Practice Quiz

NCLEX-RN

Category - Care Management

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Rick Rescue, RN has floated to the cardiac unit. His clients include: a 60-year-old male, 4 hours post-angioplasty; a 58-year-old female, possible discharge home this afternoon, complaining of indigestion and slightly diaphoretic; a 52-year-old female receiving heparin drip, most recent PT/INR 2.6; an 80-year-old male, ambulating, talking and laughing with family in hallway with walker, telemetry alarming SVT. In what order should Rick Rescue, RN visit these clients?

I. 60-year-old
II. 58-year-old
III. 52-year-old
IV. 80-year-old
  1. III, IV, I, II
  2. II, IV, I, III
  3. I, III, IV, II
  4. IV, II, III, I
Explanation
Answer: B- The client who is complaining of indigestion and diaphoretic is the most unstable client and requires priority assessment. The client ambulating and visiting in the hallway is showing no indication of distress despite the telemetry alarm. Priority is given to the patient who is most unstable or has greatest potential for life-threatening events. The lab values of the client receiving anticoagulation therapy (heparin drip) indicate therapeutic levels
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