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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Related Questions
Correct Answer is B
Explanation
A. Instructions on how to change ventilator settings:
Ventilator settings are typically adjusted by respiratory therapists or healthcare providers based on the client's respiratory status. While nurses may be involved in monitoring, changing ventilator settings is not part of the routine nursing care bundle.
B. Instructions on mouth care
Mouth care is an important component of the ventilator care bundle to prevent ventilator-associated pneumonia (VAP). Proper oral hygiene, including regular mouth care, can help reduce the risk of infection.
C. Instructions to suction the client’s tracheostomy every 2 hr:
Suctioning frequency is determined based on the client's needs and is not a fixed component of the ventilator care bundle. Suctioning is performed as necessary to maintain airway patency.
D. Instructions to place the client in a supine position:
The positioning of the client may be individualized based on the clinical condition. However, placing the client in a supine position is not a fixed component of the ventilator care bundle. The emphasis is on practices that prevent complications associated with mechanical ventilation.
Correct Answer is C
Explanation
A. Reduces inflammation:
This action is more characteristic of anti-inflammatory medications, such as corticosteroids. Expectorants, however, do not primarily reduce inflammation.
B. Dries mucous membranes:
This action is more characteristic of antihistamines or decongestants, which may help reduce nasal congestion by drying mucous membranes. Expectorants have the opposite effect; they promote the thinning of mucus.
C. Stimulates secretions
An expectorant is a type of medication that works by promoting the clearance of mucus from the respiratory tract. It does so by thinning and loosening mucus, making it easier for the patient to cough up and expel. Expectorants help in facilitating the removal of excessive mucus and can be useful in conditions where there is a productive cough associated with excessive mucus production.
D. Suppresses the urge to cough:
This action is associated with antitussive medications, which are cough suppressants. Expectorants, on the other hand, stimulate the removal of mucus and do not suppress the urge to cough
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