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.
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Correct Answer is D
Explanation
a. Continuing both medications may exacerbate the somnolence and difficulty arousing experienced by the client. It's essential to address the adverse effects promptly.
b. NSAIDs are not typically the first choice for severe pain management in terminal illness, especially when opioids are already prescribed. Moreover, replacing the opioid with an NSAID may not adequately address the pain.
c. Administering the benzodiazepine alongside the opioid may further potentiate the sedative effects and worsen the client's condition.
d. This is the most appropriate action. Withholding the benzodiazepine can help mitigate the sedation while continuing the opioid ensures ongoing pain relief for the client's comfort without introducing additional sedating medications.
Correct Answer is B
Explanation
Rationale for A: The abbreviation "MS" is not recommended for use in prescriptions because it can be confused with magnesium sulfate or morphine sulfate. This can lead to medication errors, making this option unsafe for transcription.
Rationale for B: This prescription is the correct choice because it clearly spells out "morphine sulfate," avoiding any potential confusion with similar abbreviations. It also uses the appropriate dosage and frequency without unnecessary trailing zeros, reducing the risk of errors.
Rationale for C: The abbreviation "MSO4" is considered dangerous because it can be confused with magnesium sulfate (MgSO4). Additionally, using abbreviations in prescriptions can lead to misinterpretation and medication errors.
Rationale for D: Although this option spells out "morphine sulfate," it uses a trailing zero in "10.0 mg," which can be misinterpreted as a higher dose, such as 100 mg. Trailing zeros should be avoided to prevent potential overdose.
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