A nurse on a med-surge unit is caring for four clients. The nurse should recognize that which of the following clients is the priority?
A client who is postoperative following a laminectomy 12 hour and is unable to void
A client who is scheduled for a tubal ligation in 2 hours and is crying
A client who has peripheral vascular disease and has an absent pulse in the right foot
A client who has type 1 diabetes and needs the first dressing change for an ulcer
The Correct Answer is C
a. The client postoperative following a laminectomy and unable to void is a concern, but not immediately life- threatening.
b. The client scheduled for a tubal ligation and is crying needs emotional support, but this is not a physiological emergency.
c. An absent pulse in the foot indicates a potential loss of circulation, which could lead to tissue death or loss of the limb, making it the most urgent issue.
d. The client with type 1 diabetes needing a dressing change for an ulcer is important, but the absence of a pulse takes precedence.
e. A client with MRSA and a low-grade fever is a concern for infection control, but not as immediately critical as the loss of circulation.
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Related Questions
Correct Answer is D
Explanation
a. While reviewing the chart for nonrestraint alternatives is important, the immediate priority is to ensure the client's safety by removing the restraints that were inappropriately applied.
b. Informing the unit manager can be done after taking immediate action to address the situation and ensure the client's safety.
c. Speaking with the AP about the incident can be done after addressing the immediate need to remove the restraints from the client's wrist.
d. Removing the restraints from the client’s wrist is the first action the nurse should take to prevent any potential harm or injury to the client due to the inappropriate use of restraints.
Correct Answer is B
Explanation
a. This transcription includes "MS," which could be misinterpreted as "magnesium sulfate." It is essential to avoid abbreviations that could lead to medication errors.
b. This transcription provides a clear and accurate representation of the prescribed medication, dose, route, frequency, and indication for pain. It follows standard medication transcription practices.
c. While "MSO4" represents morphine sulfate, the abbreviation for "IV push" (IVP) is missing, which could lead to confusion regarding the administration route.
d. This transcription includes unnecessary decimal points in the medication dose, which may lead to dosing errors. It is important to use clear and concise notation when transcribing medication orders.
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