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

Answer and Explanation

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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Correct Answer is C

Explanation

a. Assault: Assault is the threat of harm to another individual, such as threatening to administer the injection against the client's will. However, since the nurse actually administers the injection, it does not constitute assault.
b. Libel: Libel refers to a false statement that is written and published, which is not relevant in this scenario.
c. Battery: Battery involves the unauthorized or harmful physical contact with another individual, such as administering the injection without the client's consent.
d. False imprisonment: False imprisonment occurs when an individual is unlawfully restrained or confined. While the client's movement may be restricted by administering the injection, the primary issue here is the unauthorized physical contact, making battery the more appropriate choice.

A. A client who has Alzheimer’s disease and bacterial pneumonia with newly onset restlessness B. A client who is newly admitted with diabetes mellitus and whose fasting blood glucose level is 200 mg/dL C. A client who is 24 hr postoperative following surgical reduction of a hip fracture and reports a pain level of 7 on a scale from 0-10 D. A client who is 3 days postoperative following abdominal surgery and is ready for discharge

Correct Answer is A

Explanation

a. The client with Alzheimer's disease and bacterial pneumonia experiencing newly onset restlessness may indicate a change in their condition, such as worsening infection or delirium, which requires immediate assessment and intervention to address their underlying medical needs.
b. While hyperglycemia in a newly admitted client with diabetes mellitus is concerning, it does not typically require immediate assessment unless accompanied by signs of diabetic ketoacidosis or other acute complications.
c. Although the client postoperative from hip fracture reduction reporting a pain level of 7 requires attention, it is not as urgent as assessing the client with newly onset restlessness, which may indicate a more acute issue.
d. The client who is 3 days postoperative and ready for discharge does not require immediate assessment compared to the client with newly onset restlessness, whose condition may be deteriorating.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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