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).
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A: Compare data from clients' records regarding skin integrity with established criteria.
Choice A rationale:
Comparing data from clients' records regarding skin integrity with established criteria (Choice A) is essential for evaluating the effectiveness of the plan to decrease pressure injuries. This action helps identify trends, improvements, or areas that still need attention.
Choice B rationale:
Measuring staff attendance at an educational program on managing pressure injuries (Choice B) assesses staff participation but does not directly evaluate the plan's impact on pressure injury rates. Attendance does not necessarily translate to improved implementation.
Choice C rationale:
Interviewing clients regarding their satisfaction with their care (Choice C) focuses on client satisfaction rather than evaluating the effectiveness of the plan in reducing pressure injuries. While satisfaction is important, it does not directly measure the plan's success.
Choice D rationale:
Monitoring use of supplies used to prevent pressure injuries (Choice D) provides information on resource utilization but does not provide comprehensive data on the plan's effectiveness. It does not account for the effectiveness of staff adherence to pressure injury prevention protocols.
Correct Answer is D
Explanation
The correct answer is choice D: Explore alternative solutions to address unit workflow with the nurses.
Choice A rationale:
Scheduling the nurses to work on alternating shifts (Choice A) might alleviate the immediate conflict, but it doesn't address the root cause of the issue, which is their perceived unequal workload. This approach could also disrupt the unit's continuity of care and potentially lead to further conflicts.
Choice B rationale:
Organizing a task force to evaluate the situation (Choice B) could be beneficial in the long run for identifying systemic issues contributing to the conflict. However, this approach might take time to yield results. In the meantime, the conflict could continue to negatively impact the unit's functioning.
Choice C rationale:
Telling the nurses that it's their responsibility to cooperate with coworkers (Choice C) is oversimplifying the situation. While cooperation is important, conflicts often arise from deeper issues that need to be addressed constructively. This choice doesn't provide a clear plan for resolving the workload disparity.
Choice D rationale:
Exploring alternative solutions to address unit workflow with the nurses (Choice D) is the most effective approach. By engaging the nurses in problem-solving discussions, the charge nurse can identify the reasons behind their perception of unfair workload distribution and collaboratively develop strategies to ensure a more equitable division of tasks. This approach promotes communication, collaboration, and shared accountability.
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