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 C

Explanation

Choice A reason: The client's code status is not part of the background information, but rather the recommendation or request section of the SBAR Communication tool. The code status indicates the level of resuscitation the client wishes to receive in case of a cardiac or respiratory arrest.

Choice B reason: The client's vital signs are not part of the background information, but rather the assessment section of the SBAR Communication tool. The vital signs reflect the client's current condition and response to treatment.

Choice C reason: The client's name is part of the background information, along with the client's age, diagnosis, reason for admission, and relevant medical history. The background information provides a brief overview of the client's situation and helps to identify the client.

Choice D reason: A prescribed consultation is not part of the background information, but rather the recommendation or request section of the SBAR Communication tool. A consultation is a referral to another health care professional for further evaluation or management of the client's condition.

A. Provides protection against malpractice B. Designates a health care surrogate to make health care decisions C. Documents that the client gave informed consent D. Allows the client to refuse life-sustaining treatments

Correct Answer is D

Explanation

Choice A reason: A living will does not provide protection against malpractice. It is a legal document that expresses the client's wishes regarding medical care in the event of a terminal illness or injury.

Choice B reason: A living will does not designate a health care surrogate to make health care decisions. A health care surrogate is a person who is authorized by the client or the court to make health care decisions for the client when the client is unable to do so.

Choice C reason: A living will does not document that the client gave informed consent. Informed consent is the process of obtaining the client's voluntary agreement to a proposed treatment or procedure after providing adequate information about the benefits, risks, and alternatives.

Choice D reason: A living will allows the client to refuse life-sustaining treatments. This is the main purpose of a living will, as it gives the client the right to self-determination and autonomy over their own body and health.

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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

A nurse is preparing to transfer a client from the emergency department to a medical-surgical unit using the SBAR Communication tool. Which of the following information should the nurse include in the background portion of the report?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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