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

Answer and Explanation

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.

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Correct Answer is ["B","C","E","F"]

Explanation

A. Bowel sounds are hypoactive in all four quadrants, which is expected after an appendectomy due to anesthesia and decreased peristalsis. This is not a finding that needs to be reported to the provider.
B. Oxygen saturation is 93% on room air, which is below the normal range of 95% to 100%. This could indicate impaired gas exchange, respiratory depression, or infection. This is a finding that needs to be reported to the provider.
C. Nausea is a common feature of appendicitis and should go away with appendectomy. This finding should, therefore, be reported to the healthcare provider.
D. Vomiting is also a common side effect of morphine and anesthesia, and can be managed with antiemetics and fluids. This is not a finding that needs to be reported to the provider unless it persists or interferes with oral intake.
E. Pain level is 6 on a scale of 0 to 10.The client received morphine as prescribed at 1815, and the pain level is still significant. This isa finding that needs to be reported to the provider
F. Heart rate is 110/min, which is above the normal range of 60 to 100/min. This could indicate pain, anxiety, dehydration, infection, or bleeding. This is a finding that needs to be reported to the provider.
G. Incision characteristics are clean and dry, which is expected after an appendectomy. However, the nurse should monitor for signs of infection such as redness, swelling, warmth, drainage, or odor. This is a finding that needs to be reported to the provider if any signs of infection are present.
H. Lungs sounds are clear on auscultation, which is expected after an appendectomy. However, the nurse should encourage deep breathing and coughing exercises to prevent atelectasis and pneumonia. This is a finding that needs to be reported to the provider if any abnormal lung sounds are heard such as crackles, wheezes, or diminished breath sounds.

A. The LPN and AP lower the side rails before lifting the client up in bed. B. Prior to lifting the client, the LPN and AP raise the bed to waist level. C. The LPN and the AP grasp the client under his arms to lift him up in bed. D. The LPN and the AP ask the client to flex his knees and push his heels into the bed as they lift.

Correct Answer is C

Explanation

- A. The LPN and AP lower the side rails before lifting the client up in bed is incorrect. This is a safe practice that prevents injury to the client and staff by providing more space for movement and reducing the risk of falling.

- B. Prior to lifting the client, the LPN and AP raise the bed to waist level is incorrect. This is a safe practice that prevents injury to the client and staff by reducing the need for bending and lifting.

- C. The LPN and the AP grasp the client under his arms to lift him up in bed is correct. This is an unsafe practice that can cause injury to the client's shoulders, neck, and axillae by applying excessive pressure and friction. The LPN and AP should use a draw sheet or a mechanical lift device to move the client up in bed.

- D. The LPN and the AP ask the client to flex his knees and push his heels into the bed as they lift is incorrect. This is a safe practice that encourages active participation from the client and reduces the workload for the staff by using leverage.

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A nurse working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C","E","F"]

Explanation

An RN is observing a licensed practical nurse (LPN) and an assistive personnel (AP) move a client up in bed. For which of the following situations should the nurse intervene?

Correct Answer is C

Explanation

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