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

Answer and Explanation

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. The client tucks their chin when they swallow:
This is a proper swallowing technique. Tucking the chin helps close off the airway during swallowing, reducing the risk of aspiration. It facilitates the safe passage of food or liquids into the esophagus
B. The client adjusts the head of their bed to 90°:
This action is appropriate. Keeping the head of the bed elevated to 30 to 45 degrees is recommended for clients with dysphagia as it helps prevent aspiration during swallowing.
C. The client drinks their thickened juice with a straw:
This action indicates a potential problem. The use of a straw with thickened liquids is generally not recommended for clients with dysphagia. Thickened liquids are used to slow down the flow of the liquid and reduce the risk of aspiration. Drinking thickened juice through a straw may compromise the effectiveness of thickening and increase the risk of aspiration.
D. The client takes frequent breaks while eating:
This action is also appropriate. Clients with dysphagia may need to take breaks between bites to ensure safe and effective swallowing. It allows the client to pace themselves and reduces the risk of aspiration.

A. Loosen the client's clothing. B. Help the client lie on the floor. C. Turn the client onto their side. D. Move items in the room away from the client.

Correct Answer is B

Explanation

A. Loosen the client's clothing:
While ensuring a patent airway is essential, it is not the immediate priority when the client is actively seizing. The primary concern is preventing injury by helping the client lie on the floor.
B. Help the client lie on the floor:
This is the correct answer. When a client is having a seizure, the priority is to ensure their safety. Lying the client on the floor helps prevent injury during the seizure, reducing the risk of falling from a chair or bed. Placing the client in a lateral (side) position can also help maintain an open airway.
C. Turn the client onto their side:
This action is part of the process after helping the client lie on the floor. Turning the client onto their side helps prevent aspiration in case of vomiting and maintains an open airway.
D. Move items in the room away from the client:
While creating a safe environment by moving objects away is important, the immediate priority is to prevent injury to the client. Helping the client lie on the floor takes precedence to minimize the risk of injury during the seizure.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is prioritizing care for a client. Which of the following procedures should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?

Correct Answer is C

Explanation

A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is teaching a client about progressing from a clear liquid diet to a full liquid diet. Which of the following food selections by the client indicates an understanding of the teaching?

A nurse is caring for an adolescent client who has full-thickness burns on their leg. The client expresses concern about their future. Which of the following is a therapeutic response by the nurse?

A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.)

A nurse is caring for a client who is anxious about being admitted to a health care facility for the first time. Which of the following statements should the nurse make?

A nurse is teaching a client who can only bear weight on one leg how to ambulate using crutches. Which of the following crutch gaits should the nurse plan to instruct the client to use?

A nurse is performing an eye assessment for a newly admitted client. Which of the following findings should the nurse expect?

A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hr. Which of the following actions should the nurse take first?

A nurse is caring for a client who has severe rheumatoid arthritis in her hands and is unable to feed herself. For which of the following health care team members should the nurse request a referral from the provider?