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A nurse is caring for a group of patients. Which patient should the nurse see first?

A.

A patient with hypercapnia wearing an oxygen mask

B.

A patient with a chest tube ambulating with the chest tube unclamped

C.

A patient with thick secretions being tracheal suctioned first and then orally

D.

A patient with a new tracheostomy and tracheostomy obturator at bedside

Answer and Explanation

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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View Related questions

Correct Answer is ["A","B","C","D"]

Explanation

A. A patient with an indwelling catheter requires regular perineal care to prevent infection due to increased risk from the catheter.

B. Urinary and fecal incontinence increase the risk of skin breakdown and infection, necessitating frequent perineal care.

C. Surgical dressings in the rectal and genital areas require perineal care to maintain hygiene and prevent wound contamination.

D. Bariatric patients often need regular perineal care due to skin folds and increased risk of moisture-related skin breakdown.

E. A circumcised, ambulatory male typically has a lower risk of infection and may not require as frequent perineal care unless other factors are present.

Correct Answer is A

Explanation

A. Encouraging self-care helps promote independence and functional recovery in stroke patients, supporting rehabilitation and enhancing self-esteem.

B. Bed rest is not recommended as it can contribute to muscle deconditioning and complications associated with immobility.

C. While coordination with therapy is beneficial, gait training is typically handled by physical therapy rather than occupational therapy.

D. Providing a complete bed bath limits the patient’s autonomy; encouraging partial participation supports the patient's involvement in self-care.

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