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 C
Explanation
Choice A rationale:
The age of the client might influence the care plan and potential complications, but it's not the primary factor for evaluating cost effectiveness. Cost efficiency is more directly related to the resources utilized during the client's stay.
Choice B rationale:
The availability of community support groups contributes to the client's psychosocial well-being and support network, but it doesn't directly assist in evaluating the cost effectiveness of care. This factor focuses more on the quality of life after discharge.
Choice C rationale:
This is the correct choice. The length of the client's stay directly impacts the cost of care. A longer stay involves more resources, medications, and services, leading to increased costs. Evaluating and optimizing the length of stay is a critical aspect of cost-effective care.
Choice D rationale:
The type of insurance the client carries affects their financial responsibility for the care received, but it's not the main consideration for evaluating cost effectiveness. It primarily influences the patient's out-of-pocket expenses rather than the overall cost of care.
Correct Answer is D
Explanation
Choice A rationale:
The National League for Nursing (NLN) focuses on nursing education standards and resources for nursing faculty. While it could provide useful insights, it's not the primary resource for policy creation related to procedures like catheter insertion.
Choice B rationale:
The American Academy of Nursing (AAN) is a professional organization that promotes leadership and education within nursing. While it might offer recommendations, it's not the primary resource for policy related to procedural changes in clinical settings.
Choice C rationale:
The Agency for Healthcare Research and Quality (AHRQ) is involved in research and quality improvement initiatives in healthcare. While it could provide evidence-based practices, it's not the primary source for policies specific to nursing procedures.
Choice D rationale:
The State Nurse Practice Act (NPA) outlines the scope of nursing practice within a particular state. It governs what nurses are allowed to do, including procedures like catheter insertion. The NPA ensures that nursing actions are within legal and regulatory bounds, making it the most relevant resource for creating a policy about catheter insertion.
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