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. Ask the AP about her concerns with the assignment is appropriate as it allows the nurse to understand and address any potential issues or reasons for refusal.
B. Report the AP to the charge nurse should only be done if the refusal cannot be resolved through discussion.
C. Take the specimen to the laboratory should be done if needed, but it is important to first understand why the AP refused.
D. Complete an incident report might be premature without understanding the reason behind the refusal.
Correct Answer is A
Explanation
Rationale:
A. Withholding a dose of narcotic pain medication when there is respiratory depression aligns with nonmaleficence, as it prevents further harm by not exacerbating the client's respiratory issues.
B. Discussing advance directives is important but is more related to autonomy and respect for the client’s wishes rather than nonmaleficence.
C. Providing comfort care is a supportive measure but does not specifically address nonmaleficence in terms of preventing harm.
D. Allowing unlimited visitation respects family wishes but does not directly relate to the principle of nonmaleficence regarding the client’s immediate medical needs.