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 D

Explanation

A. Provide a schedule of visiting hours to the client's family: While this is important, it is not a priority in the context of initial assessment and history.

B. Develop a plan of care for the client: Developing a plan of care is important but should come after completing the initial assessment and gathering all necessary information.

C. Teach the client about his diagnosis: Teaching about the diagnosis is important but is not a priority over ensuring that crucial health information, such as allergies, is documented.

D. Document the client's allergies in the electronic medical record: Documenting allergies is the priority as it is crucial for preventing potential allergic reactions and ensuring the safety of the client during their care.

A. Surgeon B. Surgical suite nurse C. Nurse D. Anesthesiologist

Correct Answer is A

Explanation

A. Surgeon: The surgeon is responsible for obtaining informed consent from the client. This includes providing the client with all necessary information about the procedure, including its risks, benefits, and alternatives, to ensure that the client can make an informed decision.

B. Surgical suite nurse: While the surgical suite nurse may assist with explaining aspects of the procedure and verifying consent, the primary responsibility for obtaining informed consent lies with the surgeon.

C. Nurse: Although the nurse plays a role in patient education and ensuring the client understands the procedure, the formal process of obtaining informed consent is the responsibility of the surgeon.

D. Anesthesiologist: The anesthesiologist provides information about anesthesia risks and effects but does not obtain consent for the surgical procedure itself.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing the initial admission assessment and history for a client. Which of the following is the priority action for the nurse to take?

Correct Answer is D

Explanation

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?

Correct Answer is A

Explanation

A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction during a previous transfusion. The nurse should administer diphenhydramine prior to the transfusion for which of the following allergic responses?

A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation?

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

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 administering an oral medication to an older adult client. The client states, "The pill I always take is green. I don't take an orange pill." Which of the following responses should the nurse make?

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?