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. I will check your medication order again: This response addresses the client's concern by verifying that the medication is correct and reassures the client by ensuring that the prescribed medication matches their expectation.
B. Sometimes the same pill comes in a different color: While this might be true, this response does not directly address the client’s concern about the specific medication they are supposed to take.
C. Let me explain the purpose of the medication: This response is helpful but does not address the client's concern about the discrepancy in the medication's appearance.
D. This is the medication that your doctor wants you to take: This response may not resolve the client's concern about the pill's color and does not involve verifying the medication’s accuracy.
Correct Answer is ["A","C","D"]
Explanation
A. 2 mg: This is an acceptable abbreviation for the dosage of medication, as it uses standard metric units that are clear and precise.
B. MSO4: This abbreviation for morphine sulfate is not recommended due to the potential for confusion with magnesium sulfate. The use of "morphine sulfate" is preferred to avoid ambiguity.
C. 30 mL: This is an acceptable abbreviation for the volume of a liquid medication or fluid, using standard metric units.
D. bid: This abbreviation stands for "twice a day" and is generally acceptable in medical documentation, though "twice a day" is preferable to avoid errors.
E. Q.D.: This abbreviation for "every day" is not recommended because it can be confused with "QID" (four times a day). The use of "daily" is preferred for clarity.
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