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 B

Explanation

a. Root cause analysis: Root cause analysis is used to investigate the underlying causes of errors or adverse events, rather than comparing performance metrics between different units or organizations.
b. Benchmarking: Benchmarking involves comparing performance metrics, such as medication error rates, against those of other similar units or organizations to identify areas for improvement and best practices.
c. Risk benefit analysis: Risk benefit analysis involves weighing the potential risks and benefits of a particular course of action, such as a medical intervention, to make informed decisions. It is not directly related to comparing performance metrics.
d. Structure audit: Structure audit involves assessing the physical or organizational aspects of healthcare delivery, such as the availability of resources or adherence to protocols, which is not specifically addressed in the scenario.

A. Ask the client's son to go to the waiting area B. File an incident report C. Treat and discharge the client D. Ask the client about his injuries with the son present

Correct Answer is A

Explanation

1. A. Asking the client's son to go to the waiting area is the appropriate first step if elder abuse is suspected. It allows the nurse to speak with the client privately, which can help the client feel more secure and be more open about discussing sensitive issues such as abuse without fear of retaliation or immediate consequences.
  
  B. Filing an incident report is an important step in documenting suspected abuse, but it should not be the first action taken. Documentation should occur after an initial assessment and gathering of information that supports the suspicion of abuse.
  
  C. Treating and discharging the client may address the immediate physical health needs but does not address the potential safety concerns or the suspicion of abuse. Discharging the client back into a potentially harmful environment without further assessment or intervention could place the client at risk of further harm.
  
  D. Asking the client about his injuries with the son present is not advisable if abuse is suspected. The presence of the potential abuser can influence the client's responses and may prevent the client from disclosing abuse due to fear or intimidation.

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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 A

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