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. Inform the state medical board for an immediate investigation is not the initial step; concerns should first be reported to appropriate facility personnel.
B. Counsel the provider to determine the cause of the substance abuse is not the nurse’s role; this is a serious issue that requires reporting rather than counseling.
C. Notify the nursing supervisor of the concerns is the appropriate initial step to address the issue according to facility protocol.
D. Encourage clients to change to a different provider is not within the nurse’s scope of practice for handling the provider's behavior and does not address the root issue.
Correct Answer is B
Explanation
Rationale:
A. "I want you to review the facility's policy on personal attire before you begin the shift." does not address the specific concern regarding infection risk related to artificial nails.
B. "There is a higher risk of infection for our clients associated with artificial nails." provides a clear and factual explanation of why artificial nails are not appropriate, focusing on client safety rather than personal appearance or policy.
C. "Why would you wear artificial nails to work when you know it's against the rules?" is confrontational and does not address the issue in a constructive manner.
D. "You should know that artificial nails have a very unprofessional appearance." focuses on appearance rather than the potential risk to clients' health.