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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
A. Notify risk management before initiating treatment: While risk management may need to be involved in certain situations, the priority in this case is to address the client's immediate medical needs.
B. Contact the client's next of kin to obtain consent for treatment: In emergency situations where the client is unable to provide consent and there is no surrogate decision-maker available,
healthcare providers are generally authorized to proceed with necessary treatment to stabilize the patient.
C. Proceed with treatment without obtaining written consent: This is the correct answer. In emergencies where immediate treatment is required to prevent further harm or stabilize the patient's condition, obtaining written consent may not be feasible or appropriate.
D. Have the client sign a consent for treatment: If the client is disoriented and has a cardiac arrhythmia, they may not be capable of providing informed consent at that moment. Therefore, waiting for them to sign a consent form could delay necessary treatment.
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