The nurse has identified several diagnoses for a client in the hospital. Which problems should the nurse identify as having highest priority?
Problems that cause severe discomfort to the client
Problems the client deems most important
Problems that are immediately life-threatening for the client
Problems that are identified as priority by the physician
The Correct Answer is C
A) Problems that cause severe discomfort to the client: While addressing discomfort is important in providing holistic care, it is not the highest priority in nursing. The nurse’s primary focus should be on life-threatening issues or those that could deteriorate the client’s condition rapidly. Severe discomfort can be managed once immediate threats to life are addressed.
B) Problems the client deems most important: Although it’s essential to consider the client’s perspective and involve them in their care plan, problems that are most important to the client may not always be the most urgent or life-threatening. For example, the client may prioritize pain management, but addressing life-threatening issues must always take precedence.
C) Problems that are immediately life-threatening for the client: This is the correct answer. According to Maslow’s hierarchy of needs and the nursing prioritization framework, life-threatening problems should always be the nurse's first priority. These are issues that, if not addressed immediately, can lead to death or severe complications. For instance, airway obstruction, severe bleeding, or shock would require immediate intervention.
D) Problems that are identified as priority by the physician: While the physician’s orders and priorities should be taken into consideration, the nurse must independently assess and prioritize care based on the overall health status of the client. This includes using clinical judgment to identify life-threatening conditions, even if they are not explicitly stated in the physician’s orders. Nurses are trained to identify priority issues through their assessments and are responsible for making decisions that ensure the client’s safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["20"]
Explanation
Identify the total units of heparin in the bag:
The IV bag contains 25,000 units of heparin in 250 mL.
Identify the desired hourly dose:
The client is ordered to receive 2,000 units of heparin per hour.
Calculate the mL containing 2,000 units:
We can set up a proportion:
(25,000 units) / (250 mL) = (2,000 units) / (x mL)
Solving for x, we get:
x = (2,000 units x 250 mL) / 25,000 units x = 20 mL
Correct Answer is D
Explanation
A) Polyethylene Glycol: Polyethylene glycol is a medication typically used to treat constipation by promoting bowel movements. While it can be useful in managing constipation, it is not commonly prescribed after a myocardial infarction. In this situation, the focus is more on medications that promote heart health, reduce cardiac workload, and prevent complications related to the heart attack.
B) Bisacodyl: Bisacodyl is a stimulant laxative used to relieve constipation. However, this medication is not typically prescribed immediately following a myocardial infarction. Stimulant laxatives can cause dehydration and excessive fluid shifts, which can be harmful to a client recovering from a heart attack. The focus would be on safer options for bowel management in this context.
C) Senna: Senna is also a stimulant laxative, used for relieving constipation. Similar to bisacodyl, it is not ideal for clients who have recently experienced a myocardial infarction due to its potential for causing dehydration and electrolyte imbalances, which could negatively affect heart function. A gentler approach to bowel management is preferred for these clients.
D) Docusate Sodium: Docusate sodium is a stool softener commonly prescribed to prevent constipation, especially in clients who have recently had a myocardial infarction. After a heart attack, it's important to avoid straining during bowel movements, as this could increase pressure on the heart. Docusate sodium helps soften stools and promotes smoother bowel movements without stimulating the gastrointestinal system in a way that would elevate cardiac stress. It is the most appropriate choice for this client.
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