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 A
Explanation
Rationale:
A. Cooperating involves finding a solution that satisfies both parties, as seen in allowing the nurses to go to lunch together while managing their clients.
B. Compromising would involve both parties giving up something to reach a middle ground, which is not exactly what is described.
C. Avoiding would mean not addressing the conflict directly, which is not the case here.
D. Competing involves asserting one’s own position at the expense of others, which does not align with the actions described.
Correct Answer is D
Explanation
Rationale:
A. WBC 6,000/mm³ is within normal range and does not require follow-up.
B. BUN 15 mg/dL is within normal range and does not require follow-up.
C. Hemoglobin 14 g/dL is within normal range for most adults and does not require follow-up.
D. Platelet count 60,000/mm³ is significantly low and requires follow-up as it can increase the risk of bleeding during surgery.