A nurse has been assigned 4 patients to care for at the beginning of their shift. Using the Safety and Risk Reduction priority setting framework, which of the following patients should be the priority to see first by the nurse?
A patient who is a fall risk, has a bed alarm in place and is sleeping.
A patient who is complaining of pain at a level 7 on the pain scale and is due for pain medication
A patient with a tracheostomy who is wheezing, has increase secretions and is due for tracheostomy suction.
A patient with a pressure ulcer (wound) to the sacrum who was just turned on their left side an hour ago.
The Correct Answer is C
A. While a fall-risk patient is important, the patient is currently sleeping and has a bed alarm in place, reducing immediate risk.
B. Pain management is important, but the patient is not in immediate distress, and pain can be addressed after the more critical patient is attended to.
C. A patient with a tracheostomy experiencing wheezing and increased secretions may be at risk for airway compromise and need immediate attention.
D. Turning a patient with a pressure ulcer, while important for prevention, is not as urgent as addressing potential airway issues in the tracheostomy patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.5"]
Explanation
To answer this question, we need to use the formula: D/H x Q = X, where D is the desired dose, H is the dose on hand, Q is the quantity of the drug on hand, and X is the amount to administer. In this case, D is 15 mg, H is 30 mg, Q is 1 mL, and X is unknown. Plugging these values into the formula, we get:
15/30 x 1 = X
0.5 = X
Therefore, the nurse will administer 0.5 mL of codeine to the patient every four hours.
Correct Answer is D
Explanation
A. Laxative usage is more likely to cause diarrhea or loose stools rather than rectal pain from distended veins.
B. Paralytic ileus is characterized by a lack of bowel motility and is not associated with distention of veins in the rectum.
C. Diarrhea is unlikely to cause pain related to distention of rectal veins.
D. Hemorrhoids are swollen veins in the rectum and anus, causing pain and discomfort, especially during bowel movements.
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