A nurse from the medical-surgical floor floated to the orthopedic unit should be given clients with stable condition as those have care similar to her training and experience. A client who is in postoperative state is more likely to be on a stable condition.
Decontaminating an open wound is the first priority for the client. This minimizes absorption of radiation in the client’s body.
Assessing respiratory status is the first priority. Remember ABC.
Broccoli are gas forming and therefore, should be avoided.
The priority nursing action when caring for a client who underwent colposcopy is to assist in controlling potential bleeding by applying silver nitrate to the cervix.
The patient with problem of the airway should be given highest priority. Remember Airway, Breathing, and Circulation (ABC) is a priority.
Assess first for responsiveness.
Lack of trust is the common reason for reluctance in delegation of tasks.
Wound infection is the most common complication among obese clients who had undergone surgery. This is due to their poor blood supply in their adipose tissues.
Indirect care refers to activities and tasks performed by healthcare professionals that support the delivery of direct patient care. It includes administrative tasks, documentation, communication, collaboration with other healthcare members, and ensuring the availability of necessary equipment and supplies. Change of shift report and collaborating with other healthcare members are forms of communication and coordination that facilitate the continuity of care. Ensuring the availability of needed equipment is essential for providing efficient and effective care to patients. These activities are crucial in maintaining the overall functioning of a healthcare facility and optimizing patient outcomes.
When prioritizing care as a medical-surgical nurse, the primary nursing intervention should be assessing client situations.
Assessing client situations involves gathering information about the patients' conditions, identifying their needs, and determining the urgency and priority of care. This step is crucial for developing an effective plan of care and allocating resources appropriately. By assessing client situations, the nurse can identify any changes or deterioration in the patients' conditions, anticipate potential complications, and prioritize interventions accordingly.
When considering airway management for a patient with chronic obstructive pulmonary disease (COPD), there are certain interventions that can be delegated to a nursing assistant or patient care technician (PCT). One such intervention that can be delegated is assisting the patient to sit up on the side of the bed.
When caring for a patient with chronic obstructive pulmonary disease (COPD), the assessment of shortness of breath should be addressed as a priority. Shortness of breath, also known as dyspnea, is a common and significant symptom in patients with COPD. It can indicate worsening respiratory function, inadequate oxygenation, or the potential for an acute exacerbation.
If the nurse observes that the nursing assistant answers the phone while wearing gloves, it is appropriate for the nurse to intervene. Answering the phone while wearing gloves poses a risk of cross-contamination.
Gloves are used as personal protective equipment (PPE) to prevent the transmission of pathogens and protect both the healthcare worker and the patient from infection. Gloves should be worn when there is a risk of contact with blood, body fluids, mucous membranes, or non-intact skin. However, gloves should be removed and discarded appropriately before touching non-contaminated surfaces or objects.
Medication administration is considered a dependent nursing intervention.
Dependent nursing interventions are those actions and procedures that require an order, prescription, or direction from a licensed healthcare provider (such as a physician or advanced practice nurse) before they can be carried out. These interventions are performed by nurses based on the healthcare provider's orders and are within the scope of nursing practice.
The implementation step entails starting particular nursing interventions and treatments that are intended to assist the patient in achieving predetermined outcomes. Patient care information is acquired during the assessment process by observation, interviews, and physical evaluation. Patient data are evaluated, verified, and clustered to discover patient issues during the diagnosis stage. Each issue is then described using standardized terminology as a distinct nursing diagnostic to ensure that all healthcare professionals can understand it. The nurse decides whether the patient's goals have been reached, assesses the efficacy of interventions, and decides whether the plan of care should be abandoned, continued, or modified during the evaluation stage.
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NCLEX Nursing Prioritization Test #3
