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 to the groin area
A client who has a raised red skin rash on his arms, neck, and face
A client who reports shortness of breath and left shoulder and neck pain
A client who reports right-sided flank pain
The Correct Answer is C
A. A client with active bleeding from a puncture wound to the groin area requires immediate attention; however, the priority is determined by assessing the severity and potential complications associated with each condition.
B. A raised red skin rash could indicate an allergic reaction or infection, but it is not life-threatening compared to respiratory distress.
C. A client who reports shortness of breath and left shoulder and neck pain is the highest priority because these symptoms can indicate a serious condition, such as a myocardial infarction or pulmonary embolism. Both conditions require urgent assessment and intervention to prevent deterioration.
D. Right-sided flank pain can indicate kidney stones or other issues but is less critical than the risk of respiratory compromise present in option C.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
54) A nurse is preparing to delegate bathing and turning of a newly admitted client who has end-stage bone cancer to experienced assistive personnel. Which of the following assessments should the nurse make before delegating care?
a. Is the client’s family present so the AP can show them how to turn the client
b. Does the AP have time to change the client’s central IV-line dressing after turning her?
c. Has data been collected about specific client needs related to turning?
d. Has the AP checked the client’s pain level prior to turning her?
Correct Answer is A
Explanation
A. Helping the assistive personnel immediately ensures the client’s safety, which is the nurse’s top priority. Incorrect transfer techniques can lead to falls or injury, so the nurse must intervene right away to prevent harm.
B. Demonstrating proper transfer technique is important for education, but it should occur after the immediate safety issue is resolved.
C. Instructing the AP to request assistance when unsure is appropriate teaching, but it does not address the immediate risk to the client during the transfer.
D. Referring the AP to the procedure manual is not a priority in an active situation where the client could be injured. Education and reference can occur later.
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