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

A client who is postoperative following a laminectomy 12 hour and is unable to void

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

Answer and Explanation

The Correct Answer is C

A. Postoperative urinary retention is common after surgery, especially within the first 12 hours. While this requires monitoring and possible intervention, it is not the highest priority.
B. Emotional distress before surgery is important to address, but it is not an immediate physiological concern requiring urgent intervention.
C. An absent pulse in the right foot indicates potential acute arterial occlusion, which is a medical emergency. This condition can lead to tissue ischemia and necrosis if not treated promptly. Immediate intervention is needed to restore circulation.
D. A dressing change for a diabetic ulcer is important for wound healing and infection prevention, but it does not take priority over a potential loss of circulation.

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Free Nursing Study Resources

Correct Answer is D

Explanation

a. Review the chart for nonrestraint alternatives for agitation: While reviewing alternatives is important, the immediate concern is ensuring the safety and well-being of the client by removing the restraints.
b. Inform the unit manager: While it's important to inform the unit manager, the first action should be to address the immediate safety issue by removing the restraints.
c. Speak with the AP about the incident: While it's important to discuss the incident with the assistive personnel, the first priority is to remove the restraints to prevent harm to the client.
d. Remove the restraints from the client’s wrist: This is the correct action to take first to ensure the client's safety and prevent further harm. Afterward, the nurse can address the situation with the assistive personnel and review alternatives for managing the client's agitation.

A. A system for tracking client information B. A sufficient supply of personal protective equipment C. A mental health specialist on the response team D. A network for communication between staff members and families

Correct Answer is B

Explanation

a. A system for tracking client information: While important for managing patients during a disaster, it may not be the highest priority resource in response to a bioterrorism event where protection against exposure to hazardous materials is paramount.
b. A sufficient supply of personal protective equipment: In a bioterrorism event, such as exposure to biological agents, personal protective equipment (PPE) is critical to prevent the spread of pathogens and protect healthcare workers and patients from contamination.
c. A mental health specialist on the response team: Mental health support is important for both staff and patients during and after a disaster, but it may not be the highest priority resource in the immediate response to a bioterrorism event.
d. A network for communication between staff members and families: Communication is essential during any disaster response, but ensuring an adequate supply of personal protective equipment takes precedence in the face of potential exposure to biological agents.

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A nurse on a med-surge 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 charge nurse making rounds observes that assistive personnel has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

42) A nurse participating in the development of a disaster management plan for a hospital. The nurse should recognize that which of the following resources is the highest priority to have available in response to a bioterrorism event?

Correct Answer is B

Explanation

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