One of the highest priorities of nursing care is:
maintaining skin integrity
adequate nutrition
pain control
airway management
The Correct Answer is D
A. Maintaining skin integrity:
Maintaining skin integrity is crucial for preventing pressure ulcers and other skin-related issues, especially for patients who are bedridden or have limited mobility. Preventive measures, like turning the patient regularly and keeping the skin clean and dry, are essential. While important, it is not always the highest priority and can be managed alongside other nursing interventions.
B. Adequate nutrition:
Providing adequate nutrition is vital for the patient's overall health and recovery. Malnutrition can impair the healing process and weaken the immune system. However, in immediate critical situations, addressing the airway, breathing, and circulation (ABCs) takes precedence over nutritional concerns. Once the patient is stable, addressing nutrition becomes a priority in the nursing care plan.
C. Pain control:
Managing pain is crucial for a patient's comfort and well-being. Uncontrolled pain can cause anxiety, impair healing, and decrease the overall quality of life. Pain control is a high priority, but in certain emergencies where the patient's airway or circulation is compromised, managing pain might be temporarily secondary until the primary issues are addressed.
D. Airway management:
Ensuring a clear airway is often the highest priority in emergency situations. Without a patent airway, the patient cannot breathe effectively, leading to oxygen deprivation and potential cardiac arrest. Nurses and healthcare providers focus on maintaining or establishing a clear airway to ensure the patient can breathe adequately. Once the airway is secured, attention can be directed to other aspects of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Make revisions in the plan as indicated by the shift report.
Reviewing the nursing care plan before beginning care allows the nurse to integrate the information from the shift report into the plan. If there are necessary revisions based on the shift report, the nurse can make informed adjustments to the care plan.
B. Skip the shift report and begin with the initial assessment.
Skipping the shift report is not advisable. Shift reports are crucial for continuity of care. The nurse needs to receive information about the patient's condition and ongoing care before starting the shift.
C. Begin nursing interventions without needing an initial assessment.
Starting interventions without an initial assessment can be unsafe and ineffective. Assessments provide the foundation for understanding the patient's current condition and planning appropriate care.
D. Use critical thinking skills to organize care for the patient.
Reviewing the care plan before starting care enables the nurse to utilize critical thinking skills. By understanding the existing care plan and the patient's current status, the nurse can organize and prioritize care effectively, making informed decisions based on the patient's needs and the provided care plan.
Correct Answer is D
Explanation
A. Use open-ended questions:
Open-ended questions are typically avoided when communicating with aphasic patients. These questions require more complex responses, which might be difficult for someone with language impairments.
B. Not assume that the patient can understand what is heard:
This is a prudent approach. Assuming comprehension without confirmation can lead to misunderstandings. It's better to confirm understanding through non-verbal cues or other communication methods.
C. Talk to the family instead:
While involving family members is important, it doesn't replace direct communication with the patient. The nurse should attempt to communicate directly with the patient, using appropriate techniques.
D. Ask one question at a time:
This is the most suitable option. Asking one question at a time allows the patient to focus on a specific topic and respond more effectively, especially if they have difficulty processing complex information.
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