The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority?
Maintaining accurate records of intake and output
Maintaining a patent airway
Inserting a nasogastric (NG) tube as prescribed
Providing appropriate pain control
The Correct Answer is B
A. Maintaining accurate records of intake and output: While monitoring intake and output is important for assessing fluid balance and kidney function, it is not as immediate a concern as maintaining an airway in an unconscious client.
B. Maintaining a patent airway: This is the highest priority because an unconscious client is at high risk of airway obstruction due to the loss of protective reflexes. Ensuring that the airway remains open is critical to prevent respiratory distress or arrest.
C. Inserting a nasogastric (NG) tube as prescribed: Inserting an NG tube might be necessary for feeding or draining gastric contents, but it is secondary to the more urgent need of ensuring a clear airway.
D. Providing appropriate pain control: Pain control is important but should be considered after addressing more immediate threats to the client's safety, such as maintaining a patent airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Hematologic spread: Hematologic spread (through the bloodstream) is a common mechanism for metastasis to distant organs like bones and liver. This is the most likely mechanism for the spread described.
B. Lymphatic circulation: Lymphatic spread often leads to regional lymph nodes rather than distant organs like bones and liver.
C. Invasion: Invasion involves local spread into adjacent tissues but does not typically account for distant metastasis.
D. Angiogenesis: Angiogenesis refers to the formation of new blood vessels to supply the tumor, not the mechanism by which cancer cells spread to distant sites.
Correct Answer is B
Explanation
A. Disorganized speech: Disorganized speech involves incoherent or illogical speech patterns, which is not the primary observation here.
B. A hallucination: The client is interacting with an unseen entity, which suggests a hallucination, a false sensory perception, particularly common in schizophrenia.
C. An illusion: An illusion involves a misinterpretation of a real external stimulus, which is not applicable in this situation as there is no stimulus present.
D. Anhedonia: Anhedonia refers to a loss of interest or pleasure in activities, which does not describe the behavior observed.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.