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 A

Explanation

A. Black tags are typically used for individuals who are deceased or expected to die imminently. The chances of survival for this patient are very minimal since the burn surface area is more than 50% with full thickness burns
B. Yellow tags are used for those who require observation but are not in immediate danger.
C. Red tags are for those with severe injuries who require immediate treatment but have a chance of survival.
D. Green tags are used for individuals with minor injuries or those who require minimal medical assistance.

A. Is the client's family present so the AP can show them how to turn the client? B. Has the AP checked the client's pain level prior to turning her? C. Does the AP have time to change the client's central IV line dressing after turning her? D. Has data been collected about specific client needs related to turning?

Correct Answer is D

Explanation

A. While involving the family might be beneficial for education, it's not directly related to assessing the client's needs for turning.
B. Assessing the client's pain level is important, but it's only one aspect of comprehensive care when delegating turning to the AP.
C. Checking the AP's availability for other tasks after turning the client is important but not the primary assessment before delegation.
D. Before delegating care, the nurse should assess and collect data about the client's specific needs related to turning due to the client's condition. Understanding the client's condition and requirements for turning is crucial for effective delegation.

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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

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Explanation

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