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. Maintaining a client tracking system is crucial for managing large numbers of clients during a disaster.
B. Performing concise client assessment is essential for determining the severity of each client’s condition and prioritizing care.
C. Preventing cross-contamination of clients is important to prevent the spread of toxic substances.
D. Transferring a client to the discharge location is the lowest priority during a disaster, as immediate care and management of acute conditions take precedence over discharge planning.
Correct Answer is D
Explanation
Rationale:
A. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6 needs pain management, but this is less urgent compared to potential signs of hypotension.
B. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous indicates normal progression of wound healing; thus, it is less critical.
C. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL needs blood glucose management, but this is less urgent than assessing for potential hypovolemia or shock.
D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg is experiencing a significant drop in blood pressure, which could indicate hypovolemia or shock. This requires immediate assessment and intervention to prevent complications.