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. Medication reconciliation involves reviewing all medications the client was taking at home and comparing them with the prescriptions ordered on admission. This process helps identify discrepancies, prevent omissions, duplications, or potential interactions, and ensures continuity of care.

B. Comparing a standard list of medications for a condition is not part of medication reconciliation because it may not reflect the individual client’s needs, allergies, or previous therapy. The focus should be on the client’s actual home medications.

C. This step refers to the “three checks” of medication administration, which is different from the initial reconciliation process. Reconciliation focuses on matching home medications with admission orders, not verifying labels prior to each dose.

D. While checking for allergies is a critical safety step, it is only one component of safe medication administration. Medication reconciliation is broader, ensuring that all home medications are considered and that any changes or omissions are intentional and documented.

A. Smoked salmon B. Grapefruit C. Spinach D. Cottage cheese

Correct Answer is A

Explanation

Rationale:
A. Smoked salmon: Smoked and cured meats are rich in tyramine, which can trigger a hypertensive crisis when combined with monoamine oxidase inhibitors (MAOIs) such as phenelzine. Clients must avoid aged, fermented, or smoked foods to prevent dangerous elevations in blood pressure related to MAOI therapy.

B. Grapefruit: Grapefruit primarily interacts with medications metabolized by the cytochrome P450 enzyme system, but it does not have a clinically significant interaction with MAOIs like phenelzine. Therefore, grapefruit is not restricted for clients taking this medication.

C. Spinach: Fresh vegetables, including spinach, contain negligible amounts of tyramine and are safe to consume with phenelzine. A diet rich in fresh fruits and vegetables is encouraged to support overall health and medication adherence.

D. Cottage cheese: Unlike aged cheeses, cottage cheese contains minimal tyramine and is considered safe for clients on MAOIs. It provides a good source of protein and calcium without the risk of precipitating hypertensive complications.

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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

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