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.
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Related Questions
Correct Answer is D
Explanation
A. Grab bars: Grab bars are useful for preventing falls in the bathroom but are unrelated to the client’s atrophy of olfactory organs, which affects the sense of smell.
B. Nonslip mats: Nonslip mats can help prevent falls but are not related to the client’s diminished sense of smell.
C. Baseboard heaters: Baseboard heaters are unrelated to olfactory atrophy and do not address the safety concerns associated with a reduced sense of smell.
D. A smoke detector: A smoke detector is essential for this client because the atrophy of olfactory organs means the client may not be able to detect the smell of smoke, increasing the risk of not noticing a fire.
Correct Answer is D
Explanation
A. Demonstrate empathy for the client by trying to mimic the client's state of anxiety. This is not appropriate as it could exacerbate the client’s anxiety rather than alleviate it. The nurse should remain calm and provide reassurance.
B. Tell the client that you must leave to go report his symptoms to the psychiatrist on duty. Leaving the client alone during a panic attack could increase their feelings of fear and isolation, worsening the situation.
C. Tell the client this is an acute exacerbation with a positive prognosis and low morbidity. While this information is correct, it does not directly address the client's immediate need for reassurance and safety during the panic attack.
D. Stay with the client, emphasizing that he is safe and that you will remain with him. This is the most appropriate intervention as it provides the client with a sense of safety and security, which is crucial during a panic attack.
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