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 B

Explanation

Choice A rationale:

The child having red fissures at the corners of the mouth is not the priority finding. While this could indicate a nutritional deficiency, such as vitamin B2 (riboflavin) deficiency, the presence of bruises on the child's legs raises more immediate concerns related to potential physical abuse or safety issues.

Choice B rationale:

The child having several small bruises on both legs is the priority finding. Bruising on a school-age child could indicate physical abuse or an unsafe living environment. Ensuring the child's safety and well-being takes precedence over other findings. Assessing the nature, pattern, and explanation for the bruises is crucial.

Choice C rationale:

The child sleeping for about 13 hours each night is not the priority finding in this scenario. While sleep patterns are important, the potential for physical abuse and safety concerns associated with the bruises takes precedence.

Choice D rationale:

The child not regularly attending school is a concern, but it is not the priority finding when compared to the possibility of physical abuse indicated by the bruises. Both issues need to be addressed, but ensuring the child's immediate safety is the primary focus.

A. The client's dressing change schedule. B. The client's level of consciousness. C. The client's vital signs from the previous shift. D. The client's occupation.

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.

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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?

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