A nurse is caring for a group of patients. Which patient should the nurse see first?
A patient with hypercapnia wearing an oxygen mask
A patient with a chest tube ambulating with the chest tube unclamped
A patient with thick secretions being tracheal suctioned first and then orally
A patient with a new tracheostomy and tracheostomy obturator at bedside
The Correct Answer is B
A. A patient with hypercapnia requires monitoring, but wearing an oxygen mask indicates some level of intervention is in place.
B. A patient with a chest tube should never ambulate with the chest tube unclamped, as this can lead to a collapsed lung and respiratory distress; thus, this patient should be prioritized.
C. While a patient with thick secretions may need suctioning, this is not as critical as ensuring the safety of a patient with an unclamped chest tube.
D. A patient with a new tracheostomy requires monitoring, but the presence of the obturator indicates readiness for emergencies; this does not take priority over the safety of the patient with the chest tube.
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Correct Answer is A
Explanation
A. "Readiness for enhanced urinary elimination" is classified as a health promotion diagnosis, indicating the patient’s desire to improve their health condition and adopt new health behaviors.
B. A risk diagnosis is used when there is a potential for problems to occur, not applicable in this scenario as the patient is actively seeking improvement.
C. A problem-focused diagnosis describes an existing problem that requires intervention; this situation reflects readiness for improvement, not an existing issue.
D. A collaborative problem involves potential complications that require both nursing and medical management; this case focuses on the patient's willingness to learn a self-management skill rather than managing a specific medical problem.
Correct Answer is D
Explanation
A. Grief evaluation refers to assessing the grief process rather than actively engaging in supportive dialogue, which is not the primary focus of the nurse's action.
B. Pain-management techniques would not apply directly to this context, as the discussion centers on emotional support rather than physical pain.
C. Palliative care encompasses a broader approach to managing patients with serious illnesses but does not specifically address the emotional support provided in this situation.
D. The nurse's action of discussing the child's life and death helps the parents express their grief and memories, thereby facilitating normal mourning, making this the most appropriate principle demonstrated.