NCLEX® QUESTION OF THE WEEK

Question of the Week – May 11, 2022

The nurse is caring for a patient with intractable nausea and vomiting. The patient has a temperature of 99°F, a pulse of 100, a respiratory rate of 24, a blood pressure of 90/60, and oxygen saturation of 91%. What is the first action the nurse should take?

Show Answer Answer
Correct! The answer is number 4

Rationale:

Answer: 4 Airway patency is the priority for this patient and the first thing the nurse should do is take measures to ensure the airway will be patent by making sure suction is readily available. Intractable nausea and vomiting pose a safety risk for aspiration. The other choices are all acceptable actions, but ensuring there is a patent airway is the first thing the nurse should do.

Additional Info:

Focus

Prioritization

QSEN

Patient-Centered Care

Concept

Gas Exchange

Practice Question Sourced From: Resources for Prioritization, Delegation, and Assignment, 5th Edition

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