Priority Assessment 1

There are four clients with infections in the ED and only one private room is available. Which among the clients is the most appropriate to occupy the private room?

• A client with a cough who my have tuberculosis

• A client with toxic shock syndrome and a temperature of 102.4F

• A client with diarrhea caused by C. Difficile

• A client with a wound infected with Vancomycin-resistant enterococci (VRE)

Answer explanation

Private rooms should be occupied mainly for clients with infections that require airborne precautions such as TB. Despite the gains in tuberculosis control and the decline in both new cases and mortality, it still accounts for a huge burden of morbidity and mortality worldwide.

Option B: Standard precautions are required for the client with toxic shock syndrome. Any source of bacteria such as tampons or nasal packing should immediately be removed. Emergent surgical consultation should be obtained for any wound debridement or surgical cause. This is critical in the early management of toxic shock syndrome.

Option C: The primary mode of the disease transmission is the fecal-oral route. Effective prevention of C. difficile infection includes several generalized strategies and certain targeted strategies. General strategies such as early detection of the disease, placing the patient under isolation with a dedicated toilet and contact precautions, promoting hygiene measures such as improved hand hygiene, and environmental cleaning are effective measures in preventing infections from C. difficile infections.

Option D: Clients with VRE infections that require contact precautions should ideally be placed in private rooms; however, they can be placed in rooms with other clients with the same diagnosis. The primary transmission of vancomycin-resistant Enterococcus in the hospital setting is through the hands of healthcare providers. Basic infection control prevention practices such as hand hygiene can help. Contact precautions such as wearing gowns and gloves also decrease transmission.

The nurse plans to care for a client in the post-anesthesia care unit. Which of the following should the nurse assess first? 

• respiratory status

• level of consciousness

• Level of pain

• reflexes and movement of extremities

Answer explanation

Assessing respiratory status is the first priority. Remember ABC. General anesthesia and mechanical ventilation impair pulmonary function, even in normal individuals, and result in decreased oxygenation in the postanesthesia period. They also cause a reduction in functional residual capacity of up to 50% of the preanesthesia value.

Option B: A level of consciousness assessment is also helpful, such as the AVPU scale or the Glasgow Coma Scale. The AVPU scale assesses if the patient is alert and oriented, responds to voice, responds to pain, or is unresponsive. The Glasgow Coma Scale is an objective way to record the conscious state of a patient, examining eye, verbal, and motor responses. 

Option C: Pain is a common occurrence after most all types of surgical procedures and is probably the most significant postoperative problem in the eyes of the patient. Prompt and adequate pain relief is a critical nursing intervention.

Option D: Neurologic functions can be assessed by the patient’s response to verbal stimuli, pupils’ responsiveness to light and accommodation, ability to move all extremities, and strength and equality of a hand grip.

Nurse Channing is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first?

• A client with diabetes was discharged today.

• A 35-year-old male with tracheostomy and copious secretions.

• A teenager scheduled for physical therapy this morning.

• A 78-year-old female client with a pressure ulcer that needs a dressing change.

Answer explanation

The patient with an airway problem should be given the highest priority. The ABCs identifies the airway, breathing and cardiovascular status of the patient as the highest of all priorities in that sequential order.

Option A: The client who was discharged today is not a priority because he is stable enough to be sent home. Maslow’s Hierarchy of Needs identifies the physiological or biological needs, including the ABCs, the safety/psychological/emotional needs, the need for love and belonging, the needs for self-esteem and the esteem by others and the self-actualization needs in that order of priority.

Option C: The teenager who will undergo physical therapy is under Maslow’s safety and physiological needs. The psychological or emotional, safety, and security needs include needs like low level stress and anxiety, emotional support, comfort, environmental and medical safety and emotional and physical security.

Option D: The client needing a dressing change for her pressure ulcer belongs to Maslow’s physical and biological needs. Some physical needs include the need for the ABCs of airway, breathing and cardiovascular function, nutrition, sleep, fluids, hygiene and elimination.

After exposure to hot weather and sun, clients with signs and symptoms of heat-related ailment rush to the Emergency Department (ED). Which patient will you room first?

• an elderly traffic enforcer who complains of dizziness and syncope after standing under the heat of the sun for several hours to perform his job

• a sportsman who complains of severe leg cramps and nausea, and displays paleness, tachycardia, weakness, and diaphoresis

• an abandoned person who is a teacher; has altered mental state, weak muscle movement, hot, dry, pale skin; and whose duration of heat exposure is unknown

• a comparatively healthy housewife who states that the air conditioner has been down for 5 days and how exhibits hypotension, tachypnea, profuse diaphoresis, and fatigue

Answer explanation

The abandoned person

The elderly traffic enforcer

The sportsman

the homemaker

Nurse Skye is assigned to the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first?

• A client scheduled for cardiac ultrasound this morning.

• A client with syncope being discharged today.

• A client with chronic bronchitis on nasal oxygen.

• A client with diabetic foot ulcer that needs a dressing change

Answer explanation

A client with airway problems should be attended first. When the nurse needs to prioritize patients, Maslow’s hierarchy of needs theory is used to decide which patient is to be seen first. A part of Maslow’s hierarchy of needs is airway, breathing, and circulation (ABC),which are physiological elements that are needed for the body to survive and help determine one’s level of health. Observing ABCs is a rapid assessment of life-threatening conditions in order of priority.

Option A: Clinical judgment and prioritization of patient care is built on the nursing process. Nurses learn the steps of the nursing process in their foundational nursing course and utilize it throughout their academic and clinical career to direct patient care and determine priorities. Analysis (interpreting what is going on with the patient through reviewing lab work, diagnostic testing, patient history, complaints and observations) comes after assessment.

Option B: The client who was discharged today is not a priority because he is stable enough to be sent home. Maslow’s Hierarchy of Needs identifies the physiological or biological needs, including the ABCs, the safety/psychological/emotional needs, the need for love and belonging, the needs for self-esteem and the esteem by others and the self-actualization needs in that order of priority.

Option D: The client needing a dressing change for her pressure ulcer belongs to Maslow’s physical and biological needs. Some physical needs include the need for the ABCs of airway, breathing and cardiovascular function, nutrition, sleep, fluids, hygiene and elimination.

A newly admitted client is suspected to have avian influenza (“bird flu”) due to increasing dyspnea and dehydration. Which of these prescribed actions will the nurse implement first?

• Give first dose of oseltamivir (Tamiflu)

• Instill 5% dextrose in water at 100 ml/hr

• Collect blood and sputum specimens for testing

• Start oxygen using a non-rebreather mask

Answer explanation

The nurse’s first action should be to start oxygen therapy because the respiratory manifestations linked to avian influenza are most likely life-threatening. Patients with respiratory compromise should be placed on supplemental oxygen and monitored closely for signs of deterioration as these patients are at high risk of requiring intubation and mechanical ventilation.

Option A: The World Health Organization released Rapid Advice Guidelines in 2007, outlining consensus treatment recommendations for H5N1 influenza outbreaks. Similar recommendations can likely be used in avian influenza outbreaks due to other strains of the virus. These recommendations include neuraminidase inhibitors (especially oseltamivir) for strongly suspected or confirmed cases of H5N1.

Option B: Treatment of avian influenza usually consists of supportive care and antiviral medications. The majority of care should aim at managing the sequelae of infection. For instance, patients with volume loss or possible electrolyte imbalances should receive volume resuscitation and treatment to correct imbalances. 

Option C: The preferred source of a sample for testing is a nasopharyngeal swab or aspirate, but other body fluids are usable if the nasopharyngeal swab or aspirate is not available. Because the infection carries high mortality risk, a negative rapid antigen test should not rule out AIV infection when high suspicion exists.

The high-pressure alarm on a patient’s ventilator goes off. When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should you take next?

• reassure the patient that the ventilator will do the work of breathing for him

• Manually ventilate the patient while assessing possible reasons for the high-pressure alarm

• Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning

• Insert an oral airway to prevent the patient from biting on the endotracheal tube

Answer explanation

Manual ventilation of the patient will allow you to deliver a FiO2 of 100% to the patient while you attempt to determine the cause of the high-pressure alarm. Proper ventilation techniques with the BVM should consider safe ventilation parameters for each individual patient and their conditions.

Option A: The patient may need reassurance, but this is not the priority nursing intervention. Indicators of appropriate ventilation include but are not limited to patient chest rise, skin color, electronic vital sign monitoring, resistance on bag squeeze according to patient lung pathology, CO2 monitoring, and a flashing light on the BVM for rate of breath delivery.

Option C: Excessive volume, pressure or flow may result in morbidity from lung damage, stomach insufflation, or hemodynamic and pulmonary compromise. Lower tidal volumes are needed in ARDS to prevent regional overdistension.

Option D: The patient may need insertion of an oral airway, but the first step should be an assessment of the reason for the high-pressure alarm and resolution of the hypoxemia. PEEP (5–20 cmH2O) is a key element of protective ventilation and is routinely applied in all patients with ARDS to facilitate adequate oxygenation and maintain alveolar recruitment.

Several clients arrive in the ED with the same complaint of abdominal pain. which one would you room first based on the severity of their condition?

• The 42-year-old woman with vomiting needs evaluation for gallbladder problem, which seems to be worsening. Occlusion of the cystic duct or malfunction of the mechanics of gallbladder emptying is the pathophysiology of this disease. Cases of acute untreated cholecystitis could lead to perforation of the gallbladder, sepsis, and death.

• The 25-year-old woman with lower left quadrant pain is at risk for ectopic pregnancy, which is a life-threatening condition.

• The 12-year-old girl needs evaluation to rule out appendicitis. Appendicitis is an acute inflammatory process involving the appendix. It is the number one surgical emergency and one of the most common causes of abdominal pain, particularly in children.

• The 68-year-old man with pulsating mass is experiencing abdominal aneurysm that may rupture, and he may abruptly deteriorate. Rupture of an abdominal aortic aneurysm is life-threatening. These patients may present in shock often with diffuse abdominal pain and distension. Most patients with a ruptured abdominal aortic aneurysm die before hospital arrival.

• The 38-year-old man has food poisoning, which is usually self-limiting. Most food-borne illnesses are mild and improve without any specific treatment. Some patients have severe disease and require hospitalization, aggressive hydration, and antibiotic treatment. 

Answer explanation

68- year-old man with pulsating mass

25-year-old woman with LLQ pain

12-year-old girl needing evaluation to r/o appy

42-year-old woman with vomiting needs

38-year-old mand has food poisoning

Prior to oral defense, a 21-year-old nursing student goes straight to the clinic due to tingling sensations, palpitations, and chest tightness. Deep, rapid breathing and carpal spasms are also observed. What is the nursing priority action for this situation?

• Give supplemental oxygen

• allow the student to breathe into a paper bag

• report to the physician immediately

• get an order for an anxiolytic medication

Answer explanation

The student is hyperventilating secondary to anxiety, and breathing into a paper bag will provide rebreathing of carbon dioxide. Encouraging slow breathing will also help. The idea behind breathing into a paper bag or mask is that rebreathing exhaled air helps the body put CO2 back into the blood.

Option A: Acute anxiety may require treatment with a benzodiazepine. Chronic anxiety treatment consists of psychotherapy, pharmacotherapy, or a combination of both. Anxiety disorders appear to be caused by an interaction of biopsychosocial factors. Genetic vulnerability interacts with situations that are stressful or traumatic to produce clinically significant syndromes.

Option C: Report it to the physician once there is a recurrence or the breathing did not improve. Anxiety is one of the most common psychiatric disorders but the true prevalence is not known as many people do not seek help or clinicians fail to make the diagnosis. Anxiety is one of the most common psychiatric disorders in the general population. Specific phobia is the most common with a 12-month prevalence rate of 12.1%. Social anxiety disorder is the next most common, with a 12-month prevalence rate of 7.4%.

Option D: Selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), benzodiazepines, tricyclic antidepressants, mild tranquilizers, and beta-blockers treat anxiety disorders.

The nurse assessed the client and noted shortness of breath and a recent trip to China. The client is strongly suspected of having Severe Acute Respiratory Syndrome (SARS). Which of these prescribed actions will the nurse take first?

• Place the client on airborne and contact precautions

• Start normal saline at 75ml/hr

• Give methylprednisolone (SOLU-Medrol) 1g IV

• Take blood, urine, sputum cultures

Answer explanation

SARS is considered deadly so the initial action is to protect other clients and healthcare workers by securing the client in isolation. If an airborne-agent isolation (negative-pressure) room is not yet available, droplet precautions should be initiated until the client can be moved to a negative-pressure room.

Option B: Early in the pandemic, a combination of ribavirin and corticosteroids was adopted as the standard treatment in Hong Kong, Canada and elsewhere because of the apparent good results of the first few patients. Subsequent reports showed that ribavirin was associated with a high rate of toxicity and lacked in vitro antiviral effect on SARS-coronavirus (SAR-CoV).

Option C: The timing and dosage regimens of steroids in the treatment of SARS are controversial. Pulse methylprednisolone 250 to 500 mg/day for 3 to 6 days has been reported to have some efficacy in a subset of patients with “critical SARS”, i.e., critically ill SARS patients with deteriorating radiographic consolidation, increasing oxygen requirement with PaO2 <10 kPa or SpO2 <90% on air, and respiratory distress (rate of 30/min). 

Option D: Handle these specimens using Universal Precautions, which includes use of gloves, gown, mask, and eye protection. Any procedure with the potential to generate fine-particulate aerosols (e.g., vortexing or sonication of specimens in an open tube) should be performed in a biological safety cabinet (BSC).