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. Radiologic is correct as a "dirty bomb" (radiological dispersal device) involves the dispersal of radioactive materials.
B. Anthrax is a biological agent, not associated with a dirty bomb.
C. Chemical refers to a chemical weapon, which is not what a dirty bomb involves.
D. Sarin is a nerve agent, not related to the concept of a dirty bomb.
Correct Answer is A
Explanation
Rationale:
A. The physiologic status of the clients is the most critical factor in assigning tasks, ensuring that clients with more complex needs receive appropriate care.
B. Social relationships are secondary to patient safety and quality of care.
C. Personal comfort level should not influence assignment decisions; patient care needs are the priority.
D. Assigning the most experienced nurse to complex clients is appropriate, but it should be based on client needs rather than just experience alone.