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

A client who reports right-sided flank pain and is diaphoretic

A client who reports shortness of breath and left neck and shoulder pain

A client who has active bleeding from a puncture wound of the left groin area

A client who has a raised red skin rash on his arms, neck, and face

Answer and Explanation

The Correct Answer is B

A: Right-sided flank pain and diaphoresis could indicate a kidney stone or infection, which is painful but not immediately life-threatening.

B: Shortness of breath combined with pain in the neck and shoulder could suggest a myocardial infarction (heart attack), which is a medical emergency requiring immediate attention.

C: Active bleeding from a puncture wound is concerning and requires prompt intervention, but it may not be as immediately life-threatening as a potential heart attack.

D: A raised red skin rash could be a sign of an allergic reaction or infection. While it may require medical attention, it is not as urgent as a potential myocardial infarction.

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Correct Answer is C

Explanation

A. Informing the unit manager is essential but not the first immediate action when a client is improperly restrained.
B. Speaking with the AP about the incident is important, but the priority is to ensure the client's safety and well-being.
C. Removing the restraints from the client's wrists is the first action to address the
inappropriate application of restraints without a prescription to ensure the client's safety and prevent harm.
D. Reviewing the chart for nonrestraint alternatives for agitation is important, but the priority is to address the immediate issue of the improperly applied restraints to the client.

A. Obtain telephone consent from the facility administrator before the surgery. B. Delay the surgery until the nurse can obtain informed consent. C. Ask the anesthesiologist to sign the consent. D. Transport the client to the operating room without verifying informed consent.

Correct Answer is D

Explanation

A. Telephone consent from the facility administrator might not be sufficient for the specific informed consent required for surgery on an unconscious client.
B. Delaying surgery to ensure proper informed consent is obtained is not appropriate since the client is in a critical condition and delaying surgery might cause death.
C. Asking the anesthesiologist to sign the consent is not appropriate as the responsibility for obtaining informed consent typically lies with the surgeon or responsible provider.
D. Transporting the client to the operating room without informed consent is appropriate in emergency situations where the client is unconscious.

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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

A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse in the emergency department is assessing a client who is unconscious following a motor-vehicle crash. The client requires immediate surgery. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is assessing an older adult client who was brought to the emergency department by his adult son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take?

To resolve a conflict between staff members regarding potential changes in policy, a nurse manager decides to implement the changes she prefers regardless of the feelings of those who oppose those changes. Which of the following conflict resolution strategies is the nurse manager using?

A nurse is preparing to delegate bathing and turning of a newly admitted client who has end- stage bone cancer to an experienced assistive personnel (AP). Which of the following assessments should the nurse make before delegating care?

A charge nurse witnesses an assistive personnel (AP) failing to follow facility protocol when discarding contaminated linens. Which of the following actions should the nurse take first?

A nurse is caring for a client who has a prescription for transcutaneous electrical nerve stimulation (TENS). Which of the following members of the interdisciplinary team should the nurse contact for assistance?

A nurse is providing change-of-shift report for an oncoming nurse. Which of the following information should the nurse include in the report?

A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding of isolation guidelines?

A nurse is caring for a client who has cancer. The client's adult child asks the nurse for information about the client's treatment plan. Which of the following responses should the nurse make?