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
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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Related Questions
Correct Answer is D
Explanation
a. While a client with type 1 diabetes using an insulin pump may require interdisciplinary collaboration for optimal management, this scenario does not suggest an immediate need for an interdisciplinary conference.
b. A client receiving heparin with an aPTT of 34 seconds may require adjustment of the heparin dosage, but this situation does not necessitate an interdisciplinary conference.
c. A client with orthostatic hypotension receiving IV fluids may require close monitoring and collaboration among healthcare providers, but this situation does not suggest an immediate need for an interdisciplinary conference.
d. A client at risk for pressure ulcers with an albumin level of 4.2 g/dl may require an interdisciplinary conference to address nutrition, wound care, and preventive measures to reduce the risk of pressure ulcer development.
Correct Answer is A
Explanation
- Rationale for A: Client confidentiality is a fundamental part of nursing ethics and legal practice. A nurse may disclose information to a family member only if the client has given permission, ensuring respect for the client's autonomy and privacy.
- Rationale for B: While it is true that nurses play a crucial role in patient education, the primary responsibility for informing clients about treatment options lies with the attending physician or healthcare provider.
- Rationale for C: The use of restraints is highly regulated in healthcare settings. Restraints can only be applied based on specific criteria and orders that are not on a PRN (as needed) basis, to protect the safety and rights of the client.
- Rationale for D: Administering medications without consent, even as part of a research study, is unethical and illegal unless specific and stringent consent procedures are followed, which include informed consent and approval by an institutional review board (IRB).
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