The nurse cares for a group of clients. Which client should the nurse prioritize?

A client who needs assistance ambulating in the hall

A client with pain 4/10 requesting pain medication

A client with a scheduled wound dressing change

A client with a change in their level of consciousness

Answer and Explanation

The Correct Answer is D

A. A client who needs assistance ambulating in the hall: Helping with ambulation is important to prevent falls, but it does not indicate an immediate threat to life or safety. This task can be delegated or scheduled after addressing higher-priority needs.

B. A client with pain 4/10 requesting pain medication: Moderate pain requires timely management to promote comfort, but it is not an urgent threat to physiologic stability. Pain management can follow assessment of clients with acute changes.

C. A client with a scheduled wound dressing change: Routine wound care is necessary for healing and infection prevention, but it is a planned intervention that does not indicate an urgent change in status. It can be scheduled after clients with acute concerns are addressed.

D. A client with a change in their level of consciousness: Altered mental status can indicate hypoxia, infection, intracranial pathology, or metabolic disturbance. This represents an immediate, potentially life-threatening change and requires rapid assessment and intervention.

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Correct Answer is ["A","B","D"]

Explanation

A. Assess extremity circulation distal to the restraints: Continuous monitoring of circulation, sensation, and movement below the restraints is essential to prevent tissue ischemia, nerve injury, and pressure injuries. Early detection of compromised circulation allows timely intervention and restraint adjustment.

B. Remove the restraints when they are no longer needed: Restraints should be used for the shortest duration necessary to ensure client safety. Removing them promptly when no longer required reduces the risk of physical and psychological complications, including skin breakdown and agitation.

C. Ask the client if they want the restraints removed: Clients who are intubated or otherwise unable to safely remove restraints may lack the capacity to make this decision. Safety overrides preference in acute situations, and reliance on client request alone is insufficient.

D. Replace the restraints with new ones when soiled or wet: Wet or soiled restraints increase the risk of skin breakdown, infection, and discomfort. Routine replacement ensures hygiene and maintains safe, effective restraint application.

E. Remove the restraints every four hours for five minutes: Current standards recommend more frequent assessment and removal based on institutional policy, client condition, and regulatory guidelines. Typically, restraints are removed and range-of-motion exercises performed every 2 hours, not every 4 hours.

A. Open the sterile drape and place it on the table B. Put on sterile personal protective equipment C. Clean a work surface and raise it to waist level D. Arrange sterile instruments on the sterile field

Correct Answer is C

Explanation

A. Open the sterile drape and place it on the table: Opening sterile supplies before preparing the environment increases the risk of contamination. The surface must be clean, dry, and positioned appropriately before any sterile items are opened. Environmental preparation precedes establishing the sterile field.

B. Put on sterile personal protective equipment: Sterile gloves and PPE are donned after the sterile field is set up, not before. Donning them too early increases the risk of contamination during setup. Hand hygiene and environment preparation come first.

C. Clean a work surface and raise it to waist level: The work surface must be disinfected and positioned at or above waist level to maintain visibility and prevent contamination. Sterile fields kept below waist level are considered contaminated. Preparing the environment is the first step in sterile setup.

D. Arrange sterile instruments on the sterile field: Sterile instruments are handled only after the sterile field has been properly established. Placing instruments occurs later in the setup sequence. This action depends on prior preparation of the field.

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The nurse cares for a group of clients. Which client should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","D"]

Explanation

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Correct Answer is C

Explanation

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