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 D
Explanation
a. “You should contact the provider about your wishes for your family member”: While involving the provider is essential, it doesn’t directly address the conflicting wishes between the partner and the family member.
b. “You should speak with the facility’s ethics committee about your concerns”: While acknowledging the need for ethical guidance, this option may not be the most immediate step.
c. “We’ll need to have the nursing supervisor review the client’s advance directives”: Although reviewing advance directives is crucial, it doesn’t directly address the current disagreement.
d. “As the health care surrogate, the client’s partner can make this decision”: This response recognizes the legal authority of the health care surrogate (partner) to make decisions on behalf of the unconscious client. It aligns with established principles.
Correct Answer is A
Explanation
a. In emergency situations where immediate treatment is necessary to stabilize the client and prevent further deterioration, obtaining written consent may not be feasible or necessary. The principle of implied consent applies in emergency situations where the client is unable to provide consent due to their condition.
b. Notifying risk management before initiating treatment is not necessary in this emergency situation, as the priority is to provide timely and appropriate care to the client.
c. Having the client sign a consent for treatment may not be possible if the client is disoriented or incapacitated due to their condition.
d. Contacting the client's next of kin to obtain consent may delay necessary treatment, which could be detrimental to the client's health in an emergency situation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today