Which patient’s needs must be addressed first by the registered nurse?

The patient who is nauseated and vomiting after receiving narcotic pain medication.

The patient who is waiting for discharge teaching in order to go home.

The patient with chest pain after two doses of sublingual nitroglycerin.

The constipated patient who needs to use the toilet after receiving a laxative.

Answer and Explanation

The Correct Answer is C

Choice A reason: This is an incorrect choice because the patient who is nauseated and vomiting after receiving narcotic pain medication is not the most urgent patient. Nausea and vomiting are common side effects of narcotic pain medication and can be managed with antiemetics and hydration. The patient's condition is not life-threatening and does not require immediate intervention.

Choice B reason: This is an incorrect choice because the patient who is waiting for discharge teaching in order to go home is not the most urgent patient. Discharge teaching is an important part of patient education and care transition, but it can be delayed until the more critical patients are attended to. The patient's condition is stable and does not require immediate intervention.

Choice C reason: This is the correct choice because the patient with chest pain after two doses of sublingual nitroglycerin is the most urgent patient. Chest pain is a sign of myocardial ischemia, which can lead to myocardial infarction or heart attack. Sublingual nitroglycerin is a medication that dilates the coronary arteries and relieves chest pain. If the chest pain persists after two doses of sublingual nitroglycerin, the patient may have unstable angina or acute coronary syndrome, which are medical emergencies that require immediate intervention⁴.

Choice D reason: This is an incorrect choice because the constipated patient who needs to use the toilet after receiving a laxative is not the most urgent patient. Constipation is a common gastrointestinal problem that can be treated with laxatives and dietary changes. The patient's condition is not life-threatening and does not require immediate intervention.

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Correct Answer is B

Explanation

Choice A reason: This is incorrect. Total urinary incontinence related to inability to feel urge to urinate is not appropriate for a patient with xerostomia. Xerostomia is the condition of having a dry mouth due to reduced or absent saliva production. It does not affect the urinary system or the sensation of bladder fullness.

Choice B reason: This is correct. Impaired oral mucous membranes related to decreased salivation and dry mouth is appropriate for a patient with xerostomia. Xerostomia can cause oral mucous membranes to become dry, cracked, inflamed, or infected. It can also affect the patient's ability to chew, swallow, speak, or taste.

Choice C reason: This is incorrect. Bathing self-care deficit related to inability to perceive left-sided body parts is not appropriate for a patient with xerostomia. Xerostomia does not affect the patient's perception of body parts or the ability to perform bathing activities.

Choice D reason: This is incorrect. Disturbed sensory perception related to feeling of electric pain in feet and hands is not appropriate for a patient with xerostomia. Xerostomia does not cause electric pain in the extremities. This symptom may be related to a nerve disorder, such as peripheral neuropathy.

A. Making sure that the earpieces fit loosely in the nurse’s ear canals B. Utilizing a stethoscope with the longest possible tubing C. Placing the diaphragm firmly against the patient’s skin D. Positioning the bell very lightly over the patient’s sternum

Correct Answer is C

Explanation

Choice A reason: This is incorrect. Making sure that the earpieces fit loosely in the nurse’s ear canals will not help the nurse hear the heartbeat more clearly. Loose earpieces can let in ambient noise and reduce the sound quality.

Choice B reason: This is incorrect. Utilizing a stethoscope with the longest possible tubing will not help the nurse hear the heartbeat more clearly. Long tubing can reduce the sound transmission and create interference.

Choice C reason: This is correct. Placing the diaphragm firmly against the patient’s skin will help the nurse hear the heartbeat more clearly. The diaphragm is the flat circular part of the chest piece that is used to listen to low-pitched sounds, such as the heart. Firm pressure creates a good seal and blocks out external noise.

Choice D reason: This is incorrect. Positioning the bell very lightly over the patient’s sternum will not help the nurse hear the heartbeat more clearly. The bell is the small cup-shaped part of the chest piece that is used to listen to high-pitched sounds, such as the lungs. Light pressure is needed to avoid activating the diaphragm, but the sternum is not the best location to listen to the apical pulse.

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Which patient’s needs must be addressed first by the registered nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing diagnosis is most appropriate for a patient with xerostomia?

Correct Answer is B

Explanation

The nurse is having difficulty hearing his patient’s apical pulse with his stethoscope. Which action will help the nurse hear the heartbeat more clearly?

Correct Answer is C

Explanation

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