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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. Keeping the ring for the client until after the surgery may not ensure its safety and could lead to loss or misplacement.
b. Placing the client's ring in the facility safe ensures its security and prevents loss or theft during the surgical procedure.
c. Taping the ring securely to the client's finger may not be comfortable or safe during surgery and could potentially lead to complications.
d. Placing the ring in the bag with the client's clothes may not ensure its security and could lead to loss or misplacement.
Correct Answer is A
Explanation
a. Postoperative care, especially for a client with a PCA pump (Patient-Controlled Analgesia), requires skills commonly found in medical-surgical units, making it suitable for an RN with experience in that area.
b. Managing preeclampsia and labor induction involves obstetric-specific knowledge and skills, which are better suited for a nurse with experience in obstetrics.
c. Gestational diabetes management and nonstress tests are part of routine obstetrical care and do not necessarily require specialized medical-surgical skills.
d. A client with premature rupture of membranes at 32 weeks gestation requires close monitoring and potentially specialized obstetric care, not typically provided by medical-surgical nurses.
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