Which patient’s needs must be addressed first by the registered nurse?

The patient who is nauseated and vomiting after receiving narcotic pain medication.

The patient who is waiting for discharge teaching in order to go home.

The patient with chest pain after two doses of sublingual nitroglycerin.

The constipated patient who needs to use the toilet after receiving a laxative.

Answer and Explanation

The Correct Answer is C

Choice A reason: This is an incorrect choice because the patient who is nauseated and vomiting after receiving narcotic pain medication is not the most urgent patient. Nausea and vomiting are common side effects of narcotic pain medication and can be managed with antiemetics and hydration. The patient's condition is not life-threatening and does not require immediate intervention.

Choice B reason: This is an incorrect choice because the patient who is waiting for discharge teaching in order to go home is not the most urgent patient. Discharge teaching is an important part of patient education and care transition, but it can be delayed until the more critical patients are attended to. The patient's condition is stable and does not require immediate intervention.

Choice C reason: This is the correct choice because the patient with chest pain after two doses of sublingual nitroglycerin is the most urgent patient. Chest pain is a sign of myocardial ischemia, which can lead to myocardial infarction or heart attack. Sublingual nitroglycerin is a medication that dilates the coronary arteries and relieves chest pain. If the chest pain persists after two doses of sublingual nitroglycerin, the patient may have unstable angina or acute coronary syndrome, which are medical emergencies that require immediate intervention⁴.

Choice D reason: This is an incorrect choice because the constipated patient who needs to use the toilet after receiving a laxative is not the most urgent patient. Constipation is a common gastrointestinal problem that can be treated with laxatives and dietary changes. The patient's condition is not life-threatening and does not require immediate intervention.

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Correct Answer is B

Explanation

Choice A reason: This is incorrect. Total urinary incontinence related to inability to feel urge to urinate is not appropriate for a patient with xerostomia. Xerostomia is the condition of having a dry mouth due to reduced or absent saliva production. It does not affect the urinary system or the sensation of bladder fullness.

Choice B reason: This is correct. Impaired oral mucous membranes related to decreased salivation and dry mouth is appropriate for a patient with xerostomia. Xerostomia can cause oral mucous membranes to become dry, cracked, inflamed, or infected. It can also affect the patient's ability to chew, swallow, speak, or taste.

Choice C reason: This is incorrect. Bathing self-care deficit related to inability to perceive left-sided body parts is not appropriate for a patient with xerostomia. Xerostomia does not affect the patient's perception of body parts or the ability to perform bathing activities.

Choice D reason: This is incorrect. Disturbed sensory perception related to feeling of electric pain in feet and hands is not appropriate for a patient with xerostomia. Xerostomia does not cause electric pain in the extremities. This symptom may be related to a nerve disorder, such as peripheral neuropathy.

A. Apical B. Carotid C. Radial D. Brachial

Correct Answer is A

Explanation

Choice A reason: This is the correct choice because the apical pulse is the most accurate measurement of the heart rate and rhythm. Digoxin is a cardiac medication that affects the heart rate and can cause arrhythmias. Therefore, the nurse should use the apical pulse to monitor the patient's response to the medication.

Choice B reason: This is an incorrect choice because the carotid pulse is not the best site to measure the heart rate before administering digoxin. The carotid pulse is located in the neck and can be affected by external factors such as pressure or movement. The carotid pulse is also not recommended for routine use because it can stimulate the vagus nerve and lower the heart rate.

Choice C reason: This is an incorrect choice because the radial pulse is not the best site to measure the heart rate before administering digoxin. The radial pulse is located in the wrist and can be affected by peripheral factors such as circulation or temperature. The radial pulse can also be inaccurate or irregular if the patient has an arrhythmia.

Choice D reason: This is an incorrect choice because the brachial pulse is not the best site to measure the heart rate before administering digoxin. The brachial pulse is located in the upper arm and can be affected by arm position or blood pressure. The brachial pulse is also not as reliable as the apical pulse for detecting changes in the heart rate and rhythm.

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Which patient’s needs must be addressed first by the registered nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing diagnosis is most appropriate for a patient with xerostomia?

Correct Answer is B

Explanation

Which site will the nurse use to measure the patient’s pulse rate before administering the cardiac medication Digoxin?

Correct Answer is A

Explanation

Which is the most important question for the nurse to ask the patient who has just arrived at the hospital with chest pain?

Which is the safest sleep aid for the elderly patient with insomnia?

Which step of the nursing process is being performed by the nurse who carefully enters a new patient’s medical history and current medication list into the agency’s electronic health record (EHR)?

The nurse is having difficulty hearing his patient’s apical pulse with his stethoscope. Which action will help the nurse hear the heartbeat more clearly?

Why is acute pain particularly dangerous for a patient having a heart attack?

What are the priority actions of the nurse who enters the patient’s room to begin teaching the patient about wound care management and notes that the patient is nauseated due to medication side effects? (Select all that apply).

The nurse is caring for a patient who took 60 acetaminophen tablets. Which resource will the nurse contact for treatment guidelines when the patient arrives in the emergency room?

Which assessment findings put the patient at high risk for development of vision problems? (Select all that apply)