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. Naloxone would reverse morphine effects, which is not relevant to the immediate need for surgical intervention.
B. The client might not be able to sign the consent if under the effects of morphine, and obtaining consent might be delayed.
C. Delaying surgery might not be appropriate if the client’s condition is critical and requires urgent intervention.
D. Implied consent is used in emergencies when a patient cannot provide consent due to their condition, and it is assumed they would consent to life-saving treatment.
Correct Answer is B
Explanation
Rationale:
A. A client who has diabetes mellitus and is having difficulty self-administering insulin because of poor eyesight may need home health services but not necessarily hospice care unless they are terminally ill.
B. A client who has terminal cancer and needs assistance with pain management is appropriate for hospice care, which focuses on comfort and end-of-life care.
C. A client who has dementia and needs help with activities of daily living might benefit from long-term care or home care services but not necessarily hospice unless they are in the terminal stages.
D. A client who is recovering from a stroke and needs someone to provide care while his spouse is at work requires supportive care rather than hospice care.