Upon evaluating the patient, the nurse identifies the following nursing diagnoses. Arrange them in order of priority, with the most critical (as 1) and least critical (as 4).
Constipation
Expected grieving
Inadequate airway clearance
Insufficient tissue perfusion
The Correct Answer is C,D,A,B
C. Inadequate airway clearance is the highest priority (number 1) because it represents a threat to the "Airway" in the ABC (Airway, Breathing, Circulation) hierarchy. Without a patent airway, oxygenation cannot occur, leading to rapid physiological collapse and death within minutes. Ensuring the patient can clear secretions or maintain an open passage is the most fundamental requirement for life.
D. Insufficient tissue perfusion is the second priority (number 2) as it corresponds to "Circulation" in the ABC framework. Once the airway and breathing are secured, the heart must be able to deliver oxygenated blood to the vital organs and peripheral tissues. Poor perfusion can lead to organ failure and systemic shock, making it a critical physiological need that must be addressed immediately.
A. Constipation is the third priority (number 3) because it is an actual physiological problem, but it is not immediately life-threatening. According to Maslow's Hierarchy of Needs, physiological needs like elimination are important, but they fall below the urgent requirements of oxygenation and circulation. It requires intervention to prevent long-term complications, but it does not take precedence over respiratory or cardiac stability.
B. Expected grieving is the lowest priority (number 4) in this specific list because it is a psychosocial diagnosis. While emotional and spiritual health are essential components of holistic nursing care, they must be addressed after the patient is physiologically stable. In a prioritization scenario, life-sustaining physical needs always outweigh the psychological responses to illness or loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.Right communication is one of the essential "Five Rights of Delegation," requiring the nurse to provide a clear, concise, and complete description of the task. This includes specific instructions on the objective, limits, and expected results of the delegated activity. Effective communication ensures that the assistive personnel understands exactly what is required and when to report back to the nurse.
B.While timing is important in clinical care, "Right Time" is not formally listed as one of the five specific rights of delegation established by the ANA and NCSBN. The formal rights focus on the task, circumstances, person, direction, and supervision. Timing is considered a component of the "Right Circumstance" rather than a standalone right within the delegation framework.
C.Documentation is a vital nursing responsibility that must be completed after a task, but it is not one of the designated "Five Rights of Delegation." The nurse remains responsible for ensuring the AP's findings are documented, but the delegation process itself is focused on the transfer of authority. The formal rights are intended to guide the decision-making process before the task begins.
D."Right Room" is not a component of the delegation framework; the physical location is secondary to the safety and appropriateness of the task. Delegation is based on the complexity of the patient's condition and the competency of the assistive personnel. The nurse must assess the "Right Circumstance" and "Right Task" rather than focusing on the patient's room assignment.
Correct Answer is C
Explanation
A.Increased technology awareness: While using digital systems might improve a staff member's technical skills, this is a secondary effect rather than a primary clinical advantage. The main goal of the EHR is to improve patient outcomes and documentation efficiency. Personal skill development is not a standard advantage cited for healthcare systems.
B.Required system changes: The need to constantly adapt to new software interfaces or hardware requirements is generally viewed as a challenge or burden. System changes require extensive staff training and can lead to temporary decreases in productivity. This represents a significant administrative hurdle rather than a benefit to patient care delivery.
C.Facilitation of effective communication: EHRs provide a centralized, real-time repository of patient data that is accessible by all members of the interdisciplinary team simultaneously. This reduces the risk of information silos and ensures that clinicians are making decisions based on the most current data. It enhances the continuity and safety of patient care.
D.Frequent technology updates needed: The necessity of regular software patches and hardware upgrades is a logistical and financial challenge for healthcare organizations. Updates can lead to system downtime and require ongoing education for the nursing staff. This is a maintenance requirement rather than a clinical advantage that improves patient outcomes.
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