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 B
Explanation
Rationale:
A. "I want you to review the facility's policy on personal attire before you begin the shift." does not address the specific concern regarding infection risk related to artificial nails.
B. "There is a higher risk of infection for our clients associated with artificial nails." provides a clear and factual explanation of why artificial nails are not appropriate, focusing on client safety rather than personal appearance or policy.
C. "Why would you wear artificial nails to work when you know it's against the rules?" is confrontational and does not address the issue in a constructive manner.
D. "You should know that artificial nails have a very unprofessional appearance." focuses on appearance rather than the potential risk to clients' health.
Correct Answer is A
Explanation
Rationale:
A. Check the client's medical record for the provider's prescription is the appropriate action to confirm whether the enema was indeed ordered and to ensure that the client’s concerns are addressed.
B. Inform the charge nurse that the client refused the enema might be premature without first verifying the order and addressing the client's concerns.
C. Explain to the client that the provider prescribed the procedure is not appropriate if you have not confirmed the order. It may be premature if the order is not documented.
D. Assure the client that enemas are commonly prescribed for constipation does not address the client’s specific concern about whether the enema was actually ordered.