Which nursing intervention takes highest priority for the nurse caring for an unconscious patient?
Inserting an indwelling urinary catheter
Putting a nasogastric (NG) tube in place
Maintaining a patent airway
Administering an enema daily
The Correct Answer is C
A. Inserting an indwelling urinary catheter – Incorrect. While catheterization may be necessary, it is not the highest priority for an unconscious patient.
B. Putting a nasogastric (NG) tube in place – Incorrect. NG tube placement can be useful for feeding or decompressing the stomach, but airway management takes precedence.
C. Maintaining a patent airway – Correct Answer. Airway patency is the top priority in an unconscious patient to prevent aspiration, hypoxia, or respiratory failure.
D. Administering an enema daily – Incorrect. This is not a priority in unconscious patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Leave the television on as a distraction – Noise and distractions can increase anxiety and confusion in some patients.
B. Limit patient physical activity – Regular exercise is essential to maintain mobility and prevent muscle atrophy.
C. Provide patient supervision – Clients with Parkinson’s disease are at high risk for falls due to muscle rigidity and balance difficulties. Supervision ensures safety and helps prevent injuries.
D. Speak loudly to the patient – Parkinson’s does not typically cause hearing loss. Speaking clearly and slowly is more effective than speaking loudly.
Correct Answer is C
Explanation
A. Hct 45%. – Normal range for hematocrit (Hct) is 38-50%. No need to report.
B. Hgb 14.7 g/dL. – Normal range for hemoglobin (Hgb) is 13-17 g/dL. No need to report.
C. WBC 1,700/mm³. – Correct Answer. Normal WBC count is 4,000-11,000/mm³. A WBC count of 1,700/mm³ (neutropenia) places the patient at high risk for infection, requiring immediate intervention.
D. Platelets 160,000/mm³. – Normal range for platelets is 150,000-450,000/mm³. No need to report.
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