Prioritization And First Action - NCLEX Rn

1. What is the first action when a client expresses suicidal intent with a specific plan?

   Initiate safety precautions with continuous observation. Prevents imminent self-harm by implementing immediate protective measures and constant monitoring in high-risk situations.

2. Which client should be assessed first: postoperative day $1$ with increasing restlessness, stable pain, or requesting water?

   Postoperative day $1$ with increasing restlessness. May indicate postoperative complications like hypoxia or hemorrhage requiring immediate assessment, unlike stable or minor needs.

3. What principle prioritizes the most urgent physiologic needs over psychosocial needs?

   Maslow hierarchy: physiologic needs take priority. Maslow's hierarchy places physiological needs like air and food at the base, requiring fulfillment before addressing higher-level psychosocial needs.

4. What delegation rule requires the RN to perform assessment, teaching, and evaluation tasks?

   RN must do assessment, teaching, evaluation, and judgment. Ensures that tasks requiring professional nursing judgment and expertise are not delegated to maintain patient safety and care quality.

5. What is the first action when a client suddenly becomes hypotensive during a blood transfusion?

   Stop the transfusion. Halts the source of a potential hemolytic or allergic reaction immediately to prevent further harm and stabilize the patient's condition.

6. Which client should be seen first: new confusion, stable COPD on $2\,\text{L/min}$, anxiety, or constipation?

   New confusion. May signal acute neurological changes or metabolic imbalances necessitating prompt evaluation to prevent rapid deterioration or complications.

7. What is the first action when a client reports shortness of breath after opioid administration?

   Assess airway and respiratory status immediately. Ensures rapid detection of potential opioid-induced respiratory depression, which is critical for timely reversal and preventing hypoxia.

8. Which task is highest priority: assess new onset chest pain, administer scheduled stool softener, or provide discharge teaching?

   Assess new onset chest pain. Addresses potential acute cardiac issues that could be life-threatening, taking precedence over routine or non-urgent tasks.

9. What is the first action when you find an adult unresponsive with no normal breathing?

   Activate emergency response and start CPR. Follows Basic Life Support guidelines to initiate emergency response and cardiopulmonary resuscitation promptly in cases of suspected cardiac arrest.

10. Which is the first step of RACE: Rescue, Alarm, Contain, or Extinguish/Evacuate?

    Rescue. Focuses on saving lives by evacuating those in peril before activating alarms or containing the fire, per standard protocol.

11. What is the first action when a client has a new medication order that seems unsafe for their condition?

    Hold the medication and clarify the order with the provider. Safeguards the patient by withholding potentially harmful medication and seeking clarification to ensure order appropriateness.

12. Which finding requires first action: stridor, mild wheeze, sore throat, or nonproductive cough?

    Stridor. Signals potential upper airway obstruction requiring urgent intervention to maintain patency, unlike less severe respiratory symptoms.

13. What is the first action when a client has a seizure in bed?

    Protect from injury and maintain airway positioning. Ensures patient safety during the seizure by preventing trauma and supporting airway patency without restricting movements.

14. Which assessment finding is the highest priority: airway obstruction, pain $8/10$, fever $39\,^{\circ}\text{C}$, or nausea?

    Airway obstruction. Represents an immediate threat to life by compromising oxygenation, superseding other symptoms that do not directly impair basic physiological functions.

15. Which task can be delegated to UAP: initial assessment, IV push meds, sterile dressing change, or obtain vital signs?

    Obtain vital signs. Falls within the scope of unlicensed assistive personnel for routine monitoring, unlike tasks needing nursing judgment or advanced skills.

16. What priority framework should you apply first when determining immediate nursing action?

    ABCs (airway, breathing, circulation) with immediate threats first. Prioritizes life-threatening issues by addressing airway, breathing, and circulation sequentially to ensure immediate survival needs are met before other concerns.

17. What is the first action when an IV infiltrates and the site is swollen and cool?

    Stop the infusion and remove the IV catheter. Prevents further tissue damage from extravasation and allows for immediate assessment and management of the infiltration site.

18. Which client is most urgent: active arterial bleeding, closed arm fracture, minor laceration, or mild headache?

    Active arterial bleeding. Poses an immediate risk of exsanguination and circulatory collapse, demanding urgent control unlike less critical injuries or symptoms.

19. What is the first action when you discover a fire in a client room?

    Rescue the client (RACE: Rescue first). Prioritizes removing individuals from immediate danger in accordance with the RACE fire safety protocol to prevent harm.

20. Which is the first action for suspected hypoglycemia: check glucose, give insulin, ambulate, or teach diet?

    Check blood glucose. Confirms the diagnosis accurately to guide appropriate treatment and avoid interventions that could worsen the condition if misdiagnosed.

21. Which is the first action for a client actively seizing: restrain limbs, place on side, or give oral meds?

    Place the client on the side to maintain airway. Facilitates drainage of oral secretions and prevents aspiration, prioritizing airway protection during the convulsive phase.

22. What triage principle prioritizes clients with the greatest chance of survival with rapid intervention?

    Disaster triage: do the greatest good for the greatest number. Allocates limited resources in mass casualties to maximize survivors by focusing on those with high survival potential through immediate care.

23. Which action is first for a client with suspected transfusion reaction: stop blood, flush with dextrose, or document only?

    Stop the blood transfusion. Immediately ceases administration of the offending blood product to mitigate adverse effects and allow for further assessment.

24. What is the first action when a client is found on the floor after a fall?

    Assess for injury before moving the client. Determines the extent of potential injuries to guide safe mobilization and prevent exacerbation of undetected trauma.

25. Which client is highest priority: chest pain with diaphoresis, chronic back pain, stable UTI, or postoperative nausea?

    Chest pain with diaphoresis. Indicates a potential acute myocardial infarction requiring immediate intervention to prevent mortality, unlike the other stable or chronic conditions.

Study these flashcards