Priority Moves

Froggy Jumps

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Deciding What Comes First

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Priority Moves


Froggy Jumps Priority MovesVersión en línea Deciding What Comes First por RNPRPEPBESTIE 1 During morning rounds, a pt with type 1 diabetes refuses breakfast and appears irritable. Capillary glucose is 64 mg/dL. Rapid-acting insulin remains scheduled. The client is diaphoretic and pacing. Which provider order requires clarification now? a Give scheduled rapid-acting insulin before food intake b Recheck capillary glucose in thirty minutes c Encourage the client to eat the breakfast tray 2 During morning hygiene, a client with chronic C6 spinal cord injury becomes restless and diaphoretic. BP rises from 128/76 to 194/102 within minutes. Foley tubing shows thick sediment and minimal output. Which finding must the nurse act on FIRST? a Restlessness and sweating noted during routine morning care b Rapid increase in blood pressure from the client’s usual baseline c Thick sediment and minimal urine output in Foley tubing 3 Twelve hours after long-bone repair, a client becomes restless and reports chest tightness. Oxygen saturation falls to 88% on room air. Fine petechiae appear on the upper chest and conjunctiva. Which situation should the nurse escalate first? a Sudden complaint of chest tightness with new restlessness b Oxygen saturation falling to 88% c Fine petechial rash across the upper chest 4 Before an invasive procedure, a pt who signed consent earlier receives premeds. The pt becomes drowsy and asks the nurse if the procedure is necessary. Family urge staff to continue prep. Which nursing action requires immediate intervention? a Continuing preparation without reassessing the client’s wishes b Telling family consent was already obtained c Assisting the client onto the procedure table 5 A child with sickle cell crisis receiving IV opioids becomes unusually quiet and stops requesting pain medication. RR fall from 26 to 18/min. Cap refill is 4 seconds and hands feel cool. Which finding requires urgent follow-up? a Child stops requesting pain medication during crisis b Respiratory rate decreasing after opioid therapy c Capillary refill of four seconds with cool extremities 6 A postpartum client after placental abruption develops bleeding from IV sites and gums. Platelets drop to 68,000/mm³ and petechiae spread across the chest. New orders are received. Which provider order requires clarification? a Begin continuous heparin infusion b Transfuse cryoprecipitate c Monitor vital signs every fifteen minutes 7 A client taking lithium reports poor appetite and loose stools for several days. During assessment the client speaks slowly, misplaces personal items, and needs support while walking to a chair. Labs pending. Which finding requires urgent follow-up? a Slowed speech and difficulty recalling where items were placed b Reduced appetite with several days of loose stools c Needing support while walking short distance to chair 8 A client arrives after a house fire. Soot is noted around the mouth and eyebrows are singed. The client coughs and speaks in hoarse phrases while appearing anxious. Facial burns are present. Which action should the nurse take FIRST? a Prepare for airway support and give high-flow oxygen b Apply sterile moist dressings to burned areas c Establish large-bore IV access for fluid therapy 9 A client on telemetry develops wide-complex tachycardia at 168/min. The client is awake, reports palpitations and lightheadedness. Blood pressure is 92/60 and skin appears cool. Peripheral pulses are present. Which action should the nurse take FIRST? a Obtain a twelve-lead ECG tracing b Prepare for synchronized cardioversion c Start oxygen at 2 L per nasal cannula 10 An older adult with type 2 diabetes arrives confused and very thirsty. Skin is dry and tented. Glucose reads 620 mg/dL. Blood pressure is 88/54 and heart rate 124. Urine output has been minimal today. Which action should the nurse take FIRST? a Start rapid IV infusion of isotonic saline b Prepare to administer regular insulin infusion c Obtain serum electrolyte and osmolality levels 11 A client with stage 4 chronic kidney disease is admitted for fluid overload. Potassium is 5.6 mEq/L and urine output has been minimal. New provider orders are reviewed. Which provider order requires clarification now? a Administer spironolactone for blood pressure control b Restrict daily sodium intake to 2 grams c Prepare furosemide IV for diuresis 12 A client with systemic lupus attends a follow-up visit after a recent flare. The client takes prednisone and hydroxychloroquine. During assessment the nurse reviews recent symptoms and daily habits. Which client statement requires priority follow-up? a “My eyes look puffy when I wake up in the morning.” b “My joints feel stiff before I get moving each day.” c “Sunlight makes the rash on my face more visible.” 13 A pt with ulcerative colitis returns for follow-up while taking mesalamine and tapering prednisone. The nurse reviews medication timing, supplement use, and symptom patterns during daily routines. Which client statement requires priority follow-up? a “I take loperamide before work so I can avoid urgent bowel trips.” b “I take my mesalamine with meals to reduce stomach upset.” c “I added a multivitamin because my appetite has been low.”

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Priority Moves

Froggy Jumps

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Priority MovesVersión en línea

por RNPRPEPBESTIE

During morning rounds, a pt with type 1 diabetes refuses breakfast and appears irritable. Capillary glucose is 64 mg/dL. Rapid-acting insulin remains scheduled. The client is diaphoretic and pacing. Which provider order requires clarification now?

During morning hygiene, a client with chronic C6 spinal cord injury becomes restless and diaphoretic. BP rises from 128/76 to 194/102 within minutes. Foley tubing shows thick sediment and minimal output. Which finding must the nurse act on FIRST?

Twelve hours after long-bone repair, a client becomes restless and reports chest tightness. Oxygen saturation falls to 88% on room air. Fine petechiae appear on the upper chest and conjunctiva. Which situation should the nurse escalate first?

Before an invasive procedure, a pt who signed consent earlier receives premeds. The pt becomes drowsy and asks the nurse if the procedure is necessary. Family urge staff to continue prep. Which nursing action requires immediate intervention?

A child with sickle cell crisis receiving IV opioids becomes unusually quiet and stops requesting pain medication. RR fall from 26 to 18/min. Cap refill is 4 seconds and hands feel cool. Which finding requires urgent follow-up?

A postpartum client after placental abruption develops bleeding from IV sites and gums. Platelets drop to 68,000/mm³ and petechiae spread across the chest. New orders are received. Which provider order requires clarification?

A client taking lithium reports poor appetite and loose stools for several days. During assessment the client speaks slowly, misplaces personal items, and needs support while walking to a chair. Labs pending. Which finding requires urgent follow-up?

A client arrives after a house fire. Soot is noted around the mouth and eyebrows are singed. The client coughs and speaks in hoarse phrases while appearing anxious. Facial burns are present. Which action should the nurse take FIRST?

A client on telemetry develops wide-complex tachycardia at 168/min. The client is awake, reports palpitations and lightheadedness. Blood pressure is 92/60 and skin appears cool. Peripheral pulses are present. Which action should the nurse take FIRST?

An older adult with type 2 diabetes arrives confused and very thirsty. Skin is dry and tented. Glucose reads 620 mg/dL. Blood pressure is 88/54 and heart rate 124. Urine output has been minimal today. Which action should the nurse take FIRST?

A client with stage 4 chronic kidney disease is admitted for fluid overload. Potassium is 5.6 mEq/L and urine output has been minimal. New provider orders are reviewed. Which provider order requires clarification now?

A client with systemic lupus attends a follow-up visit after a recent flare. The client takes prednisone and hydroxychloroquine. During assessment the nurse reviews recent symptoms and daily habits. Which client statement requires priority follow-up?

A pt with ulcerative colitis returns for follow-up while taking mesalamine and tapering prednisone. The nurse reviews medication timing, supplement use, and symptom patterns during daily routines. Which client statement requires priority follow-up?