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

A client who reports frequent and painful urination

A client who reports left arm pain following a fall

A client who has hypertension and reports a severe headache

A client who has heart failure and received a diuretic 30 min ago

Answer and Explanation

The Correct Answer is C

Rationale:
A. A client who reports frequent and painful urination: This client likely has a urinary tract infection, which requires assessment and treatment but is not immediately life-threatening.

B. A client who reports left arm pain following a fall: Pain from trauma requires evaluation, but unless there are signs of impaired circulation or severe injury, it is lower priority than potential neurologic emergencies.

C. A client who has hypertension and reports a severe headache: A severe headache in a client with hypertension may indicate a hypertensive crisis or impending stroke. Immediate assessment is required to prevent life-threatening complications, making this the highest priority.

D. A client who has heart failure and received a diuretic 30 min ago: Monitoring is necessary to assess diuretic effects, but this client is stable and does not require immediate intervention compared with the client at risk for hypertensive emergency.

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Correct Answer is A

Explanation

Rationale:
A. "This clears blood from the tubing and the catheter.": Flushing an intermittent infusion device prevents blood from clotting within the catheter and tubing, maintaining patency for future medication administration.

B. "This helps to keep you hydrated.": Flushing the device does not significantly contribute to the client’s hydration status, as only small volumes of fluid are used.

C. "This prevents leakage of fluid and medication.": Flushing does not primarily prevent leakage; its main purpose is to maintain catheter patency rather than seal the device.

D. "This makes sure it stays sterile.": While flushing uses aseptic technique, the primary reason for flushing is to prevent occlusion, not to ensure sterility of the catheter.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

Rationale for Correct Choices

• Evaluating the fetal heart rate tracing: The client presents with severe preeclampsia, as indicated by hypertension (166/110 mm Hg), 3+ proteinuria, and hyperreflexia. The priority is to assess fetal well-being since decreased fetal movement and maternal hypertension can compromise placental perfusion, placing the fetus at risk for hypoxia or distress.

• Administering magnesium sulfate IV: Once fetal assessment confirms stability, magnesium sulfate should be initiated to prevent eclamptic seizures. This medication stabilizes the central nervous system by reducing neuromuscular excitability and cerebral irritation associated with severe preeclampsia.

Rationale for Incorrect Choices

• Administering acetaminophen PO: The client already reported that acetaminophen was ineffective for headache relief. The headache is a sign of severe preeclampsia, not a benign pain complaint, so administering more acetaminophen does not address the underlying pathology.

• Obtaining 24-hour urine collection: While important for confirming the degree of proteinuria, this action is not an immediate priority. Stabilizing maternal and fetal conditions takes precedence over diagnostic collection.

• Inserting an indwelling urinary catheter: The catheter is required for strict intake and output monitoring during magnesium therapy, but it is not performed before ensuring fetal stability and initiating seizure prophylaxis.

• Administering betamethasone IM: Betamethasone promotes fetal lung maturity, which is appropriate in preterm conditions; however, it is not the immediate priority. Seizure prevention and fetal assessment are more urgent interventions at this stage.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is flushing a client's intermittent infusion device. The client states, "Why do you have to do that if you are not giving me medicine?" Which of the following statements should the nurse make?

Correct Answer is A

Explanation

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

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