2.7 Learning Activities

2.7 Learning Activities

Flashcards

Click the Turn button to flip each card and see the answer, then use the arrow to move to the next card. Continue through the set and revisit cards as needed until you can recall the answers on your own.

Knowledge Check

Read each question carefully. Select the answer you think is correct. Then select Check to submit your answer. If your answer is incorrect, select Retry to try again. Use the arrow buttons to move between questions.

Check 1: Prioritization

Fill-in-the-Blank

Complete each statement by entering the correct word or phrase in the blank. Select Check to submit your answer and review your response.

Fill-in-the-Blank 1: Prioritization

NCLEX Next Generation-Style Question

Test your clinical judgment with this NCLEX Next Generation-style question.

Open the NCLEX Next Generation-style case study activity

Case Study

Atrial Fibrillation and Prioritization

The nurse is conducting an assessment on a 70-year-old male client who was admitted with atrial fibrillation. The client has a history of hypertension and Stage 2 chronic kidney disease. The nurse begins the head-to-toe assessment and notes the client is having difficulty breathing and is complaining about chest discomfort. The client states, “It feels as if my heart is going to pound out of my chest and I feel dizzy.” The nurse begins the head-to-toe assessment and documents the findings. Client assessment findings are presented in the table below. Select the assessment findings requiring immediate follow-up by the nurse.

Vital Signs

Vital signs assessment findings and results
Assessment Finding	Result
Temperature	98.9°F, or 37.2°C.
Heart Rate	182 beats/min.
Respirations	36 breaths/min.
Blood Pressure	152/90 mmHg.
Oxygen Saturation	88% on room air.
Capillary Refill Time	>3 seconds.
Pain	9/10 chest discomfort.

Physical Assessment Findings

Physical assessment findings and results
Assessment Finding	Result
Glasgow Coma Scale Score	14.
Level of Consciousness	Alert.
Heart Sounds	Irregularly regular.
Lung Sounds	Clear bilaterally anterior/posterior.
Pulses—Radial	Rapid/bounding.
Pulses—Pedal	Weak.
Bowel Sounds	Present and active × 4.
Edema	Trace bilateral lower extremities.
Skin	Cool, clammy.

Nursing Actions

The following nursing actions may or may not be required at this time based on the assessment findings. Indicate whether the actions are “Indicated,” meaning appropriate or necessary; “Contraindicated,” meaning could be harmful; or “Nonessential,” meaning makes no difference or is not necessary.

Classification of nursing actions as indicated, contraindicated, or nonessential
Nursing Action	Indicated	Contraindicated	Nonessential
Apply oxygen at 2 liters per nasal cannula.
Call imaging for a STAT lung CT.
Perform the National Institutes of Health (NIH) Stroke Scale Neurologic Exam.
Obtain a comprehensive metabolic panel (CMP).
Obtain a STAT EKG.
Raise the head-of-bed to less than 10 degrees.
Establish patent IV access.
Administer potassium 20 mEq IV push STAT.

CURE Hierarchy Prioritization

The CURE hierarchy has been introduced to help novice nurses better understand how to manage competing client needs. The CURE hierarchy uses the acronym “CURE” to help guide prioritization based on identifying the differences among Critical needs, Urgent needs, Routine needs, and Extras.

You are the nurse caring for the clients in the following table. For each client, indicate if this is a “critical,” “urgent,” “routine,” or “extra” need.

Classification of client needs using the CURE hierarchy
Client Need	Critical	Urgent	Routine	Extra
Client exhibits new left-sided facial droop.
Client reports 9/10 acute pain and requests PRN pain medication.
Client with BP 120/80 and regular heart rate of 68 has scheduled dose of oral amlodipine.
Client with insomnia requests a back rub before bedtime.
Client has a scheduled dressing change for a pressure ulcer on their coccyx.
Client is exhibiting new shortness of breath and altered mental status.
Client with fall risk precautions ringing call light for assistance to the restroom for a bowel movement.

Case study answers are located in the Answer Key at the end of the book.

License

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