The nurse has received her client assignment for the day. which client should the nurse care for first?

1. Check the client's blood glucose level.
2. Give the client ½ cup (118 mL) of fruit juice to drink.
3. Take the client's vital signs.
4. Retest the blood glucose level.
5. Give the client a small snack of carbohydrate and protein.
6. Document the client's complaints, actions taken, and outcome.

Rationale:The client is experiencing symptoms of mild hypoglycemia. If symptoms such as hunger, irritability, shakiness, or weakness occur, the nurse first will check the client's blood glucose level to verify that the client is experiencing hypoglycemia. Once this is verified, the nurse will give the client 10 to 15 g of carbohydrates, such as a ½ cup (118 mL) of fruit juice. The nurse will retest the blood glucose level after 15 minutes. While waiting the 15 minutes, the nurse will check the client's vital signs. The nurse will give the client another 10- to 15-g carbohydrate food item if the client's symptoms do not resolve. Otherwise, the nurse will provide a small snack of carbohydrates and protein if the client's next scheduled meal is more than 1 hour away from the time of the occurrence. After treatment and resolution of the hypoglycemic event, the nurse will document the occurrence, actions taken, and outcome.
Cognitive Ability: Synthesizing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Implementation
Content Area: Leadership/Management: Prioritizing
Strategy(ies): Subject
Priority Concepts: Clinical Judgment, Glucose Regulation

2.Observing the client's behavior
3.Measuring the client's height and weight
5.Monitoring oral intake and urinary output

Rationale:The general survey is a review of the client's main health problems and includes assessment of vital signs, height and weight, general behavior, and appearance. The nurse can delegate some aspects, such as measuring height and weight and monitoring intake and output, to UAPs, but the nurse is responsible for performing the general survey, including assessment of general appearance, behavior, and skin.
Cognitive Ability: Analyzing
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process: Planning
Content Area: Leadership/Management: Delegating
Strategy(ies): Subject
Priority Concepts: Care Coordination, Safety

The nurse manager meets with the staff nurses and announces that management has developed a new policy and procedure that is significantly different from old practices. Which statement by the nurse manager reflects the manager's use of legitimate power?
Rationale:Option 3 describes legitimate power. Legitimate power is based on a person's position within an organization or society. The organizational leadership has mandated performance outcomes, and management has the responsibility to see that the mandate is met. Option 1 demonstrates informational power. The manager is using data to drive compliance with the mandate. Option 2 reflects an example of coercive power. Coercive power is a "do this or else" type of approach. Option 4 reflects expert power. The manager is asking the staff nurses to comply with the mandate because the manager possesses expert knowledge and skill levels. In addition to coercive, informational, expert, and legitimate power, the manager has referent, reward, and personal power.Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Communication and DocumentationContent Area: Leadership/Management: DelegatingStrategy(ies): SubjectPriority Concepts: Communication, Health Care Organizations
1."The health care system services a client population that presents particular challenges. The changes made will enhance client safety and reduce errors." 2."If you don't follow the new policy and procedure, I'll have no choice but to give you a notice about poor performance, which could lead to termination of your employment." 3."Every manager has the responsibility to see that these new policies and procedures are followed 100% of the time. Please join me in this organization's effort to continue to improve quality care." 4."You're just going to have to trust me on this one. I was a member of the committee that wrote the policy and procedure, and there are good reasons why the specific nursing actions need to be done this new way."

The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend to first?
Rationale:Priority nursing care in disaster situations needs to be delivered to the living and not the dead. The child who is bleeding badly is the priority. The bleeding could be from an arterial vessel; if the bleeding is not stopped, the child is at risk for shock and death. The pregnant client is the next priority, but the absence of fetal movement may or may not be indicative of fetal demise. The young child is with a family member and is safe at this time. The older victim will need comfort measures; there is no information indicating she is physically hurt.Cognitive Ability: SynthesizingClient Needs: Physiological IntegrityIntegrated Process: Nursing Process: AssessmentContent Area: Leadership/Management: DisastersStrategy(ies): ABCs—Airway, Breathing, Circulation, Maslow's Hierarchy of Needs Theory, Strategic WordsPriority Concepts: Care Coordination, Clinical Judgment
1.A pregnant woman who exclaims, "My baby is not moving." 2.A child who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" 3.A young child standing next to an adult family member who is screaming, "I want my mommy!" 4.An older victim who is sitting next to her husband sobbing, "My husband is dead. My husband is dead."

Which client should the nurse assess first?

When planning care for a client which action is a priority for the nurse?

Which client should the nurse safely assign to the unlicensed assistive personnel UAP )?

Which client should the emergency department triage nurse classify as emergent?