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 {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

Rationale:

Insert a nasogastric tube and maintain low intermittent suction: This is anticipated to help decompress the stomach, reduce nausea and vomiting, and prevent aspiration in a client with severe pancreatitis who is vomiting and has abdominal distension.
Administer IV lactated Ringer's: IV fluids are critical for hydration and to correct electrolyte imbalances in acute pancreatitis. Lactated Ringer’s is preferred over normal saline because it better maintains acid-base balance.
Insert an indwelling urinary catheter: This is generally contraindicated unless necessary, as it increases the risk of infection. No information indicates urinary retention or need for strict output monitoring that outweighs infection risks.
Administer IV famotidine: Famotidine reduces gastric acid secretion, which helps protect the gastric mucosa and may be beneficial in preventing stress ulcers in critically ill clients. It is appropriate in this situation.

A. Nurses notes are used to create the critical pathway B. Critical pathways should reduce health care costs C. Critical pathways have an unlimited timeframe for completion. D. Nurses should discontinue the critical pathway if variances occur

Correct Answer is B

Explanation

Rationale:

A. Nurses notes are used to create the critical pathway: Critical pathways are developed from evidence-based clinical guidelines and best practices, not directly from nurses’ notes. While documentation may help track progress, it is not the foundation for pathway creation.

B. Critical pathways should reduce health care costs: Critical pathways standardize care for specific diagnoses, promoting timely interventions and reducing unnecessary treatments or delays. This efficiency helps lower healthcare costs while improving patient outcomes.

C. Critical pathways have an unlimited timeframe for completion: Each critical pathway includes a defined timeline with expected outcomes for each phase of care. This structure ensures care is efficient and progress is monitored closely to prevent delays or complications.

D. Nurses should discontinue the critical pathway if variances occur: Variances are deviations from the expected outcomes and are used to evaluate and adjust care. They do not justify discontinuing the entire pathway but rather indicate a need for reassessment or individualized modifications.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse plan to include?

Correct Answer is B

Explanation

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