A nurse is caring for four clients in an emergency department. The nurse should plan to see which of the following clients first?

A client who is confused, is febrile and has foul-smelling urine

A client who has sickle cell disease and reports severe joint pain

A client who has slurred speech, is disoriented, and reports a headache

A client who has a dislocated left shoulder

Answer and Explanation

The Correct Answer is C

A. A client who is confused, is febrile, and has foul-smelling urine: These symptoms suggest a urinary tract infection potentially progressing to sepsis, which is serious but does not take priority over signs of possible stroke or brain injury.
B. A client who has sickle cell disease and reports severe joint pain: Severe pain is expected in sickle cell crises and requires prompt management, but it is not as time-sensitive as neurologic deterioration.
C. A client who has slurred speech, is disoriented, and reports a headache: These findings suggest a possible stroke or other neurological emergency such as a brain hemorrhage or increased intracranial pressure, which requires immediate evaluation and intervention.
D. A client who has a dislocated left shoulder: Although painful and requiring attention, a shoulder dislocation is not immediately life-threatening and does not take precedence over potential neurologic compromise.

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Correct Answer is C

Explanation

A. Remove the peripheral IV site: The IV site should be maintained with normal saline to keep access open for potential emergency medications or further treatment. Removing it too early may hinder urgent intervention.
B. Infuse 0.9% sodium chloride through the infusion set tubing: Normal saline should be infused after stopping the transfusion, but it must be done through new tubing to avoid continued exposure to the blood product.
C. Stop the transfusion of the blood: Itching and flushing are signs of a mild allergic transfusion reaction. The immediate priority is to stop the transfusion to prevent the reaction from progressing. This action helps prevent further antigen exposure.
D. Monitor the client's vital signs every 30 min: While vital sign monitoring is important, it is not the first or most urgent action. The priority is to stop the transfusion and address the reaction promptly.

A. “Morphine 3 mg subcutaneous every 4 hr PRN for pain." B. “Morphine 3 mg SC q a hr PRN for pain," C. “Morphine 3.0 mg sub q every 4 hr PRN for pain." D. “Morphine 3 mg SQ every 4 hr PRN for pain."

Correct Answer is A

Explanation

A. “Morphine 3 mg subcutaneous every 4 hr PRN for pain.": This entry uses correct and safe medication documentation practices. It includes the drug name, dose without trailing zero, full route written out, frequency, and indication, reducing the risk of misinterpretation.
B. “Morphine 3 mg SC q 4 hr PRN for pain,": Abbreviations like “SC” and “q” are discouraged by The Joint Commission due to the potential for misreading. The full words "subcutaneous" and "every" are preferred for clarity and safety.
C. “Morphine 3.0 mg sub q every 4 hr PRN for pain.": The trailing zero (“3.0 mg”) increases the risk of dosage error if the decimal point is not seen. Safe practice omits trailing zeros in medication doses.
D. “Morphine 3 mg SQ every 4 hr PRN for pain.": The abbreviation “SQ” can be mistaken for “SL” (sublingual) or “5Q,” leading to errors. The route should be written out fully as “subcutaneous” to ensure clear communication.

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A nurse is caring for four clients in an emergency department. The nurse should plan to see which of the following clients first?

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