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

A client who has active bleeding from a puncture wound of the left groin area

A client who has a raised red skin rash on his arms, neck, and face

A client who reports right-sided flank pain and is diaphoretic

A client who reports shortness of breath and left neck and shoulder pain

Answer and Explanation

The Correct Answer is D

A. A client who has active bleeding from a puncture wound of the left groin area – Although this client is at risk for significant blood loss, the immediate priority is to assess and address any potential cardiac issues in clients with respiratory distress.

B. A client who has a raised red skin rash on his arms, neck, and face: While a rash may indicate an allergic reaction or infection, it is not immediately life-threatening compared to active bleeding.
C. A client who reports right-sided flank pain and is diaphoretic: Flank pain and diaphoresis could indicate various serious conditions such as kidney stones or myocardial infarction, but active bleeding requires more immediate intervention.

D. A client who reports shortness of breath and left neck and shoulder pain – This client is experiencing symptoms that may indicate a serious cardiac event, such as a myocardial infarction or pulmonary embolism, which requires urgent evaluation and intervention. The combination of shortness of breath and pain in these areas raises the highest concern for potential life-threatening conditions.

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Correct Answer is B

Explanation

- A. Bite block: This is not the correct choice. A bite block is used to prevent a patient from biting down on tubes or other equipment, not typically required for a patient with dysphagia.
- B. Yankauer suction device: This is the correct choice. A Yankauer suction device is used to clear the oral cavity of secretions or food particles, which is essential for a patient with dysphagia to prevent aspiration.
- C. Large-handled utensils: While these may be helpful for a patient with dysphagia to feed themselves more easily, they are not as critical as ensuring the airway is clear of obstructions.
- D. Nasal cannula and oxygen: This equipment would be necessary if the patient had respiratory issues, but it is not specifically related to the management of dysphagia.

A. Withdraws the medication from the ampule using a subcutaneous needle B. Breaks the top of the ampule using an antiseptic wipe C. Performs 3 checks of the medication before administration D. Disposes of the ampule by placing it in a sharps container

Correct Answer is A

Explanation

A. Withdrawal of medication from an ampule should be done using a filter needle or a needle with a filter straw to prevent glass particles from being drawn into the syringe. Using a subcutaneous needle is not appropriate for this purpose and may lead to contamination or injury.
B. Breaking the top of the ampule using an antiseptic wipe is an acceptable method to access the medication within the ampule.
C. Performing 3 checks of the medication before administration is a standard safety practice to ensure the correct medication, dose, and route.

D. Disposing of the ampule by placing it in a sharps container is the correct method for safe disposal of glass ampules after use.

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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 charge nurse is assessing the room of a newly admitted client who has dysphagia. Which of the following pieces of equipment should the nurse ensure is available in the client's room?

Correct Answer is B

Explanation

A nurse is observing a newly licensed nurse prepare a medication from an ampule for a client's injection. For which of the following actions by the newly licensed nurse should the nurse intervene?

Correct Answer is A

Explanation

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