Chapter 19

Delegating/Prioritizing Questions

151. A client is being admitted to the neurological unit from the emergency department with a diagnosis of a cervical (C4) spinal cord injury. Which assessment should the nurse perform first when admitting the client to the nursing unit?

1. Listen to breath sounds.

2. Check peripheral pulses.

3. Check for muscle flaccidity.

4. Assess extremity muscle strength.

Level of Cognitive Ability:

Analyzing

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/ Assessment/Data Collection

Content Area:

Delegating/Prioritizing

ANSWER: 1

Rationale:

Because compromise of respiration is a leading cause of death in cervical cord injury, respiratory assessment is the highest priority. Assessment of peripheral pulses and muscle strength can be done after adequate oxygenation is ensured.

Test-Taking Strategy:

Note the strategic word first. Eliminate options 3 and 4 first because they are comparable or alike. Next use the ABCs—airway, breathing, and circulation—to direct you to the correct option. Remember that a cord injury, particularly at the level of C4, can affect respiratory status. Breath sounds will be diminished if respiratory muscles are weakened or paralyzed. Review: priority care of the client with a C4 spinal cord injury.

Tip for the Beginning Nursing Student:

A spinal cord injury is caused by a traumatic disruption of the spinal cord occurring from a car crash or another type of violent impact. It is often associated with extensive musculoskeletal injury. Where the injury occurred in the spinal cord (level of injury) determines the effect on the client. A major concern with a cervical spinal cord injury is respiratory status. You will learn about spinal cord injuries and the important nursing interventions in your medical-surgical nursing course when you study neurological disorders.

References

deWit, Kumagai (2013), p. 511; Ignatavicius, Workman (2013), p. 969.

152. The nurse notes redness, warmth, and a purulent drainage at the insertion site of a central venous catheter in a client receiving total parenteral nutrition (TPN). The nurse should take which priority action?

1. Change the intravenous tubing.

2. Notify the health care provider.

3. Slow the rate of infusion of the TPN.

4. Call the pharmacy for a new bag of TPN solution.

Level of Cognitive Ability:

Analyzing

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Implementation

Content Area:

Delegating/Prioritizing

ANSWER: 2

Rationale:

Redness, warmth, and purulent drainage are signs of an infection. Infections of a central venous catheter site can lead to septicemia; therefore, the health care provider needs to be notified. Although the nurse may change the intravenous tubing and hang a new bag of TPN solution, these are not priority actions. The nurse should not adjust the rate of an intravenous solution without a specific prescription to do so. In addition, this action is unrelated to the client’s complication.

Test-Taking Strategy:

Note the strategic word priority. Also note the words redness, warmth, and a purulent drainage, and recall that these signs indicate infection. Recalling that infections of a central venous catheter site can lead to septicemia (a life-threatening condition) will direct you to the correct option. Review: nursing interventions related to complications associated with total parenteral nutrition.

Tip for the Beginning Nursing Student:

Total parenteral nutrition involves the administration of nutrients by a route other than orally and is usually administered intravenously. It is administered by means of an intravenous catheter through a central vein, such as the subclavian vein. The tip of the catheter normally rests in the superior vena cava. This type of catheter is known as a central venous catheter, and meticulous nursing care is required in the care of the catheter and catheter site to prevent infection. You will learn about TPN and central venous catheters in your medical-surgical nursing course.

References

deWit, Kumagai (2013), pp. 54, 57; Ignatavicius, Workman (2013), pp. 211, 232; Lewis et al (2011), pp. 939-940.

153. A client is brought to the emergency department by emergency medical services after having seriously lacerated both wrists. The nurse should perform which action first?

1. Assess and treat the wound sites.

2. Perform a psychosocial assessment.

3. Contact the crisis intervention team.

4. Encourage the client to talk about his feelings.

Level of Cognitive Ability:

Analyzing

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Implementation

Content Area:

Delegating/Prioritizing

ANSWER: 1

Rationale:

The initial action when a client has attempted suicide is to assess and treat any injuries. Although options 2, 3, and 4 may be appropriate at some point, the initial action should be to treat the wounds.

Test-Taking Strategy:

Note the strategic word first. Use Maslow’s Hierarchy of Needs theory to prioritize. Physiological needs come first. The correct option is the only one that addresses a physiological need. Options 2, 3, and 4 address psychosocial needs. Review: initial care to the client who has attempted suicide.

Tip for the Beginning Nursing Student:

Suicide is the intentional taking of one’s own life. A suicide attempt is an act taken by a client to intentionally take one’s own life. If a client has attempted suicide, it is extremely important to assess the injuries as a result of the suicide attempt. Other very important interventions include one-to-one supervision of the client and other therapy. You will learn about the concepts related to suicide and the important nursing interventions for a client at risk for self-harm in your psychiatric/mental health nursing course.

References

deWit, Kumagai (2013), p. 1060; Fortinash, Holoday-Worret (2012), pp. 513-514.

154. The nurse develops a plan of care for a client receiving a chemotherapy treatment with intravenous bleomycin sulfate. The nurse should document which priority intervention in the plan?

1. Monitor for dyspnea.

2. Monitor for alopecia.

3. Monitor for anorexia.

4. Monitor for a change in bowel patterns.

Level of Cognitive Ability:

Analyzing

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Planning

Content Area:

Delegating/Prioritizing

ANSWER: 1

Rationale:

Bleomycin sulfate, an antineoplastic medication, can cause interstitial pneumonitis that can progress to pulmonary fibrosis. The nurse needs to monitor for dyspnea and monitor lung sounds for adventitious sounds that indicate pulmonary toxicity. Pulmonary function studies along with hematological, hepatic, and renal function tests need to be monitored. Also, the nurse needs to notify the health care provider immediately if pulmonary toxicity occurs. Alopecia (hair loss) can occur, but monitoring for it is not a priority intervention. Monitoring for anorexia and bowel pattern changes are important but are not the priority.

Test-Taking Strategy:

Note the strategic word priority and use the ABCs—airway, breathing, and circulation. Select the option that relates to airway. Review: the interventions associated with caring for the client receiving bleomycin sulfate.

Tip for the Beginning Nursing Student:

Chemotherapy is the use of medications in the treatment of cancer that kill cancer cells. A concern with the use of chemotherapy is that it also affects and destroys normal cells. This is what causes the side and adverse effects of the medications. Many chemotherapeutic agents cause nausea, vomiting, and alopecia (hair loss), among other effects. Also some chemotherapeutic medications affect specific cells in certain organs. Bleomycin sulfate is one of these medications and can cause interstitial pneumonitis that can progress to pulmonary fibrosis. Pneumonitis refers to inflammation of the lungs, and pulmonary fibrosis refers to the formation of scar tissue in the connective tissue of the lungs. You will learn about bleomycin sulfate and other chemotherapeutic medications in a pharmacology course or in your medical-surgical nursing course when you study oncologic disorders.

References

Hodgson, Kizior (2013), p. 139; Lehne (2013), p. 1283.

155. Quinapril hydrochloride (Accupril) is prescribed as an adjunctive therapy in the treatment of heart failure. After administering the first dose, the nurse should specifically monitor which parameter as the priority?

1. Respirations

2. Urine output

3. Lung sounds

4. Blood pressure

Level of Cognitive Ability:

Analyzing

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Assessment/Data Collection

Content Area:

Delegating/Prioritizing

ANSWER: 4

Rationale:

Quinapril hydrochloride (Accupril) is an angiotensin-converting enzyme (ACE) inhibitor. It is used in the treatment of hypertension and as adjunctive therapy in the treatment of heart failure. Excessive hypotension (“first-dose syncope”) can occur in clients with heart failure or in clients who are severely salt or volume depleted. Although respirations, urine output, and lung sounds should be monitored, the nurse should most closely monitor the client’s blood pressure.

Test-Taking Strategy:

Focus on the name of the medication, and note the strategic word priority. This tells you that all options may be correct and that you must prioritize. Recall that most ACE inhibitor names end with the letters –pril and that these medications are used to treat hypertension. Review: the side, adverse, and toxic effects of quinapril hydrochloride (Accupril).

Tip for the Beginning Nursing Student:

Quinapril hydrochloride (Accupril) is a medication that is primarily used to treat hypertension and manage heart failure. This medication is classified as an angiotensin-converting enzyme (ACE) inhibitor and antihypertensive. A priority nursing intervention when a medication with antihypertensive effects is administered is to monitor the client’s blood pressure. Additional important interventions include client teaching related to safety because of the hypotensive effects of the medication. One important point to teach the client is to rise slowly from a lying to sitting position and to permit the legs to dangle from the bed momentarily before standing. You will learn about this medication in a pharmacology course or in your medical-surgical nursing course when you study cardiovascular disorders.

References

Hodgson, Kizior (2013), p. 992; Lehne (2013), pp. 512-513.

156. The nurse is preparing a plan of care for a postoperative client who is receiving morphine sulfate by continuous intravenous infusion for pain. The nurse should include monitoring of which item as a priority nursing action in the plan of care?

1. Constipation

2. Urine output

3. Temperature

4. Blood pressure

Level of Cognitive Ability:

Analyzing

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Planning

Content Area:

Delegating/Prioritizing

ANSWER: 4

Rationale:

Morphine sulfate suppresses respirations and decreases the client’s blood pressure; therefore, monitoring for both decreased respirations and decreased blood pressure are priority nursing actions. Although monitoring of options 1, 2, and 3 may be a component of the plan of care for this client, option 4 identifies the priority nursing action.

Test-Taking Strategy:

Note the strategic word priority. Use the ABCs—airway, breathing, and circulation—to direct you to the correct option. Monitoring blood pressure determines the circulatory status of the client. Review: the effects of morphine sulfate.

Tip for the Beginning Nursing Student:

Morphine sulfate is an opioid analgesic that is used to alleviate pain in a client. It is used to treat pain that occurs in many types of disorders and is frequently used to alleviate pain in the postoperative client or the client with cancer. Because it is an opioid analgesic it will cause a decrease in vital signs, specifically respirations and blood pressure. Monitoring vital signs, specifically respirations and blood pressure, is a critical nursing intervention. You will learn about morphine sulfate and other opioid analgesics in a pharmacology course or in your medical- surgical nursing course.

References

Hodgson, Kizior (2013), p. 794; Lehne (2013), pp. 297-299.

157. A postoperative client who underwent pelvic surgery suddenly develops dyspnea and tachypnea. The nurse suspects that the client has a pulmonary embolism and should prepare to take which action first?

1. Insert a urinary (Foley) catheter.

2. Administer low-flow oxygen through a nasal cannula.

3. Obtain an intravenous (IV) infusion pump to administer heparin.

4. Increase the rate of the IV fluids infusing to prevent hypotension.

Level of Cognitive Ability:

Analyzing

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Implementation

Content Area:

Delegating/Prioritizing

ANSWER: 2

Rationale:

Pulmonary embolism is a life-threatening emergency. Maintenance of cardiopulmonary stability is the first priority. The nurse should prepare to administer low-flow oxygen by nasal cannula first. Hypotension is treated with fluids as prescribed. IV anticoagulation may be initiated. Some clients may require endotracheal intubation to maintain an adequate PaO₂. A perfusion scan among other tests may be performed, and the electrocardiogram (ECG) is monitored for the presence of dysrhythmias. In addition, a urinary catheter may be inserted. However, the first nursing action is to administer oxygen.

Test-Taking Strategy:

Note the strategic word first. Use of the ABCs—airway, breathing, and circulation—will direct you to the correct option. Review: the immediate nursing actions when pulmonary embolism occurs.

Tip for the Beginning Nursing Student:

Pulmonary embolism is characterized by the blockage of a pulmonary artery by fat, air, tumor tissue, or a thrombus that usually arises from a peripheral vein. It is characterized by dyspnea, tachycardia, anxiety, sudden chest pain, shock, and cyanosis. It is a life-threatening condition and requires immediate and aggressive treatment. Airway, however, is the priority. You will learn about pulmonary embolism in your medical-surgical nursing course when you study respiratory and cardiovascular disorders.

References:

deWit, Kumagai (2013), p. 312; Ignatavicius, Workman (2013), p. 665.

158. A client returns to the nursing unit from the postanesthesia care unit (PACU) following a transurethral resection of the prostate. The nurse should perform which action first?

1. Check the client’s respirations.

2. Check the color of the client’s urine.

3. Check the urinary (Foley) catheter for patency.

4. Read the nursing notes written by the PACU nurse.

Level of Cognitive Ability:

Analyzing

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Implementation

Content Area:

Delegating/Prioritizing

ANSWER: 1

Rationale:

The first action of the nurse is to assess the patency of the airway, and the nurse should observe the client and assess the breathing pattern and respirations. If the airway is not patent and the client is not breathing, immediate measures must be taken for the survival of the client. The nurse then assesses cardiovascular function, the condition of the surgical site, the tubes or drains for patency and drainage, and function of the central nervous system. The PACU nurse normally provides a verbal report. Even so, reading the nursing notes would not be the first action.

Test-Taking Strategy:

Note the strategic word first. Use the ABCs—airway, breathing, and circulation. This will direct you to the correct option. Airway patency and respirations are the priorities. Review: priority nursing assessments in the postoperative client.

Tip for the Beginning Nursing Student:

A transurethral resection of the prostate is a surgical procedure in which a cystoscope (an instrument used for examining and treating lesions of the urinary tract) is passed through the urethra to resect (remove tissue from) the prostate. An important point to remember is that airway is always the priority in the care of a client. You will learn about this surgical procedure when you study renal disorders in your medical-surgical nursing course, and you will learn about perioperative care in your fundamentals of nursing course.

References

deWit, Kumagai (2013), pp. 83-84; Ignatavicius, Workman (2013), pp. 286-288.

159. A child with a diagnosis of pertussis (whooping cough) is being admitted to the pediatric unit. As soon as the child arrives on the unit, which action should the nurse perform first?

1. Weigh the child.

2. Take the child’s temperature.

3. Place the child on a pulse oximeter.

4. Administer the prescribed antibiotic.

Level of Cognitive Ability:

Analyzing

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Implementation

Content Area:

Delegating/Prioritizing

ANSWER: 3

Rationale:

To adequately determine if the child is getting enough oxygen, the child is placed on a pulse oximeter. The pulse oximeter will then provide ongoing information on the child’s oxygen level. The child is also immediately placed on a cardiorespiratory monitor to provide early identification of periods of apnea and bradycardia. The nurse should then perform an assessment, including taking the child’s temperature and weight and asking the parents about the child. An antibiotic may be prescribed, but the child’s airway status needs to be assessed first.

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