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. Administer magnesium sulfate to the client: Magnesium sulfate is typically used for neuroprotection before 32 weeks or to manage preeclampsia; it is not indicated for rupture of membranes at 36 weeks unless there are other risk factors.

B. Administer betamethasone to the client: Betamethasone is used to enhance fetal lung maturity, most beneficial before 34 weeks. At 36 weeks, the lungs are usually mature enough that corticosteroids are not routinely indicated.

C. Monitor the client's temperature every 2 hr: This helps detect early signs of chorioamnionitis, a serious infection risk after membrane rupture, especially with prolonged rupture.

D. Monitor fetal heart rate every 4 hr: Fetal heart monitoring should be more frequent in the presence of membrane rupture to promptly identify signs of distress or infection, not every 4 hours.

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

Explanation

Rationale for correct choices:

A change in mood: Isotretinoin is associated with serious neuropsychiatric side effects, including depression, mood swings, and suicidal ideation. Adolescents are particularly vulnerable, and any mood changes should be reported immediately to prevent potential harm.
Decreased night vision: Isotretinoin can cause visual disturbances, including impaired night vision, which may develop suddenly and without warning. This adverse effect can pose safety risks, especially when driving or navigating in low-light conditions, and requires prompt provider evaluation.

Rationale for incorrect choices:

Dry mouth: Dry mucous membranes are a common and expected side effect of isotretinoin due to its drying effects on the skin and mucosa. While it may cause discomfort, it is not typically urgent or dangerous unless accompanied by other systemic symptoms.
The development of dry eyes: Dry eyes are a frequent and expected adverse effect of isotretinoin. This symptom can usually be managed with artificial tears or lubricating eye drops and does not require immediate provider notification unless severe or worsening.
Sunburn: Isotretinoin increases photosensitivity, making clients more prone to sunburn. However, this is a manageable and anticipated side effect. The client should be advised to use sunscreen and protective clothing rather than treat it as an emergency.
Engagement in sexual activity: Sexual activity becomes relevant only if pregnancy is a risk, due to isotretinoin’s severe teratogenicity. Since the client currently tests negative on hCG and is not sexually active, it is not a priority concern unless that status changes.
Worsening of acne: A temporary worsening of acne, known as an initial flare, is common in the first few weeks of isotretinoin therapy. It is not considered dangerous and does not warrant immediate discontinuation or urgent evaluation unless accompanied by severe systemic symptoms.

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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 caring for a client who is 36 weeks of gestation and experiences a spontaneous rupture of membranes. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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

Explanation

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