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. Encourage the wife to voice her feelings about having a husband with Parkinson's disease: While it is important to provide emotional support and encourage expression of feelings, this does not address her specific question about alternative or complementary cures.
B. Tell the wife that her husband's neurologist would know more about alternative treatments to cure Parkinsonism: Referring to the neurologist may seem appropriate, but it avoids answering the wife’s concern directly.
C. Explain that there are no known conventional, alternative, or complimentary therapies that cure Parkinson's disease: Parkinson’s is a progressive neurodegenerative disorder, and while medications and some therapies can manage symptoms, no cure currently exists. This response provides clear, evidence-based information and directly answers the wife’s question.
D. Compile a list of alternative medications that are effective in curing Parkinson's disease: No alternative or complementary medications have been proven to cure Parkinson’s disease. Providing such a list would give false hope and misinformation.
Correct Answer is B
Explanation
A. Abdominal cramping: Mild to moderate abdominal cramping is a common symptom of acute gastritis and may not indicate a complication. While it should be monitored, it is not typically an emergency sign.
B. Bloody emesis: Vomiting blood may indicate gastrointestinal bleeding, a serious complication of acute gastritis. Immediate reporting is essential to prevent significant blood loss and allow prompt medical intervention.
C. Low grade fever: A mild fever can accompany gastritis due to inflammation or infection but is not usually life-threatening. It should be monitored but does not require urgent reporting unless it worsens.
D. Bruising of the skin: Easy bruising is not a typical manifestation of gastritis and is not directly related to acute gastrointestinal complications. It may suggest another underlying condition but is not the priority concern for this client.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
