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

Answer and Explanation

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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Correct Answer is A

Explanation

A. The patient’s paralyzing agent dose is adequate, but needs to be given more often.
In a Train-of-four (TOF) assessment, four stimuli are delivered in rapid succession, and the response is observed. The number of twitches in the patient's thumb indicates the degree of neuromuscular blockade. In this case, if the patient's thumb twitches three times, it suggests that there is still some residual neuromuscular blockade, and the paralyzing agent dose is adequate. However, the frequency of administration may need to be increased to maintain the desired level of paralysis or neuromuscular blockade.

B. The patient’s paralyzing agent dose is too low and needs to be increased:
This would be indicated if there were fewer than three twitches in response to the TOF assessment.

C. The patient’s paralyzing agent dose is appropriate and does not need to be changed:
The response of three twitches suggests that there is still some neuromuscular blockade, so the dose or frequency may need adjustment.

D. The patient’s paralyzing agent dose is too high and needs to be reduced:
If there were no twitches or a complete absence of twitches, this might suggest an excessive dose. However, three twitches indicate some degree of neuromuscular blockade.

A. A client who was administered acyclovir for cellulitis reports pain in the affected leg B. A client who was administered adalimumab for Crohn’s disease, has a serum calcium level of 10 mg/dL, and reports a headache C. A client who was administered erythromycin for acute glomerulonephritis and reports reddish brown urinary output D. A client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dl

Correct Answer is D

Explanation

A. Pain in the affected leg could indicate worsening of cellulitis or a potential complication like deep vein thrombosis (DVT), but there is no immediate indication of a life-threatening condition. This client should be assessed, but may not be the top priority unless other signs of complications are present.

B. A serum calcium level of 10 mg/dL is within the normal range (8.5 to 10.5 mg/dL). A headache, while concerning, is not immediately life-threatening unless there are additional symptoms suggesting something more severe.

C.Reddish brown urine suggests hematuria, a symptom of glomerulonephritis. This could indicate ongoing kidney issues, but unless there are signs of severe kidney failure or systemic infection, this might not be the most urgent case.

D. A blood glucose level of 68 mg/dL is low and can lead to hypoglycemia, which can be immediately life-threatening if it progresses to severe hypoglycemia. Symptoms of hypoglycemia include confusion, dizziness, sweating, and can escalate to seizures or unconsciousness if not promptly treated.

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A nurse on a surgical unit is caring for a group of clients. Which of the following is the priority action of the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with acute respiratory distress syndrome is receiving a paralyzing agent. With a Train-of-four (TOF) assessment, the patient’s thumb twitches 3 times. How would the nurse interpret this response?

Correct Answer is A

Explanation

A nurse has received morning report on the following four clients. Which of the following clients should the nurse assess first?

Correct Answer is D

Explanation

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