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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale:

The nurse should not include the client's dressing change schedule in the verbal report when transferring care to the medical-surgical unit. While this information is important for the client's care, it is not a priority for the receiving unit to know during the immediate transfer. Dressing change schedules can vary based on the type of surgery and wound healing progress, and the medical-surgical unit will focus on the client's overall condition.

Choice B rationale:

The client's level of consciousness is a critical piece of information to include in the verbal report when transferring care. Changes in level of consciousness can indicate neurological deterioration or potential complications, especially after a major surgery like open heart surgery. This information helps the receiving nurses monitor the client's condition closely and respond appropriately if any deterioration occurs.

Choice C rationale:

While reporting the client's vital signs from the previous shift is important, it might not be the most relevant information during the immediate transfer from the postoperative unit to the medical-surgical unit. Vital signs can change rapidly, and the receiving nurses will assess the client's current vital signs upon arrival. Therefore, this information is not the priority for the verbal report.

Choice D rationale:

The client's occupation is not a critical piece of information to include in the verbal report during a transfer from the postoperative unit to the medical-surgical unit. The primary focus of the transfer report should be on the client's immediate postoperative condition, potential complications, and any other information directly related to their current medical status.

A. The right to be treated with respect and dignity. B. The right to full access of the facility. C. The right to refuse their medications. D. The right to leave regardless of provider recommendations. E. The right to be fully informed of their health conditions.

Correct Answer is ["A","C","D","E"]

Explanation

The correct answers are choices A, C, D, and E:

Choice A rationale: The right to be treated with respect and dignity is a fundamental client right in any healthcare setting, including long-term care facilities. This right ensures that clients receive care in a compassionate and respectful manner.
Choice B rationale: Full access to the facility is not a standard client right in long-term care facilities. Access to certain areas might be restricted for safety reasons or to maintain privacy.
Choice C rationale: The right to refuse medications is an essential aspect of client autonomy, allowing clients to make informed decisions about their care. It is important to address this right during orientation.
Choice D rationale: The right to leave regardless of provider recommendations is another aspect of client autonomy. Clients should be informed of their right to refuse care or leave the facility if they wish, even if it goes against the advice of healthcare providers.
Choice E rationale: The right to be fully informed of their health conditions is a crucial aspect of client autonomy and transparency in healthcare. Clients should be aware of their health status and treatment options to make informed decisions about their care.

In conclusion, when conducting an orientation class for new clients and their families at a long-term care facility, the nurse should address the rights to be treated with respect and dignity, refuse medications, leave the facility (even if it is against the recommendations of healthcare providers), and be fully informed of their health conditions.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 3 days postoperative following open heart surgery and will be transferred to the medical-surgical unit. Which of the following information should the nurse plan to include in the verbal report?

Correct Answer is B

Explanation

A nurse is conducting an orientation class for new clients and their families at a long-term care facility. Which of the following client rights should the nurse address at the orientation? (Select all that apply.).

Correct Answer is ["A","C","D","E"]

Explanation

A nurse is reviewing a client's clinical pathway upon discharge following hip arthroplasty. Which of the following information can assist the nurse in evaluating the cost effectiveness of the care?

A charge nurse is observing a nurse perform a sterile dressing change for a client. Which of the following actions should the charge nurse identify as demonstrating sterile technique?

A nurse on a medical-surgical unit is caring for a client transferred from another department. The nurse should verify that the client has given informed consent prior to which of the following procedures?

A nurse asks a newly hired assistive personnel (AP) to remove a client's indwelling urinary catheter. Which of the following actions should the nurse take to ensure the AP is qualified to perform this task?

A nurse is reviewing the plan of care for a client following a total hip arthroplasty. Which of the following actions should the nurse plan to take?

A nurse is developing a plan of care for a school-age child whose family is homeless. Which of the following findings should the nurse identify as the priority?

A nurse is serving on a committee that is considering the creation of a policy that will allow nurses to insert peripherally inserted central catheters in the intensive care unit. Which of the following resources should the nurse consult in planning for this policy?

A nurse is reviewing a client's clinical pathway upon discharge following hip arthroplasty. Which of the following information can assist the nurse in evaluating the cost effectiveness of the care?