A nurse in an emergency department is assessing four clients. Which of the following clients should the nurse see first?
A client who reports a sudden onset of dizziness when sitting up
A client who has new onset urticaria and angioedema
A client who has numerous rectal polyps and blood-tinged stools
A client who has a subluxation of the fifth digit on the left foot
The Correct Answer is B
Rationale:
A. A client who reports a sudden onset of dizziness when sitting up: Although concerning, dizziness on position change may indicate orthostatic hypotension and is not immediately life-threatening. This client requires monitoring but is not the top priority based on airway or circulatory compromise.
B. A client who has new onset urticaria and angioedema: New urticaria and angioedema suggest a potential anaphylactic reaction, which can quickly progress to airway obstruction. This is a life-threatening emergency requiring immediate intervention to secure the airway and administer epinephrine.
C. A client who has numerous rectal polyps and blood-tinged stools: This condition could indicate a colorectal condition such as polyposis or malignancy, but it is not acutely life-threatening. The client needs evaluation, but not before those with airway or circulatory risks.
D. A client who has a subluxation of the fifth digit on the left foot: A subluxation is a partial dislocation, which can be painful but does not involve vital organ systems. This musculoskeletal issue is stable and can be addressed after more urgent needs are met.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C,D,A,B
Explanation
Rationale:
A. Close all nearby windows and doors: Containment helps prevent the spread of smoke and flames. Closing doors and windows minimizes oxygen supply to the fire and keeps it from moving into other areas.
B. Use the unit's fire extinguisher to attempt to put out the fire: The final step is to extinguish the fire, but only if it is safe to do so. The nurse should not attempt this before ensuring safety, alerting others, and containing the fire.
C. Transport the client to another area of the nursing unit: The first priority in a fire situation is rescue, removing anyone in immediate danger, especially vulnerable clients who cannot evacuate themselves.
D. Activate the facility's fire alarm system: Once the client is safe, the next step is to alarm the system to alert others in the facility and begin emergency response protocols.
Correct Answer is D
Explanation
Rationale:
A. A 25-gauge needle: A 25-gauge needle is too small and not designed for accessing implanted ports. Using such a needle may cause damage to the port septum and does not ensure reliable blood flow or medication administration.
B. An angiocatheter: Angiocatheters are used for peripheral venous access and are not suitable for accessing implanted ports. Their sharp tips can damage the septum of the port and compromise its integrity.
C. A butterfly needle: Butterfly needles are designed for short-term peripheral access. They are not appropriate for implanted ports and can damage the port’s self-sealing septum, leading to malfunction.
D. A noncoring needle: Noncoring (Huber) needles are specifically designed for accessing implanted venous ports. Their curved tip prevents coring of the port septum, reducing damage and maintaining the port’s function and sterility.
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