Priorities of the Patient Leap

Froggy Jumps

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Clinical decision practice

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RNPRPEPBESTIE

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Priorities of the Patient Leap


Froggy Jumps Priorities of the Patient LeapVersión en línea Clinical decision practice por RNPRPEPBESTIE 1 A client with a femur fracture suddenly becomes restless and states, “I can’t catch my breath.” Petechiae are noted across the chest. Which action should the nurse take first? a Elevate the affected extremity on pillows b Apply oxygen and notify the provider c Administer PRN medication for anxiety 2 A client with SIADH reports worsening headache and nausea. The nurse notes new confusion and muscle twitching during assessment. Which action should the nurse take first? a Initiate seizure precautions b Review the client’s sodium level trend c Restrict oral fluid intake 3 A client 12 hours after thyroidectomy reports “tightness” in the neck. The nurse notes frequent swallowing and a muffled voice. Which action should the nurse take first? a Inspect the surgical dressing for drainage b Prepare for possible airway intervention c Reposition the client with HOB elevated 4 A client with ulcerative colitis reports sudden relief of abdominal pain. The abdomen is now rigid and distended with HR 122. Which action should the nurse take first? a Reassess bowel sounds in all quadrants b Notify the provider immediately c Administer the prescribed antidiarrheal medication 5 A client with Parkinson disease repeatedly attempts to get out of bed without assistance and states, “I can walk fine on my own.” Which action should the nurse take first? a Activate the bed alarm and stay nearby b Reorient the client to time and place c Request a physical therapy consultation 6 A client with a new ileostomy avoids looking at the stoma and states, “I don’t think I can live like this.” Which response by the nurse is best? a "Your provider can discuss reconstruction options later." b "The stoma should become easier to manage with time." c "Tell me what feels hardest about this right now." 7 A client with internal bleeding after a liver biopsy becomes increasingly restless. BP 82/48, HR 134, skin cool, abdomen firm. Which action should the nurse take first? a Prepare to administer IV fluids rapidly b Check the biopsy site for external bleeding c Reposition the client onto the right side 8 A client receiving magnesium sulfate begins speaking less clearly and no longer asks for pain medication between contractions. Which action should the nurse take first? a Document decreased discomfort after medication b Reposition the client to the left side c Check the client’s respiratory rate

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Priorities of the Patient Leap

Froggy Jumps

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Froggy Jumps

Priorities of the Patient LeapVersión en línea

por RNPRPEPBESTIE

A client with a femur fracture suddenly becomes restless and states, “I can’t catch my breath.” Petechiae are noted across the chest. Which action should the nurse take first?

A client with SIADH reports worsening headache and nausea. The nurse notes new confusion and muscle twitching during assessment. Which action should the nurse take first?

A client 12 hours after thyroidectomy reports “tightness” in the neck. The nurse notes frequent swallowing and a muffled voice. Which action should the nurse take first?

A client with ulcerative colitis reports sudden relief of abdominal pain. The abdomen is now rigid and distended with HR 122. Which action should the nurse take first?

A client with Parkinson disease repeatedly attempts to get out of bed without assistance and states, “I can walk fine on my own.” Which action should the nurse take first?

A client with a new ileostomy avoids looking at the stoma and states, “I don’t think I can live like this.” Which response by the nurse is best?

A client with internal bleeding after a liver biopsy becomes increasingly restless. BP 82/48, HR 134, skin cool, abdomen firm. Which action should the nurse take first?

A client receiving magnesium sulfate begins speaking less clearly and no longer asks for pain medication between contractions. Which action should the nurse take first?