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

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason: This is not the correct choice because this assignment is not appropriate for a licensed practical nurse. A client who requires discharge instructions for type 1 diabetes mellitus needs education on self-care, medication administration, blood glucose monitoring, diet, and exercise. These are complex tasks that require the knowledge and skills of a registered nurse.

Choice B reason: This is the correct choice because this assignment is appropriate for a licensed practical nurse. A client who is 1 day postoperative and has a continuous bladder irrigation needs routine care, such as vital signs, wound assessment, fluid intake and output, and catheter care. These are basic tasks that can be performed by a licensed practical nurse under the supervision of a registered nurse.

Choice C reason: This is not the correct choice because this assignment is not appropriate for a licensed practical nurse. A client who requires a blood transfusion to be administered needs careful monitoring, such as checking for compatibility, verifying informed consent, observing for adverse reactions, and documenting the transfusion. These are advanced tasks that require the judgment and authority of a registered nurse.

Choice D reason: This is not the correct choice because this assignment is not appropriate for a licensed practical nurse. A client who is receiving IV chemotherapy needs specialized care, such as preparing and administering the medication, managing side effects, providing emotional support, and following safety precautions. These are specialized tasks that require the training and certification of a registered nurse.

A. Contact the client's next of kin to obtain consent for treatment. B. Proceed with treatment without obtaining written consent. C. Have the client sign a consent for treatment. D. Notify risk management before initiating treatment.

Correct Answer is B

Explanation

Choice A reason: Contacting the client's next of kin to obtain consent for treatment is not a correct action, as it may delay the necessary and urgent care for the client. The nurse should assume that the client would consent to life-saving treatment and act in the client's best interest.

Choice B reason: Proceeding with treatment without obtaining written consent is the correct action, as it is justified by the emergency doctrine. The nurse should provide immediate and appropriate care for the client who is unable to give consent due to their condition.

Choice C reason: Having the client sign a consent for treatment is not a correct action, as the client is disoriented and cannot give informed consent. The nurse should not ask the client to sign any documents that they may not understand or remember.

Choice D reason: Notifying risk management before initiating treatment is not a correct action, as it is not a priority in an emergency situation. The nurse should focus on the client's needs and safety and document the care provided and the rationale for the actions taken.

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A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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