A nurse is caring for four clients on a medical-surgical unit. Which of the following clients should the nurse assess first?
A client who has COPD and the capillary refill time on both hands is 4 seconds
A client who has late-stage cirrhosis and whose breath has a fruity odor
A client who has a nasogastric tube for decompression and the gastric aspirate is green with a pH of 5.3
A client who had an indwelling urinary catheter removed 5 hr ago and has not voided
The Correct Answer is D
Rationale:
A. Capillary refill time of 4 seconds is concerning but less urgent compared to immediate post-catheter removal issues.
B. Fruity breath odor in late-stage cirrhosis could indicate a metabolic issue but is less immediate than issues related to urinary output.
C. Green gastric aspirate with a pH of 5.3 is within normal range for NG tube decompression.
D. A client who has not voided 5 hours after catheter removal is at risk for urinary retention or other complications and should be assessed immediately.
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Correct Answer is C
Explanation
Rationale:
A. Reassign the task to another nurse is not immediately necessary; first, the issue needs to be addressed with the LPN.
B. Report the issue to the unit manager should be done if the problem persists, but initial action should involve resolving the immediate issue.
C. Change the client's dressing is essential to address the immediate need and ensure the client’s care is up-to-date.
D. Verify the LPN knows how to do a dressing change might be necessary in the long term, but addressing the immediate issue of the uncompleted task is a priority.
Correct Answer is C
Explanation
Rationale:
A. Reporting the observation to the nurse caring for that client is important but not the immediate priority.
B. Informing the nursing supervisor is necessary but should be done after assessing the situation directly.
C. Approaching the man and asking why he is making copies is the most immediate and direct action. It allows the nurse to assess the situation and determine if the man has legitimate access to the client's medical record or if further action is needed.
D. Notifying hospital security may be necessary if the man’s actions are unauthorized, but the first step is to gather more information.