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

Answer and Explanation

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.

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Correct Answer is D

Explanation

a. Involving the client's partner may be helpful for additional support, but it does not ensure accurate communication if the partner also does not speak the same language as the client.
b. While incorporating gestures and hand signals can be useful, they may not fully convey complex medical information and may lead to misunderstandings.
c. Interpreting the client's body language can provide some insight into their understanding, but it may not accurately represent their comprehension of the information.
d. Providing an interpreter ensures accurate communication and understanding between the nurse and the client, promoting effective teaching and informed decision-making.

A. Review the chart for nonrestraint alternatives for agitation B. Inform the unit manager C. Speak with the AP about the incident D. Remove the restraints from the client’s wrist

Correct Answer is D

Explanation

a. Review the chart for nonrestraint alternatives for agitation: While reviewing alternatives is important, the immediate concern is ensuring the safety and well-being of the client by removing the restraints.
b. Inform the unit manager: While it's important to inform the unit manager, the first action should be to address the immediate safety issue by removing the restraints.
c. Speak with the AP about the incident: While it's important to discuss the incident with the assistive personnel, the first priority is to remove the restraints to prevent harm to the client.
d. Remove the restraints from the client’s wrist: This is the correct action to take first to ensure the client's safety and prevent further harm. Afterward, the nurse can address the situation with the assistive personnel and review alternatives for managing the client's agitation.

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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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Correct Answer is D

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