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 B
Explanation
A) Touch the tip of the bottle to the lacrimal duct: Touching the tip of the bottle to the lacrimal duct is not a recommended practice when administering eye drops. This could introduce bacteria into the eye or nose, leading to potential infection. The goal is to administer the drops without contamination, and the tip of the bottle should never touch the eye or any part of the face.
B) Apply pressure to inner canthus for 2 minutes: Applying pressure to the inner canthus (the corner of the eye near the nose) for about 2 minutes after administering ophthalmic drops is a key step when using systemically acting eye medications like propranolol. This helps to prevent the systemic absorption of the medication through the nasolacrimal duct, reducing the risk of systemic side effects such as bradycardia or hypotension. This step ensures that the medication stays localized in the eye.
C) Have client lie down or tilt the back of their head: While lying down or tilting the head back may help the client instil the drops more comfortably, it is not a required step for the proper absorption or effectiveness of eye drops. The key to effective administration lies in positioning the drop in the correct part of the eye and minimizing systemic absorption, which is achieved by applying pressure to the inner canthus, not necessarily by tilting the head.
D) Have client pull down their lower eyelid: Pulling down the lower eyelid is a standard step in administering eye drops, as it creates a small pocket to hold the drop. However, it does not specifically address the concern for reducing systemic absorption of a medication like propranolol. The primary step for preventing systemic effects is applying pressure to the inner canthus after administration, making this less relevant for this specific question.
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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