motion) and systemic infection symptoms (eg, fever), which may indicate septic arthritis. Possible causes include recent surgery, injections, trauma, or spread from adjacent infection (eg, cellulitis). A septic hip is considered a surgical emergency. The hip joint is prone to develop avascular necrosis (eg, damage to the femoral head) from compromised blood supply due to infection or injury (eg, fracture). This can result in sequelae that are significant in both the short term (eg, sepsis, death) and long term (eg, joint destruction). How is septic arthritis treated? - ANS- Management includes culturing synovial fluid and blood, giving antibiotics, and debriding the infected joint. The nurse receives report on 4 pediatric clients in the emergency department. Which client should be seen first? - ANS- 3 week old with fever who is sleeping more than usual and refuses to feed - these are symptoms of sepsis in a neonate -Subtle changes such as irritability, increased sleepiness, and poor feeding should be considered red flags. Blood, urine, and cerebrospinal fluid cultures should be obtained immediately and broad-spectrum antibiotics started. 4 month old has painless, new onset, bilateral testicular swelling - what does this indicate? - ANS- The infant has hydrocele, a fluid-filled testicular mass. Most hydroceles resolve before the first birthday and are not a medical emergency. What chest tube conditions are expected in a patient with pnuemothorax? - ANS- In a client with a pneumothorax, intermittent bubbling in the water-seal chamber consistent with respirations (due to air escaping from the pleural space) is expected until the lung has fully expanded. What is the normal range for B natriuretic peptide level? - ANS- Less than 125 pg/mL for patients aged 0-74 years. Less than 450 pg/mL for patients aged 75-99 years. The clinic nurse receives multiple phone calls regarding client status. Which call should the nurse return first? - ANS- A 16 year old with mono 10 days ago who reports severe abdominal pain - this indicated ruptured spleen I chose: Patient with kawasaki's disease 2 weeks ago who has peeling skin - This is expected in the subacute stage The nurse receives a report on the assigned clients for the shift. Which client should the nurse assess first? - ANS- Patient who underwent thyriodectomy and has a positive trousseau's sign What is Trousseau's sign? - ANS- Inflate BP cuff and hold for 3 minutes. Patient with low Ca will get carpel tunnel symptoms. What can acute hypocalcemia cause? - ANS- Acute hypocalcemia can cause tetany, laryngeal stridor, seizures, and cardiac dysrhythmias. A nurse on the medical surgical unit has just received report. Which client should be seen first? - ANS- Patient with DVT yesterday who reports some chest discomfort and cough - The nurse should prioritize the assessment of any client with DVT who is experiencing respiratory signs and symptoms and/or chest pain due to potential development of PE. I chose: Patient with HTN and BP of 180/92 who reports a headache - The nurse should assess this client after the client with DVT and administer any antihypertensives needed. The nurse is planning to assess 4 assigned clients. Which client situation is of greatest concern and warrants immediate assessment? - ANS- Patient with an inguinal hernia who has abdominal pain, rates it as a 10, and reports bloating, nausea, and vomiting - Manifestations of a mechanical bowel obstruction (eg, pain, distension, nausea, vomiting) are caused by compressed loops of bowel incarcerated by the hernia. - Subsequent bowel ischemia and strangulation can lead to infection and death. Immediate evaluation and urgent surgical intervention are critical. What are manifestations of mechanical bowel obstruction? - ANS- pain, distention, nausea, and vomiting CONTINUES...