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. A toddler with asthma and a pulse oximetry reading of 95% is stable and manageable with current oxygen therapy.
B. An adolescent with sickle cell disease is in pain but does not require immediate intervention compared to other scenarios.
C. A toddler with otitis media has a fever and discharge but is not in immediate danger.
D. A school-age child with acute epiglottitis is at high risk for airway obstruction and requires urgent care due to the drooling and absence of spontaneous cough, which are signs of a potentially life-threatening condition.
Correct Answer is B
Explanation
Rationale:
A. A client who was administered erythromycin for acute glomerulonephritis and reports reddish-brown urinary output requires assessment for possible drug reaction or hematuria, but this may not be immediately life-threatening compared to hypoglycemia.
B. A client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dL is at risk for hypoglycemia, which requires prompt assessment and intervention to prevent severe complications.
C. A client who was administered adalimumab for Crohn's disease, has a serum calcium level of 10 mg/dL, and reports a headache should be assessed, but the calcium level and headache are less urgent compared to immediate treatment needs for hypoglycemia.
D. A client who was administered acyclovir for cellulitis reports pain in the affected leg may require assessment for infection or medication side effects, but this is less critical than addressing hypoglycemia.