The nurse has identified several diagnoses for a client in the hospital. Which problems should the nurse identify as having highest priority?

Problems that cause severe discomfort to the client

Problems the client deems most important

Problems that are immediately life-threatening for the client

Problems that are identified as priority by the physician

Answer and Explanation

The Correct Answer is C

A) Problems that cause severe discomfort to the client: While addressing discomfort is important in providing holistic care, it is not the highest priority in nursing. The nurse’s primary focus should be on life-threatening issues or those that could deteriorate the client’s condition rapidly. Severe discomfort can be managed once immediate threats to life are addressed.

B) Problems the client deems most important: Although it’s essential to consider the client’s perspective and involve them in their care plan, problems that are most important to the client may not always be the most urgent or life-threatening. For example, the client may prioritize pain management, but addressing life-threatening issues must always take precedence.

C) Problems that are immediately life-threatening for the client: This is the correct answer. According to Maslow’s hierarchy of needs and the nursing prioritization framework, life-threatening problems should always be the nurse's first priority. These are issues that, if not addressed immediately, can lead to death or severe complications. For instance, airway obstruction, severe bleeding, or shock would require immediate intervention.

D) Problems that are identified as priority by the physician: While the physician’s orders and priorities should be taken into consideration, the nurse must independently assess and prioritize care based on the overall health status of the client. This includes using clinical judgment to identify life-threatening conditions, even if they are not explicitly stated in the physician’s orders. Nurses are trained to identify priority issues through their assessments and are responsible for making decisions that ensure the client’s safety.

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Correct Answer is A

Explanation

CYP 450 enzymes are responsible for the metabolism of many drugs. Smoking can induce certain CYP 450 enzymes, particularly CYP1A2, which leads to an increase in the metabolism of drugs that are substrates of this enzyme. When a person begins smoking, the induction of these enzymes can cause drugs to be metabolized more quickly, which typically results in lower drug levels in the body. However, the statement asks whether the level of medication will increase in this client, and since smoking induces enzyme activity, it would typically lead to decreased, not increased, drug levels. However, in the context of drug-drug interactions and other metabolic pathways, the metabolism rate could be altered in ways that might increase or affect the therapeutic response.

A. Right dose B. Right route C. Right reason D. Right time

Correct Answer is B

Explanation

A) Right dose: The right dose was administered. The order specifies 1000 mg of
acetaminophen, and the nurse gave 1000 mg. Therefore, the right dose was given, and this is not the issue in this situation.

B) Right route: The right route was not followed in this situation. The order specifies that acetaminophen should be administered IV, but the nurse administered the medication PO. The route of administration is crucial for ensuring the medication is delivered in the appropriate manner for the intended therapeutic effect. By giving the medication orally instead of intravenously, the nurse deviated from the prescribed route, which is a violation of the "right route."

C) Right reason: The right reason was followed because acetaminophen is commonly given for pain or fever management, and no information suggests the wrong reason for administering the drug. The nurse's action doesn’t indicate a mistake in the reasoning for giving the medication.

D) Right time: The right time is not affected here, as the nurse did administer the acetaminophen at the scheduled time. The issue is with the route, not the timing.

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The nurse has identified several diagnoses for a client in the hospital. Which problems should the nurse identify as having highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client currently prescribed a medication highly metabolized by the CYP 450 recently began smoking due to a stressful life event. True or False: The level of medication will increase in this client.

Correct Answer is A

Explanation

The client is to receive acetaminophen 1000 mg IV Q6 hours. Today, the nurse administered acetaminophen 1000 mg PO. Which of the 9 rights was not followed in this situation?

Correct Answer is B

Explanation

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