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 A
Explanation
A. Closing the documentation program on the computer is the most immediate action to prevent further unauthorized access to protected health information (PHI). It directly addresses the breach of confidentiality and limits potential damage.
B. While it is important to identify the staff member responsible for leaving the program open, this does not immediately address the current breach of confidentiality. This action would be a subsequent step after securing the PHI.
C. Notifying the charge nurse is an important step in the process of addressing the breach. However, it is not the first action to take as it does not prevent further exposure of the PHI.
D. Informing the visitor about the confidentiality of client records is necessary, but it is not the first action to take. The priority is to secure the PHI before addressing the visitor's behavior.
Correct Answer is C
Explanation
. Inform the client that she cannot leave without a discharge prescription from the provider
Rationale:
a. Offering a sedative may not address the client's concerns and is not an appropriate response to the situation.
b.Inform the client that she cannot leave without a discharge prescription from the provider. Clients have the right to leave against medical advice; informing them otherwise infringes on their rights.
C Have the client sign the Against Medical Advice form. This action respects the client's autonomy while ensuring documentation of her decision to leave against medical advice, which protects both the client and healthcare facility legally.
d. Assigning a security officer to the client's room may escalate the situation unnecessarily. The focus should be on communication and education.
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