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 {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

Rationale for Correct Options:

Preeclampsia is a hypertensive disorder of pregnancy that typically occurs after 20 weeks of gestation. This client has elevated blood pressure (156/96 mm Hg), proteinuria (25 mg/dL), hyperreflexia, headache, right upper quadrant pain, and facial edema—all hallmark signs of preeclampsia.
Urinalysis shows elevated protein, which is a diagnostic criterion for preeclampsia. Proteinuria is a result of kidney involvement due to endothelial damage from hypertension indicating kidney involvement due to the systemic vascular changes in preeclampsia.

Rationale for Incorrect Options:

Chorioamnionitis typically presents with maternal fever, uterine tenderness, foul-smelling amniotic fluid, and fetal tachycardia. This client is afebrile and has no signs of intrauterine infection.
Preterm labor is indicated by cervical changes and regular uterine contractions, neither of which are present. The fetal monitor shows no contractions, and there are no reports of vaginal drainage or pressure.
Serum WBC count is mildly elevated at 12,500/mm³, which can be normal in pregnancy and does not indicate infection or inflammation in this context.
Fundal assessment: The fundal height of 29 cm at 30 weeks is within the normal range (+/- 2 cm), so it does not evidence a particular risk.

A. “Avoid high-fiber foods while taking this medication.” B. “Remove the patch for 8 hours every day to reduce the risk of tolerance." C. “Avoid hot tubs while wearing the patch.” D. “Apply the patch to your forearm.”

Correct Answer is C

Explanation

A. “Avoid high-fiber foods while taking this medication.”: Fentanyl can cause constipation, so a diet high in fiber is actually recommended to promote bowel regularity. Avoiding fiber would worsen one of the drug’s common side effects.
B. “Remove the patch for 8 hours every day to reduce the risk of tolerance.": Fentanyl patches are designed for continuous, 72-hour use. Removing the patch disrupts pain control and may lead to withdrawal symptoms or inadequate analgesia.
C. “Avoid hot tubs while wearing the patch.”: Heat exposure, including hot tubs or heating pads, can increase fentanyl absorption, potentially leading to overdose. Clients should be advised to avoid external heat sources near the patch.
D. “Apply the patch to your forearm.”: The patch should be applied to a flat, non-irritated area of the upper torso or upper arm. The forearm is not typically recommended due to its mobility and potential for detachment or reduced absorption.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

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Correct Answer is C

Explanation

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