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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

Rationale:

A. Decreased creatine kinase-MB: CK-MB is a cardiac enzyme that rises within 4–6 hours of myocardial infarction and peaks around 24 hours. A decrease in CK-MB would not indicate acute myocardial injury and is not a diagnostic marker in this case.

B. Decrease in respiratory rate: A lower respiratory rate is not a typical or reliable indicator of myocardial infarction. Clients experiencing an MI are more likely to show signs of dyspnea, anxiety, or increased respiratory effort due to pain or decreased oxygenation.

C. ST segment depression: ST segment depression may indicate myocardial ischemia or a non-ST elevation myocardial infarction (NSTEMI), but it is less specific than biomarkers like troponin. It may also appear in other conditions such as angina or electrolyte imbalances.

D. Increased troponin I: Troponin I is a highly specific and sensitive cardiac biomarker that rises within 3–6 hours of myocardial injury. An elevated troponin I level 6 hours after the onset of chest pain strongly supports the diagnosis of myocardial infarction.

A. Establish a patent oral airway. B. Remove the client's clothing. C. Warm blood products prior to administration. D. Assign the client a score on the Glasgow Coma Scale

Correct Answer is A

Explanation

Rationale:

A. Establish a patent oral airway: The airway is the highest priority in trauma care, following the ABCs (Airway, Breathing, Circulation). Without a patent airway, the client cannot oxygenate properly, which can quickly become life-threatening.

B. Remove the client's clothing: This helps with full-body assessment and prevention of missed injuries, but it should only be done after ensuring the client’s airway and breathing are stable.

C. Warm blood products prior to administration: While this helps prevent hypothermia during transfusion, warming blood is not the immediate priority in a trauma situation. Circulation support follows airway and breathing in priority.

D. Assign the client a score on the Glasgow Coma Scale: Neurological assessment is important but comes after airway stabilization. The GCS helps evaluate consciousness but should not delay securing the airway in an emergency.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 working in an emergency department is assessing a client who is experiencing chest pain that began 6 hr ago. Which of the following findings indicates that the client is having a myocardial Infarction?

Correct Answer is D

Explanation

A nurse is caring for a client who is in the emergency department with multiple traumatic injuries following a motor-vehicle crash. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is caring for the client.Exhibits Select the 5 findings that indicate the client's condition has improved.

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays toxicity. Which of the following actions should the nurse take?

A nurse is planning care for a client who has reduced visual sensory perception. Which of the following interventions should the nurse include in the plan of care?

A nurse is assessing a client who has antisocial personality disorder. Which of the following manifestations should the nurse expect?

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?

A nurse is planning care for a client who has a chest tube. Which of the following interventions should the nurse include in the plan? (Select all that apply)

A nurse is caring for a client who has an end-stage lung disease. The client requests not to be resuscitated if their condition worsens. Which of the following actions should the nurse take?

A nurse is caring for a client who has not voided since giving birth vaginally 10 hours ago. Which of the following actions should the nurse take?