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 C
Explanation
A. A client who is taking a thiazide diuretic:
Thiazide diuretics can cause loss of potassium and metabolic alkalosis, not metabolic acidosis.
B. A client who is vomiting:
Vomiting can lead to the loss of stomach acid (hydrochloric acid) and may result in metabolic alkalosis, not metabolic acidosis.
C. A client who has diarrhea.
Diarrhea can lead to the loss of bicarbonate, an important buffer in the body that helps maintain acid-base balance. The loss of bicarbonate in diarrhea can result in an excess of acid, contributing to metabolic acidosis.
D. A client who is having an acute anxiety attack:
Acute anxiety is not typically associated with metabolic acidosis. It is not directly related to changes in acid-base balance.
Correct Answer is A
Explanation
A. Cooperating:Cooperating involves working together to find a mutually beneficial solution. In this case, the charge nurse resolves the conflict by allowing both nurses to go to lunch together and taking care of their clients, ensuring that both nurses’ needs are met.
B. Avoiding:Avoiding means ignoring the conflict or withdrawing from the situation. The charge nurse is not ignoring the conflict; rather, they are actively facilitating a resolution by allowing both nurses to take lunch together.
C. Compromising:Compromising involves both parties giving up something to reach a mutually acceptable solution. While the charge nurse is helping to resolve the conflict by allowing the nurses to go to lunch, it does not imply that either nurse has made a concession in their argument, making this option less accurate.
D. Competing:
Competing involves pursuing one's own concerns at the expense of others. It is a win-lose approach to conflict resolution. The charge nurse is not demonstrating a competitive approach in this scenario, as both nurses are accommodated to go to lunch together without one person's needs being prioritized over the other.
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