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.
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Related Questions
Correct Answer is C
Explanation
A. Notify the nurse manager: While notifying the nurse manager is important, it is not the immediate priority when a medication error occurs.
B. Complete an incident report: Completing an incident report is necessary for documentation but should not be done before ensuring the client's safety.
C. Assess the client: This is the correct first action. The nurse must first assess the client to determine if there are any immediate adverse effects or reactions to the incorrect medication.
D. Call the client's provider: While it is important to inform the provider, assessing the client's condition takes precedence to address any immediate health concerns.
Correct Answer is ["A","D","E"]
Explanation
A. Question any part of the order that is unclear or inappropriate: It is important to clarify any ambiguities or inaccuracies in the prescription to ensure patient safety and proper treatment.
B. Transcribe the order into the client's health record: While this is a necessary step, it is not sufficient on its own to ensure the accuracy of the telephone prescription without verification.
C. Implement a recorded order message if the nurse can hear and understand it clearly: Implementing a recorded message is not typically part of standard protocol for ensuring accuracy.
D. Repeat the order back to the provider: This is a critical step to confirm that the order was understood correctly and to avoid errors.
E. Obtain the provider's signature within 8 hr: It is required to obtain the provider's signature on the written order within a specific timeframe (usually within 24 hours) to comply with legal and institutional policies.
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