A nurse on a surgical unit is caring for a group of clients. Which of the following is the priority action of the nurse?
Assessing a client who experiences unilateral calf pain when ambulating
Reassuring the partner of a client who sustained a closed head injury
Taking a telephone prescription about a client who is to be transferred from PACU
Reinforcing a client’s dressing for the surgical site of an above the knee amputation
The Correct Answer is A
A. Assessing a client who experiences unilateral calf pain when ambulating.
Unilateral calf pain in a client who is ambulating can be indicative of a potential deep vein thrombosis (DVT), which is a serious condition that requires prompt assessment and intervention. DVTs are a risk after surgery, and early detection is crucial to prevent complications such as a pulmonary embolism. Assessing the client experiencing calf pain is the priority to determine the cause and initiate appropriate interventions.
B. Reassuring the partner of a client who sustained a closed head injury:
While providing support and reassurance to family members is important, it is not as urgent as assessing a client with potential signs of a DVT.
C. Taking a telephone prescription about a client who is to be transferred from PACU:
While obtaining and implementing orders in a timely manner is important, assessing and addressing a potential DVT takes precedence due to the immediate risk to the client's well-being.
D. Reinforcing a client’s dressing for the surgical site of an above-the-knee amputation:
Dressing reinforcement is important for wound care, but it is not as urgently needed as assessing a client with possible signs of a DVT. The assessment of calf pain takes priority.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A client who has a prescription for insulin, and his premeal capillary blood glucose was 110 mg/dL, and his post-meal capillary blood glucose is now 160 mg/dL:
While changes in blood glucose levels are important to monitor, the described change is not as significant as a sudden drop in blood pressure. The blood glucose levels in this scenario are still within a reasonable range.
B. A client whose blood pressure at 0800 was 138/86 mm Hg, and at 1200 is 106/60 mm Hg:
This is the priority client. The significant drop in blood pressure raises concerns about hypovolemia or circulatory issues, which require immediate attention to prevent complications such as inadequate organ perfusion.
C. A client who reports pain as 4 on a scale of 1 to 10 at 0800 and now reports pain as 6:
Pain management is important, but the change in pain intensity from 4 to 6, while indicating an increase, may not be as urgent as addressing a significant drop in blood pressure. Pain assessment and management can be addressed after stabilizing the client with the acute change.
D. A client whose wound drainage at 0800 was sanguineous, and now it is serosanguineous:
Changes in wound drainage color can be important for assessing the healing process, but a shift from sanguineous to serosanguineous is generally within the expected progression of wound healing. It may not require immediate intervention as compared to a significant drop in blood pressure.
Correct Answer is D
Explanation
A. PEEP decreases the peak respiratory pressures:
PEEP may increase peak respiratory pressures, especially during inspiration, but its primary purpose is to prevent alveolar collapse and improve oxygenation.
B. “PEEP increases the number of breaths the patient takes on his own.”:
PEEP does not increase the number of breaths the patient takes. It primarily affects the quality of ventilation by preventing alveolar collapse.
C. “PEEP augments the patient’s overall tidal volumes.”:
PEEP does not necessarily increase overall tidal volumes. It focuses on maintaining positive pressure at the end of expiration to prevent alveolar collapse.
D. “PEEP improves oxygenation by keeping alveoli open after exhalation.”
Positive end-expiratory pressure (PEEP) is used in mechanical ventilation to maintain positive pressure in the airways and alveoli at the end of the respiratory cycle (expiration). This helps prevent alveolar collapse and improves oxygenation by keeping the alveoli open, particularly in patients with conditions like acute respiratory distress syndrome (ARDS). PEEP is commonly used to increase functional residual capacity (FRC) and improve oxygenation.
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