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 D

Explanation

A. Collaborating involves working together with all parties to find a mutually beneficial solution. This approach values input from others and seeks consensus, which is not demonstrated in the scenario.

B. Cooperating typically refers to acknowledging and accommodating others' concerns while trying to maintain relationships. The nurse manager’s approach does not reflect this strategy, as she is disregarding opposing feelings.

C. Compromising seeks a middle ground where both parties can give and take to reach an agreement. The nurse manager's unilateral decision-making does not align with compromising.

D. Competing is characterized by an assertive and uncooperative stance, where one party seeks to impose their preferred solution without regard for others’ input or feelings. The nurse manager’s decision to implement changes despite opposition exemplifies this strategy.

A. A client who is scheduled for an endoscopy later today and requires an enema B. A newly admitted client who has sickle cell anemia and requires the development of an initial plan of care C. A client who had a myocardial infarction and will be transferring to the unit from the CCU D. A newly admitted client who has diabetes mellitus and requires initial teaching on self-administration of insulin

Correct Answer is A

Explanation

Rationale:
a. Administering an enema for a scheduled endoscopy is within the scope of practice for an LPN. It involves a task that is repetitive, stable, and does not require critical thinking.
b. Developing an initial plan of care for a client with sickle cell anemia involves critical thinking and assessment, which are within the scope of practice for an RN.
c. A client transferring from the CCU after a myocardial infarction requires close monitoring and assessment, which are typically within the scope of practice for an RN.
d. Teaching a newly admitted client about self-administration of insulin involves education, assessment, and critical thinking, which are typically within the scope of practice for an RN.

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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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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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