A charge nurse notices that two staff nurses are not taking meal breaks during their shifts.

Which of the following actions should the nurse take first?

A. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot is the highest priority. An absent pedal pulse indicates potential arterial occlusion, which could lead to tissue ischemia and necrosis if not addressed promptly. This situation is critical and requires immediate intervention to restore circulation and prevent permanent damage.

B. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38°C (101°F) is not the highest priority. A mild fever in a client with MRSA indicates infection, but it is not immediately life-threatening. This client needs monitoring and possible adjustment of antibiotics, but the situation does not require urgent intervention.

C. A client who is postoperative following a laminectomy 12 hr ago and is unable to void is concerning, as it could indicate a complication such as urinary retention or spinal nerve damage. However, it is not immediately life-threatening and can be addressed after the more critical issue of a potential arterial occlusion in the client with peripheral vascular disease

D. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy: While this client's diagnosis and treatment plan are significant, they may not require immediate intervention compared to the potential complications of urinary retention in the postoperative client.

A. Reinforce the potential consequences of not having this information on record to the nursing staff: While reinforcing the importance of advance directives is necessary, the immediate priority is to ensure that missing information is obtained.
B. Ask nurses who are caring for clients without this information in the medical record to obtain it: This is the correct answer. The priority action is to address the missing documentation by
instructing nurses to obtain advance directive information from clients who lack it in their medical records.
C. Meet with nursing staff to review the policy regarding advance directives: While policy review may be necessary, it is not the immediate action needed to address the missing documentation.
D. Remind nurses to obtain this information during the admission process: While obtaining advance directive information during the admission process is important, the priority is to address the missing documentation for current clients.