A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parenteral nutrition administration, and reports a pain level of 6 on a scale from 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first?
Administer pain medication to the first client.
Weigh the second client.
Change the dressings of both clients.
Obtain vital signs for both clients.
The Correct Answer is A
A. Administer pain medication to the first client: Pain management is a priority, especially for a postoperative patient with a pain level of 6 out of 10. Addressing pain can improve the client’s comfort and ability to participate in other aspects of care, such as nutrition administration and mobility.
B. Weigh the second client: While important for monitoring nutritional status, weighing the client is not as urgent as managing pain for a postoperative patient.
C. Change the dressings of both clients: Dressing changes are necessary but can be scheduled after addressing the more immediate needs such as pain management for the postoperative client.
D. Obtain vital signs for both clients: While vital signs are important for assessing overall health, pain management should be prioritized to address the immediate discomfort and potential impacts on recovery.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Pull the auricle down and out: For a child under 3 years old, the ear canal is more horizontal, so the auricle should be pulled down and out to straighten the ear canal for proper instillation of ear drops.
B. Pull the auricle up and back: This technique is used for children older than 3 years old, as their ear canal becomes more vertical.
C. Pull the auricle up and out: This technique is incorrect for a 3-year-old child as it does not account for the horizontal position of the ear canal in younger children.
D. Pull the auricle down and back: This technique is not recommended for ear drops in young children and does not align with the anatomical considerations for their ear canal.
Correct Answer is C
Explanation
A. "Documentation provides information for a client audit": While documentation can be used for audits, this is not the primary purpose of documentation.
B. "Documentation allows providers to monitor the nurse's activities": This is incorrect. While documentation is reviewed for quality assurance, its primary purpose is to communicate client care and treatment, not to monitor individual activities.
C. "Documentation is a communication tool for the interprofessional health care team": This is correct. The primary purpose of documentation is to provide a comprehensive and accurate record of client care and facilitate communication among the health care team.
D. "Documentation provides information to the client about financial charges for care provided": This is incorrect. Documentation focuses on clinical information and care, not on financial aspects.
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