Nokea
The 2nd priority needs according to the MAAUAR method of priority setting include which of the following?
- A. Assessment
- B. Movement
- C. Understanding level
- D. Risks
Correct Answer: D
Rationale: The MAAUAR method prioritizes: Mental status, Acute pain, Acute eliminated needs, Urgent needs, Abnormal vital signs, Risks. The second priority is Acute pain, but among the options, Risks aligns as a high-priority need following initial physiological concerns.
You may also like to solve these questions
A widowed client who is receiving chemotherapy tells the nurse that he does not like to cook for himself. A community resource for this client is:
- A. Hospice Association.
- B. Visiting Nurses' Association (VNA).
- C. Meals on Wheels.
- D. American Association of Retired Persons (AARP).
Correct Answer: C
Rationale: Meals on Wheels provides home-delivered meals, which directly addresses the client's difficulty with cooking. Hospice is for end-of-life care, VNA focuses on nursing services, and AARP offers advocacy, not meal services.
The nurse is caring for a client with a history of osteoarthritis. Which of the following non-pharmacologic interventions should be included in the plan of care?
- A. Apply heat to affected joints.
- B. Restrict weight-bearing activities.
- C. Encourage a low-protein diet.
- D. Limit range-of-motion exercises.
Correct Answer: A
Rationale: Heat therapy reduces stiffness and pain in osteoarthritis.
The nurse is providing instructions to the parent of a child who had a myringotomy with insertion of tympanostomy tubes. Which instructions should the nurse provide the parent in case the tubes fall out?
- A. Bring the child to the emergency department immediately.
- B. It is not an emergency, but it is best to call the health care clinic.
- C. It is important to replace them immediately so that the surgical opening does not close.
- D. Clean the tubes with half-strength hydrogen peroxide for 30 minutes and then replace them into the child's ears.
Correct Answer: B
Rationale: The parent should be assured that if the tympanostomy tubes fall out, it is not an emergency, but it is best if the primary health care provider or health care clinic is notified. The size and appearance of the tympanostomy tubes should be described to the parent after surgery so that he or she will be familiar with their appearance. The remaining options are incorrect.
A client, admitted to the emergency department reporting severe, radiating chest pain, is extremely restless, frightened, and dyspneic. Immediate admission prescriptions include oxygen by nasal cannula at 4 L per minute; troponin, creatinine phosphokinase, and isoenzymes blood levels; a chest x-ray; and a 12-lead ECG. Which action should the nurse take first?
- A. Obtain the 12-lead ECG.
- B. Draw the blood specimens.
- C. Apply the oxygen to the client.
- D. Schedule the chest x-ray study.
Correct Answer: C
Rationale: The first action would be to apply the oxygen because the client can be experiencing myocardial ischemia. The ECG can provide evidence of cardiac damage and the location of myocardial ischemia. However, oxygen is the priority to prevent further cardiac damage. Drawing the blood specimens would be done after oxygen administration and just before or after the ECG, depending on the situation. Although the chest x-ray can show cardiac enlargement, having the chest x-ray would not influence immediate treatment.
A client with a history of heart failure is prescribed enalapril (Vasotec). The nurse should monitor the client for which of the following adverse effects?
- A. Hyperkalemia.
- B. Hypotension.
- C. Weight loss.
- D. Tachycardia.
Correct Answer: A, B
Rationale: Enalapril, an ACE inhibitor, can cause hyperkalemia and hypotension.