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. Postoperative urinary retention is common after surgery, especially within the first 12 hours. While this requires monitoring and possible intervention, it is not the highest priority.
B. Emotional distress before surgery is important to address, but it is not an immediate physiological concern requiring urgent intervention.
C. An absent pulse in the right foot indicates potential acute arterial occlusion, which is a medical emergency. This condition can lead to tissue ischemia and necrosis if not treated promptly. Immediate intervention is needed to restore circulation.
D. A dressing change for a diabetic ulcer is important for wound healing and infection prevention, but it does not take priority over a potential loss of circulation.

A. A client who reports night sweats and fever for the last week B. A client who has compound fractures of the tibia and humerus C. A client who reports severe vomiting and diarrhea D. A client who has soot markings around each naris following a house fire

Correct Answer is D

Explanation

- A: Night sweats and fever could indicate an infection or a chronic condition, which, while important, may not require immediate attention compared to life-threatening conditions.
- B: Compound fractures are serious and require medical attention, but they are not immediately life-threatening if the patient is stable.
- C: Severe vomiting and diarrhea can lead to dehydration and electrolyte imbalance, which are concerning but can be managed with prompt treatment and do not typically pose an immediate threat to life.
- D: Soot markings around the naris indicate possible inhalation injury from a fire, which is a critical condition that can rapidly worsen and lead to airway compromise, making it the highest priority for immediate assessment and intervention.

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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

A nurse on a med-surge unit is caring for four clients. The nurse should recognize that which of the following clients is the priority?

Correct Answer is C

Explanation

A nurse working in an emergency department is performing triage. To which of the following clients should the nurse assign priority?

Correct Answer is D

Explanation

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