A nurse has been assigned 4 patients to care for at the beginning of their shift. Using the Safety and Risk Reduction priority setting framework, which of the following patients should be the priority to see first by the nurse?
A patient who is a fall risk, has a bed alarm in place and is sleeping.
A patient who is complaining of pain at a level 7 on the pain scale and is due for pain medication
A patient with a tracheostomy who is wheezing, has increase secretions and is due for tracheostomy suction.
A patient with a pressure ulcer (wound) to the sacrum who was just turned on their left side an hour ago.
The Correct Answer is C
A. While a fall-risk patient is important, the patient is currently sleeping and has a bed alarm in place, reducing immediate risk.
B. Pain management is important, but the patient is not in immediate distress, and pain can be addressed after the more critical patient is attended to.
C. A patient with a tracheostomy experiencing wheezing and increased secretions may be at risk for airway compromise and need immediate attention.
D. Turning a patient with a pressure ulcer, while important for prevention, is not as urgent as addressing potential airway issues in the tracheostomy patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
A. Administering an enema may not be the first-line intervention and may have potential risks. Dietary and lifestyle changes are usually recommended first.
B. A high-fiber diet promotes regular bowel movements and helps prevent constipation.
C. Regular exercise, such as walking, can stimulate bowel activity and improve overall health.
D. Well-cooked fruits and vegetables are beneficial, but the emphasis should be on increasing fiber intake.
E. Increasing consumption of eggs, meat, and dairy may not address the constipation issue and might contribute to a low-fiber diet.
Correct Answer is D
Explanation
A. The helping relationship phases and nursing process are not specific communication tools for addressing safety concerns.
B. The nursing process is a systematic approach to patient care but is not a communication tool specifically for addressing safety concerns.
C. SBAR (Situation, Background, Assessment, Recommendation) is a structured communication tool commonly used in healthcare settings for reporting and addressing safety concerns.
D. CUS (I am concerned, I feel uncomfortable, this is unsafe) is a communication tool for expressing concerns, for instance, by saying something like this: "I am concerned about the patient's risk for falls. I feel uncomfortable seeing you walk the patient without a gait belt or non-skid socks. This is unsafe for the patient and could cause harm or injury. Please use a gait belt and non-skid socks when walking the patient." This way, the nurse can convey their message in a clear, respectful, and assertive way, and prompt the UAP to take action to ensure the patient's safety.
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