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 D

Explanation

A. Combining medications with the formula in the feeding bag:

This is not recommended because it may lead to interactions between the medications and the enteral feeding formula. Medications may also adhere to the tubing or interfere with the absorption of nutrients from the feeding formula.

B. Diluting each crushed medication with warm water:

While diluting medications may be necessary for some drugs, it is not a general rule for all medications. Additionally, dilution with warm water may not be appropriate for all drugs, and the amount of water needed may vary. It's safer to use a standardized method, such as flushing the tube with sterile water.

C. Mixing the medications together in a single syringe:

This is generally not recommended because different medications may have incompatible properties or form precipitates when mixed together. Mixing medications in a single syringe can compromise the effectiveness of each medication and may lead to unpredictable reactions.

D. Flush the NG tube with 5 mL of sterile water for irrigation prior to administration:

Flushing the tube with sterile water helps ensure that the tube is clear of any residual formula, preventing potential interactions between the medication and the enteral feeding. It also helps clear the tube, reducing the risk of clogs or blockages. Using sterile water helps maintain aseptic technique.

A. Supine in low-Fowler's position B. Side-lying with the right side of the chest elevated C. Right lateral in Trendelenburg position D. Prone with pillows under the lower extremities

Correct Answer is C

Explanation

a. Supine in low-Fowler's position - This position is not effective for draining the left lower lobe.

b. Side-lying with the right side of the chest elevated - This position would not effectively drain the left lower lobe.

c. Right lateral in Trendelenburg position - This is correct. Placing the client on their right side with the chest lower than the hips (Trendelenburg position) helps gravity assist in draining secretions from the left lower lobe.

d. Prone with pillows under the lower extremities - This position would not be effective for draining the left lower lobe.

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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

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