A nurse is prioritizing care for four clients.
Which of the following tasks should the nurse perform first?

Administer an antibiotic for a client who has methicillin-resistant Staphylococcus aureus.

Change the dressing for a client who has a decubitus ulcer.

Initiate oxygen therapy via nasal cannula for a client who has COPD.

Initiate a 24-hour urine collection for a client who has end-stage kidney disease.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Administering an antibiotic for a client with methicillin-resistant Staphylococcus aureus is essential to manage the infection. However, it does not require immediate attention compared to conditions threatening airway or oxygenation.

Choice B rationale

Changing the dressing for a decubitus ulcer is important for infection prevention and wound healing. However, it does not represent a life-threatening priority requiring urgent action compared to oxygenation needs.

Choice C rationale

Initiating oxygen therapy for a client with COPD addresses compromised oxygenation, a critical and life-threatening issue. Ensuring adequate oxygen levels is the highest priority in the ABCs of nursing (Airway, Breathing, Circulation).

Choice D rationale

Initiating a 24-hour urine collection for end-stage kidney disease is essential for diagnostic purposes but is not an immediate life-threatening need. Other tasks take precedence due to the urgency of stabilizing respiratory function. .

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Correct Answer is C

Explanation

Choice A rationale

Applying suction during catheter insertion can damage the tracheal mucosa due to mechanical abrasion. Additionally, it can cause hypoxia as it interrupts normal oxygenation. Best practice is to apply suction only during withdrawal to limit the duration of suction-induced hypoxia.

Choice B rationale

Wearing clean gloves instead of sterile gloves during suctioning increases the risk of introducing pathogens into the airway. A tracheostomy is a direct path to the lungs, requiring aseptic technique to prevent infections such as tracheitis or pneumonia.

Choice C rationale

Waiting 2 minutes between suction passes allows adequate time for the client to reoxygenate and stabilize. Prolonged hypoxia from frequent suctioning can cause complications such as arrhythmias. This practice ensures safer oxygen saturation levels during the procedure.

Choice D rationale

Using suction pressures of 200 mm Hg exceeds the recommended range of 80 to 120 mm Hg for adults. Excessive suction pressure can damage tracheal tissue and cause atelectasis. Proper pressure minimizes risks while effectively clearing secretions.

A. Stopping feeding for a client who becomes short of breath. B. Telling a client she will return with a medication and she does. C. Dividing time and care evenly between clients. D. Administering a pain medication to a client before ambulation.

Correct Answer is B

Explanation

Choice A rationale

Stopping feeding for a client who becomes short of breath demonstrates clinical judgment rather than fidelity. Fidelity specifically involves loyalty and adherence to commitments made to the client, which is not evidenced in this action.

Choice B rationale

Telling a client she will return with a medication and doing so exemplifies fidelity. It demonstrates the nurse's reliability and dedication to fulfilling promises or commitments made to the client, building trust and maintaining professional integrity.

Choice C rationale

Dividing time and care evenly between clients highlights fairness rather than fidelity. While fairness ensures equal treatment, fidelity focuses on maintaining trust and honoring specific promises or commitments made to individuals.

Choice D rationale

Administering a pain medication to a client before ambulation reflects prioritization of care and pain management. However, it does not illustrate fidelity, which involves fulfilling promises or responsibilities that the nurse has explicitly committed to.

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A nurse is prioritizing care for four clients.Which of the following tasks should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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A nurse is prioritizing care for four clients.
Which of the following tasks should the nurse perform first?