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 D

Explanation

A) Peptic ulcer: Scopolamine is an anticholinergic medication that works by blocking acetylcholine, which can reduce nausea and motion sickness. While scopolamine can have anticholinergic effects that may slightly reduce gastric motility, it is not directly contraindicated in clients with a history of peptic ulcer. The medication does not significantly exacerbate the condition of peptic ulcers.

B) Asthma: While scopolamine can have anticholinergic effects that may lead to dry mouth and slight airway narrowing, it is not contraindicated in clients with asthma. However, the nurse should be cautious and monitor the client for any signs of respiratory distress, as anticholinergic medications can cause some bronchial smooth muscle relaxation, which could theoretically worsen asthma symptoms. It is not an absolute contraindication.

C) Heart disease: Scopolamine is not specifically contraindicated for individuals with heart disease, although caution should be used in patients with cardiovascular conditions due to its potential effects on heart rate and blood pressure. However, heart disease itself is not a direct contraindication for the use of scopolamine.

D) Glaucoma: Scopolamine is an anticholinergic medication, and anticholinergics can increase intraocular pressure. This is especially dangerous for clients with narrow-angle glaucoma, as the medication can exacerbate the condition, leading to a potential acute glaucoma attack. Therefore, individuals with a history of glaucoma, particularly narrow-angle glaucoma, should avoid scopolamine.

Correct Answer is ["20"]

Explanation

Identify the total units of heparin in the bag:

The IV bag contains 25,000 units of heparin in 250 mL.

Identify the desired hourly dose:

The client is ordered to receive 2,000 units of heparin per hour.

Calculate the mL containing 2,000 units:

We can set up a proportion:

(25,000 units) / (250 mL) = (2,000 units) / (x mL)

Solving for x, we get:

x = (2,000 units x 250 mL) / 25,000 units x = 20 mL

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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

The health care provider prescribes scopolamine for a client who is planning to take cruise and is concerned about motion sickness. What information in the past medical history would serve as a contraindication for this medication?

Correct Answer is D

Explanation

A client is to be started on a heparin intravenous infusion at 2,000 units per hour. On hand is an IV bag labeled 25,000 units/ 250 mL. At what rate (mL/hour) will the nurse set the pump? (Answer to the nearest whole number)

Correct Answer is ["20"]

Explanation

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