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A nurse is prioritizing care for four clients. Which of the following tasks should the nurse perform first?

A.

Initiate oxygen therapy via nasal cannula for a client who has COPD.

B.

Initiate a 24-hr urine collection for a client who has end-stage kidney disease.

C.

Administer an antibiotic for a client who has methicillin-resistant Staphylococcus aureus.

D.

Change the dressing for a client who has a decubitus ulcer.

Answer and Explanation

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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View Related questions

Correct Answer is A

Explanation

A. Difficulty swallowing (dysphagia) is the priority because it increases the risk of aspiration, which can lead to aspiration pneumonia, a serious and potentially life-threatening complication for clients with Parkinson's disease.

B. Insomnia, while impacting quality of life, is not as immediately life-threatening as aspiration risk.

C. Needing additional help to stand reflects disease progression but does not carry the immediate risk of a life-threatening complication.

D. Difficulty dressing also indicates disease progression but does not pose an immediate danger to the client’s health.

Correct Answer is B

Explanation

A. Offering suggestions demonstrates a directive approach rather than a laissez-faire style, which typically involves minimal guidance.

B. Encouraging the AP to decide how they would like to divide client care tasks exemplifies laissez-faire leadership, as it empowers team members to make decisions independently.

C. Instructing the AP to report hourly indicates a more authoritarian leadership style, as it sets specific expectations for accountability.

D. Providing constructive criticism suggests active involvement in guiding the AP’s performance, contrasting with the hands-off approach of laissez-faire leadership.

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