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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Correct Answer is B

Explanation

Rationale:

A. Raise the head of the client's bed to a high-Fowler's: Placing the client in high-Fowler’s position increases hip flexion beyond 90 degrees, which raises the risk of dislocation following a hip arthroplasty. Proper positioning involves limited hip flexion.

B. Keep an abduction pillow between the client's legs: An abduction pillow maintains proper alignment by keeping the legs apart and preventing internal rotation or adduction of the hip, both of which increase the risk of dislocation after surgery.

C. Elevate the client's affected leg on a pillow when in bed: Elevating the affected leg on a pillow may cause external rotation or misalignment of the hip. Unless prescribed, this practice may inadvertently increase the risk of hip dislocation.

D. Position the client's knees slightly higher than the hips when up in a chair: Having the knees higher than the hips promotes hip flexion beyond 90 degrees, a common cause of prosthesis dislocation postoperatively. Proper chair height and posture help prevent this complication.

A. Increased salivation B. Headache C. Sensation of skin warmth D. Numbness and tingling of the extremities

Correct Answer is C

Explanation

Rationale:

A. Increased salivation: Increased salivation is not an expected effect of cardiac catheterization. It may indicate a reaction to medication or anxiety but is not directly associated with the procedure.

B. Headache: While headaches can occur with some cardiac medications or contrast agents, they are not typical or expected during catheterization itself. Persistent headaches should be reported and evaluated further.

C. Sensation of skin warmth: A warm or flushed sensation is a common and expected finding during cardiac catheterization due to the injection of contrast dye. Patients are typically informed in advance to reduce alarm.

D. Numbness and tingling of the extremities: These sensations may suggest compromised circulation or nerve involvement, which is not expected and should be promptly reported. It could indicate a complication from arterial access.

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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

A nurse is caring for a client who is postoperative following total hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation of the prosthesis?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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