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 D
Explanation
A. Setting specific times for low-priority tasks may not be the most efficient use of time, as client needs can change throughout the shift.
B. Performing complicated tasks independently may not be safe, as it is essential to collaborate with other healthcare team members when necessary for patient safety.
C. Postponing checking for new prescriptions until medications are due could lead to delays in care and negatively impact client outcomes; it's important to check for updates promptly.
D. Clustering care activities for each client promotes efficiency, minimizes interruptions, and helps ensure that all care needs are met in a timely manner.
Correct Answer is D
Explanation
A. Identifying clients by room number instead of name does not adequately protect client confidentiality, as room numbers can still be linked to specific patients.
B. Logging assistive personnel into unit computers for documentation undermines security measures, as each user should have their unique login credentials.
C. Placing the client's name on the cover sheet when faxing protected health information violates confidentiality and can lead to unauthorized access to sensitive data.
D. Conducting change-of-shift reports in a designated staff-only area ensures that client information is not overheard by unauthorized individuals, maintaining confidentiality.