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 A
Explanation
a. This statement demonstrates an understanding of the importance of protecting personal health information by encrypting it when transmitting electronically, ensuring confidentiality.
b. Using another nurse's password violates client confidentiality and compromises security protocols.
c. Discarding personal health information documents in the trash without proper disposal methods can lead to unauthorized access and breach of confidentiality.
d. Posting a client's vital signs in their room could potentially compromise their privacy, as it may be viewed by unauthorized individuals.
Correct Answer is B
Explanation
a. Rotavirus infections are typically reported to local health departments, but they are not generally considered reportable diseases to state health departments.
b. Pertussis, also known as whooping cough, is a reportable disease in most jurisdictions due to its contagious nature and potential for outbreaks.
c. Respiratory syncytial virus (RSV) infections are not usually reportable to state health departments unless they are part of a larger outbreak or cluster of cases.
d. Group B streptococcus (GBS) infections, while significant in certain populations such as newborns, are not typically reportable diseases to state health departments.
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