A nurse on a surgical unit is caring for a group of clients. Which of the following is the priority action of the nurse?
Assessing a client who experiences unilateral calf pain when ambulating
Reassuring the partner of a client who sustained a closed head injury
Taking a telephone prescription about a client who is to be transferred from PACU
Reinforcing a client’s dressing for the surgical site of an above the knee amputation
The Correct Answer is A
A. Assessing a client who experiences unilateral calf pain when ambulating.
Unilateral calf pain in a client who is ambulating can be indicative of a potential deep vein thrombosis (DVT), which is a serious condition that requires prompt assessment and intervention. DVTs are a risk after surgery, and early detection is crucial to prevent complications such as a pulmonary embolism. Assessing the client experiencing calf pain is the priority to determine the cause and initiate appropriate interventions.
B. Reassuring the partner of a client who sustained a closed head injury:
While providing support and reassurance to family members is important, it is not as urgent as assessing a client with potential signs of a DVT.
C. Taking a telephone prescription about a client who is to be transferred from PACU:
While obtaining and implementing orders in a timely manner is important, assessing and addressing a potential DVT takes precedence due to the immediate risk to the client's well-being.
D. Reinforcing a client’s dressing for the surgical site of an above-the-knee amputation:
Dressing reinforcement is important for wound care, but it is not as urgently needed as assessing a client with possible signs of a DVT. The assessment of calf pain takes priority.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Transformational leader:
Transformational leaders are characterized by their ability to inspire and motivate followers to achieve exceptional outcomes. They focus on building relationships, fostering creativity, and encouraging individual and team growth. Transformational leaders are often seen as visionary and charismatic.
B. Situational leader:
Situational leadership is a flexible approach where leaders adjust their style based on the situation and the readiness or maturity of their followers. The leader may use different leadership styles, ranging from directing to delegating, depending on the circumstances.
C. Bureaucratic leader:
Bureaucratic leaders strictly enforce rules and regulations. They rely on established policies and procedures to maintain order and control within the organization. This style is often associated with a more structured and rule-based approach to leadership.
D. Laissez-faire leader:
Laissez-faire leaders adopt a hands-off or delegative approach, providing little guidance or direction to their team members. They allow team members a high degree of autonomy and decision-making authority. While this style can promote creativity and independence, it may lead to a lack of structure and accountability in certain situations.
Correct Answer is ["1170"]
Explanation
To calculate the total fluid intake for a client during a 4-hour period, the nurse should convert all the measurements to milliliters (mL) and add them together. One cup is equal to 240 mL, one ounce is equal to 30 mL, and one teaspoon is equal to 5 mL. Therefore, the client consumes:
- 1 cup of coffee = 240 mL
- 4 oz of orange juice = 120 mL
- 3 oz of water = 90 mL
- 1 cup of flavored gelatin = 240 mL
- 1 cup of tea = 240 mL
- 5 oz of broth = 150 mL
- 3 oz of water = 90 mL
The total fluid intake is:
240 + 120 + 90 + 240 + 240 + 150 + 90 = 1170 mL
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