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 has heart failure and received a diuretic 30 min ago

A client who has hypertension and reports a severe headache

A client who reports frequent and painful urination

A client who reports left arm pain following a fall

Answer and Explanation

The Correct Answer is B

Rationale:

A. A client who has heart failure and received a diuretic 30 min ago: While this client should be monitored for urine output and signs of dehydration or electrolyte imbalance, there is no indication of acute distress requiring immediate attention.

B. A client who has hypertension and reports a severe headache: This could indicate a hypertensive crisis or impending stroke, both of which are life-threatening and require urgent assessment and intervention to prevent neurological damage or organ failure.

C. A client who reports frequent and painful urination: These are signs of a urinary tract infection, which, while uncomfortable, is not typically emergent unless accompanied by fever, flank pain, or systemic symptoms.

D. A client who reports left arm pain following a fall: The arm pain may indicate a fracture, but it is less urgent than potential end-organ damage from a hypertensive emergency, assuming no deformity or vascular compromise is described.

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Correct Answer is C

Explanation

Rationale:

A. "Decrease your intake of cranberry juice.": Cranberry juice is not known to worsen urge incontinence. It is more commonly used for urinary tract health. There is no need to reduce it unless the client finds it personally irritating.

B. "Limit your fluid intake to 500 milliliters per day.": Severely restricting fluids can lead to dehydration and concentrated urine, which may irritate the bladder and worsen incontinence. Adequate hydration is essential for bladder health.

C. "Plan to urinate every 3 hours while you are awake.": Scheduled voiding helps retrain the bladder by establishing regular emptying times and reducing urgency. Over time, this improves bladder control and reduces incontinence episodes.

D. "Take your diuretic medication with your evening meal.": Diuretics should be taken in the morning to avoid nocturia and sleep disturbances. Evening dosing increases the risk of nighttime incontinence due to increased urine production during sleep.

A. "Client in room 303 is requesting snacks between meals." B. "Client in room 304 has a laptop that they use for relaxation." C. "Client in room 302 has multiple visitors." D. "Client in room 301 is in the cardiac catheterization lab."

Correct Answer is D

Explanation

Rationale:

A. "Client in room 303 is requesting snacks between meals.": While client preferences are important, this information is non-urgent and can be communicated through care plans or written notes. It does not directly impact immediate nursing care during a shift change.

B. "Client in room 304 has a laptop that they use for relaxation.": This is personal, non-clinical information and is not essential for safe and effective handoff communication. Shift reports should focus on medical status, treatment plans, or immediate needs.

C. "Client in room 302 has multiple visitors.": Visitor status is not a priority item in a shift report unless it directly affects client care, safety, or monitoring. Including such information can distract from more clinically significant updates.

D. "Client in room 301 is in the cardiac catheterization lab.": This is critical information because it reflects a current procedure, potential risks, and possible post-procedure care needs. Reporting this ensures continuity of monitoring and prioritization.

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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?

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