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 A
Explanation
A. Nausea: This is considered subjective data as it is reported by the client and cannot be measured directly.
B. Petechiae: This is objective data; it is a visible finding that the nurse can observe and document.
C. Blood pressure: This is objective data obtained through measurement.
D. Cyanosis: This is an observable sign and therefore objective data.
Correct Answer is B
Explanation
A. The client waits 10 min between inhalations: Waiting 10 minutes between inhalations is unnecessary for a rescue inhaler like albuterol. Typically, it is sufficient to wait for 1 to 2 minutes if more doses are required.
B. The client holds his breath for 10 seconds after inhaling the medication: This is correct. Holding the breath for about 10 seconds after inhalation allows the medication to settle in the airways and enhances its effectiveness.
C. The client takes a quick inhalation while releasing the medication from the inhaler: This is incorrect. A slow, deep inhalation is recommended to ensure that the medication reaches the lower airways.
D. The client exhales as the medication is released from the inhaler: This is incorrect. The client should exhale fully before inhaling the medication to ensure that the medication can be inhaled deeply into the lungs.
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