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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
To determine if the client's dose is safe and therapeutic, we need to calculate the appropriate dosing range based on the client's weight and compare it with the ordered dose.
Client's weight: 45 kg
Ordered dose: 500 mg every 8 hours, which equals 1500 mg/day (500 mg × 3 doses).
Calculate the therapeutic range:
The dosing range in the Davis Drug Guide is 20 to 40 mg/kg/day. So, for this client, based on their weight of 45 kg:
Minimum dose: 20 mg × 45 kg = 900 mg/day
Maximum dose: 40 mg × 45 kg = 1800 mg/day
The ordered dose of 1500 mg/day falls within this range (900 mg/day to 1800 mg/day), which means it is safe and therapeutic for the client.
Correct Answer is ["12"]
Explanation
1. Convert the child's weight from pounds to kilograms:
There are approximately 2.2 pounds in 1 kilogram.
33 pounds / 2.2 pounds/kg = 15 kg (approximately)
2. Calculate the total milligrams of amoxicillin needed per dose:
The order is for 20 mg/kg/dose.
The child weighs 15 kg.
20 mg/kg * 15 kg = 300 mg
3. Determine the concentration of the amoxicillin suspension:
The label shows the concentration is 125 mg/5 mL.
4. Set up a proportion to find the volume (in mL) needed:
125 mg / 5 mL = 300 mg / x mL
5. Solve for x:
Cross-multiply: 125x = 300 * 5
125x = 1500
x = 1500 / 125
x = 12 mL
Answer: You will administer 12 mL per dose.
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