Question

A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the priority?

A. A client who is scheduled for a tubal ligation in 2 hr and is crying
B. A client who has peripheral vascular disease and has an absent pulse in the right foot
C. A client who has type 1 diabetes mellitus and needs the first dressing change for an ulcer
D. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38° C (100.4° F)

Answer 1

The nurse should prioritize the client with peripheral vascular disease and an absent pulse in the right foot as they are experiencing a potentially life-threatening condition.

Step-by-step explanation:

The nurse should recognize that the client with peripheral vascular disease and an absent pulse in the right foot is the priority. This client is experiencing a potentially life-threatening condition known as peripheral arterial disease (PAD), which can lead to tissue damage and amputation if not addressed promptly.

Peripheral arterial disease (PAD) is a major risk factor for non-healing ulcers and gangrene due to impaired blood flow. The client with type 1 diabetes mellitus and the need for a dressing change for an ulcer is at risk for complications, but it is not an immediate life-threatening condition.

The client scheduled for a tubal ligation who is crying may be emotionally distressed, but this does not indicate an immediate health risk. The client with MRSA and a low-grade fever has an infection, but the absence of severe symptoms suggests it is not an immediate priority.