A nurse on a surgical unit is caring for a group of clients. Which of the following is the priority action of the nurse?
Reassuring the partner of a client who sustained a closed head injury
Reinforcing a client's dressing for the surgical site of an above-the-knee amputation
Taking a telephone prescription about a client who is to be transferred from PACU
Assessing a client who experiences unilateral calf pain when ambulating
The Correct Answer is D
Rationale:
A. Reassuring the partner is important for emotional support but does not directly impact the immediate safety of clients.
B. Reinforcing a dressing is important for wound care but does not address urgent concerns.
C. Taking a telephone prescription is necessary but not as immediate as addressing a potential complication.
D. Assessing a client with unilateral calf pain is the priority as it may indicate a serious condition such as deep vein thrombosis (DVT), which requires immediate evaluation and intervention.
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Correct Answer is D
Explanation
Rationale:
A. Blood for PaCO2 is a specialized specimen that requires venipuncture and specific handling to ensure accuracy, which should be performed by a licensed nurse or phlebotomist.
B. Random stool specimen collection is a routine task that can be delegated to the AP. It requires minimal specialized skill and is within the AP's scope of practice.
C. Wound drainage for culture requires sterile technique and proper handling to avoid contamination, which is beyond the AP's responsibilities.
D. Urine from an indwelling catheter requires specialized techniques and knowledge to ensure proper collection, and should be performed by a nurse.
Correct Answer is A
Explanation
Rationale:
A. An infant who has pertussis and is receiving oxygen via nasal cannula requires immediate assessment to ensure that the oxygen therapy is adequate and to monitor for any signs of respiratory distress or worsening condition.
B. An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions does not require immediate assessment as the client is stable enough for discharge planning.
C. A school-age child who has diabetes mellitus and requires blood glucose monitoring should be assessed, but it is less urgent compared to a client with a respiratory condition.
D. A toddler who has both arms in casts and needs to be fed his breakfast needs attention, but this is less critical compared to monitoring a client with a respiratory condition.