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 C

Explanation

Rationale:

A. Nitroglycerin transdermal patch: This prescription is incomplete because it lacks a dosage strength, application site, frequency, and duration. Without these details, safe administration cannot be ensured.

B. Aspirin 1 tablet daily: The prescription is incomplete as it does not specify the tablet’s strength (e.g., 81 mg or 325 mg). "1 tablet" is ambiguous and can vary based on available formulations.

C. Metoprolol 5 mg IV now: This is a complete prescription it includes the medication name, dose (5 mg), route (IV), and timing ("now"). It gives the nurse all essential information to safely administer the drug.

D. Furosemide 20 mg BID: While the medication, dosage, and frequency are provided, the route is missing. Furosemide can be given orally or intravenously, so this omission makes the prescription incomplete.

A. Place the client in a supine position. B. Remind the client to eat scheduled meals daily. C. Speak in a loud tone when addressing the client. D. Offer the client a blanket to keep warm.

Correct Answer is D

Explanation

Rationale:

A. Place the client in a supine position: The supine position may impair respiratory function and increase discomfort, especially in terminal clients who may experience dyspnea. A semi-Fowler’s or side-lying position is often preferred for comfort and easier breathing.

B. Remind the client to eat scheduled meals daily: For clients nearing end of life, appetite naturally decreases, and forcing meals can cause distress. Care should focus on comfort, allowing the client to eat only if and when they desire rather than adhering to structured meal times.

C. Speak in a loud tone when addressing the client: Loud speech is not appropriate unless the client has documented hearing impairment. A calm, soft tone is more comforting and respectful, especially in the emotionally sensitive context of end-of-life care.

D. Offer the client a blanket to keep warm: Clients nearing the end of life often experience poor circulation and may feel cold. Providing a blanket is a comfort-focused, non-invasive intervention that promotes warmth and dignity during this phase.

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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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