A preceptor advises the novice nurse to prioritize which client intervention?
Attending to personal hygiene
Ensuring client safety
Meeting psychosocial needs
Providing patient-focused care
The Correct Answer is B
Choice A reason: Attending to personal hygiene improves comfort and prevents infection but is not the highest priority. Safety, including preventing falls or medication errors, prevents immediate harm, as hygiene issues pose less urgent risks, making this a secondary intervention compared to ensuring client safety.
Choice B reason: Ensuring client safety is the priority, preventing immediate harm like falls, medication errors, or equipment-related injuries. Safety is foundational, as unsafe conditions can lead to life-threatening complications, making this the most critical intervention to prioritize in any clinical setting for client well-being.
Choice C reason: Meeting psychosocial needs supports emotional well-being but is secondary to safety. Unaddressed safety risks, like falls, pose immediate physical harm, whereas psychosocial issues have longer-term impacts, making safety the priority over emotional or social support in clinical care.
Choice D reason: Providing patient-focused care ensures individualized treatment but is less urgent than safety. Safety prevents immediate harm, like falls or errors, while patient-focused care enhances outcomes over time, making it a secondary priority compared to ensuring the client’s physical safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Notifying the provider delays airway restoration in a tracheostomy dislodgement. The priority is maintaining the airway, as the stoma may close rapidly in a chronic tracheostomy, risking respiratory distress, making immediate tube reinsertion critical over notification.
Choice B reason: Ventilating with a bag-valve-mask provides temporary oxygenation but does not address the dislodged tracheostomy tube. In a chronic tracheostomy, the stoma is the primary airway, and reinserting the tube prevents closure, making ventilation a secondary action.
Choice C reason: Attempting to reinsert a new tracheostomy tube is the priority, as chronic tracheostomy stomas may close rapidly, risking airway loss. Prompt reinsertion maintains patency, preventing respiratory distress or emergent surgical intervention, making this critical for client safety and breathing.
Choice D reason: Covering the stoma with an occlusive dressing risks airway obstruction in a chronic tracheostomy, where the stoma is the primary airway. This could lead to respiratory distress, as the client depends on the tracheostomy, making this incorrect compared to tube reinsertion.
Correct Answer is C
Explanation
Choice A reason: Localized redness is an expected sign of early wound infection due to localized inflammation but does not necessarily indicate worsening. It reflects immune response to infection, manageable with antibiotics, but systemic signs like fever and tachycardia suggest severe infection, requiring more urgent intervention.
Choice B reason: Serous drainage is normal in early wound healing or mild infection but does not indicate worsening. Purulent or foul-smelling drainage would suggest progression, but serous drainage is less concerning, making it a lower priority than systemic signs like fever and tachycardia.
Choice C reason: Fever of 101.5°F and increased heart rate indicate a worsening wound infection, suggesting systemic spread (sepsis). These signs reflect the body’s response to significant bacterial proliferation, risking septic shock, requiring immediate intervention like antibiotics or surgical debridement to prevent life-threatening complications.
Choice D reason: Mild tenderness is expected in an infected wound due to localized inflammation but does not indicate worsening. Systemic signs like fever and tachycardia suggest severe infection or sepsis, making tenderness a less urgent finding requiring monitoring rather than immediate intervention.
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