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A nurse is assessing a group of clients. Which of the following clients should be categorized as Emergency Severity Index Level 1?

Client D ran out of diuretics yesterday. The client's blood pressure is 136/84, heart rate is 88/min, respiratory rate is 18/min, and pulse oximetry is 95%

Client B is obese and has right lower leg pain and swelling. The client's heart rate is 76/min and regular, blood pressure is 126/78, respiratory rate is 18/min, and pulse oximetry is 96%.

Client A reports dizziness and confusion. The client's heart rate is 120/min and irregular, blood pressure is 88/52, respiratory rate is 26/min, and pulse oximetry is82%

Client C reports a urinary tract infection (UTI). The client's heart rate is 72/min, blood pressure is 110/70, respiratory rate is 15/min, and pulse oximetry is 98%.

Answer and Explanation

The Correct Answer is C

A. Client D ran out of diuretics yesterday. The client's blood pressure is 136/84, heart rate is 88/min, respiratory rate is 18/min, and pulse oximetry is 95%: This client is stable with normal vital signs and does not show evidence of immediate life-threatening conditions. Although running out of diuretics may require prompt attention, it does not qualify as ESI Level 1.
B. Client B is obese and has right lower leg pain and swelling. The client's heart rate is 76/min and regular, blood pressure is 126/78, respiratory rate is 18/min, and pulse oximetry is 96%: This presentation could indicate a deep vein thrombosis, which is serious but not immediately life-threatening. The client is hemodynamically stable and does not meet the criteria for ESI Level 1.
C. Client A reports dizziness and confusion. The client's heart rate is 120/min and irregular, blood pressure is 88/52, respiratory rate is 26/min, and pulse oximetry is 82%: This client shows signs of hemodynamic instability, including hypotension, hypoxia, altered mental status, and an irregular, rapid heart rate. These findings indicate a critical condition requiring immediate life-saving interventions, qualifying the client for ESI Level 1.
D. Client C reports a urinary tract infection (UTI). The client's heart rate is 72/min, blood pressure is 110/70, respiratory rate is 15/min, and pulse oximetry is 98%: This client is stable with no signs of systemic or life-threatening complications. UTI symptoms can be uncomfortable but are not immediately life-threatening if vital signs are normal.

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Correct Answer is C

Explanation

A. Administer acetaminophen by mouth for pain control: While pain management is important, it is not the first priority. The primary concern after a traumatic fall is to rule out any life-threatening conditions, such as intracranial bleeding or fractures, which require diagnostic imaging before administering pain relief.
B. Insert an indwelling urinary catheter to monitor urine output: Inserting a catheter may be necessary later, but the first step should be assessing for any immediate life-threatening injuries or complications resulting from the fall, which can be done through imaging studies.
C. Prepare for a STAT non-contrast CT scan: The first priority after a traumatic fall, especially if there is a concern about head injury or internal bleeding, is to assess for any potential life-threatening conditions through a non-contrast CT scan. This helps identify fractures, bleeding, or brain injuries that need immediate attention.
D. Perform a thorough health history: While gathering a health history is important, it should come after ensuring that any potential life-threatening injuries have been ruled out. Diagnostic imaging should be the first intervention to address any immediate risks.

A. "Avoid foods that have been fried." B. "Avoid consuming undercooked foods." C. "Avoid using decongestants for seasonal allergies/colds due to their positive link to developing a peptic ulcer," D. "Avoid using hormone replacement therapy as this can increase your risk for a peptic ulcer."

Correct Answer is A

Explanation

A. "Avoid foods that have been fried.": Fried foods are high in fat, which can increase stomach acid production and irritate the gastric mucosa, contributing to the development of peptic ulcers. Avoiding such foods can help reduce the risk of ulcer formation.
B. "Avoid consuming undercooked foods.": While undercooked foods can carry the risk of infection, particularly from bacteria like H. pylori, this statement is more relevant to food safety and does not directly address the risk of peptic ulcers.
C. "Avoid using decongestants for seasonal allergies/colds due to their positive link to developing a peptic ulcer.": Decongestants are not typically associated with an increased risk of peptic ulcers. The main culprits for ulcers are NSAIDs, alcohol, smoking, and H. pylori infection.
D. "Avoid using hormone replacement therapy as this can increase your risk for a peptic ulcer.": Hormone replacement therapy (HRT) is not a major factor in the development of peptic ulcers. The primary risk factors include NSAID use, smoking, and infection with H. pylori.

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A nurse is assessing a group of clients. Which of the following clients should be categorized as Emergency Severity Index Level 1?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has had a traumatic fall. Which of the following interventions should the nurse implement first?

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