Which patient's needs must be addressed first by the nurse?
The patient who is nauseated and vomiting after receiving narcotic pain medication.
The constipated patient who needs to use the toilet after receiving a laxative.
The patient who is waiting for discharge teaching in order to go home.
The patient with chest pain and shortness of breath after two doses of sublingual nitroglycerin.
The Correct Answer is D
Choice A rationale
Nausea and vomiting after narcotic pain medication, while uncomfortable, are often expected side effects. The nurse should address these symptoms with antiemetics or other comfort measures, but this is generally not the highest priority unless the vomiting is severe or leads to dehydration or electrolyte imbalance.
Choice B rationale
A constipated patient needing to use the toilet should be assisted promptly for comfort and to prevent further complications. However, this need is generally not life-threatening and can usually be addressed after more urgent issues.
Choice C rationale
A patient waiting for discharge teaching is important, but discharge planning can typically be done once the patient is stable and other immediate needs are addressed. While timely discharge is a goal, it is not the priority when a patient is experiencing acute distress.
Choice D rationale
Chest pain and shortness of breath after nitroglycerin administration are signs of potential serious cardiovascular or respiratory compromise. Nitroglycerin should relieve chest pain; if it persists or worsens with shortness of breath, it could indicate worsening angina, myocardial infarction, or an adverse reaction to the medication. This situation requires immediate assessment and intervention as it poses an immediate threat to the patient's well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0438"]
Explanation
Step 1: Add 12 to the hour if the time is PM. Since 4: am is in the morning, no change to the hour is needed.
Step 2: Combine the hour and minutes, separated by a colon. The military time is 0438.
Correct Answer is A
Explanation
Choice A rationale
Maslow's hierarchy of needs is a framework that prioritizes human needs in a hierarchical order, starting with physiological needs, followed by safety, love and belonging, esteem, and self-actualization. In the planning phase of nursing, this framework helps nurses to establish priorities of care by addressing the most basic and urgent needs first before moving to higher-level needs.
Choice B rationale
Piaget's cognitive developmental theory describes the stages of intellectual development in children and adolescents. While understanding cognitive development can inform nursing care, it is not the primary framework used for establishing priorities of care during the planning phase.
Choice C rationale
Erikson's stages of psychosocial development outline the social and emotional challenges individuals face across the lifespan. While relevant to understanding a client's psychosocial well-being, it is not the primary framework for prioritizing immediate nursing interventions in the planning phase.
Choice D rationale
Kohlberg's stages of moral development describe the progression of moral reasoning. While understanding a client's moral perspective can be relevant in certain situations, it is not the central framework used for establishing the priorities of physiological and safety needs in the nursing care plan. .
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