A nurse is collecting data from a client who is 1 day postoperative following a total hip arthroplasty. Which of the following findings is the priority for the nurse to report to the provider?
The client has had postoperative emesis.
The client reports pain as 8 on a scale of 0 to 10.
The client's urinary output is 30 mL over 1 hr.
The client has mottling in the affected leg.
The Correct Answer is D
A. Postoperative emesis is a common occurrence and may not be critical unless it persists or is accompanied by other concerning signs.
B. While an 8 out of 10 pain level is significant, it can be managed with appropriate interventions and does not indicate an immediate complication.
C. Urinary output of 30 mL over 1 hour is low but does not necessarily indicate a critical condition that requires immediate intervention.
D. Mottling in the affected leg is a serious finding that may indicate compromised circulation or a thromboembolic event, making it the priority for reporting to the provider.
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Correct Answer is B
Explanation
A. Offering suggestions demonstrates a directive approach rather than a laissez-faire style, which typically involves minimal guidance.
B. Encouraging the AP to decide how they would like to divide client care tasks exemplifies laissez-faire leadership, as it empowers team members to make decisions independently.
C. Instructing the AP to report hourly indicates a more authoritarian leadership style, as it sets specific expectations for accountability.
D. Providing constructive criticism suggests active involvement in guiding the AP’s performance, contrasting with the hands-off approach of laissez-faire leadership.
Correct Answer is A
Explanation
A. Obtaining the client's capillary blood glucose level is the first action because it determines the appropriate timing and dosage of insulin administration, ensuring safe and effective diabetes management.
B. Administering prescribed insulin should occur after assessing the client's blood glucose level to avoid the risk of hypoglycemia or hyperglycemia.
C. Providing the client's breakfast is important but should only occur after assessing blood glucose and administering insulin as needed to maintain stable glucose levels.
D. Checking the calibration of the glucometer is essential for accurate readings but does not directly address the immediate need to assess the client's glucose level.