A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the priority?

A client who is scheduled for a tubal ligation in 2 hr 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 mellitus and needs the first dressing change for an ulcer.

A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38°C (100.4°F).

Answer and Explanation

The Correct Answer is B

Choice A rationale:

A client who is scheduled for a tubal ligation in 2 hr and is crying. Rationale: While the emotional well-being of this client is important, the absence of pulse in the right foot of the client in choice B indicates a potentially critical vascular issue that requires immediate attention.

Choice B rationale:

A client who has peripheral vascular disease and has an absent pulse in the right foot. Rationale: The correct choice. An absent pulse in a client with peripheral vascular disease suggests compromised blood flow and potential tissue ischemia. This is a critical situation that requires urgent intervention to prevent further complications.

Choice C rationale:

A client who has type 1 diabetes mellitus and needs the first dressing change for an ulcer. Rationale: While dressing changes are important, they are not as time-sensitive as addressing compromised blood flow and potential tissue damage seen in choice B.

Choice D rationale:

A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38°C (100.4°F). Rationale: Although an elevated temperature can be concerning, the absence of a pulse in a peripheral vascular disease client (choice B) takes precedence as it suggests a more immediate threat to the client's limb and overall health.

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Correct Answer is D

Explanation

Answer is: d. "Clients are the experts on their own pain."

Explanation: The charge nurse's response acknowledges the client's self-report of pain, which is considered the most reliable indicator of pain presence and intensity. This approach emphasizes the importance of individualized pain management and respects the client's autonomy.

Statement a. is wrong because the nurse is suggesting an intervention without assessing the client's pain or consulting the healthcare provider. Although nonpharmacological interventions may be appropriate, they should be discussed with the client and provider before making decisions.

Statement b. is wrong because withholding prescribed medication without a valid reason or consultation with the healthcare provider is inappropriate and could result in inadequate pain management.

Statement c. is wrong because contacting mental health services for a consultation based on the assumption that the client is seeking drugs may be premature and overlook the client's reported pain. A thorough assessment and discussion with the healthcare provider should precede any consultation.

A. Report the findings to the hospital ethics committee. B. Alert central supply. C. Fill out an incident report. D. Notify the quality improvement team.

Correct Answer is D

Explanation

Choice A rationale:

Reporting the findings to the hospital ethics committee is not the appropriate action in this scenario. Ventilator-associated pneumonia (VAP) is a clinical issue related to patient care and safety, not an ethical concern. The hospital ethics committee is generally responsible for addressing ethical dilemmas and conflicts.

Choice B rationale:

Alerting central supply is not the correct action in this situation. Central supply typically handles the procurement and distribution of medical supplies, equipment, and materials. While maintaining proper equipment and supplies is important, addressing VAP requires a focus on infection prevention and patient care practices.

Choice C rationale:

Filling out an incident report is not the best course of action for addressing an increase in ventilator-associated pneumonia. Incident reports are typically used to document unexpected events, accidents, or errors that occur in the healthcare setting. However, addressing the rise in VAP involves implementing measures to prevent and control infections, which falls under the purview of the quality improvement team.

Choice D rationale:

The correct action is to notify the quality improvement team. Ventilator-associated pneumonia is a healthcare-associated infection that can lead to serious complications for patients on ventilators. The quality improvement team is responsible for monitoring and improving the quality of patient care, including infection prevention and control. By notifying the quality improvement team, the nurse manager can initiate a comprehensive review of current practices, identify potential areas for improvement, and implement evidence-based interventions to reduce the incidence of VAP.

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A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the priority?

Nursing Test Bank

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