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).
The Correct Answer and Explanation is:
In this scenario, the priority client is B. A client who has peripheral vascular disease and has an absent pulse in the right foot.
Explanation:
When prioritizing client care, it’s essential to use the principles of urgency and potential for harm. The priority should be given to clients whose condition could lead to significant complications or who are at immediate risk of deterioration.
1. Client with Absent Pulse in the Right Foot:
Peripheral vascular disease (PVD) can significantly impact blood flow to the extremities. An absent pulse in the right foot is a serious concern because it indicates potential compromised blood circulation. This could be due to an acute arterial occlusion or worsening of the PVD, both of which can lead to critical complications like tissue necrosis or limb ischemia. Immediate assessment and intervention are necessary to prevent severe outcomes such as limb loss or systemic complications. Therefore, this client’s condition is the highest priority due to the potential for immediate and severe consequences if blood flow is not restored.
2. Client Scheduled for Tubal Ligation:
While the emotional distress of the client scheduled for a tubal ligation is important, it is not as urgent as a life-threatening physical condition. The client’s crying indicates emotional distress but does not pose an immediate threat to their physical health or require urgent intervention. Emotional support can be provided with less immediacy compared to addressing physical health issues.
3. Client with Type 1 Diabetes Mellitus Needing Dressing Change:
Although the need for a dressing change for an ulcer is important in diabetes management, it is not as urgent as addressing the absence of a pulse. The ulcer, while needing proper care, does not present an immediate risk of severe or life-threatening complications compared to the risks associated with poor peripheral circulation.
4. Client with MRSA and Elevated Temperature:
An axillary temperature of 38°C (100.4°F) in a client with MRSA indicates a fever, which is a common sign of infection. While this is a concern and requires appropriate management, it is not as immediately life-threatening as the absent pulse in the context of peripheral vascular disease. Fevers can be managed with appropriate medications and monitoring, but the urgent need for intervention is less critical than addressing compromised blood flow.
In summary, the client with the absent pulse is prioritized due to the urgent need to address potential life-threatening complications associated with peripheral vascular disease.