When triaging emergency room clients, which client should the nurse assess first?

A male adolescent who has been vomiting for the past 12 hours and describes himself as very weak.

A female client with severe right lower abdominal pain who is febrile and vomiting.

An elderly client with peripheral vascular disease who is complaining of severe leg pain when ambulating.

A child who has had a cold for two days and now is coughing up green sputum.

Answer and Explanation

The Correct Answer is B

Choice A Reason: This is not the first priority because it is not a life-threatening condition. The male adolescent may have gastroenteritis or food poisoning, which can cause dehydration and electrolyte imbalance. The nurse should monitor his vital signs and fluid intake, but he can wait for further assessment.

Choice B Reason: This is the first priority because it is a potential surgical emergency. The female client may have appendicitis, which can cause peritonitis and sepsis if left untreated. The nurse should assess her pain level, vital signs, and abdominal signs, and prepare her for diagnostic tests and possible surgery.

Choice C Reason: This is not the first priority because it is a chronic condition that does not require immediate intervention. The elderly client may have intermittent claudication, which is a symptom of peripheral arterial disease. The nurse should educate him on leg care and exercise, but he can wait for further assessment.

Choice D Reason: This is not the first priority because it is a common condition that can be treated with antibiotics. The child may have a bacterial infection, such as bronchitis or pneumonia, which can cause productive cough and fever. The nurse should auscultate his lungs and check his temperature, but he can wait for further assessment.

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Correct Answer is D

Explanation

Choice A Reason: This action requires assessment and evaluation skills, which are beyond the scope of practice of the PN. The nurse is responsible for providing client education and ensuring that the client understands the discharge instructions.

Choice B Reason: This action requires teaching and evaluation skills, which are beyond the scope of practice of the PN. The nurse is responsible for educating the clients about their prescribed dietary changes and assessing their learning needs and readiness.

Choice C Reason: This action requires critical thinking and decision-making skills, which are beyond the scope of practice of the PN. The nurse is responsible for establishing the blood pressure parameters for client monitoring and adjusting them as needed.

Choice D Reason: This action can be safely delegated to the PN, as it involves reinforcing previous teaching done by the nurse. The PN can review the diet information with the client and answer any questions they may have.

A. Administered two medications to the same client at the wrong time. B. Documented data in the clinical record before assessing client's condition. C. Served a diet tray to a client who was NPO for a scheduled procedure. D. Changed work assignments without prior approval from charge nurse.

Correct Answer is B

Explanation

Choice A Reason: This is not the best action because it is a medication error that can be corrected and prevented by following the rights of medication administration. The nurse manager should counsel the staff nurse and provide education on safe medication practices.

Choice B Reason: This is the best action because it is a serious breach of professional ethics and standards. The nurse manager should report the staff nurse to the PRC for falsifying documentation and compromising client care.

Choice C Reason: This is not the best action because it is a mistake that can be rectified by removing the diet tray and notifying the healthcare provider. The nurse manager should reprimand the staff nurse and review the policy on NPO status.

Choice D Reason: This is not the best action because it is a minor issue that can be resolved by communicating with the charge nurse and other staff members. The nurse manager should remind the staff nurse of the importance of teamwork and collaboration.

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