A nurse is prioritizing care for four clients. Which of the following tasks should the nurse perform first?
Initiate oxygen therapy via nasal cannula for a client who has COPD.
Initiate a 24-hr urine collection for a client who has end-stage kidney disease.
Administer an antibiotic for a client who has methicillin-resistant Staphylococcus aureus.
Change the dressing for a client who has a decubitus ulcer.
The Correct Answer is A
A. Initiating oxygen therapy for a client with COPD is a priority because oxygenation is critical for clients with respiratory conditions. Hypoxia can lead to serious complications, making this intervention urgent.
B. While initiating a 24-hour urine collection is important for monitoring kidney function, it does not require immediate action compared to the need for oxygen therapy in a client with respiratory distress.
C. Administering antibiotics is essential, especially for a client with an infection like MRSA; however, the need for immediate oxygen therapy takes precedence over medication administration.
D. Changing the dressing for a decubitus ulcer is important for preventing infection and promoting healing but is not as time-sensitive as ensuring adequate oxygenation for the client with COPD.
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Correct Answer is B
Explanation
A. Smoke alarm batteries should be changed at least once a year, not every 2 years, so this statement reflects a misunderstanding of fire safety recommendations.
B. Spraying the extinguisher from side to side at the base of the fire is the correct technique for using a fire extinguisher, indicating the client understands proper fire safety.
C. Attempting to extinguish a fire before calling the fire department can be dangerous; the client should call for help first if the fire is large or spreading.
D. A Class A extinguisher is suitable for ordinary combustibles like wood and paper, but for electrical fires, a Class C extinguisher should be used, indicating a misunderstanding of fire extinguisher types.
Correct Answer is A
Explanation
A. Raisin toast is a bland carbohydrate that is generally well-tolerated and can help settle the stomach, making it a suitable choice for clients experiencing chemotherapy-induced nausea.
B. Soft-serve ice cream may be too rich and can upset the stomach for some clients undergoing chemotherapy, leading to increased nausea.
C. String cheese is high in fat and protein, which might not be well-tolerated during episodes of nausea, as heavy foods can exacerbate discomfort.
D. Hot tea may be soothing for some clients; however, certain herbal teas can sometimes provoke nausea or have an adverse effect, making it less ideal than bland carbohydrates.