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 C
Explanation
A. Irrigate conjunctiva with ophthalmic saline prior to instilling antibiotic ointment: Routine irrigation is not typically necessary unless instructed for debris removal. Over-manipulation may increase the risk of infection or injury to the healing eye.
B. Limit exposure to sunlight during the first 2 weeks when the cornea is healing: While sunglasses can protect the eyes from UV light, strict limitation of sunlight is not usually required for 2 weeks. Standard protective measures and avoiding direct glare are sufficient.
C. Avoid straining at stool, bending, or lifting heavy objects: These activities increase intraocular pressure, which can compromise the surgical site and healing process after cataract extraction. Avoiding them is critical to prevent complications such as wound dehiscence or hemorrhage.
D. Do not read without direct lighting for 6 weeks: Reading is generally safe after cataract surgery as long as the client uses appropriate lighting. There is no standard requirement to avoid reading for 6 weeks.
Correct Answer is ["B","C","D","E"]
Explanation
A. Instruct to give additional dose if the baby vomits after administration: Giving an extra dose after vomiting can result in digoxin toxicity because the exact amount absorbed is uncertain. Parents should never repeat a dose without consulting the healthcare provider.
B. Demonstrate how to measure the correct amount of the oral solution: Accurate measurement is critical for safe digoxin administration, as small errors can lead to underdosing or toxicity. Using an appropriate oral syringe or dropper ensures the correct dose.
C. Notify the healthcare provider before giving digoxin if your baby is ill: Illness can affect heart rate, hydration, and electrolyte balance, which increases the risk of digoxin toxicity. Parents should contact the provider to determine whether to hold or adjust the dose.
D. Show the correct technique to obtain an apical pulse: Digoxin can slow the heart rate. Parents should learn to assess the apical pulse for a full minute and understand the parameters for withholding medication based on heart rate guidelines.
E. Administer digoxin on a strict every 12-hour schedule: Maintaining consistent timing ensures stable blood levels, improving efficacy and reducing the risk of toxicity. A strict schedule is essential for therapeutic effectiveness.
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