A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the priority?

A client who is scheduled for a tubal ligation in 2 hr 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 mellitus and needs the first dressing change for an ulcer.

A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38°C (100.4°F).

Answer and Explanation

The Correct Answer is B

Choice A rationale:

A client who is scheduled for a tubal ligation in 2 hr and is crying. Rationale: While the emotional well-being of this client is important, the absence of pulse in the right foot of the client in choice B indicates a potentially critical vascular issue that requires immediate attention.

Choice B rationale:

A client who has peripheral vascular disease and has an absent pulse in the right foot. Rationale: The correct choice. An absent pulse in a client with peripheral vascular disease suggests compromised blood flow and potential tissue ischemia. This is a critical situation that requires urgent intervention to prevent further complications.

Choice C rationale:

A client who has type 1 diabetes mellitus and needs the first dressing change for an ulcer. Rationale: While dressing changes are important, they are not as time-sensitive as addressing compromised blood flow and potential tissue damage seen in choice B.

Choice D rationale:

A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38°C (100.4°F). Rationale: Although an elevated temperature can be concerning, the absence of a pulse in a peripheral vascular disease client (choice B) takes precedence as it suggests a more immediate threat to the client's limb and overall health.

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Correct Answer is A

Explanation

The correct answer isChoice A: Place the client in a dorsal recumbent position for the examination.

Choice A rationale:

The dorsal recumbent position, where the client lies on their back with knees bent and feet flat on the bed, is ideal for abdominal assessments.This position helps relax the abdominal muscles, making it easier to palpate and auscultate the abdomen.

Choice B rationale:

Auscultating for vascular bruits should be done with the bell of the stethoscope, not the diaphragm.The bell is more sensitive to low-frequency sounds like bruits.

Choice C rationale:

The assessment should begin with inspection and auscultation before palpation.Palpation can alter bowel sounds, leading to inaccurate findings.

Choice D rationale:

The client should have an empty bladder before the assessment to avoid discomfort and ensure accurate findings.

A. Child Protective Services. B. Public Health. C. Home Health. D. Women, Infants, and Children.

Correct Answer is C

Explanation

Choice A rationale:

Child Protective Services would not be the appropriate agency to refer the guardian of the newborn who requires apnea monitoring at home. Child Protective Services deals with child abuse, neglect, and welfare concerns, which are not related to the specific medical needs of the newborn.

Choice B rationale:

Public Health is the correct choice. Public Health agencies are responsible for promoting and protecting the health of the community. They often provide services such as education, vaccinations, and resources for newborn care. Referring the guardian to Public Health can ensure that they receive appropriate guidance on how to manage the newborn's apnea monitoring needs at home and any other relevant health-related information.

Choice C rationale:

Home Health is not the most suitable agency in this context. Home Health agencies generally provide healthcare services directly in patients' homes, often for individuals who require medical assistance or supervision due to illnesses or post-surgical care. However, for a newborn requiring apnea monitoring, the focus is more on education and support rather than direct medical care.

Choice D rationale:

Women, Infants, and Children (WIC) is not the appropriate agency for referring the guardian of the newborn needing apnea monitoring. WIC is a program that provides supplemental nutrition and support to pregnant women, breastfeeding mothers, and young children. While it is important for the overall health of the newborn, it is not directly related to apnea monitoring or home care.

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A nurse on a medical-surgical 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

A charge nurse is preparing to observe a newly licensed nurse perform a routine abdominal assessment. Which of the following actions should the charge nurse expect the newly licensed nurse to take?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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