A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parenteral nutrition administration, and reports a pain level of 6 on a scale from 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first?
Administer pain medication to the first client.
Weigh the second client.
Change the dressings of both clients.
Obtain vital signs for both clients.
The Correct Answer is A
A. Administer pain medication to the first client: Pain management is a priority, especially for a postoperative patient with a pain level of 6 out of 10. Addressing pain can improve the client’s comfort and ability to participate in other aspects of care, such as nutrition administration and mobility.
B. Weigh the second client: While important for monitoring nutritional status, weighing the client is not as urgent as managing pain for a postoperative patient.
C. Change the dressings of both clients: Dressing changes are necessary but can be scheduled after addressing the more immediate needs such as pain management for the postoperative client.
D. Obtain vital signs for both clients: While vital signs are important for assessing overall health, pain management should be prioritized to address the immediate discomfort and potential impacts on recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Identifying the client by name when making a referral for home health services: This action is generally permissible if done in the context of necessary care coordination and with appropriate privacy measures in place.
B. Reporting laboratory findings to a member of the client's family: This action violates confidentiality unless the client has given explicit consent for the release of such information.
C. Discussing a client's surgical procedure with the nurse manager: This is usually acceptable within the healthcare team, provided it is done for care coordination or quality improvement purposes and the information is kept confidential.
D. Notifying the provider of physical examination findings: This action is part of standard care procedures and is necessary for the provider to make informed decisions about the client's treatment.
Correct Answer is D
Explanation
A. Tell the client the physician wants him to take the medications: This does not address the client’s concerns and may not resolve the issue.
B. Document that the client refuses the medications: While documentation is important, the nurse should first address the client’s concerns before documenting.
C. Ask the client why he is refusing to take the medications: Understanding the client’s reasons for refusal is important, but the initial step should be to explain the purpose of the medications.
D. Explain the purpose for the medications: Providing information about the purpose and benefits of the medications helps the client make an informed decision and may address concerns leading to refusal.
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