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

Answer and Explanation

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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Correct Answer is C

Explanation

A. Random, rapid growth of the tumor: Benign tumors generally grow slowly and are less likely to invade nearby tissues. Rapid growth is more characteristic of malignant tumors.

B. Cells colonizing to distant body parts: Benign tumors do not metastasize to distant parts of the body; this is a feature of malignant tumors.

C. Tumor pressure against normal tissues: Even though benign tumors do not invade other tissues, they can still cause problems by pressing against surrounding normal tissues, potentially leading to significant functional issues depending on their location.

D. Emission of abnormal proteins: Abnormal protein emission is more relevant to malignancies that may cause paraneoplastic syndromes rather than benign tumors.

A. client's anxiety level decreased B. client's pain level decreased C. assessment completed D. client understood the importance of the assessment

Correct Answer is B

Explanation

A. client's anxiety level decreased: While reducing anxiety is important, it is not the initial priority when a client is experiencing physical pain that is affecting their ability to engage in the assessment.

B. client's pain level decreased: The initial desired outcome is to address the client's immediate physical pain. Once the pain is managed, the client will likely be better able to participate in the assessment and respond to questions about their mental health.

C. assessment completed: Completing the assessment is important, but it should not be prioritized over managing the client's immediate physical pain, which is currently hindering their ability to participate.

D. client understood the importance of the assessment: The client’s understanding of the assessment’s importance is less critical than addressing their immediate physical discomfort, which is a more pressing concern in this scenario.

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The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client is diagnosed with a benign brain tumor. Which of the following features of a benign tumor is of most concern to the nurse?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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