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 lifesaving interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
- A is incorrect because IV tubing for total parenteral nutrition should be changed every 24 hours to prevent infection.
- B is incorrect because abdominal distention is not an expected effect of total parenteral nutrition. It could indicate a complication such as fluid overload or bowel obstruction.
- C is incorrect because gastric residual is not relevant for total parenteral nutrition, which bypasses the gastrointestinal tract.
- D is correct because weight measurement is an important indicator of fluid balance and nutritional status for clients receiving total parenteral nutrition.
Correct Answer is A
Explanation
Option A. Instruct the client to void, because this reduces the risk of bladder injury during the procedure. The other options are incorrect because they are not necessary or appropriate for a paracentesis.
Option B, position the client on their left side, is incorrect because the client should be positioned upright or semi-Fowler's to allow gravity to assist with fluid drainage.
Option C, insert an IV catheter, is incorrect because an IV catheter is not required for a paracentesis unless the client needs fluid replacement or medication administration.
Option D, prepare the client for moderate (conscious) sedation, is incorrect because a paracentesis is usually performed under local anesthesia and does not require sedation
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