Which patient needs attention first?

Correct Answer: D

Rationale: In this scenario, the correct answer is option D, the homeless person with altered mental status, poor muscle coordination, and hot, dry, ashen skin. This patient is likely experiencing severe dehydration and hyperthermia, which are life-threatening conditions requiring immediate attention. Dehydration can lead to electrolyte imbalances and organ failure, while hyperthermia can progress to heat stroke. Option A, the elderly person with dizziness and syncope after sun exposure, may have heat exhaustion, but the symptoms in option D indicate a more critical condition. Option B, the marathon runner with leg cramps and other symptoms, likely has heat exhaustion, which is serious but not as immediately life-threatening as the conditions in option D. Option C, the homemaker with signs of heat exhaustion due to a broken air conditioner, also requires attention but is not as critical as the altered mental status and poor coordination seen in option D. In the context of medical-surgical nursing, it is essential to prioritize patients based on the severity and acuity of their conditions. This question highlights the importance of recognizing critical signs and symptoms that require immediate intervention to prevent further deterioration and potential life-threatening outcomes. Nurses must be able to quickly assess and prioritize patients based on the urgency of their needs to provide timely and appropriate care.

Correct Answer: C

Rationale: In the context of medical-surgical nursing, delegating tasks appropriately is crucial for optimal patient care. The most appropriate task to delegate to a nursing assistant among the options provided is "Assist with postmortem care (Option C)." This task involves non-invasive care after a patient has passed away and can be safely and effectively performed by a nursing assistant under the supervision of a registered nurse. Option A, escorting the family to a place of privacy, requires sensitivity, communication skills, and potentially providing emotional support to the family members. This task is more suited for a registered nurse who has the training and expertise to handle such delicate situations effectively. Option B, going with the organ donor specialist to talk to the family, involves complex discussions about organ donation that require specialized knowledge and training. This task should be handled by a healthcare professional with specific expertise in organ donation and counseling. Option D, assisting the family to collect belongings, also involves emotional support and sensitivity, as well as potential interactions that may require medical knowledge. This task is best performed by a healthcare professional who can address any medical concerns or emotional needs that may arise during the process. Educationally, understanding the principles of delegation in nursing is essential for providing safe and effective care. Nurses must consider factors such as the complexity of the task, the skills and training of the assistive personnel, and the needs of the patient and family when delegating responsibilities. By selecting the appropriate tasks for delegation, healthcare providers can optimize teamwork, efficiency, and patient outcomes.

Correct Answer: A

Rationale: In this scenario, the priority nursing diagnosis is option A: Risk for Infection related to organisms specific to cat bites. The rationale behind this choice is that cat bites have a high risk of infection due to the bacteria present in a cat's mouth. Infections from cat bites can lead to serious complications if not addressed promptly, including cellulitis, abscess formation, and even septicemia. Option B, Impaired Skin Integrity related to puncture wounds, while important, is not the priority in this case because the risk of infection takes precedence over skin integrity. Infections can quickly worsen and become systemic if not managed effectively. Option C, Ineffective Health Maintenance related to immunization status, is not the priority at this moment because the immediate concern is addressing the risk of infection from the cat bite. While immunization status is important for overall health, it is not the most urgent issue in this context. Option D, Risk for Impaired Mobility related to potential tendon damage, is also not the priority compared to the risk of infection. Mobility issues can be addressed once the infection risk is managed, as infections can have life-threatening implications if not dealt with promptly. In an educational context, this question highlights the importance of prioritizing nursing diagnoses based on the immediate needs of the patient. Understanding the urgency of different health concerns and being able to prioritize them is a crucial skill for nurses in providing effective and timely care to patients.

Correct Answer: B

Rationale: In the context of preoperative preparation for elective surgery, the correct answer is option B) Complete blood count, metabolic panel, and pregnancy test. This choice is appropriate because these tests provide crucial information about Donna's baseline health status, including her blood counts, metabolic function, and any potential pregnancy that could impact the surgery. Option A) Pulmonary function test and chest x-ray may not be necessary for a healthy individual like Donna without any respiratory issues or symptoms. Option C) Urine culture, thyroid panel, and cortisol level, while important in certain medical contexts, are not typically included in routine preoperative preparation for elective surgery in a healthy individual. Option D) Glucose tolerance test, ankle-brachial index, and electrocardiogram (EKG) are not typically part of the standard preoperative testing for an elective surgery in a healthy individual like Donna. In an educational context, understanding the rationale behind preoperative testing is vital for nurses, nurse practitioners, and physician assistants to provide safe and effective care to surgical patients. By knowing which tests are necessary and appropriate based on the patient's health status and the type of surgery, healthcare providers can ensure optimal preoperative preparation and reduce the risk of complications during and after surgery.

Correct Answer: B

Rationale: In the case of Denise recovering from an open cholecystectomy, the correct answer is B) Respiratory complications. This is because after abdominal surgeries like a cholecystectomy, patients are at an increased risk of developing respiratory complications such as atelectasis, pneumonia, or respiratory distress. The incision site and pain can lead to shallow breathing, ineffective coughing, and decreased lung expansion, predisposing the patient to these respiratory issues. Option A) Myocardial infarction is less likely in this scenario as the surgery does not directly impact the heart or its blood supply. Option C) Deep vein thrombosis (DVT) is a concern post-surgery due to immobility, but it is more commonly associated with lower limb surgeries rather than cholecystectomy. Option D) Wound infection is a general risk with any surgical procedure but is not specific to the respiratory issues that are more likely after an open cholecystectomy. Educationally, understanding the specific risks associated with different surgeries is crucial for nurses caring for postoperative patients. By knowing the potential complications, nurses can implement appropriate interventions to prevent, monitor, and manage these risks effectively, improving patient outcomes and recovery.