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 ["4"]

Explanation

Identify the desired dose: The doctor has ordered 40 mg of atorvastatin.

Identify the available tablet strength: Each tablet contains 10 mg of atorvastatin.

Set up the calculation: We need to find out how many tablets are needed to administer 40 mg of the medication.

We can use the following formula:

(Desired dose) / (Tablet strength) = Number of tablets

Plug in the values and calculate:

(40 mg) / (10 mg/tablet) = 4 tablets

A. Evaluation B. Planning C. Implementation D. Assessment E. Diagnosis

Correct Answer is D

Explanation

A) Evaluation: Evaluation is the phase where the nurse assesses whether the goals or outcomes of the care plan have been met. It involves determining if the interventions provided were effective in achieving the desired outcomes. In this scenario, the nurse is still
gathering information before the action is taken, so evaluation is not the correct phase.

B) Planning: Planning is the phase in the nursing process where the nurse develops a care plan, which includes setting goals and determining interventions based on the client's needs. Although reviewing the medical record and blood glucose level is important for planning the administration of insulin, this is more about gathering data rather than forming a plan of care.

C) Implementation: Implementation refers to the actual delivery of the nursing interventions or actions. In this case, administering the insulin would be part of the implementation phase, but reviewing the medical history and obtaining a fingerstick blood glucose reading are steps taken before implementing the medication.

D) Assessment: The nurse is collecting pertinent information about the client’s condition, including reviewing the medical record and obtaining the blood glucose level. Assessment is the first step in the nursing process and involves gathering information to help guide clinical decisions.

E) Diagnosis: Diagnosis is the phase in which the nurse analyzes the assessment data to identify the client’s health problems or potential risks. While the nurse is collecting data, the diagnosis comes after the assessment phase, when the nurse has enough information to make a clinical judgment about the client's health status.

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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 client is ordered to receive 40 mg of atorvastatin PO daily. In the medication cabinet, you find 10 mg tablets. How many tablets will you administer to the client? (Enter a numerical value only)

Correct Answer is ["4"]

Explanation

A client is to receive insulin lispro at 0730. Prior to administering the medication, the nurse reviews the medical records for past medical history and obtains the client's fingerstick blood glucose reading. What phase of the nursing process does this represent?

Correct Answer is D

Explanation

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