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 C

Explanation

a. Delaying the client's discharge without exploring other options may not address the partner's concerns and could lead to further issues.
b. While placing the client in a long-term care facility may be an option, it should be discussed with the case manager and considered alongside other options.
c. Contacting the case manager is appropriate to discuss the partner's concerns and explore alternative discharge arrangements that meet the client's needs.
d. Requesting another family member to assist may not be feasible or address the partner's ability to provide care.

A. Review the chart for nonrestraint alternatives for agitation B. Inform the unit manager C. Speak with the AP about the incident D. Remove the restraints from the client’s wrist

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.

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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

14) A nurse is preparing to discharge a client who has end- stage heart failure. the client's partner tells the nurse she can no longer handle caring for the client. which of the following actions should the nurse take?

Correct Answer is C

Explanation

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

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