A nurse working in an emergency department is performing triage. To which of the following clients should the nurse assign priority?

A client who reports night sweats and fever for the last week

A client who has compound fractures of the tibia and humerus

A client who reports severe vomiting and diarrhea

A client who has soot markings around each naris following a house fire

Answer and Explanation

The Correct Answer is D

a. A client who reports night sweats and fever for the last week:

Night sweats and fever can be indicative of various underlying conditions, including infections. While these symptoms may require medical attention, they do not necessarily indicate an immediately life-threatening condition compared to other options.

b. A client who has compound fractures of the tibia and humerus:

Compound fractures involve broken bones that penetrate through the skin, leading to a risk of severe bleeding, infection, and other complications. This client's injuries are significant and require immediate attention to prevent further complications and provide pain management and stabilization.

c. A client who reports severe vomiting and diarrhea:

Severe vomiting and diarrhea can lead to dehydration, electrolyte imbalances, and other complications, especially if prolonged or accompanied by other symptoms such as fever. While this client requires prompt assessment and treatment, the urgency may not be as high as for other conditions.

d. A client who has soot markings around each naris following a house fire:

Soot markings around the nares (nostrils) suggest inhalation injury, which can lead to airway compromise, respiratory distress, and other serious complications. This client requires immediate assessment and intervention to ensure airway patency, oxygenation, and respiratory support.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

a. Providing a 10-minute rest period prior to meals:

This action is not specifically related to feeding technique for clients with dysphagia. While providing a rest period before meals may be beneficial for some clients, especially those who experience fatigue or dyspnea, it is not a standard technique for managing dysphagia during mealtime.

b. Elevating the head of the client’s bed to 30 degrees during mealtime:

The head of the bed should be elevated to at least 45–90 degrees during meals to minimize the risk of aspiration. A 30-degree elevation is insufficient for safe swallowing and increases the likelihood of aspiration.

c. Instructing the client to place her chin toward her chest when swallowing:

This technique, known as the chin-tuck maneuver, helps reduce the risk of aspiration in clients with dysphagia by improving airway protection and directing food and liquid down the esophagus instead of the trachea. It is a widely recommended method to promote safe swallowing.

d. Withholding fluids until the end of the meal:

Fluids should not be withheld until the end of the meal as they are often necessary to help the client swallow food safely and prevent choking. Thickened fluids may be prescribed for clients with dysphagia to aid in safe swallowing.

A. Educate the client about the risks of refusing the procedure B. Complete the incident report C. Inform the provider that the client requires clarification about the procedure D. Answer the client’s questions concerning the procedure

Correct Answer is C

Explanation

a. Educate the client about the risks of refusing the procedure:

This option suggests providing information about the potential consequences of not undergoing the gastroscopy. While educating the client about risks is essential, the immediate concern is the client's lack of understanding about the procedure itself.

b. Complete the incident report:

Filling out an incident report is typically reserved for situations where there has been an actual incident, such as a medical error or adverse event. In this case, the client's lack of understanding does not constitute an incident but rather a need for clarification.

c. Inform the provider that the client requires clarification about the procedure:

This is the correct action. It involves escalating the issue to the provider responsible for performing the gastroscopy. The provider can then address the client's concerns, answer questions, and provide additional information to ensure informed consent.

d. Answer the client’s questions concerning the procedure:

While answering the client's questions is important, it's not solely the nurse's responsibility to ensure the client understands the procedure. The provider, who will perform the gastroscopy, should be informed of the client's confusion so they can address it effectively.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse working in an emergency department is performing triage. To which of the following clients should the nurse assign priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is supervising an assistive personnel who is feeding a client who has dysphagia. Which of the following actions by the AP should the nurse identify as correct technique?

Correct Answer is C

Explanation

A nurse enters a client’s room to witness an informed consent for a gastroscopy. The client states he does not understand the procedure. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who has a new diagnosis of chlamydia. Which of the following actions should the nurse take?

A nurse is preparing to complete an incident report regarding a medication error. Which of the following actions should the nurse plan to take? SATA

A nurse is caring for four clients. Which of the following should the nurse assess first?

A charge nurse is observing a licensed practical nurse assist a client who has dysphagia while eating. Which of the following actions by the LPN should the charge nurse identify as providing safe care?

A nurse overhears two assistive personnel discussing a client’s care in the cafeteria. Which of the following actions should the nurse take?

A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should the nurse recommend for an interdisciplinary care conference?

A nurse is preparing a client for surgery. The client has signed the consent form but tells the nurse that she has reconsidered because she is worried about the pain. Which of the following responses by the nurse is appropriate?

Nurses on an inpatient care unit are working to help reduce unit costs. Which of the following actions is appropriate to include in the cost-containment plan?