A nurse working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first?
An older adult client who reports constipation of 4 days
A preschooler who has a skin rash
An adolescent who has a closed fracture
A middle adult client who has unstable vital signs
The Correct Answer is D
A. This choice is incorrect because an older adult client who reports constipation of 4 days is not an urgent situation that requires immediate attention. The nurse should assess the client's hydration status, bowel habits, and medication use, and provide education on dietary and lifestyle modifications to prevent constipation.
B. This choice is incorrect because a preschooler who has a skin rash is not an urgent situation that requires immediate attention. The nurse should assess the type, location, and distribution of the rash, as well as any history of allergies, exposure, or infection, and provide appropriate treatment and education.
C. This choice is incorrect because an adolescent who has a closed fracture is not an urgent situation that requires immediate attention. The nurse should assess the site of injury, neurovascular status, pain level, and immobilization device, and provide analgesia and education on fracture care.
D. This choice is correct because a middle adult client who has unstable vital signs is an urgent situation that requires immediate attention. The nurse should assess the client's level of consciousness, airway, breathing, circulation, and possible causes of instability, and initiate life-saving interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A client who has cellulitis and is receiving oral antibiotics every 8 hr has a mild to moderate infection that can be managed at home with proper wound care and medication adherence. The client does not require hospitalization unless there are signs of systemic infection or complications.
B. A client who is postoperative following an upper endoscopy procedure and is alert but does not have a gag reflex has a high risk of aspiration and airway obstruction due to impaired swallowing function. The client requires close monitoring and intervention until the gag reflex returns, which can take several hours or longer depending on the type and amount of anesthesia used.
C. A mother and their newborn 12 hr postdelivery have not completed the minimum recommended stay of 24 to 48 hours for uncomplicated vaginal deliveries or 72 to 96 hours for cesarean deliveries, according to the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. The mother and their newborn require assessment, education, support, and follow-up care to ensure their health and well-being.
D. A client who has lower extremity weakness and is newly admitted for observation has an undiagnosed condition that could indicate a serious neurological or vascular problem, such as stroke, spinal cord injury, or peripheral artery disease. The client requires diagnostic testing, evaluation, treatment, and rehabilitation to prevent further deterioration or complications.
Correct Answer is A
Explanation
Choice A reason:
Increased haemoglobin is correct. level Epoetin alfa is a medication used to stimulate the production of red blood cells in the bone marrow, and it is often prescribed to treat anaemia. Anaemia is characterized by a decrease in the number of red blood cells or a decrease in the amount of haemoglobin, which is responsible for carrying oxygen in the blood.
The therapeutic response to epoetin alfa is an increase in the haemoglobin level. This indicates that the medication is effectively stimulating the production of red blood cells, leading to an improvement in the client's anaemia and overall oxygen-carrying capacity of the blood.
Choice B reason:
Increased platelet count: Platelets are involved in blood clotting and are not directly affected by epoetin alfa.
Choice C reason:
Increased neutrophil count: Neutrophils are a type of white blood cell involved in the body's immune response. Epoetin alfa primarily affects red blood cells and does not directly impact white blood cell levels.
Choice D reason:
Increased erythrocyte sedimentation rate (ESR): ESR is a non-specific indicator of inflammation in the body and is not directly related to the therapeutic response of epoetin alfa in treating anaemia.
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