NCLEX 2018 - Prioritization Client Care

A nurse is charting at the nurses’ station when a client uses the call light to ask for assistance to the bathroom.  As the nurse answers the call light, a second client uses the call system to say “I think I need some help!  My IV site is bleeding a lot!”  What criteria should the nurse use to prioritize these two clients?

• The client who called for assistance first should receive assistance first. The bleeding IV is probably not life threatening
• The client who called for assistance to the bathroom should be seen first. This client might attempt to get up alone if no one arrives to help.
• The client who reported the bleeding IV should be seen first. There is no way to know without examining the IV site to know how much blood was lost, or what meds might be infusing through the IV
• The nurse could choose to assist either client first – both are of equal acuity

A nurse working on a telemetry unit receives an end-of-shift report from the previous nurse. The oncoming nurse receives report on: (1) two stable post cardiac cath clients; (2) a client with frequent PVCs who is diaphoretic and complaining of indigestion; & (3) a client admitted the previous shift for observation after presenting to the ER with atypical chest discomfort and cardiac enzyme levels that have been within normal range for 12 hours.  Which client should the oncoming nurse assess first?

• Either of the two clients that are post cardiac cath
• The client with frequent PVCs
• The client admitted from the ER with atypical chest discomfort and negative cardiac enzymes
• The order does not matter since all four of the same acuity level

The nurse has just received a report from the previous shift. Which of the following clients should the nurse see first?

• a.A 50-year-old COPD client with a PCO2 or 50
• a.A 24-year-old admitted after a MVA complaining of shortness of breath
• a.A client with cancer requesting pain medication
• A 1-day postoperative cholecystectomy with a temperature of 100 degrees F