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.
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Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Answer: The nurse should first address the patient’s oxygen saturation followed by the patient’s hypotension.
Rationale:
1st Priority: Oxygen Saturation → The client’s oxygen saturation has dropped to 88% on room air, which is below the expected range (typically ≥95% in healthy individuals). Hypoxia must be addressed immediately to prevent further complications. The nurse should apply supplemental oxygen and reassess respiratory status.
2nd Priority: Hypotension → The client’s blood pressure has dropped to 94/59 mmHg, which is significantly lower than the earlier reading of 102/76 mmHg. This may contribute to dizziness and syncope. The nurse should monitor for signs of hemodynamic instability, assess for ongoing blood loss (related to heavy menstrual bleeding), and anticipate interventions such as IV fluids or further evaluation for anemia-related hypotension.
Correct Answer is D
Explanation
A. Improve venous circulation and prevent VTE formation. – Incorrect. While repositioning does help with circulation, it is primarily done to prevent pressure injuries.
B. Prevent flexion and contractures of the extremities. – Incorrect. Contracture prevention is important, but passive ROM exercises are more effective for this purpose.
C. Decrease the development of a paralytic ileus. – Incorrect. Paralytic ileus is managed through bowel programs and early mobility, not repositioning alone.
D. Prevent the development of pressure ulcers. – Correct Answer. Paralyzed patients are at high risk for pressure ulcers, especially over bony prominences like the sacrum. Repositioning reduces prolonged pressure, which can lead to skin breakdown.
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