A nurse is prioritizing care for a client. Which of the following procedures should the nurse perform first?
Endotracheal suctioning
Urinary catheter care
Enteral feeding
Wound Irrigation
The Correct Answer is A
A. Endotracheal suctioning:
This is the correct answer. If a client requires endotracheal suctioning, it is likely due to respiratory distress or compromised airway clearance. Ensuring a patent airway and maintaining adequate oxygenation is the top priority, making endotracheal suctioning the first procedure to be performed.
B. Urinary catheter care:
Urinary catheter care is important for preventing infections and maintaining urinary function, but it is generally not as urgent as addressing respiratory distress. If the client is experiencing respiratory issues, addressing these concerns should take precedence.
C. Enteral feeding:
While enteral feeding is essential for providing nutrition, it is not typically as urgent as addressing respiratory needs. If a client requires endotracheal suctioning for respiratory support, it should be prioritized over enteral feeding.
D. Wound irrigation:
Wound irrigation is important for wound care, but it is generally not as time-sensitive as addressing respiratory needs. If the client's airway is compromised, it takes precedence over wound irrigation.
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Related Questions
Correct Answer is B
Explanation
A. Administer the PN and fat emulsion separately:
Administering the PN and fat emulsion separately is not a typical practice. Usually, PN formulations are prepared to include both macronutrients (carbohydrates and fat) in a single bag to provide a balanced nutritional profile. Administering them separately might lead to inconsistencies in the client's nutritional intake.
B. Prepare the client for a central venous line:
This is the correct action. Parenteral nutrition (PN) with a high concentration of dextrose (20%) and fat emulsions can be hypertonic and irritating to peripheral veins. Therefore, a central venous line is often recommended for the administration of such solutions. Preparing the client for a central venous line helps ensure the safe and effective delivery of PN.
C. Change the PN infusion bag every 48 hr:
The frequency of changing the PN infusion bag is not solely determined by time but rather by factors such as the stability of the solution, risk of contamination, and compatibility of the components. The specific recommendation for changing the PN bag should be based on institutional policies and the characteristics of the PN solution being used.
D. Obtain a random blood glucose daily:
While monitoring blood glucose is important in clients receiving PN, obtaining a random blood glucose daily is not specific enough for managing the potential hyperglycemic effects of a 20% dextrose solution. Continuous glucose monitoring or more frequent and scheduled blood glucose checks may be necessary.
Correct Answer is B
Explanation
A. "Tell me more about your partner.":
While understanding the client's feelings about their partner is important, the immediate concern is the client's statement expressing a desire to die. Therefore, focusing on the client's thoughts about self-harm (Option B) takes precedence in ensuring their safety.
B. "Have you thought about harming yourself?":
This response is appropriate because it directly addresses the client's statement expressing a desire to die. It opens a dialogue about the client's thoughts and intentions related to self-harm, allowing the nurse to assess the client's risk and initiate appropriate interventions.
C. "Why did you stop taking your medication?":
While understanding the reasons behind medication non-compliance is important, the immediate concern is the client's current statement indicating suicidal ideation. Exploring the client's medication adherence can be addressed after addressing the acute safety concern.
D. "You should discuss these feelings with your provider.":
This response might be seen as avoiding the client's immediate expression of distress. It is important for the nurse to directly assess the client's risk and initiate appropriate interventions rather than deferring the responsibility to another healthcare provider at this moment.
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