Which situation takes the highest priority?

Patient with suicidal ideation with a sitter at the bedside with her back towards the patient

Post-op patient with leg swelling and thready pedal pulses

Patients with rapidly decreasing blood pressure

Patient requesting a second dose of pain medication

Answer and Explanation

The Correct Answer is C

Rationale:
A. Patient with suicidal ideation with a sitter at the bedside with her back towards the patient is incorrect as the highest priority because, although patient safety is crucial, a sitter is present, and immediate life-threatening physiological compromise is not occurring. The situation should be corrected to ensure proper observation, but it is not more urgent than unstable vital signs.

B. Post-op patient with leg swelling and thready pedal pulses is incorrect as the highest priority because this indicates possible peripheral vascular compromise or early signs of deep vein thrombosis. While serious and requiring prompt assessment, it is not immediately life-threatening compared to rapidly falling blood pressure.

C. Patients with rapidly decreasing blood pressure is correct because hypotension can indicate shock, internal bleeding, or other life-threatening complications. Rapidly decreasing blood pressure threatens perfusion to vital organs and requires immediate intervention to prevent organ failure or death. According to ABC (Airway, Breathing, Circulation) and Maslow’s hierarchy of needs, circulation issues take the highest priority.

D. Patient requesting a second dose of pain medication is incorrect as the highest priority because pain management is important for comfort and quality of care, but it is not immediately life-threatening. Interventions for unstable vital signs take precedence over pain relief.

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Free Nursing Study Resources

Correct Answer is ["C","D","E"]

Explanation

Rationale:

A. "Provide discharge instructions to a confused client's spouse" is incorrect because teaching requires assessment of learning needs and comprehension, which is within the scope of the registered nurse (RN), not the LPN. Providing discharge teaching involves critical thinking and evaluation, so it cannot be delegated.

B. "Initiate a plan of care for a client who is postoperative from an appendectomy" is incorrect because developing and initiating the plan of care requires assessment, nursing judgment, and care prioritization, which are responsibilities of the RN. LPNs can implement portions of the plan, but not initiate it independently.

C. "Obtain vital signs from a client who is 6 hr postoperative" is correct because obtaining vital signs is a routine, non-invasive task within the LPN’s scope. The LPN can collect the data, while the RN remains responsible for interpreting results and determining interventions.

D. "Catheterize a client who has not voided in 8 hr" is correct because urinary catheterization is a skill within the LPN’s scope in most states or facilities. The LPN can perform the procedure safely and report output and patient response to the RN.

E. "Administer a tap-water enema to a client who is preoperative" is correct because administering enemas is a common LPN task. It is a procedural intervention that does not require complex assessment or independent nursing judgment beyond following protocol.

A. Adjust the water temperature to feel hot. B. Rub hands and arms to dry. C. Apply 4 to 5 mL of liquid soap to the hands. D. Hold the hands higher than the elbows.

Correct Answer is C

Explanation

Rationale:

A. Adjust the water temperature to feel hot is incorrect because water that is too hot can cause skin irritation or damage. The correct practice is to use warm or lukewarm water to maintain skin integrity while effectively removing pathogens.

B. Rub hands and arms to dry is incorrect because vigorous rubbing can damage the skin. Proper hand hygiene involves patting hands and forearms dry with a clean paper towel to prevent skin irritation and maintain hygiene.

C. Apply 4 to 5 mL of liquid soap to the hands is correct because this amount is sufficient to create a lather that covers all hand surfaces, including palms, backs, fingers, and thumbs. Adequate soap volume ensures effective removal of microorganisms during handwashing.

D. Hold the hands higher than the elbows is incorrect because the hands should be positioned lower than the elbows during handwashing. This allows water and soap to flow from the fingertips toward the elbows, preventing contamination from water running back onto clean hands.

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Which situation takes the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients, Which of the following tasks should the nurse delegate to the LPN? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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