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 C

Explanation

a. While educating the client about the risks of refusing the procedure is important, it should not be the first action taken when the client does not understand the procedure itself.
b. Completing an incident report is not necessary in this situation, as there is no indication of an adverse event or error.
c. When a client does not understand a procedure, it is essential to inform the provider so that they can provide clarification and address any questions or concerns the client may have.
d. While answering the client's questions is important, the nurse may not have the expertise or authority to provide the level of clarification required. It is best to involve the provider in this situation.

A. Providing a 10min rest period prior to meals B. Elevating the head of the client’s bed to 30 degrees during mealtime C. Instructing the client to place her chin toward her chest when swallowing D. Withholding fluids until the end of the meal

Correct Answer is B

Explanation

a. Providing a rest period prior to meals may be appropriate for some clients, but it is not a standard technique for managing dysphagia during mealtime.
b. Elevating the head of the client’s bed to 30 degrees during mealtime helps prevent aspiration and facilitates swallowing in clients with dysphagia.
c. Instructing the client to place her chin toward her chest when swallowing is not recommended and may increase the risk of aspiration.
d. Withholding fluids until the end of the meal is not recommended for clients with dysphagia, as they may need fluids to help with swallowing and to prevent dehydration.

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is B

Explanation

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