Safe, Effective Care Environment
51. In prioritizing care, to which client should a nurse respond first?
Safe, Effective Care Environment
51. In prioritizing care, to which client should a nurse respond first?
. Client on NG bolus feeding, with NG medication due and tube is pulled out.
. Client with IV chemotherapy and the infusion pump is alarming.
. Client who is incontinent and lying in feces.
. Client is yelling, "I want to go home" and pressing the call button.
Test-Taking Tip
Look for the client who is most vulnerable to a serious consequence. Eliminate those answers that focus on GI feeding (Answer 1), elimination (Answer 3), and psychosocial need (Answer 4).
Content Area: Adult Health, Triage; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Safe and Effective Care Environment/Management of Care/Establishing Priorities
Safe, Effective Care Environment
.
Answer 1 is incorrect because there is no immediate risk to the client. Answer 2 is correct because chemotherapy drugs are toxic and can cause tissue destruction if infiltrated, and maintaining the access port is vital to therapy. Answer 3 is incorrect because there is no immediate risk to the client. Answer 4 is incorrect because there is no immediate risk to the client.