The nurse is caring for 4 clients. Which of these clients will the nurse see first?

Correct Answer: A

Rationale: In this scenario, the nurse should prioritize client safety and urgent needs. Option A, a client with sudden and increasing pain in a fractured arm, should be seen first. This client's condition requires immediate attention to assess for complications like compartment syndrome. Option B, a client needing crutch teaching before discharge, is important but can wait as it is not immediately life-threatening. Option C, a client with RA and scheduled pain medication, has a planned intervention and is not in acute distress. Option D, a client with a fractured ankle requesting water, has a relatively lower priority compared to the client in severe pain. Educationally, this question highlights the significance of prioritizing care based on client needs. It reinforces the concept of triaging and addressing urgent issues promptly in a clinical setting to ensure optimal patient outcomes. Nurses must be able to differentiate between urgent, important, and routine tasks to provide safe and effective care.

Correct Answer: D

Rationale: In understanding the causes of pressure ulcers, it is crucial to recognize the role of perfusion in preventing these skin injuries. Adequate perfusion, which refers to the circulation of blood to tissues, is essential for maintaining the health of the skin and preventing the development of pressure ulcers. When tissues do not receive enough blood flow, they are more susceptible to damage from prolonged pressure, leading to the formation of pressure ulcers. Immobility, poor nutrition, and moisture are all well-established risk factors for pressure ulcers. Immobility can result in prolonged pressure on certain areas of the body, reducing blood flow and causing tissue damage. Poor nutrition can impair the body's ability to repair and maintain healthy skin, making individuals more vulnerable to pressure ulcers. Moisture, especially when combined with pressure, can further increase the risk of skin breakdown and ulcer formation. In an educational context, understanding the causes of pressure ulcers is essential for healthcare professionals, caregivers, and patients themselves. By recognizing the significance of factors such as immobility, poor nutrition, moisture, and perfusion, individuals can implement preventive measures to reduce the incidence of pressure ulcers. Educating patients on the importance of mobility, proper nutrition, skin care, and circulation can empower them to take proactive steps in maintaining skin integrity and overall well-being.

Correct Answer: B

Rationale: In this scenario, the correct answer is option B: a client that recently traveled and developed a fever with cough. This client should be placed in isolation for airborne precautions due to the potential risk of carrying an airborne infectious disease such as tuberculosis or influenza. Option A, a high school wrestling champion with a rash, does not indicate a need for airborne precautions as rashes are typically not transmitted through the air. Option C, a client with an unknown skin infection, would not require airborne precautions unless the skin infection is associated with an airborne pathogen, which is not mentioned in the scenario. Option D, a client with heart palpitations, does not require airborne precautions as heart palpitations are not indicative of an airborne infectious disease. In an educational context, understanding the different types of precautions in healthcare settings is crucial for preventing the spread of infections. Airborne precautions are specifically used for diseases that are transmitted through the air via droplet nuclei. It is important for healthcare providers to correctly identify which clients require airborne precautions to ensure the safety of both patients and healthcare workers.

Correct Answer: D

Rationale: In caring for a client with Rheumatoid Arthritis (RA), the best goal for pain control is for the client to have pain less than 8/10 throughout the day (Option D). This goal is considered appropriate because RA is a chronic condition characterized by persistent pain and inflammation. Achieving pain levels below 8/10 can significantly improve the client's quality of life, mobility, and overall well-being. Option A, focusing on healthy meals and hydration, although important for overall health and managing RA symptoms, does not directly address the immediate goal of pain control. Option B, having pain throughout the entire day, is not a suitable goal as it does not aim for pain reduction. Option C, having pain less than 3/10 for most of the day, may be too ambitious for some clients with RA and may not be realistic or sustainable in the long term. In an educational context, understanding the importance of setting realistic and achievable goals for pain management in clients with RA is crucial. Educators should emphasize the individualized nature of pain management goals and the need to balance aspirations for pain reduction with the client's unique circumstances and limitations. By focusing on realistic and attainable goals, healthcare providers can better support clients in managing their pain effectively and improving their overall quality of life.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Nociceptive pain. Nociceptive pain occurs due to tissue damage or inflammation, which is typically the case after an amputation surgery. The client's complaint of pain distal to the amputation site indicates that the pain is originating from the remaining tissues and nerves around the amputated area. Option B) Neuropathic pain is characterized by nerve damage or dysfunction. While it can occur after an amputation, in this case, the pain is more likely nociceptive in nature as it is directly related to the tissue trauma from the surgery. Option C) Visceral pain originates from internal organs, which is not relevant in the context of an amputation scenario. Option D) Cutaneous pain is related to the skin, which is not the primary source of pain in this case as the client is experiencing pain distal to the amputation site. Educationally, understanding different types of pain is crucial for healthcare professionals to accurately assess and manage their patients' pain. Recognizing the type of pain a client is experiencing helps in determining appropriate treatment strategies, such as medication choices or physical therapy interventions, to provide effective pain relief and improve the client's overall well-being.