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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Correct Answer is A

Explanation

a. Before taking any further action, the charge nurse should first determine the reasons why the nurses are not taking their scheduled breaks. Understanding the underlying causes will help address the issue effectively.
b. Providing coverage for the nurses' breaks may be necessary but should not be the first action taken. It is important to understand why the nurses are not taking breaks before providing coverage.
c. While reviewing facility policies is important, it should not be the first step when addressing the issue of nurses not taking breaks.
d. Discussing time management strategies with the nurses may be helpful, but it should come after understanding the reasons behind their behavior.

A. Document in the client’s chart that an incident report has been filed B. Call risk management to interview the client C. Contact the nurse manager D. Reassure the client that the staff is well trained

Correct Answer is C

Explanation

a. While documenting that an incident report has been filed is important, it should not be the first action taken. The nurse should first take steps to address the issue.
b. In this situation, contacting risk management may be necessary, but the immediate priority should be to address the client's concerns and ensure appropriate follow-up.
c. Contacting the nurse manager is the appropriate first action to report the client's complaint and initiate further investigation and intervention as needed.
d. Reassuring the client about the staff's training is not sufficient in addressing the client's complaint of excessive force. The issue should be reported to the appropriate authority for investigation and resolution.

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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

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Explanation

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Correct Answer is C

Explanation

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