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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A client with compromised immunity (e.g., neutropenic precautions) should be placed in a positive air pressure room to protect them from outside contaminants, not a negative air pressure room. Negative air pressure rooms are used for clients with airborne infections, such as tuberculosis.
B. An N95 respirator mask is required for airborne precautions, not droplet precautions. Droplet precautions typically require the use of a surgical mask, not an N95 mask.
C. Contact precautions focus on preventing the spread of infections through direct or indirect contact. A mask is not required for visitors unless the client also has a respiratory infection requiring droplet or airborne precautions.
D. A client on airborne precautions (e.g., for tuberculosis or measles) should wear a mask when leaving the room to prevent the spread of airborne pathogens to others in the facility. This ensures the safety of other clients and staff.
Correct Answer is A
Explanation
a. The physical therapist specializes in pain management techniques such as transcutaneous electrical nerve stimulation (TENS) and can provide guidance on the appropriate use of this modality for the client.
b. The respiratory therapist focuses on respiratory care and would not typically be involved in the management of pain using TENS.
c. The occupational therapist specializes in activities of daily living and may not have the specific expertise needed for TENS therapy.
d. The pharmacist primarily deals with medication management and would not be directly involved in providing assistance with TENS therapy.
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