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. Assessment includes the current status and vital signs of the client, which are part of the information the nurse provides to assess the client’s condition.
B. Situation describes the problem or concern that prompted the communication, not detailed vital signs.
C. Background provides context or history relevant to the situation but does not include current vital signs.
D. Recommendation involves suggesting actions or solutions but does not include the current condition details.
Correct Answer is B
Explanation
Rationale:
A. "If you let us know ahead of time that you plan to perform a procedure, we could do better job of having the supplies available." may be perceived as placing blame and does not address the immediate concern of the provider's anger.
B. "It must be very frustrating when you don't have what you need to perform the procedure." acknowledges the provider's frustration and validates their feelings, which can help de-escalate the situation and improve communication.
C. "I will help you with this procedure instead of the staff nurse." does not address the underlying issue and might not resolve the conflict or improve the situation.
D. "You should think about how you make others feel when you lose your temper." is confrontational and may escalate the situation further rather than resolving it.