The nurse is caring for a patient who just had surgery. What is the nurse's highest priority?
A) Assessing for hemorrhage
B) Maintaining a patent airway
C) Managing the patient's pain
D) Assessing vital signs every 15 minutes
Ans: B
Feedback: The priority concern is the patient's airway, as demonstrated by the ABC principle: A = Airway, B = Breathing, C = Circulation. Assessing for hemorrhage and vital sign assessment are also important but constitute second and third priorities. Pain management is important but only after the patient has been stabilized.
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A client has received a terminal diagnosis and tells the nurse, "Why is God angry with me? Do I deserve this punishment?" Which nursing diagnosis is MOST appropriate for this client?
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