Which nursing intervention takes highest priority for the nurse caring for an unconscious patient?
Inserting an indwelling urinary catheter
Putting a nasogastric (NG) tube in place
Maintaining a patent airway
Administering an enema daily
The Correct Answer is C
A. Inserting an indwelling urinary catheter – Incorrect. While catheterization may be necessary, it is not the highest priority for an unconscious patient.
B. Putting a nasogastric (NG) tube in place – Incorrect. NG tube placement can be useful for feeding or decompressing the stomach, but airway management takes precedence.
C. Maintaining a patent airway – Correct Answer. Airway patency is the top priority in an unconscious patient to prevent aspiration, hypoxia, or respiratory failure.
D. Administering an enema daily – Incorrect. This is not a priority in unconscious patients.
Nursing Test Bank
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Related Questions
Correct Answer is D
Explanation
A. Neutropenic – Used for low WBC count, not platelets.
B. Contact – Used for infections like C. diff or MRSA.
C. Droplet – Used for respiratory illnesses like flu or meningitis.
D. Bleeding – Correct Answer. A low platelet count increases the risk of bleeding, so bleeding precautions are necessary (e.g., soft toothbrush, avoiding IM injections, fall precautions).
Correct Answer is B
Explanation
A. Give the patient access to a video about diabetes. – Incorrect. Educational materials are helpful but should be provided after assessing the patient's current knowledge level.
B. Determine what the patient knows about managing diabetes. – Correct Answer. The first step in teaching is to assess the patient's baseline knowledge to tailor the education to their needs.
C. Establish short-term, realistic goals for the patient. – Incorrect. Goal-setting is important but should come after assessing the patient’s knowledge and readiness to learn.
D. Evaluate the effectiveness of the patient's admission teaching plan. – Incorrect. The nurse should first determine what new information needs to be taught before evaluating previous teaching.
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