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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. It's better to document assessment findings and interventions soon after interventions to ensure accuracy and avoid forgetting details.
B. Delaying cleaning personal work area until the end of the shift could lead to clutter and inefficiency throughout the shift.
C. Gather supplies for a client's dressing change after removing the old dressing.

Supplies should be gathered beforehand to streamline the process and reduce the time the wound is exposed.
D. This approach helps maintain focus and efficiency, reducing the chance of errors and ensuring that care is fully and effectively provided to one client before moving to another.

A. Recording the client's progress in the nurses' notes B. Noting changes in the treatment plan in the client's medical record C. Having interdisciplinary team meetings for the client on a regular basis D. Posting swallowing precautions at the head of the client's bed

Correct Answer is C

Explanation

A. While important for documenting the client's progress, this choice does not directly promote communication among staff members.
B. While essential for maintaining accurate records, this action does not directly facilitate communication among staff.
C. Interdisciplinary team meetings allow healthcare professionals from different disciplines to collaborate, share information, and develop comprehensive care plans tailored to the client's needs. This promotes effective communication among staff caring for the client with expressive aphasia and right hemiparesis.
D. While important for the client's safety, this action does not address the need for ongoing communication and collaboration among staff members.

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A nurse in the emergency department is receiving report on a group of clients. Which of the following clients should the nurse assess first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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