One of the highest priorities of nursing care is:
maintaining skin integrity
adequate nutrition
pain control
airway management
The Correct Answer is D
A. Maintaining skin integrity:
Maintaining skin integrity is crucial for preventing pressure ulcers and other skin-related issues, especially for patients who are bedridden or have limited mobility. Preventive measures, like turning the patient regularly and keeping the skin clean and dry, are essential. While important, it is not always the highest priority and can be managed alongside other nursing interventions.
B. Adequate nutrition:
Providing adequate nutrition is vital for the patient's overall health and recovery. Malnutrition can impair the healing process and weaken the immune system. However, in immediate critical situations, addressing the airway, breathing, and circulation (ABCs) takes precedence over nutritional concerns. Once the patient is stable, addressing nutrition becomes a priority in the nursing care plan.
C. Pain control:
Managing pain is crucial for a patient's comfort and well-being. Uncontrolled pain can cause anxiety, impair healing, and decrease the overall quality of life. Pain control is a high priority, but in certain emergencies where the patient's airway or circulation is compromised, managing pain might be temporarily secondary until the primary issues are addressed.
D. Airway management:
Ensuring a clear airway is often the highest priority in emergency situations. Without a patent airway, the patient cannot breathe effectively, leading to oxygen deprivation and potential cardiac arrest. Nurses and healthcare providers focus on maintaining or establishing a clear airway to ensure the patient can breathe adequately. Once the airway is secured, attention can be directed to other aspects of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Maslow's hierarchy of needs:
This statement is true. Prioritizing patient problems is often based on Maslow's hierarchy of needs, which categorizes human needs from basic physiological requirements to higher-level psychological needs. Patients' immediate and essential needs, such as airway, breathing, and circulation, are prioritized over other needs based on this framework.
B. The nurse-to-nurse report:
This statement is incorrect. Nurse-to-nurse report is essential for continuity of care, but it is not the basis for prioritizing patient problems. Prioritization is based on the patient's immediate needs and safety concerns.
C. Nonspecific data collection:
This statement is incorrect. Prioritization is based on specific data collected during the assessment, including physiological measurements, symptoms, and patient history. Nonspecific data collection wouldn't provide the necessary information for effective prioritization.
D. Managerial influence:
This statement is incorrect. While managers might provide guidelines and policies, the direct care nurse at the bedside typically prioritizes patient problems based on clinical judgment, immediate needs, and the nursing process.
Correct Answer is B
Explanation
A. Summarizing: Summarizing involves condensing the patient's words into a concise form. It's a useful technique when the nurse wants to review and confirm what the patient has said, ensuring understanding and demonstrating active listening.
B. General lead: A general lead is an open-ended statement or question that allows patients to express themselves without feeling restricted. For example, "Tell me how your night was?" is a general lead because it prompts the patient to share their experiences openly.
C. Offering of self: Offering of self involves making oneself available, both physically and emotionally, to the patient. This can include showing empathy, understanding, and a willingness to listen. It helps create a therapeutic nurse-patient relationship.
D. Clarifying: Clarifying is a technique used when the nurse needs more specific information. It involves asking questions to ensure that the nurse correctly understands the patient's message, avoiding misunderstandings and ensuring clear communication. For instance, the nurse might say, "Can you please explain that part again?" to clarify a confusing statement made by the patient.
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