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 C

Explanation

The correct answer isChoice C.

Choice A rationale:

Instructing a client on how to take their blood pressure is a task that involves providing education to the client on a non-invasive procedure that they can perform independently. However, this task requires a certain level of knowledge and understanding that an assistive personnel (AP) may not possess. Therefore, it is not the best task to delegate to an AP.

Choice B rationale:

Administering subcutaneous medications to a client is a task that requires a high level of skill and knowledge. It involves understanding the medication, its side effects, and the correct administration technique. This is a task that should be performed by a nurse or a healthcare professional with the appropriate training and licensure. Delegating this task to an AP could potentially put the client’s health at risk.

Choice C rationale:

Determining a client’s intake and output is a task that can be delegated to an AP.This task does not require the use of the nursing process and is within the range of function of an AP. It involves measuring and recording the amount of fluid a client consumes and excretes, which is a task that an AP is capable of performing.

Choice D rationale:

Providing a status update to a client’s family member is a task that requires a high level of discretion and understanding of the client’s condition. It involves communicating sensitive information about the client’s health status, which should be done by a nurse or a healthcare professional with the appropriate training and licensure. Delegating this task to an AP could potentially lead to miscommunication or a breach of the client’s privacy.

A. Documents client tasks at the end of the shift. B. Gathers supplies as needed while completing an activity. C. Groups tasks that are in the same location. D. Skips breaks throughout the day to complete work on time.

Correct Answer is C

Explanation

Choice A rationale:

Documenting client tasks at the end of the shift is not the most effective time-management skill. While documentation is important, it should be done in a timely manner to ensure accuracy and continuity of care. Waiting until the end of the shift might lead to missed details or inaccuracies.

Choice B rationale:

Gathering supplies as needed while completing an activity is a reasonable approach to time management. However, it is not the most effective skill listed. It's often more efficient to gather all necessary supplies before starting a task to minimize interruptions and maximize focus on the activity.

Choice C rationale:

This is the correct choice. Grouping tasks that are in the same location allows the nurse to minimize unnecessary movement and maximize efficiency. By completing tasks in close proximity, the nurse can save time and reduce the need for multiple trips back and forth.

Choice D rationale:

Skipping breaks throughout the day to complete work on time is not a recommended time-management strategy. Adequate breaks are essential for nurses to recharge, prevent burnout, and provide safe and effective care. Skipping breaks can lead to decreased performance, increased stress, and potential errors in patient 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

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Explanation

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