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

Answer and Explanation

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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Correct Answer is B

Explanation

A. Infuse the transfusion at a rate of 200 mL/hr. – Incorrect. The initial infusion should be slow (e.g., 75-100 mL/hr) to monitor for reactions.

B. Check the patient's vital signs every hour during the transfusion. – Correct Answer. Frequent monitoring is necessary to detect adverse reactions, such as fever or hypotension.

C. Leave the patient 5 minutes after beginning the transfusion. – Incorrect. The nurse should remain with the patient for the first 15 minutes, as most transfusion reactions occur early.

D. Flush the blood tubing with dextrose 5% in water. – Incorrect. Only normal saline should be used to flush blood tubing, as dextrose can cause hemolysis.

A. "Move objects away from the patient." B. "Place the patient on their back." C. "Restrain the patient." D. "Insert a padded tongue blade into the patient's mouth."

Correct Answer is A

Explanation

A. Correct. Moving objects prevents injury during a seizure.

B. Incorrect. The patient should be placed on their side to maintain airway patency.

C. Incorrect. Restraining the patient can cause injury.

D. Incorrect. Never insert anything into a seizing patient’s mouth, as it can obstruct the airway or break teeth.

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Which nursing intervention takes highest priority for the nurse caring for an unconscious patient?

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