A nurse in the emergency department is receiving report on a group of clients. Which of the following clients should the nurse assess first?
A client who has Clostridium difficile and a temperature of 38.6° C (101.5° F)
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 orthostatic hypotension and 4+ pitting edema in the lower extremities
The Correct Answer is C
A. While a temperature elevation in a client with Clostridium difficile requires assessment, it is not as urgent as potential cardiac ischemia.
B. Pain assessment in a client with a femur fracture is important but does not take priority over potential cardiac issues.
C. Left shoulder pain with S-T elevation on an ECG can indicate myocardial infarction (MI), a life-threatening condition requiring immediate assessment and intervention.
D. Orthostatic hypotension and pitting edema, while concerning, do not indicate an acute, life-threatening condition that requires immediate assessment in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While metronidazole is an antimicrobial medication, it does not pose a significant biohazard risk, and standard precautions for medication spills would suffice.
B. Ampicillin sodium is an antibiotic medication and does not pose a significant biohazard risk, and standard precautions for medication spills would suffice.
C. Doxorubicin hydrochloride is a cytotoxic chemotherapy medication that poses a significant biohazard risk due to its potential carcinogenic and mutagenic properties. Specific facility procedures for handling cytotoxic spills should be followed.
D. Phenytoin is an antiepileptic medication and does not pose a significant biohazard risk, and standard precautions for medication spills would suffice.
Correct Answer is D
Explanation
A. Suctioning or any throat examination should be avoided unless absolutely necessary and then only in a controlled environment such as an operating room because it can provoke airway obstruction.
B. While nutrition is important, the priority in acute epiglottitis is maintaining the airway, not dietary content.
C. This intervention is not related to epiglottitis but to conditions affecting pancreatic function.
D. Epiglottitis is a severe, potentially life-threatening infection, and droplet precautions should be initiated to prevent the spread of infection.
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