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. Nuclear family refers to a family unit consisting of two parents and their children. This definition matches the description provided by the parents.
B. Intergenerational family includes multiple generations living together or having frequent contact, which is not the case here.
C. Blended family involves parents who have remarried and may include children from previous relationships, which does not apply here.
D. Extended family includes additional relatives beyond the nuclear family, such as grandparents, aunts, or uncles, which is not the case in this scenario.
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.