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.

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Correct Answer is B

Explanation

A. Check that the client has a small gauge IV catheter in place.

Blood transfusions require a large-bore IV catheter (18-20 gauge) to prevent hemolysis and ensure efficient infusion. A small gauge IV (such as 22-24G) is not appropriate for PRBCs as it can slow the infusion and damage red blood cells.

B. Check the blood product's compatibility with the client's blood type: Before administering packed red blood cells (PRBCs), the nurse must verify blood compatibility to prevent a hemolytic transfusion reaction, which can be life-threatening.

C. Prime the client's primary IV tubing with lactated Ringer’s.

Only normal saline (0.9% NaCl) should be used to prime the IV tubing for a blood transfusion. Lactated Ringer’s and dextrose solutions can cause hemolysis and clotting of the blood product.

D. Confirm the identity of the client with the blood bank technician.While verifying the blood product is critical, the nurse should confirm the client’s identity at the bedside with another licensed nurse, not the blood bank technician. This ensures that the right blood is given to the right client following facility protocols.

A. Place the sterile field at the level of the nurse's hips. B. Pour liquids into containers outside the sterile field. C. Hold bottles of sterile solution with the label in the palm of the hand. D. Open the outermost flap of the sterile kit toward the body.

Correct Answer is C

Explanation

A. Place the sterile field at the level of the nurse's hips:

This is incorrect. The sterile field should be placed at a waist or chest level to maintain its sterility. Placing it at the level of the nurse's hips increases the risk of contamination from airborne particles, clothing, or unsterile surfaces.

B. Pour liquids into containers outside the sterile field:

This is incorrect. Pouring liquids into containers outside the sterile field may lead to contamination. All actions involving sterile items should be performed within the sterile field to maintain its integrity and prevent the introduction of microorganisms.

C. Hold bottles of sterile solution with the label in the palm of the hand:

Hold bottles of sterile solution with the label in the palm of the hand:This is correct. This prevents label from becoming wet and illegible.

D. Open the outermost flap of the sterile kit toward the body:

Open the outermost flap of the sterile kit toward the body:This is incorrect. When opening a sterile kit, the nurse should open the outermost flap first and away from the body. This minimizes the risk of reaching over the sterile field, reducing the chance of accidental contamination.

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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

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Correct Answer is C

Explanation

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