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 D

Explanation

Choice A rationale:

Leaving the medication on the client's bedside table is not appropriate because it doesn't address the client's concerns and may result in the client not taking the medication at all. This choice does not promote the client's well-being.

Choice B rationale:

Returning in 1 hour to administer the medication doesn't address the client's immediate concerns and also doesn't provide adequate information about the medication's importance. Delaying the medication administration without proper communication is not ideal.

Choice C rationale:

Mixing the medication in applesauce may be appropriate in some cases, but it doesn't address the client's reluctance to take the medication due to fatigue. Additionally, the client's Crohn's disease might require specific instructions for medication administration that should not be altered without consulting the healthcare provider.

Choice D rationale:

The correct answer. Informing the client of the consequences of refusing the medication is the most appropriate action. The nurse should engage in a therapeutic conversation with the client, explaining the importance of the medication in managing Crohn's disease symptoms and preventing complications. This choice respects the client's autonomy while providing necessary information for an informed decision.

A. Beneficence. B. Utility. C. Justice. D. Fidelity.

Correct Answer is D

Explanation

Choice A rationale:

Beneficence. Beneficence refers to the ethical principle of doing what is best for the client's well-being and promoting their welfare. While returning with pain medication promptly does contribute to the client's well-being, this principle does not specifically address the nurse's commitment to keeping promises or being faithful to their word.

Choice B rationale:

Utility. Utility refers to the ethical principle of seeking the greatest benefit for the greatest number of people. Fulfilling a promise to provide pain medication within the agreed-upon time frame benefits the individual client but is not necessarily related to maximizing overall utility for a broader population.

Choice C rationale:

Justice. Justice involves fairness and equitable distribution of resources and care. While ensuring timely pain relief can be seen as a just action, the concept of justice is not directly tied to keeping promises or fidelity.

Choice D rationale:

Fidelity. Fidelity, also known as "non-maleficence," centers on being faithful to commitments and maintaining trust in the nurse-client relationship. Returning with the medication as promised within 15 minutes exemplifies fidelity, as the nurse is honoring their commitment to the client's well-being and building trust through their actions.

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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 nurse is preparing to administer medication to a client who has Crohn's disease. The client states, "I want to skip this dose of my medication. I am too tired to take it." Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who requests pain medication. The nurse fulfills a promise to return with the medication within 15 minutes. The nurse is demonstrating which of the following ethical principles?

Correct Answer is D

Explanation

A nurse is developing a plan of care for a school-age child whose family is homeless. Which of the following findings should the nurse identify as the priority?

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