Question set A: which patient do you see first

WHICH PATIENT FIRST · 8 ITEMS · 8 MINUTES · MARK THE RUNG

1. A nurse receives report on four clients. Which client should the nurse see first? 1) A client with a new tracheostomy whose secretions are audible at the collar and whose cough is weak. 2) A client one day after cholecystectomy who reports incisional pain and is asking for the ordered analgesic. 3) A client with heart failure whose morning weight is up slightly from yesterday. 4) A client with diabetes mellitus waiting for insulin injection teaching before discharge.

2. Which client does the nurse assess first? 1) A client six hours after femoral cardiac catheterization whose groin dressing is now saturated and warm to the touch. 2) A client with pneumonia whose fever has come down since acetaminophen was given. 3) A client on bed rest who is asking to be repositioned. 4) A client whose family is at the desk asking to speak with the provider.

3. Four clients need attention. Which client requires the nurse's attention first? 1) A client receiving a first dose of an intravenous antibiotic who reports a tickle in the throat and new itching of the palms. 2) A client with a nasogastric tube to suction who reports a dry mouth. 3) A client with cirrhosis whose jaundice was documented on admission and looks unchanged. 4) A client after knee arthroplasty with a moderate amount of drainage in the closed suction drain.

4. Which client should the nurse see first? 1) A client with long-standing COPD whose oxygen saturation matches the baseline documented at admission. 2) A client who was oriented to person, place, and time yesterday and this morning cannot say where he is. 3) A client with chronic kidney disease scheduled for hemodialysis this afternoon. 4) A client with osteoarthritis reporting the usual morning stiffness in both knees.

5. All four clients are physiologically stable. Which client should the nurse attend to first? 1) A client with dementia who has climbed over the side rail and is standing unsteadily at the foot of the bed. 2) A client who needs help to the bathroom and has pressed the call light. 3) A client whose peripheral intravenous site is due for routine site care. 4) A client who has asked for a warm blanket.

6. Four clients are physiologically stable and none has a safety concern. Which need should the nurse meet first? 1) A client who has had nothing by mouth since midnight, whose procedure is finished, and who reports hunger. 2) A client who wants to discuss whether visiting hours can be extended for a spouse. 3) A client who has asked for the chaplain to talk about the meaning of the illness. 4) A client who wants reassurance that progress in physical therapy is on track.

7. A client recovering from surgical repair of a hip fracture repeatedly attempts to get out of bed without help and is confused each evening. Which action should the nurse take first? 1) Apply a vest restraint for the night shift. 2) Request an order for a one-to-one sitter. 3) Move the client to a room near the nurses' station, lower the bed, and activate the bed alarm. 4) Ask a family member to stay at the bedside overnight.

8. Which client should the nurse see first? 1) A client two days after abdominal surgery with a low-grade temperature whose incision is now more reddened than yesterday and whose drainage has changed from thin and pink to thick and yellow. 2) A client with a chest tube whose drainage has slowly decreased since insertion. 3) A client one day after surgery who is sleepy after an opioid dose, is easily awakened, and is breathing comfortably. 4) A client with an indwelling urinary catheter whose output has continued steadily overnight.

Margin noteif two rungs fit, you picked the wrong one.

Takeawaynaming the rung is the skill. Picking the letter is the by-product.

→ BOOK 03 · P13 for rationales.