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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not the correct choice because this response is inaccurate and misleading. Respite services do not provide medical care or treatment for the client, but rather temporary relief and support for the family caregivers. The nurse should not give false hope or unrealistic expectations to the client's partner.
Choice B reason: This is not the correct choice because this response is incomplete and vague. Respite services may include some practical assistance such as meal delivery or housekeeping, but their main purpose is to provide emotional and social support for the family caregivers. The nurse should explain how respite services can help the client's partner cope with the stress and challenges of caregiving.
Choice C reason: This is the correct choice because this response is accurate and clear. Respite services can provide the client's partner with some time off from their caregiving duties, which can help them recharge their energy, attend to their own needs, and maintain their well-being. The nurse should emphasize the benefits of respite services for the client's partner and their relationship with the client.
Choice D reason: This is not the correct choice because this response is confusing and irrelevant. Respite services do not offer psychological interventions for the client or the family, but rather companionship and support. The nurse should not imply that the client's partner needs therapy or counseling, which may be perceived as judgmental or insensitive.
Correct Answer is C
Explanation
Choice A reason: A provider's prescription is not a resource for developing a standard for removal of indwelling urinary catheters. A prescription is a specific order for a particular client, not a general guideline for a group of clients.
Choice B reason: Maslow's hierarchy of needs is not a resource for developing a standard for removal of indwelling urinary catheters. Maslow's hierarchy of needs is a theory of human motivation that ranks the basic needs of individuals from physiological to self-actualization. It does not provide specific information on how to perform nursing interventions.
Choice C reason: Evidence-based practice is a resource for developing a standard for removal of indwelling urinary catheters. Evidence-based practice is the integration of the best available research evidence, clinical expertise, and client preferences and values into clinical decision making. It helps to ensure that the nursing care is effective, safe, and consistent.
Choice D reason: A critical pathway is not a resource for developing a standard for removal of indwelling urinary catheters. A critical pathway is a tool that outlines the expected course of treatment and outcomes for a specific diagnosis or procedure. It does not provide detailed instructions on how to perform nursing interventions.
Choice E reason: A surgical record is not a resource for developing a standard for removal of indwelling urinary catheters. A surgical record is a document that records the details of a surgical procedure, such as the type of surgery, the anesthesia used, the operative findings, and the complications. It does not provide information on the postoperative care of the client.
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