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. An infant who has pertussis and is receiving oxygen via nasal cannula requires immediate assessment to ensure that the oxygen therapy is adequate and to monitor for any signs of respiratory distress or worsening condition.
B. An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions does not require immediate assessment as the client is stable enough for discharge planning.
C. A school-age child who has diabetes mellitus and requires blood glucose monitoring should be assessed, but it is less urgent compared to a client with a respiratory condition.
D. A toddler who has both arms in casts and needs to be fed his breakfast needs attention, but this is less critical compared to monitoring a client with a respiratory condition.
Correct Answer is A
Explanation
Rationale:
A. The client should sign the informed consent if they are alert, oriented, and capable of making decisions. The client's ability to understand the procedure and its implications is key to valid informed consent.
B. The client's son, who has a durable power of attorney would only sign the consent if the client were not competent or unable to understand the procedure, which is not the case here.
C. The client's partner may be involved in the decision-making process but does not have the legal authority to sign the consent unless designated as a legal representative.
D. The client's daughter, who is the primary caregiver would also not have the legal authority to sign the consent unless she holds a durable power of attorney or the client is deemed incapable of giving consent.