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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Labeling the mother as "overprotective" is dismissive and non-therapeutic.
B. This response uses therapeutic communication to explore the mother’s concerns without judgment, allowing for education and support.
C. Suggesting home-schooling may reinforce unnecessary restrictions and does not address the concern.
D. Agreeing outright does not help the mother understand that physical activity can be managed safely.
Correct Answer is D
Explanation
A. Bring fresh-cut flowers to cheer the patient up. – Incorrect. Fresh flowers should be avoided due to the risk of fungal or bacterial infections in immunocompromised patients.
B. Take the patient to the cafeteria for meals. – Incorrect. Bone marrow transplant patients are at high risk for infection, and leaving the room increases exposure to pathogens.
C. A cover gown is not necessary when entering the patient’s room. – Incorrect. Depending on the hospital’s isolation precautions, visitors may be required to wear gowns and masks to protect the patient.
D. Do not visit if you have had a recent infection. – Correct Answer. Even mild infections can be life-threatening to patients undergoing a bone marrow transplant, so visitors should stay away if they are unwell.
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