A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?
A client who has a raised red skin rash on his arms, neck, and face
A client who has active bleeding from a puncture wound of the left groin area
A client who reports shortness of breath and left neck and shoulder pain
A client who reports right-sided flank pain and is diaphoretic
The Correct Answer is B
Choice A reason: A client who has a raised red skin rash on his arms, neck, and face may have an allergic reaction or a skin infection, which are not life-threatening conditions. The nurse should monitor the client for signs of anaphylaxis or systemic infection, but this client is not the highest priority.
Choice B reason: A client who has active bleeding from a puncture wound of the left groin area is the highest priority because they are at risk of hemorrhage and shock. The nurse should apply direct pressure to the wound, elevate the affected leg, and monitor the client's vital signs and hemoglobin level.
Choice C reason: A client who reports shortness of breath and left neck and shoulder pain may have a cardiac or pulmonary problem, such as angina, myocardial infarction, or pulmonary embolism, which are serious conditions. The nurse should obtain an electrocardiogram, administer oxygen, and prepare for further diagnostic tests and interventions, but this client is not the highest priority.
Choice D reason: A client who reports right-sided flank pain and is diaphoretic may have a renal or urinary problem, such as kidney stones, pyelonephritis, or renal colic, which are painful but not life-threatening conditions. The nurse should administer analgesics, encourage fluid intake, and collect a urine sample, but this client is not the highest priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Using condoms during treatment for chlamydia is important for preventing transmission, but this is not the priority nursing action. The most critical step for the nurse is fulfilling the legal and public health obligation to report the infection to the health department, as chlamydia is a reportable sexually transmitted infection.
Choice B reason: This is not the correct choice because this action is not appropriate for clients who have chlamydia. Chlamydia is caused by bacteria, not viruses, so antiviral creams are ineffective and unnecessary. The nurse should administer the prescribed antibiotics and monitor the client for any adverse reactions or complications.
Choice C reason:Reporting the infection to the local health department is correct. Chlamydia is a reportable disease in all states, and this step ensures proper public health tracking, partner notification, and prevention of further spread. This is a nurse’s responsibility in accordance with infection control and community health regulations.
Choice D reason: This is not the correct choice because this action is not indicated for clients who have chlamydia. Contact precautions are used to prevent the transmission of infections that are spread by direct or indirect contact with the client or their environment. Chlamydia is not spread by contact, but by sexual intercourse. The nurse should use standard precautions, which include hand hygiene and wearing gloves, when caring for the client.
Correct Answer is D
Explanation
Choice A reason: Accompanying a client who just had a wound debridement to physical therapy is not a task that the nurse should assign to the LPN, as it requires the nurse to monitor the client's vital signs, wound status, and pain level. The nurse should accompany the client and delegate other tasks to the LPN or the assistive personnel.
Choice B reason: Providing postmortem care for a client who has just died is not a task that the nurse should assign to the LPN, as it requires the nurse to verify the death, notify the provider and the family, and document the care. The nurse should provide postmortem care and delegate other tasks to the LPN or the assistive personnel.
Choice C reason: Obtaining a urine specimen from an older adult client is not a task that the nurse should assign to the LPN, as it is a basic skill that the assistive personnel can perform. The nurse should assign this task to the assistive personnel and supervise their work.
Choice D reason: Reinforcing dietary teaching with a client who has heart disease is a task that the nurse should assign to the LPN, as it is within the LPN's scope of practice to reinforce the teaching that the nurse has initiated. The nurse should provide the initial teaching and evaluate the client's learning.
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