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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Transcutaneous electrical nerve stimulation (TENS) is a form of physical therapy often used for pain management. Therefore, the physical therapist would be the appropriate member of the interdisciplinary team to contact for assistance with TENS.
b. Respiratory therapists primarily focus on respiratory care and would not typically be involved in assisting with TENS therapy.
c. Occupational therapists focus on helping clients perform activities of daily living and may not have specific expertise in managing TENS therapy.
d. While pharmacists are knowledgeable about medications, they may not have the expertise required to assist with TENS therapy, which is a form of physical therapy.
Correct Answer is D
Explanation
a. Involving the client's partner may be helpful for additional support, but it does not ensure accurate communication if the partner also does not speak the same language as the client.
b. While incorporating gestures and hand signals can be useful, they may not fully convey complex medical information and may lead to misunderstandings.
c. Interpreting the client's body language can provide some insight into their understanding, but it may not accurately represent their comprehension of the information.
d. Providing an interpreter ensures accurate communication and understanding between the nurse and the client, promoting effective teaching and informed decision-making.
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