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. Postoperative urinary retention is common after surgery, especially within the first 12 hours. While this requires monitoring and possible intervention, it is not the highest priority.
B. Emotional distress before surgery is important to address, but it is not an immediate physiological concern requiring urgent intervention.
C. An absent pulse in the right foot indicates potential acute arterial occlusion, which is a medical emergency. This condition can lead to tissue ischemia and necrosis if not treated promptly. Immediate intervention is needed to restore circulation.
D. A dressing change for a diabetic ulcer is important for wound healing and infection prevention, but it does not take priority over a potential loss of circulation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. In emergency situations where immediate treatment is necessary to stabilize the client and prevent further deterioration, obtaining written consent may not be feasible or necessary. The principle of implied consent applies in emergency situations where the client is unable to provide consent due to their condition.
b. Notifying risk management before initiating treatment is not necessary in this emergency situation, as the priority is to provide timely and appropriate care to the client.
c. Having the client sign a consent for treatment may not be possible if the client is disoriented or incapacitated due to their condition.
d. Contacting the client's next of kin to obtain consent may delay necessary treatment, which could be detrimental to the client's health in an emergency situation.
Correct Answer is D
Explanation
A. A client refusing care from assistive personnel of the opposite gender is important and must be handled to respect the client's preferences, but it does not immediately impact the overall functioning of the unit or client safety. This situation can be addressed after the staffing issue.
B. No transport assistance being available for a client to go to physical therapy is a logistical issue that can be resolved with alternative arrangements, such as rescheduling the therapy or finding different personnel for transport. It is not a critical priority compared to staffing shortages.
C. A heated disagreement between two nurses over a scheduling issue is a team dynamic problem that requires attention, but it is not urgent enough to affect patient safety or unit operations in the immediate term. Resolving staffing shortages takes precedence.
D. Addressing the absence of three staff members is critical as it directly affects patient care and safety. A shortage in staff can lead to unsafe working conditions, delays in client care, and an increased risk of errors. Ensuring adequate staffing is the highest priority in this situation
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