The nurse working in a critical care unit (CCU) is assigned the care of two clients, one with pneumonia who is being mechanically ventilated, and the other who had a thoracotomy yesterday and is reporting incisional pain. Which action(s) should the nurse perform first?
Assess the level of consciousness and vital signs for both clients.
Review the plan of care and the medications that are due for both clients.
Complete a head-to-toe assessment of the client with pneumonia.
Change the surgical dressing to observe the appearance of the incision.
The Correct Answer is A
A. Assess the level of consciousness and vital signs for both clients: Assessing vital signs and mental status identifies immediate changes in condition, particularly in critically ill clients. This is a priority because it helps detect life-threatening complications early.
B. Review the plan of care and the medications that are due for both clients: While important for planning interventions, reviewing the plan does not address immediate client safety and physiological status, which takes priority.
C. Complete a head-to-toe assessment of the client with pneumonia: A comprehensive assessment is valuable, but initial priority is rapid evaluation of vital signs and consciousness to identify urgent issues in the mechanically ventilated client.
D. Change the surgical dressing to observe the appearance of the incision: Dressing changes are important for infection prevention, but they are not emergent unless there are signs of acute bleeding or infection. Immediate physiologic assessment takes precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Report any increase in the white blood cell count: An elevated WBC may indicate infection, but this is a late finding and does not directly prevent recurrence. Reporting lab changes is important but not the most immediate or effective intervention
B. Change the surgical dressing when soiled: Keeping the surgical site clean and dry is the most critical step in preventing wound infection, particularly in clients with a history of MRSA. A soiled dressing promotes bacterial growth and increases the risk of reinfection, making timely dressing changes essential.
C. Wear a face mask while performing wound care: A face mask protects against droplet spread but MRSA is primarily transmitted by direct contact. While masks may reduce overall infection risk, they are less critical than maintaining strict wound and dressing hygiene.
D. Instruct the family to adhere to contact precautions: Family education is important in preventing MRSA transmission, but in the immediate postoperative period, the nurse’s priority is direct wound care. Preventing contamination at the surgical site takes precedence.
Correct Answer is ["C","D","F"]
Explanation
A. St. John's wort: This herbal supplement is not used to manage opioid side effects and may interact with other medications, including opioids, making it inappropriate for this purpose.
B. Sildenafil: Sildenafil is used to treat erectile dysfunction and has no role in managing morphine side effects. It is unrelated to pain management or opioid-related adverse effects.
C. Ondansetron: Ondansetron is an antiemetic commonly prescribed to prevent or treat nausea and vomiting, which are frequent side effects of morphine administration.
D. Naloxone: Naloxone is an opioid antagonist used to reverse severe opioid-induced respiratory depression. It is essential for emergency management of potentially life-threatening side effects of morphine.
E. Meperidine: Meperidine is an opioid analgesic and is not used to treat side effects of morphine. Using another opioid would not address morphine-induced complications and may increase risk of adverse effects.
F. Docusate sodium: Opioid-induced constipation is common with morphine. Docusate sodium is a stool softener used prophylactically to prevent or treat constipation associated with opioid therapy.
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