You are the charge nurse in a busy med-surg unit. There are several patients under your care, and you are managing a group of nurses. Which patient should be prioritized for immediate intervention?

A patient with a fractured femur who is receiving a dose of opioid pain medication and reports a pain level of 8/10.

A patient who has just returned from a colonoscopy and is stable but complaining of minor bloating.

A patient with newly diagnosed Type 1 diabetes who is receiving insulin for the first time and reports confusion.

A patient with a history of heart failure who has a blood pressure of 90/60 mmHg and is lethargic.

Answer and Explanation

The Correct Answer is D

Choice A reason: Pain of 8/10 is significant, but the patient is receiving opioids, and pain is less immediately life-threatening than hypotension and lethargy. This is incorrect, as it’s lower priority than the nurse’s need to address a patient with unstable vital signs.

Choice B reason: Minor bloating post-colonoscopy is expected and stable, not requiring immediate intervention. Hypotension in heart failure is critical, making this incorrect, as it’s less urgent than the nurse’s priority to manage a patient with potential decompensation.

Choice C reason: Confusion in new Type 1 diabetes may indicate hypoglycemia, but hypotension and lethargy in heart failure suggest acute decompensation, a higher priority. This is incorrect, as it’s less critical than the nurse’s focus on the heart failure patient’s instability.

Choice D reason: Hypotension (90/60 mmHg) and lethargy in a heart failure patient indicate possible cardiogenic shock, requiring immediate intervention. This aligns with prioritization in acute care, making it the correct patient for the charge nurse to prioritize for urgent assessment and action.

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Correct Answer is B

Explanation

Choice A reason: Troubleshooting the ventilator delays oxygenation in a patient with acute lung failure. Manual ventilation ensures immediate breathing, making this incorrect, as it’s less urgent than the nurse’s priority to maintain the patient’s airway and oxygenation during an alarm.

Choice B reason: Manually ventilating the patient after disconnecting from the inoperative ventilator ensures oxygenation in acute lung failure. This aligns with emergency respiratory protocols, making it the correct first action the nurse should take to address the ventilator alarm.

Choice C reason: Calling the respiratory therapist is important but delays immediate oxygenation needed during a ventilator failure. Manual ventilation is the priority, making this incorrect, as it postpones the nurse’s critical action to ensure the patient’s breathing is supported.

Choice D reason: Silencing alarms without addressing the ventilator failure risks hypoxia in a lung failure patient. Manual ventilation is urgent, making this incorrect, as it’s unsafe compared to the nurse’s priority of ensuring oxygenation during the inoperative alarm.

A. The student nurse flushes the gastrostomy tube with 15 mL water between medications. B. The student nurse reinserts 50 mL stomach contents after aspiration of the gastrostomy tube. C. The student nurse checks the pH of the gastric aspirate prior to flushing the gastrostomy tube. D. The student nurse reconnects the enteral feeding immediately after the medication is given.

Correct Answer is D

Explanation

Choice A reason: Flushing with 15 mL water between medications is correct to prevent clogging and ensure delivery. Immediate feeding reconnection risks phenytoin absorption, making this incorrect, as it’s a proper action unlike the error requiring the nurse’s immediate intervention.

Choice B reason: Reinserting 50 mL of aspirated stomach contents is acceptable to maintain fluid balance. Reconnecting feeding immediately affects phenytoin efficacy, making this incorrect, as it’s a correct action compared to the student’s error needing the nurse’s urgent correction.

Choice C reason: Checking gastric aspirate pH confirms tube placement, a safety step. Immediate feeding reconnection reduces phenytoin absorption, making this incorrect, as it’s a proper action unlike the student’s mistake requiring the nurse’s immediate intervention for medication administration.

Choice D reason: Reconnecting enteral feeding immediately after phenytoin reduces its absorption, as feedings should be held for 1-2 hours. This requires immediate intervention, aligning with medication administration protocols, making it the correct action for the nurse to address in the student’s care.

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You are the charge nurse in a busy med-surg unit. There are several patients under your care, and you are managing a group of nurses. Which patient should be prioritized for immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with acute lung failure has been on a ventilator for 3 days and is being considered for weaning. When entering the room, the ventilator inoperative alarm sounds. What action should the nurse take FIRST?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

A child has a 2-day history of vomiting, hypoactive bowel sounds, and an irregular pulse. Electrolyte values are sodium, 130 mEq/L; potassium, 3.3 mEq/L; calcium, 9.5 mg/dL; and HCO3, 30 mEq/L. Which of the following imbalances is the child most likely to have? (Select all that apply)

You are the charge nurse in a busy med-surg unit. There are several patients under your care, and you are managing a group of nurses. Which patient should be prioritized for immediate intervention?

A patient’s blood pressure is 90/72 mm Hg. What is the patient’s pulse pressure?

The nurse is providing dietary education to a client with gastroesophageal reflux disease (GERD). The nurse indicates that the client understands the teaching if the client states a plan to avoid which foods to prevent symptom exacerbation? (Select all that apply)

A client with severe ulcer disease in the distal stomach undergoes a gastrojejunostomy (Billroth II procedure). Which postoperative prescription would the nurse question and verify?

In collaboration with the registered dietitian nutritionist (RDN), which foods will the nurse teach a client who is taking a potassium-sparing diuretic to avoid or use cautiously? (Select all that apply)

The nurse cares for a client in the emergency department diagnosed with deep partial thickness burns of the arms and chest. The nurse notes that the client is very restless and anxious. Which action should the nurse take FIRST?

A nurse in an emergency department is caring for a client who has a blood pressure of 254/139 mm Hg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first?