prioritization strategy questions Flashcards
(16 cards)
FIRSY PRIORITIZAITON METHOD:
If a question asks
“which assessment data (behavior/statement) is MOST concerning to the RN / highest priority / most important”
you should choose the behavior, statement, or assessment that is _____ based on what you know about the patients diagnosis and related symptoms/ signs
unexpected
if a client with depression states that “ I have lost 10 pounds since I stating feeling so bad” is that an expected symptom?
those with depression tend to have eating disorders. anorexia is very common
what is lorazepam
medications that end in - pam and what do they treat
what are 5 common side effects?
benzodiazepine
are DEPRESSANTS that produce sedation and hypnosis, relieve anxiety and muscle spasms, and reduce seizures
dry mouth
blurred vision
bladder retention
constipation
drowsiness
what are the positive and negative symptoms of schizophrenia?
positive - hallucinations, delusion, psychosis, hearing voicing (things you dont expect them to do thats ADDED)
negative - (things you do expect them to do that they’re not doing) not bathing, not eating, not interacting with Othe people
You are caring for a client with Type 2 diabetes. which of the following lab values is of most concern?
a. morning serum glucose is 154 (high)
b. glycosylated hbg is 7.6 (preferred range under 7)
c. serum k+ is 4.9 ( k+ range is 3.5 - 5.5)
d. serum creatinine is 2.1(the typical range is 0.5 - 1.1)
d. serum creatinine is 2.1
the typical range is 0.5 - 1.1
this value is high , but also NOT expected in someone with T2DM
high serum creatinine mean their kidneys aren’t excreting it, which is concerning
in this question…
A client diagnosed with major depression has sleep and appetite disturbances and a flat affect and is withdrawn. The client has been taking fluvoxamine 50 mg twice daily for 5 days. which client behavior is most important to report to the next shift?
a. clients flat affect
b. clients interacting with a visitor
c. client sleeping from 2300 hours to 0600 hours
d. client spending the entire evening in her room
how would you first approaching approach answering this method wise?
the symptoms are IN the question so youre looking for a CHANGE in the normal
A client diagnosed with major depression has sleep and appetite disturbances and a flat affect and is withdrawn. The client has been taking fluvoxamine 50 mg twice daily for 5 days. which client behavior is most important to report to the next shift?
a. clients flat affect
b. clients interacting with a visitor
c. client sleeping from 2300 hours to 0600 hours
d. client spending the entire evening in her room
its c
for b - it doesn’t say that they dont interact
its s because sleeping for 7 hours is a change from sleep disturbances. this closely reflects the data in the question
SECOND PRIORITIZAITON METHOD:
If youre given a pt, and the diagnosis and symptoms are in the question, which symptoms listed in the question should be address first when it comes to choosing an answer from the multiple choice?
/ what is the Maslow hierarchy of needs?
- physiological: objective
- safety
- comfort: subjective
- psych
nurse is evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5L/min by nasal cannula. Which finding concerns the nurse immediately?
a. fine bibasilar crackles
b. respiratory rate of 8 breaths/min
c. the patient sitting up and leaning over the nightstand
d. a large barrel chest
its b
chronic emphysema - damage of alveoli in your lungs, which makes it hard to absorb 02 in the lungs and breathe back out CO2 effectively. causes SOB
a. expect odd lung sounds
b. the normal range is 12-20 and if I have SOB id expect a high RR
c. tripod positioning , supposed to help patient breathe when they have SOB
d. lung expansion is expected because theres too much air trapped in the lungs, exchange isn’t as effected
a client who has been infected with the Ebola virus has an emesis of 750 mL of bloody fluid and complains of headache, nausea, and severe lightheadedness. Which action included in the treatment protocol should the nurse take first?
a. give Tylenol 650 mg PO
b. administer ondansetron 4 mg IV
c. infuse normal saline at 500 mL/hr
d. increase oxygen flow rate to 6 L/min
diagnosis and symptoms in the question
the objective symptoms - 750 blood fluid being lost should be addressed first
so c cause thats an isotonic solution so it will replenish the water lost
the nurse is caring for a newly admitted client with increasing dyspnea, hypoxia, and dehydration who has possible avian influenza (“bird flu”). which of the prescribed actions will the nurse implement first?
a. start oxygen using a nonrebreather mask
b. infuse 5% dextrose in water at 100ml/hr
c. administer that first dose of oral oseltamivir
d. obtain blood and sputum specimens for testing
sob is subjective
hypoxia is objective
dehydration is objective
POSSIBLE flu
answer is a
A 88 - year - old client who has not yet had the influenza vaccine is admitted after reporting symptoms of generalized muscle aching, cough and runny nose starting about 24 hours previously. which of these prescribed medications is more important for the nurse to admisnter at this time?
a. oseltamivir 75 mg PO - flu
b. guaifenesin 600 mg PO - cough/runny nose
c. acetaminophen 650 mg PO - muscle aching
d. influenza vaccine 180 mcg IM
if the patient is reporting symptoms then all the symptoms listed are subjective
this person probably has the flu
its a - osltamivir
- vir ; antiviral
you have to give this EARLY or it won’t do any good
during the initial post operative assessment of a client who has just been transferred to the postanesthesia care unit after repair of an and aortic aneurysm, the nurse obtains these data. which findings has the most immediate implications for the clients care?
a. arterial line indicates a blood pressure of 190/112 mmHg
b. cardiac monitor shows frequent premature atrial contractions
c. there is no response to verbal stimulation
d. urine output is 40 mL of amber urine
only diagnosis, no symptoms listed so which symptoms is UNEXPECTED?
a is correct ; high bp can affect circulation
a. unexpected
b. would I expect this? idk but they had an aneurysm that shouldn’t affect the heart like that (this isn’t really dangerous)
c. duh
d. 30ml is normal so 40ml isn’t crazy
if a question asks “ which order would you question?” what is it ACTUALLY asking you????
which order would be DANGEROUS to the patient
if the question asks “which order would you clarify?” what is it actually asking you?
which order was written incorrectly
