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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Gown:
- After removing gloves, the gown should be taken off. The gown is considered the second most contaminated item. It is important to avoid contact with the outer surface of the gown while removing it.
B. Gloves:
- Gloves should be removed first because they are the most likely part of the PPE to be contaminated. Care should be taken to avoid touching the outside of the gloves, and they should be disposed of properly.
C. Mask:
- The mask is removed next. Care should be taken to handle the mask by the ties or ear loops without touching the front surface. Removing the mask last helps protect the nurse from potential respiratory droplets on the mask.
D. Eyewear/Face Shield:
- Eyewear or face shield is removed last. Similar to the other components, it should be handled carefully to prevent self-contamination. This step helps protect the eyes and face from any potential splashes or airborne particles.
Correct Answer is C
Explanation
A. The hot water heater is set to 47° C (117° F).This temperature is within a safe range to prevent burns while ensuring adequate hot water for hygiene.
B. Grab bars are installed in the shower.Grab bars provide support and help prevent falls in older adults, especially those with osteoporosis who are at higher risk for fractures.
C. There is an area rug covering a tile floor.Area rugs are a significant tripping hazard, especially for older adults with osteoporosis, as a fall could lead to fractures. The nurse should intervene to recommend removing or securing the rug to reduce the risk of falls.
D. Prescriptions are stored in a medication organizer.A medication organizer helps older adults manage their medications effectively and reduces the risk of missed or incorrect doses.
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