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).
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Assigning clients who have had stem cell transplants to the same room is not a recommended practice. Clients with compromised immune systems should be isolated to reduce the risk of infection transmission. Placing them together increases the potential for exposure to infectious agents.
Choice B rationale:
Obtaining a rectal temperature on clients every 4 hours is not specifically related to caring for clients following stem cell transplants. Vital sign monitoring is essential, but the frequency and method of temperature measurement can vary based on the individual client's condition and clinical judgment.
Choice C rationale:
(Correct Choice) Wearing an N95 respirator mask while caring for clients following stem cell transplants is important due to their compromised immune systems. These clients are at higher risk of infections, and N95 masks provide enhanced respiratory protection against airborne pathogens.
Choice D rationale:
Placing clients in positive-pressure airflow rooms is not a standard practice for caring for clients following stem cell transplants. Positive-pressure rooms are often used for clients with conditions like immunodeficiency, but stem cell transplant recipients are generally placed in protective isolation rooms to minimize infection risk.
Correct Answer is ["A","B"]
Explanation
Choice A rationale:
Role model a positive approach to the changes. Rationale: The correct choice. As a charge nurse, leading by example is crucial. Demonstrating a positive attitude toward the changes sets a tone for the unit and encourages staff members to approach the situation with an open mind.
Choice B rationale:
Redirect the conversation when staff members make negative comments about the changes. Rationale: The correct choice. Addressing negativity and redirecting the conversation helps maintain a constructive and respectful work environment. This approach allows for open dialogue while discouraging excessive negativity that can hinder the adaptation process.
Choice C rationale:
Encourage staff members who support the changes to discuss the issue with resistant staff. Rationale: While encouraging open communication is important, it might not be sufficient to address the resistance completely. The charge nurse should take a more active role in managing negativity and facilitating a positive transition.
Choice D rationale:
Suggest that resistant staff members transfer to a different unit. Rationale: Transferring staff members might not be a productive solution and can lead to further discord within the unit. It's important to address the issues within the current team before considering such drastic measures.
Choice E rationale:
Reprimand staff members who are resistant to the changes. Rationale: Adopting a punitive approach can escalate tensions and foster a negative work environment. It's better to focus on positive reinforcement and facilitating open conversations to manage resistance effectively.
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