A nurse formulates several nursing diagnoses then prioritizes using Maslow's hierarchy. What nursing diagnosis should have the highest priority?

Altered Nutrition: Less Than Body Requirements

Ineffective Coping

Risk for Falls

Impaired Mobility

Answer and Explanation

The Correct Answer is A

A. Maslow’s hierarchy prioritizes physiological needs first, including nutrition, hydration, and oxygenation. This is the most immediate concern.

B. While mental health is important, psychosocial needs are a lower priority than basic physiological needs like nutrition.

C. Fall prevention is essential, but it is a potential problem rather than an existing physiological issue, making it a lower priority than inadequate nutrition.

D. Mobility is important, but ensuring adequate nutrition is more critical to prevent further complications such as muscle wasting and delayed wound healing.

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Correct Answer is B

Explanation

A. A patient who had surgery two days ago and is learning how to change the dressing. This is incorrect because this patient is stable and requires routine education, which is not an immediate priority.

B. A patient who was admitted 30 minutes ago for chest pain. This is correct because chest pain can indicate a life-threatening condition such as myocardial infarction. The nurse should assess this patient immediately, monitoring for signs of cardiac compromise and initiating emergency interventions if necessary.

C. A patient who received pain medication 10 minutes ago. This is incorrect because this patient is already receiving treatment, and there is no indication of urgent distress requiring immediate intervention.

D. A patient who is being transferred to a long-term care facility this afternoon. This is incorrect because transfer preparation is not an urgent priority compared to an unstable or potentially critical patient.

A. Teaching about medications B. Performing resuscitation C. Inserting a feeding tube D. Documenting wound care E. Ambulating a patient

Correct Answer is ["A","B","C","E"]

Explanation

A. Teaching about medications. This is correct because providing education to a patient is a direct care intervention, as it involves interaction with the patient to improve their health outcomes.

B. Performing resuscitation. This is correct because resuscitation is a hands-on, immediate intervention aimed at stabilizing a patient, making it a direct care intervention.

C. Inserting a feeding tube. This is correct because placing a feeding tube is a direct intervention that involves a hands-on nursing procedure.

D. Documenting wound care. This is incorrect because documentation is an indirect care intervention. While it is essential for communication and continuity of care, it does not directly affect the patient's condition.

E. Ambulating a patient. This is correct because physically assisting a patient with walking is a direct care intervention that helps prevent complications such as deep vein thrombosis and pneumonia.

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A nurse formulates several nursing diagnoses then prioritizes using Maslow's hierarchy. What nursing diagnosis should have the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse receives change of shift report about a group of assigned patients. Which patient should the nurse attend to first?

Correct Answer is B

Explanation

A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

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