A client arrives in the Emergency Department via ambulance with the following signs: central cyanosis, HR 42, BP 80/50. What priority level should the nurse identify for this client?

Third level priority

First level priority

Routine

Second level priority

Answer and Explanation

The Correct Answer is B

A.   This category refers to non-urgent problems, which does not apply here as the client is showing signs of severe distress and requires immediate attention.
B.   Central cyanosis, a low heart rate (bradycardia), and low blood pressure are life-threatening signs that necessitate immediate intervention to stabilize the patient.
C.   This is not a routine or minor situation. The client is in critical condition and requires urgent intervention.
D.   While second-level priorities are important, this patient has life-threatening signs requiring first-level priority, immediate action, and stabilization.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"},"H":{"answers":"B"},"I":{"answers":"B"},"J":{"answers":"A"}}

Explanation

Subjective data are based on what the patient reports. These include personal history and symptoms (e.g., allergies, menstrual period, pain level, and medication use).

Objective data are measurable facts that are observed or measured by the nurse, such as vital signs, physical findings (e.g., scars, edema), and lab results (e.g., temperature, blood pressure).

A. Bone spur B. Crepitation C. Loose tendon D. Fluid in the knee joint

Correct Answer is B

Explanation

A. A bone spur typically does not cause crunching or grating sounds and is not usually associated with morning stiffness.
B. Crepitation is the medical term for a grating or crunching sound often caused by joint issues, such as osteoarthritis, which could be the cause of the symptoms described.
C. A loose tendon would not typically cause a crunching or grating sound.
D. Fluid accumulation in the knee (effusion) would likely cause swelling and pain, but it would not typically produce a grating sound

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A client arrives in the Emergency Department via ambulance with the following signs: central cyanosis, HR 42, BP 80/50. What priority level should the nurse identify for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

​​​​​​​The nurse is performing a physical assessment on a newly admitted patient. Select subjective or objective for the findings below.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"},"H":{"answers":"B"},"I":{"answers":"B"},"J":{"answers":"A"}}

Explanation

A patient states, "I can hear a crunching or grating sound when I kneel." She also states that "it is very difficult to get out of bed in the morning because of stiffness and pain in my joints." The nurse should assess for signs of what problem?

Correct Answer is B

Explanation

When performing a physical assessment of a client's maxillary the nurse should.

A nurse assesses four clients. Which client assessment will require the nurse to perform an immediate focused assessment?

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A client arrives in the Emergency Department via ambulance with the following signs: central cyanosis, HR 42, BP 80/50. What priority level should the nurse identify for this client?

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