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 C
Explanation
Rationale:
A. "What do you have against me? It must be something or you wouldn't be criticizing my care." is defensive and confrontational, which is not appropriate for assertive communication.
B. "You shouldn't make accusations. Your nursing care doesn't always set a good example." is also defensive and shifts the focus away from addressing the concern directly.
C. "I feel as though I met the standard of care. Would you tell me more about your concerns?" is an assertive response that acknowledges the concern and seeks constructive feedback.
D. "I am at a loss for words. I always do my best to give good care to my clients." is not assertive as it does not address the concern directly or invite constructive discussion.
Correct Answer is D
Explanation
Rationale:
A. Assisting a client to cough and deep breathe is a task that can be performed by an AP under supervision.
B. Application of antiembolic stockings is within the scope of APs, though it may be monitored by an RN.
C. Administration of an enema typically requires nursing judgment and assessment, making it more appropriate for the RN.
D. Assessing a client’s sacrum for edema requires clinical assessment skills and nursing judgment, which should be performed by an RN.