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. Transporting a school-age client who is in traction involves handling a medical condition that may require specialized knowledge and skills beyond the volunteer’s capabilities.
B. Reading a book to a client who has AIDS is a supportive activity and does not pose significant risks.
C. Rocking an infant with croup is generally safe and provides comfort to the child.
D. Playing a computer video game with an adolescent is a non-medical activity that is appropriate for a volunteer.
Correct Answer is B
Explanation
Rationale:
A. A client who has diabetes mellitus and is having difficulty self-administering insulin because of poor eyesight may need home health services but not necessarily hospice care unless they are terminally ill.
B. A client who has terminal cancer and needs assistance with pain management is appropriate for hospice care, which focuses on comfort and end-of-life care.
C. A client who has dementia and needs help with activities of daily living might benefit from long-term care or home care services but not necessarily hospice unless they are in the terminal stages.
D. A client who is recovering from a stroke and needs someone to provide care while his spouse is at work requires supportive care rather than hospice care.