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. The doctor only: This option suggests that only the doctor is responsible for interdisciplinary care. In reality, interdisciplinary care involves a team of professionals from various fields working together, not just the doctor alone.
B. The therapists only: Similar to the previous option, this choice implies that therapists are solely responsible for interdisciplinary care. While therapists play a crucial role, interdisciplinary care encompasses a broader range of healthcare professionals.
C. The nurse only: This choice suggests that nurses alone are responsible for interdisciplinary care. While nurses are vital members of the healthcare team, interdisciplinary care involves collaboration among multiple professionals, not just nurses.
D. All members of the care team: This option correctly emphasizes that interdisciplinary care involves the collective efforts of all healthcare team members, including doctors, nurses, therapists, social workers, and others. Each member contributes their expertise to provide comprehensive and holistic care to the patient, addressing various aspects of their health and well-being.
Correct Answer is C
Explanation
A. Assessment:
Explanation: Assessment is the first step in the nursing process. It involves gathering information about the patient's health status. This can include a patient's medical history, physical examination, and other vital signs. It's the phase where the nurse collects data to identify the patient's problems or needs.
B. Nursing Diagnosis:
Explanation: Nursing diagnosis is the second step in the nursing process, following assessment. During this step, the nurse analyzes the data collected during the assessment to identify nursing diagnoses or issues. Nursing diagnoses are clinical judgments about individual, family, or community responses to actual or potential health problems or life processes.
C. Evaluation:
Explanation: Evaluation is the last step in the nursing process. It involves assessing the patient's response to nursing interventions and determining if the goals and outcomes have been met. In the given scenario, the nurse is evaluating whether the pain medication administered 45 minutes ago has had the desired effect and has relieved the patient's pain.
D. Implementation:
Explanation: Implementation is the third step in the nursing process. During this phase, the nurse carries out the care plan that was designed during the planning phase. This can involve a variety of nursing actions, including administering medications, providing treatments, and educating patients. In the context of the scenario, giving pain medication is part of the implementation phase.
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