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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: This is the correct answer because the acuity level of the clients reflects their complexity and intensity of care needs. The higher the acuity level, the more time and resources are required to provide safe and quality care. The charge nurse should consider the acuity level of the clients when determining the appropriate nurse-to-client ratio and staffing needs.
Choice B Reason: The physicians' plans to perform procedures on the unit is not the most important information for the charge nurse to consider because it does not directly affect the nursing workload or staffing requirements. The charge nurse should coordinate with the physicians and other departments to ensure that the procedures are scheduled and performed safely and efficiently.
Choice C Reason: The number of clients leaving the unit for diagnostic tests is not the most important information for the charge nurse to consider because it does not indicate the level of care that the clients need or receive. The charge nurse should ensure that the clients are prepared and accompanied for their tests and that their care is continued and monitored on their return.
Choice D Reason: The skill level of the personnel staffing the unit is not the most important information for the charge nurse to consider because it does not reflect the actual demand or supply of nursing care. The charge nurse should assign and delegate tasks according to the personnel's skill level and scope of practice but also consider other factors such as client acuity, availability, and preference.
Correct Answer is A
Explanation
Choice A reason: Ceftriaxone is an antibiotic that can be given by gravity infusion without an IV pump, as long as the nurse monitors the flow rate and adjusts the roller clamp as needed. The dose and duration of ceftriaxone are usually fixed and not affected by minor fluctuations in the infusion rate.
Choice B reason: Heparin is an anticoagulant that requires a precise and constant infusion rate to prevent bleeding or clotting complications. An IV pump is essential to deliver heparin safely and accurately.
Choice C reason: Magnesium is an electrolyte that can cause serious adverse effects such as cardiac arrhythmias,
respiratory depression, and muscle weakness if infused too rapidly or too slowly. An IV pump is necessary to control the infusion rate and prevent magnesium toxicity or deficiency.
Choice D reason: Regular insulin is a hormone that regulates blood glucose levels and requires careful titration based on frequent blood glucose monitoring. An IV pump is required to deliver insulin at a consistent and adjustable rate to avoid hypoglycemia or hyperglycemia.
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