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.

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. Specific characteristics of the medications: This is correct. The primary consideration for determining the medication schedule is the specific characteristics of each medication, including its pharmacokinetics, such as how often it should be administered and whether it needs to be taken with food or at certain times of the day.

B. Time at which the medication can be available from the pharmacy: While this may affect the timing of administration, it is not the primary factor. Medications should be scheduled based on their specific requirements for effectiveness and safety, regardless of pharmacy availability.

C. Institutional policies regarding routine medication administration times: Although institutional policies may provide guidelines for routine administration, they should be adjusted based on the specific needs of the medication and the client.

D. Schedule of administration that the client follows at home: While this may be relevant for maintaining continuity of care, the primary factor in determining the administration schedule should be the specific characteristics and requirements of the medications themselves.

A. Educator B. Advocate C. Caregiver D. Manager

Correct Answer is B

Explanation

A. Educator: This role involves teaching clients about their health conditions, treatments, and self-care, but it does not primarily focus on protecting the client or supporting their decisions.

B. Advocate: This role involves protecting the client's rights, supporting their decisions, and ensuring that their needs and preferences are respected in the healthcare setting.

C. Caregiver: This role involves providing direct care and performing tasks related to the client's well-being, but it does not focus specifically on advocacy or protecting client rights.

D. Manager: This role involves organizing and overseeing care, coordinating with other healthcare professionals, and ensuring that resources are used effectively, rather than focusing on advocacy and client protection.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing a client's admission record. The nurse notes that there are prescriptions for several medications. Which of the following factors should the nurse recognize is of primary consideration when determining the schedule of administration?

Correct Answer is A

Explanation

A nurse assumes a variety of roles while working with clients. Which of the following describes the nursing role of protecting the client and supporting the client's decisions?

Correct Answer is B

Explanation

A nurse is caring for a client who is scheduled for an elective surgical procedure. Which of the following actions should the nurse take regarding informed consent?

A nurse is administering several medications via a client's gastrostomy tube. At which of the following times should the nurse instill 15 to 30 mL of warm water? (Select all that apply.)

A nurse is caring for a client who requires a medication that is packaged in a single dose glass ampule. Which of the following techniques should the nurse use when opening the glass ampule?

A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following actions is an example of a violation of confidentiality?

A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure?

A nurse is preparing to administer a rectal suppository to a client. In which of the following positions should the nurse place the client for Insertion of the suppository?

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?