A nurse in an emergency department is receiving report on a group of clients. Which of the following clients should the nurse assess first?
A client who has a complete femur fracture and reports a pain level of 7 on a scale from 0 to 10
A client who has left shoulder pain and S-T elevation on a 12-lead ECG
A client who has Clostridioides difficile and a temperature of 38.60 C (101.50 F)
A client who has heart failure and 2+ pitting edema in the lower extremities
The Correct Answer is B
A. A client with a femur fracture and pain level of 7: Although painful, it is not immediately life-threatening compared to a myocardial infarction.
B. A client who has left shoulder pain and S-T elevation on a 12-lead ECG: ST-segment elevation indicates acute myocardial infarction (STEMI). This is a medical emergency requiring immediate interventions to restore coronary perfusion (e.g., oxygen, nitrates, antiplatelets, possible PCI).
C. A client with C. difficile and fever: This infection requires isolation and treatment but does not pose an immediate threat to life.
D. A client with heart failure and 2+ edema: This is a chronic condition and can safely wait for assessment after the emergent cardiac case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Infants should not be given supplemental water, as it can interfere with nutrient intake and cause electrolyte imbalances.
B. Feedings should not be time-restricted; infants should nurse until they are satisfied to ensure they receive both foremilk (hydration) and hindmilk (calories and fat).
C. Breastfeeding should be on demand, whenever the infant shows hunger cues (e.g., rooting, sucking motions, hands to mouth). This helps establish milk supply and ensures adequate nutrition.
D. Feedings should alternate breasts to promote even milk production and prevent engorgement.
Correct Answer is D
Explanation
A. This dismisses the client’s feelings and provides false reassurance instead of addressing the concern.
B. Asking “why” can sound confrontational and may discourage open communication.
C. This assumes the provider’s decision is best without considering the client’s perception, violating the nurse’s role as advocate.
D. Informing the provider of the client’s concerns demonstrates advocacy—the nurse supports the client’s right to participate in their care and ensures their voice is heard in discharge planning.
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