Prioritization And First Action - NCLEX Rn

1. A nurse receives report on four clients in an acute care setting. Which client should the nurse assess FIRST? (1) 63-year-old with chronic kidney disease and potassium 6.2 mEq/L (reference 3.5–5.0), peaked T waves noted on telemetry; (2) 51-year-old with asthma requesting PRN inhaler, SpO2 94%; (3) 38-year-old with migraine, pain 9/10, photophobia; (4) 74-year-old with constipation, no bowel movement for 3 days, abdomen soft.
   Answer: Assess the 63-year-old with potassium 6.2 mEq/L and peaked T waves This question assesses prioritization and clinical judgment skills in an acute care setting. The prioritization framework used is the ABCs, emphasizing circulation and cardiac stability. The 63-year-old with potassium 6.2 mEq/L and peaked T waves should be assessed first due to hyperkalemia risking arrhythmias. The 38-year-old has pain; the 51-year-old has mild hypoxia; and the 74-year-old has constipation. The underlying decision-making principle is to address electrolyte imbalances causing ECG changes immediately. This prevents cardiac events. A generalizable prioritization strategy is to evaluate abnormal labs with cardiac implications first, using ABCs in multi-client care.
2. In a postpartum unit, the nurse is caring for four clients. Which client should the nurse assess FIRST?
   Answer: A 29-year-old 2 hours postpartum with a boggy uterus and heavy bleeding; HR 124/min, BP 90/54 mm Hg. This question assesses prioritization and clinical judgment skills in identifying postpartum hemorrhage, a leading cause of maternal mortality. Using the circulation component of the ABC framework, the nurse must recognize that a boggy uterus with heavy bleeding, tachycardia (HR 124/min), and hypotension (BP 90/54) indicates postpartum hemorrhage requiring immediate intervention. The client is losing blood rapidly and showing signs of hypovolemic shock, which can quickly progress to organ failure and death without prompt treatment including uterine massage, uterotonics, and possible blood products. The other clients have less urgent needs: postoperative pain with a clean, dry incision is expected and manageable, mild UTI symptoms can be treated with antibiotics, and breastfeeding difficulties are important but not life-threatening. The underlying principle is that obstetric hemorrhage is a time-critical emergency where minutes matter in preventing maternal morbidity and mortality. When caring for postpartum clients, always prioritize signs of hemorrhage (boggy uterus, heavy bleeding, vital sign changes) as these require immediate intervention to prevent shock and preserve life.
3. On a surgical unit, an RN is assigning tasks for a team that includes an experienced unlicensed assistive personnel (UAP) and a licensed practical/vocational nurse (LPN/VN). Which task is most appropriate for the nurse to DELEGATE to the UAP? A. Obtain vital signs and report immediately if systolic BP is < 90 mm Hg for a 68-year-old 4 hours after total hip arthroplasty. B. Assess a 55-year-old's new onset of shortness of breath and unilateral calf swelling; HR 118/min, SpO2 90%. C. Titrate a heparin infusion based on aPTT results for a 72-year-old with a pulmonary embolism. D. Provide initial teaching on incentive spirometry to a 60-year-old postoperative client with RR 24/min.
   Answer: Obtain vital signs and report immediately if systolic BP is < 90 mm Hg for a 68-year-old 4 hours after total hip arthroplasty. This question assesses prioritization and clinical judgment skills in appropriate delegation based on scope of practice and client acuity. Using delegation principles, the nurse recognizes that UAPs can perform routine tasks like vital sign monitoring with specific parameters to report, making option A the most appropriate delegation. The postoperative hip replacement client is relatively stable at 4 hours post-op, and obtaining vital signs with clear reporting parameters (notify if SBP <90) is within UAP scope. Option B requires assessment of potential deep vein thrombosis or pulmonary embolism, which requires RN assessment skills; option C involves medication titration requiring RN judgment; and option D involves initial teaching, which is an RN responsibility. The underlying principle is that delegation must match the task complexity with the team member's scope of practice while ensuring client safety. When delegating, remember that UAPs can perform routine tasks with clear parameters, LPNs can perform more complex tasks under RN supervision, but assessment, teaching, and clinical judgment remain RN responsibilities.
4. A nurse in an acute care unit receives report on four clients. Which client should the nurse assess FIRST? (1) 50-year-old with pancreatitis reporting pain 8/10, BP 138/84, HR 98; (2) 67-year-old with GI bleed, black tarry stool, BP 104/62, HR 112, Hgb 7.4 g/dL (reference ~12–16 female, 13.5–17.5 male); (3) 73-year-old with UTI, temp 38.3°C (100.9°F), BP 128/76; (4) 45-year-old with cellulitis awaiting first dose of antibiotics, BP 122/74.
   Answer: Assess the 67-year-old with GI bleed, tachycardia, and hemoglobin 7.4 g/dL The client with GI bleed, tachycardia, and hemoglobin 7.4 g/dL is the priority because they show signs of active bleeding and potential hypovolemia, risking hemodynamic instability. The client with cellulitis awaiting antibiotics has stable blood pressure and no signs of systemic compromise; although treatment is important, it is not immediately life-threatening. The client with UTI and temperature 38.3°C has a mild fever with no hypotension, indicating a less urgent infection. The client with pancreatitis reporting pain 8/10 has elevated but stable vital signs; pain management is needed but does not outweigh the risk of hypovolemic shock. Prioritize using ABCs—circulation first—and recognize abnormal labs indicating blood loss as the highest urgency.
5. A 6-year-old is brought to the clinic after eating a cookie containing peanuts. Assessment: lip swelling, hives, hoarse voice, stridor, RR 32, SpO2 89% on room air, HR 148, BP 88/54. What is the nurse's FIRST action?
   Answer: Administer intramuscular epinephrine per anaphylaxis protocol This question assesses prioritization and clinical judgment skills in pediatric anaphylaxis. The prioritization framework used is the ABCs, focusing on airway and circulation. Administering intramuscular epinephrine per protocol is the first action to reverse severe allergic reaction and stabilize breathing and blood pressure. Starting an IV with diphenhydramine is supportive but secondary; obtaining a throat culture assumes infection; and providing fluids delays critical treatment. The underlying decision-making principle is to use epinephrine immediately in anaphylaxis to counteract histamine effects. This ensures rapid symptom reversal. A generalizable prioritization strategy is to administer reversal agents first in allergic emergencies, using ABCs to guide pediatric acute care.
6. The nurse is caring for four clients on a surgical unit. Which client should the nurse assess FIRST? (1) 58-year-old 1 day after total hip arthroplasty with pain 7/10, incision dry; (2) 64-year-old 2 hours after thyroidectomy with new hoarseness and stridor, SpO2 92%; (3) 47-year-old 3 days after appendectomy with temp 38.1°C (100.6°F); (4) 70-year-old with colostomy requesting teaching about pouch changes.
   Answer: Assess the 64-year-old post-thyroidectomy with new hoarseness and stridor This question assesses prioritization and clinical judgment skills on a surgical unit. The prioritization framework used is the ABCs, prioritizing airway patency. The 64-year-old post-thyroidectomy with new hoarseness and stridor should be assessed first due to potential airway obstruction from edema or hematoma. The 58-year-old has pain but stable incision; the 70-year-old requests teaching; and the 47-year-old has low fever. The underlying decision-making principle is to address postoperative airway risks immediately. This prevents respiratory arrest. A generalizable prioritization strategy is to evaluate new respiratory symptoms first in post-neck surgery, applying ABCs in surgical care.
7. In an acute care unit, a 26-year-old with type 1 diabetes is admitted with vomiting and abdominal pain. Assessment: dry mucous membranes, fruity breath odor, Kussmaul respirations 28/min; vital signs: HR 126/min, BP 92/58 mm Hg, T 37.1°C (98.8°F). Labs: glucose 560 mg/dL (reference 70–110), anion gap 24 (elevated), potassium 5.6 mEq/L (reference 3.5–5.0). What is the nurse's PRIORITY action?
   Answer: Initiate isotonic IV fluids as prescribed and assess urine output. This question assesses prioritization and clinical judgment skills in managing diabetic ketoacidosis (DKA), a life-threatening metabolic emergency. Using the circulation component of the ABC framework, the nurse must recognize that this client presents with classic DKA symptoms: dehydration (dry mucous membranes), metabolic acidosis (Kussmaul respirations, fruity breath), hyperglycemia (560 mg/dL), elevated anion gap, and signs of hypovolemic shock (tachycardia, hypotension). The priority action is initiating isotonic IV fluids to address severe dehydration and hypotension, which if untreated can lead to cardiovascular collapse. While insulin is essential for DKA treatment, it should not be given subcutaneously in acute DKA (option B) and must follow initial fluid resuscitation; oral fluids (option C) are inappropriate for a vomiting patient in shock; dietary education (option D) is premature during acute crisis. The underlying principle in DKA management is that fluid resuscitation takes precedence to restore circulating volume and prevent cardiovascular collapse before addressing hyperglycemia. When managing DKA, always remember the treatment sequence: fluids first, then insulin, with careful electrolyte monitoring throughout.
8. On a telemetry unit, a 70-year-old with atrial fibrillation is receiving a heparin infusion. The nurse notes oozing from the IV site and new dark, tarry stool. Vital signs: BP 98/60 mm Hg (baseline 130/76), HR 112/min, RR 20/min. Labs: aPTT 118 seconds (reference 25–35), hemoglobin 8.2 g/dL (reference 12–16). What is the nurse's PRIORITY action? A. Stop the heparin infusion and notify the provider. B. Recheck the aPTT in 1 hour to trend the result. C. Administer PRN acetaminophen for reported headache. D. Encourage oral fluids and reassess stool color in 4 hours.
   Answer: Stop the heparin infusion and notify the provider. This question assesses prioritization and clinical judgment skills in recognizing and managing a potentially life-threatening bleeding complication. Using the circulation component of the ABC framework, the nurse must recognize that this client is experiencing signs of significant bleeding: oozing from IV site, melena (dark, tarry stool indicating GI bleeding), hypotension, tachycardia, critically prolonged aPTT (118 seconds vs normal 25-35), and low hemoglobin. The priority action is to stop the heparin infusion immediately and notify the provider, as continuing the anticoagulation could lead to hemorrhagic shock and death. Rechecking the aPTT in an hour (option B) delays critical intervention, administering acetaminophen (option C) addresses a minor symptom while ignoring the emergency, and encouraging fluids (option D) is inappropriate for active bleeding. The underlying principle is that when a medication is causing life-threatening adverse effects, the first action is always to stop the medication and seek immediate medical intervention. In anticoagulation management, recognize that signs of bleeding with supratherapeutic levels require immediate cessation of the anticoagulant to prevent hemorrhagic complications.
9. A 32-year-old is 1 hour post-vaginal delivery. Assessment: uterus firm at the umbilicus, lochia rubra moderate, BP 118/72, HR 92. The client reports sudden shortness of breath and chest pain. New vitals: RR 32, SpO2 88% on room air, HR 126. What is the nurse's PRIORITY action?
   Answer: Apply oxygen, raise the head of the bed, and activate the rapid response team. The sudden onset of shortness of breath, chest pain, hypoxia, and tachycardia in a postpartum patient raises concern for pulmonary embolism or another acute respiratory emergency. The nurse's priority is to stabilize oxygenation and obtain expert help. Applying oxygen, raising the head of the bed, and activating the rapid response team directly addresses the ABC priority and brings a team able to diagnose and treat the cause. Administering ibuprofen treats postpartum discomfort but does nothing for hypoxia and delays definitive care; the clinical findings are not explained by ordinary pain. Fundal massage and uterine/lochia assessment with uterotonic preparation target postpartum hemorrhage, but the uterus is firm and the immediate abnormality is respiratory, not bleeding. Ambulating the client for gas pain could worsen oxygenation in a suspected pulmonary embolism and is unsafe until the cause is identified. Thus, applying oxygen, raising the head of the bed, and activating the rapid response team is the only option that matches the priority.
10. A 24-year-old is brought to the emergency department after an opioid overdose. Assessment: RR 6, shallow respirations, SpO2 82% on room air, pinpoint pupils, HR 58, BP 102/60. What is the nurse's FIRST action?
    Answer: Administer naloxone per protocol and prepare for repeat dosing as needed This question assesses prioritization and clinical judgment skills in opioid overdose. The prioritization framework used is the ABCs, emphasizing breathing and reversal. Administering naloxone per protocol is the first action to antagonize opioids and restore respirations. Obtaining drug screens is diagnostic but delays; inserting a catheter monitors output secondarily; and interviewing family gathers history after stabilization. The underlying decision-making principle is to reverse respiratory depression immediately in overdoses. This restores airway patency. A generalizable prioritization strategy is to use antidotes first in toxin-induced respiratory failure, applying ABCs in emergency toxicology.
11. A 70-year-old admitted for pneumonia is receiving oxygen at 4 L/min via nasal cannula. New assessment: sudden restlessness, RR 30, SpO2 84%, HR 118, BP 156/90, coarse crackles. The nurse notes the oxygen tubing is connected but the flowmeter reads 0 L/min. Which intervention should the nurse implement IMMEDIATELY?
    Answer: Turn on the oxygen flow to the prescribed rate and reassess SpO2 and work of breathing This question assesses prioritization and clinical judgment skills in managing acute hypoxia. The prioritization framework used is the ABCs, focusing on breathing and oxygenation. Turning on the oxygen flow to the prescribed rate and reassessing SpO2 and work of breathing is the immediate intervention to correct the disconnected oxygen and improve saturation. Increasing oxygen assumes worsening without addressing the cause; obtaining x-ray and ABG delays basic correction; and administering antianxiety medication ignores the hypoxic trigger. The underlying decision-making principle is to quickly resolve reversible causes of hypoxia before escalating care. This prevents unnecessary deterioration. A generalizable prioritization strategy is to check and correct equipment malfunctions first in sudden respiratory changes, applying ABCs to ensure oxygen delivery in similar scenarios.
12. The nurse is caring for a single client with multiple needs: a 62-year-old with type 1 diabetes and chronic kidney disease who is NPO for a procedure. Current data: blood glucose 48 mg/dL, diaphoretic and shaky but awake; potassium 5.6 mEq/L (reference 3.5–5.0), creatinine 2.4 mg/dL (reference ~0.6–1.3), BP 138/82, HR 96. What is the nurse's PRIORITY action?
    Answer: Administer IV dextrose per hypoglycemia protocol and recheck blood glucose This question assesses prioritization and clinical judgment skills for a single client with multiple needs. The prioritization framework used is the ABCs, prioritizing circulation and immediate metabolic threats. Administering IV dextrose per hypoglycemia protocol and rechecking blood glucose is the priority to rapidly correct severe hypoglycemia and prevent neurological damage. Monitoring for hyperkalemia is secondary; holding insulin addresses future risks but not current; and providing oral glucose is unsafe for an NPO client. The underlying decision-making principle is to treat life-threatening low glucose levels first in diabetic clients with kidney issues. This stabilizes acute symptoms efficiently. A generalizable prioritization strategy is to address reversible metabolic crises like hypoglycemia before chronic abnormalities, using ABCs in complex single-client scenarios.
13. A nurse receives report on four clients on a step-down unit. Which client should the nurse assess FIRST? (1) 57-year-old with diabetic ketoacidosis on insulin infusion, blood glucose 210 mg/dL and trending down, potassium 4.2 mEq/L; (2) 66-year-old with sepsis receiving IV antibiotics, lactate 1.8 mmol/L, BP 118/70; (3) 74-year-old with a new tracheostomy who has copious secretions, audible gurgling, RR 26, SpO2 90%; (4) 39-year-old with pancreatitis, NPO, pain controlled with PCA, RR 16.
    Answer: Assess the 74-year-old with new tracheostomy, gurgling secretions, and SpO2 90% When a stem asks who to see first, apply the ABCs and look for the client whose airway or breathing is actively threatened. The client with a new tracheostomy has copious secretions with audible gurgling, a respiratory rate of 26, and SpO2 of 90 percent — a partially obstructed artificial airway that will fail without prompt assessment and suctioning, and a new tracheostomy has no margin for delay. The septic client receiving antibiotics has a lactate of 1.8 and a blood pressure of 118 over 70, which reflects treatment that is working rather than deterioration, so this is a circulation concern already trending in the right direction. The client in diabetic ketoacidosis on an insulin infusion has a glucose of 210 trending down and a potassium of 4.2, both expected and reassuring on therapy; important to monitor, but stable. The client with pancreatitis has pain controlled on a PCA and a respiratory rate of 16, which is comfort and monitoring, not instability. Rank by physiologic threat, not by diagnosis severity or the number of interventions running: an airway or breathing problem in progress outranks a circulation issue that is improving and any stable client.
14. A nurse is reviewing a new medication administration record for four clients. The nurse should QUESTION which order? (1) 80-year-old with heart failure and potassium 5.8 mEq/L: spironolactone 25 mg PO daily; (2) 45-year-old with pneumonia: ceftriaxone IV; (3) 30-year-old with nausea: ondansetron IV PRN; (4) 67-year-old with osteoarthritis: acetaminophen PO PRN. Vital signs are stable for all clients.
    Answer: Spironolactone 25 mg PO daily for the 80-year-old with potassium 5.8 mEq/L This question assesses prioritization and clinical judgment skills in medication review. The prioritization framework used is the nursing process, focusing on safety and contraindications. The nurse should question spironolactone 25 mg PO daily for the 80-year-old with potassium 5.8 mEq/L, as this potassium-sparing diuretic risks worsening hyperkalemia. Ceftriaxone is appropriate for pneumonia; acetaminophen for pain; and ondansetron for nausea. The underlying decision-making principle is to identify orders exacerbating electrolyte imbalances. This prevents adverse effects. A generalizable prioritization strategy is to question medications contraindicated by labs, using safety checks in order reviews.
15. In an acute care medical-surgical unit, the nurse receives shift report on four clients. Which client should the nurse assess FIRST? A. A 58-year-old with type 2 diabetes who is diaphoretic and confused; bedside glucose is 42 mg/dL (reference 70–110), vital signs: T 36.8°C (98.2°F), HR 104/min, RR 18/min, BP 148/86 mm Hg. B. A 76-year-old with heart failure reporting mild dyspnea on exertion; SpO2 93% on 2 L nasal cannula, lungs with bibasilar crackles, HR 88/min, RR 20/min, BP 154/78 mm Hg. C. A 44-year-old postoperative day 1 after appendectomy with pain 7/10; incision dry, HR 92/min, RR 16/min, BP 132/74 mm Hg, T 37.2°C (99.0°F). D. A 67-year-old with a urinary tract infection receiving IV antibiotics; temperature 38.1°C (100.6°F), HR 96/min, RR 18/min, BP 126/70 mm Hg, reports burning with urination.
    Answer: A 58-year-old with type 2 diabetes who is diaphoretic and confused; bedside glucose is 42 mg/dL. This question assesses prioritization and clinical judgment skills in determining which client requires immediate intervention. The nurse should use the ABCs (Airway, Breathing, Circulation) framework and recognize that severe hypoglycemia poses an immediate threat to brain function and consciousness. The client with a blood glucose of 42 mg/dL who is diaphoretic and confused is experiencing severe hypoglycemia, which can rapidly progress to seizures, loss of consciousness, and permanent neurological damage if not treated immediately. The other clients have stable conditions: the heart failure patient has mild symptoms with adequate oxygenation, the postoperative patient has expected pain with stable vitals, and the UTI patient has a low-grade fever while receiving appropriate treatment. The underlying principle is that acute metabolic emergencies affecting neurological function take precedence over chronic conditions or expected postoperative findings. When prioritizing care, always address life-threatening conditions that can cause rapid deterioration first, particularly those affecting brain function or consciousness.
16. The nurse receives report on four postpartum clients on a mother-baby unit. Which client should the nurse assess FIRST? (1) 22-year-old 8 hours postpartum with saturated pad in 15 minutes, boggy uterus, HR 118, BP 92/56; (2) 30-year-old 2 days postpartum with mild headache and BP 142/88; (3) 26-year-old 1 day postpartum with perineal pain rated 7/10 and intact sutures; (4) 35-year-old 12 hours postpartum with temperature 38.0°C (100.4°F) after prolonged labor.
    Answer: Assess the 22-year-old with heavy bleeding, boggy uterus, and hypotension This question assesses prioritization and clinical judgment skills on a postpartum unit. The prioritization framework used is Maslow's hierarchy, prioritizing physiological needs like hemodynamic stability. The 22-year-old with heavy bleeding, boggy uterus, and hypotension should be assessed first due to signs of postpartum hemorrhage, which can lead to shock if untreated. The 26-year-old has pain but intact sutures; the 35-year-old has a low-grade fever without instability; and the 30-year-old has mild hypertension without severe symptoms. The underlying decision-making principle is to identify and address acute bleeding risks to prevent maternal morbidity. This ensures stabilization of life-threatening conditions. A generalizable prioritization strategy is to evaluate postpartum clients for hemorrhage indicators first, using Maslow's hierarchy to focus on immediate physiological threats in maternal care.
17. The nurse on a medical-surgical unit receives shift report on four clients. Which client should the nurse assess FIRST? Client data: (1) 68-year-old with COPD on 2 L/min nasal cannula, SpO2 90%, RR 22, speaking in full sentences; (2) 55-year-old 12 hours post-op abdominal surgery with BP 86/48, HR 124, pale, cool, urine output 15 mL/hr; (3) 40-year-old with type 2 diabetes, blood glucose 62 mg/dL, awake and asking for juice; (4) 72-year-old with heart failure, 2+ pedal edema, BP 148/86, HR 88, weight up 1.0 kg from yesterday.
    Answer: Assess the 55-year-old post-op client with BP 86/48, HR 124, and low urine output This question assesses prioritization and clinical judgment skills in a medical-surgical setting. The prioritization framework used is the ABCs (airway, breathing, circulation), focusing on immediate threats to life. The 55-year-old post-op client with BP 86/48, HR 124, and low urine output should be assessed first because these signs indicate hypovolemic shock, requiring urgent intervention to restore circulation. The 40-year-old with blood glucose 62 mg/dL is awake and requesting juice, which is less urgent; the 68-year-old with COPD has stable oxygenation and can speak in full sentences; and the 72-year-old with heart failure shows chronic changes without acute distress. The underlying decision-making principle is to address unstable vital signs that compromise perfusion and organ function before stable or chronic conditions. This ensures timely intervention to prevent deterioration. A generalizable prioritization strategy is to always evaluate clients with signs of circulatory instability first, using the ABC framework to guide assessments in multi-client scenarios.
18. A nurse is caring for four clients in the emergency department. Which client should the nurse assess FIRST? (1) 29-year-old with ankle sprain, pain 6/10, stable vital signs; (2) 61-year-old with sudden severe headache, BP 190/104, nausea, photophobia; (3) 46-year-old with kidney stone, pain 9/10, BP 152/88; (4) 52-year-old with influenza-like illness, temp 38.6°C (101.5°F), SpO2 96%.
    Answer: Assess the 61-year-old with sudden severe headache and BP 190/104 This question assesses prioritization and clinical judgment skills in an emergency department. The prioritization framework used is the ABCs, prioritizing neurological stability. The 61-year-old with sudden severe headache and BP 190/104 should be assessed first due to potential hypertensive emergency or stroke, requiring urgent evaluation. The 46-year-old has pain but stable vitals; the 52-year-old has fever without distress; and the 29-year-old has minor injury. The underlying decision-making principle is to address acute neurological changes with hypertension before pain or infection. This prevents irreversible damage. A generalizable prioritization strategy is to evaluate sudden onset symptoms suggesting cerebrovascular events first, applying ABCs in ED triage.
19. In an acute care unit, a 62-year-old with chronic obstructive pulmonary disease (COPD) is admitted with pneumonia and is receiving oxygen at 2 L/min via nasal cannula. The client becomes increasingly somnolent and difficult to arouse; vital signs: HR 110/min, RR 8/min and shallow, BP 142/84 mm Hg, SpO2 91%. Arterial blood gas results: pH 7.28 (reference 7.35–7.45), PaCO2 68 mm Hg (reference 35–45), PaO2 58 mm Hg (reference 80–100). What is the nurse's PRIORITY action? A. Increase oxygen to 6 L/min via nasal cannula. B. Stimulate the client, ensure airway patency, and notify the rapid response team. C. Request an order for a sedative to reduce anxiety and improve breathing pattern. D. Obtain a sputum culture before any further interventions.
    Answer: Stimulate the client, ensure airway patency, and notify the rapid response team. This question assesses prioritization and clinical judgment skills in managing respiratory failure in a COPD patient. Using the breathing component of the ABC framework, the nurse must recognize that this client is experiencing hypercapnic respiratory failure with CO2 narcosis: severe bradypnea (RR 8/min), altered mental status (somnolent), respiratory acidosis (pH 7.28, PaCO2 68), and hypoxemia (PaO2 58). The priority action is to stimulate the client to breathe, ensure airway patency, and activate the rapid response team for potential ventilatory support, as the client's respiratory drive is severely depressed. Increasing oxygen (option A) could worsen CO2 retention in COPD patients who rely on hypoxic drive; sedatives (option C) would further depress respirations; and obtaining cultures (option D) delays critical intervention. The underlying principle is that in COPD patients with CO2 retention, the immediate threat is respiratory failure from hypoventilation, not just hypoxemia. When managing COPD exacerbations, recognize that somnolence with bradypnea indicates CO2 narcosis requiring immediate intervention to support ventilation, not just oxygenation.
20. A nurse is preparing to delegate tasks for four clients on a telemetry unit. Which task is most appropriate to delegate to an experienced unlicensed assistive personnel (UAP)? Client data: (1) 58-year-old with chest pain awaiting troponin results; (2) 76-year-old with heart failure receiving IV furosemide, strict intake and output; (3) 44-year-old with new-onset atrial fibrillation on a heparin infusion; (4) 65-year-old 2 days post-stroke with dysphagia precautions. What should the nurse delegate?
    Answer: Obtain and document hourly urine output from the client receiving IV furosemide This question assesses prioritization and clinical judgment skills in delegation on a telemetry unit. The prioritization framework used is the nursing process, focusing on safe delegation within scope of practice. Obtaining and documenting hourly urine output from the client receiving IV furosemide is most appropriate to delegate to an experienced UAP, as it involves routine measurement without assessment. Performing dysphagia screening requires nursing judgment; titrating heparin involves evaluation; and assessing chest pain demands professional skills. The underlying decision-making principle is to delegate stable, non-invasive tasks to UAP while retaining complex assessments. This optimizes team efficiency safely. A generalizable prioritization strategy is to evaluate tasks for delegation based on stability and skill level, ensuring nurses handle judgments in similar unit settings.

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