Prioritization & Delegation Practice Test #5: Maslow and Safety Priorities

Answer: C. Deficient fluid volume related to losses from vomiting and diarrhea

Rationale: Maslow's hierarchy places physiological needs first. Low blood pressure, a fast heart rate, and dry mucous membranes after ongoing vomiting and diarrhea point to fluid volume loss that can progress to poor perfusion and shock, so restoring fluid volume comes first. The client's worry about work is real and should be addressed, but anxiety is a psychosocial need. Teaching about food handling is a knowledge need that is best done once the client is stable and able to learn. Risk for low self-esteem is a higher-level need in Maslow's hierarchy and is only a risk, not an actual problem.

Answer: A. An older client with dementia who is trying to climb over the bed rails and is pulling at the IV line

Rationale: When no client has an airway, breathing, or circulation problem, safety comes next in Maslow's hierarchy. A confused client climbing over the bed rails is at immediate risk of a fall and injury, and pulling at the IV line can cause bleeding or loss of IV access. The nurse should go to this client first, stay with the client, and use the least restrictive safety measures available. The crying client and the client asking for the chaplain have important emotional and spiritual needs (love and belonging), which the nurse can address next. Discharge teaching can wait until the more urgent needs are met.

Answer: D. A client with type 1 diabetes who is shaky, sweaty, and confused, with a capillary blood glucose of 52 mg/dL

Rationale: Shakiness, sweating, and confusion with a low blood glucose are signs of hypoglycemia, a physiological emergency that can lead to seizures, loss of consciousness, and injury if it is not treated quickly. The nurse should treat it right away according to the facility's hypoglycemia protocol and recheck the glucose. Exact treatment thresholds and doses vary by facility and provider orders. The client on fall precautions is asleep with safety measures in place, so that client is currently safe. Fear about surgery is a psychosocial need, and help with meal selections is a routine task that can wait or be delegated.

Answer: B. Check circulation and skin, and offer toileting, fluids, and range of motion at the intervals required by the order and facility policy

Rationale: A client in restraints depends on the nurse for basic physiological needs and safety. The nurse checks circulation, skin, and the client's position, offers fluids and toileting, provides range of motion, and reassesses whether the restraint is still needed. How often this is done is set by the prescription, facility policy, and regulations, so the nurse follows those. Restraints are tied to the bed frame, not the side rails, because lowering a side rail can pull on the client's limb and cause injury. Restraint prescriptions cannot be written as PRN (as needed). A quick-release knot is used, not a square knot, so the client can be freed quickly in an emergency.

Answer: D. Ask the client directly whether they are thinking about suicide and whether they have a plan

Rationale: A sudden calm or brighter mood after a period of depression, together with giving away valued belongings, can mean the client has made a decision and a plan to end their life. Safety is the priority. The nurse should ask directly and clearly about suicidal thoughts, a plan, and access to means. Asking does not put the idea in the client's head. The nurse then keeps the client safe and follows facility policy for observation and notifying the provider. Praising the mood, simply documenting it, or encouraging group activity would miss a serious warning sign.

Answer: A. "I have to sit up on three pillows to catch my breath at night."

Rationale: Needing to sit up on several pillows to breathe at night (orthopnea) is a physiological problem and may mean the client's heart failure is getting worse, with fluid building up in the lungs. The nurse should assess breathing, oxygen saturation, lung sounds, weight, and edema and report the findings. Worry about a pet is a safety and security concern for the client but does not threaten the client's body. Missing a daughter is a love and belonging need. Not understanding a new diuretic is a learning need that is important before discharge but comes after the physiological problem.

Answer: C. Remove loose throw rugs and keep walkways clear of cords and clutter

Rationale: Loose rugs, cords, and clutter are common causes of trips and falls at home, so removing them is a key fall-prevention step. Other helpful measures include good lighting and night lights, grab bars in the bathroom, and sturdy, closed-back shoes with non-skid soles. Keeping items on high shelves makes the person reach or climb, which raises the fall risk; often-used items should be kept between waist and shoulder height. Bath oil makes the tub or shower floor slippery. Backless slippers can slide off and cause tripping.

Answer: B. A client whose spouse cannot visit and who asks the nurse for help setting up a video call with family

Rationale: In Maslow's hierarchy, once physiological and safety needs are met, the next level is love and belonging, followed by self-esteem, and then self-actualization. The client who wants to connect with family has a love and belonging need, so it comes first among these four. Embarrassment about how a colostomy looks relates to body image and self-esteem, the next level up. Returning to painting and taking a cooking class are personal growth goals that fit self-actualization, the highest level. All of these needs matter, but the hierarchy helps the nurse decide the order.

Answer: D. Ask the client to state full name and date of birth, and compare them with the identification band and the medication record

Rationale: The Joint Commission's National Patient Safety Goals call for at least two client identifiers, such as full name and date of birth, before giving medications, blood, or treatments. Facility policy sets which identifiers are used. Asking the client to state the information (open-ended) and checking it against the ID band and medication record prevents errors. A room or bed number is never an identifier because clients move. A yes-or-no question is unsafe because a confused, hard-of-hearing, or anxious client may simply say yes. A roommate is not a reliable source of identification.

Answer: A. Call for help and assess the client for injury before moving the client

Rationale: The nurse should stay with the client, call for help, and assess before moving the client. This includes level of consciousness, airway and breathing, vital signs, head injury, pain, and signs of a fracture such as a shortened or rotated leg. Moving a client with a hip fracture or spinal injury can cause more harm, so the client is moved only after the assessment, using safe lifting methods and enough staff. The provider is notified according to facility policy. The incident report and calling the family are both done, but only after the client has been assessed and is safe.