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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:

A. Initiate fundal massage: Fundal massage is performed after delivery to prevent or manage uterine atony and postpartum hemorrhage. It is not appropriate during active labor, especially before the birth of the fetus.

B. Apply a fetal heart rate monitor: After rupture of membranes, there is an increased risk of umbilical cord prolapse or fetal distress. Continuous fetal monitoring is essential to assess fetal well-being and detect complications promptly.

C. Insert an indwelling urinary catheter: While catheterization may be done later, especially before epidural placement or cesarean delivery, it is not the most urgent action. It does not address immediate risks associated with ruptured membranes.

D. Initiate an oxytocin IV infusion: Oxytocin is used to augment or induce labor, but should not be started without first assessing fetal status. Fetal monitoring is necessary to establish a baseline before initiating uterotonic agents.

A. 1⁄2 cup apple juice B. ½ cup steamed cauliflower C. cup boiled white rice D. 1 cup cantaloupe

Correct Answer is D

Explanation

Rationale:

A. ½ cup apple juice: Apple juice contains a relatively low amount of potassium, making it a poor choice for correcting hypokalemia. It typically provides less than 150 mg per half-cup serving.

B. ½ cup steamed cauliflower: Cauliflower is low in potassium compared to other vegetables. While healthy, it does not significantly contribute to raising potassium levels in the body.

C. 1 cup boiled white rice: White rice has minimal potassium content, especially when boiled. It is not effective in increasing potassium and is typically suitable for clients requiring low-potassium diets.

D. 1 cup cantaloupe: Cantaloupe is high in potassium, offering around 400–500 mg per cup. It is among the best fruit sources for replenishing potassium and is appropriate for clients with mild hypokalemia.

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A nurse in an emergency department is assessing four clients. Which of the following clients should the nurse see first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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