One of the highest priorities of nursing care is:

maintaining skin integrity

adequate nutrition

pain control

airway management

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. itching:
This is a subjective symptom. Itching is a feeling experienced by the patient and cannot be directly observed by the nurse. The patient's report of itching is subjective until the nurse observes any visible signs of scratching or a rash.

B. headache:
Similar to itching, a headache is a subjective symptom. It is a feeling experienced by the patient and cannot be directly observed by others. The patient's report of a headache is subjective until the nurse observes signs such as the patient holding their head or wincing in pain.

C. rash:
In the given context, a red rash on the face and neck is objective data. Objective data refers to measurable and observable information about a patient's condition. In this case, the nurse can directly observe the rash, making it objective. Objective data is factual and can be verified by others.

D. nausea:
Nausea is also a subjective symptom. It is a feeling experienced by the patient and cannot be directly observed by others. The patient's report of nausea is subjective until the nurse observes signs such as the patient looking pale, sweating, or exhibiting other physical symptoms associated with nausea.

A. Summarizing B. General lead C. Offering of self D. Clarifying

Correct Answer is B

Explanation

A. Summarizing: Summarizing involves condensing the patient's words into a concise form. It's a useful technique when the nurse wants to review and confirm what the patient has said, ensuring understanding and demonstrating active listening.

B. General lead: A general lead is an open-ended statement or question that allows patients to express themselves without feeling restricted. For example, "Tell me how your night was?" is a general lead because it prompts the patient to share their experiences openly.

C. Offering of self: Offering of self involves making oneself available, both physically and emotionally, to the patient. This can include showing empathy, understanding, and a willingness to listen. It helps create a therapeutic nurse-patient relationship.

D. Clarifying: Clarifying is a technique used when the nurse needs more specific information. It involves asking questions to ensure that the nurse correctly understands the patient's message, avoiding misunderstandings and ensuring clear communication. For instance, the nurse might say, "Can you please explain that part again?" to clarify a confusing statement made by the patient.

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One of the highest priorities of nursing care is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is nauseated and vomited. She has a red rash on the face and neck, which she says is itchy. She complains of a headache and feels very irritable. Which piece of data is objective?

Correct Answer is C

Explanation

Which technique is used when a nurse asks a patient, "Tell me how your night was?"

Correct Answer is B

Explanation

The general rule is that the initial care plan for a patient is:

The electronic medical record was set up as a goal of the 2009 American Recovery and Reinvestment Act, for the purpose of providing a:

A nurse tells her neighbor personal information about a hospitalized patient. Telling her neighbor about this indicates that the:

Interdisciplinary care consists of

To conduct a physical examination of a patient, which examination technique is used?

A resident in a nursing home complains of constipation. The nurse checks the patient record and notes that he has not had a bowel movement in three days. She/he then performs a digital rectal exam and feels hard stool. Which part of the nursing process is this?

A patient expresses concerns about the outcome of a scheduled surgical procedure. Which response indicates that the nurse is using active listening?

Advantages of the problem-oriented medical record (POMR) are that this method of documentation: (Select all that apply.)