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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: A subtotal thyroidectomy is a major surgery that involves the removal of part of the thyroid gland. The client may have complications such as bleeding, infection, hypocalcemia, or vocal cord damage. The client also needs close monitoring of vital signs, blood transfusion, and airway patency. This client is not stable enough to be transferred to a general unit.
Choice B Reason: A combined partial and full-thickness burn is a serious injury that involves damage to the epidermis, dermis, and underlying tissues. The client may have complications such as infection, fluid loss, hypovolemia, shock, or respiratory distress. The client also needs wound care, pain management, fluid replacement, and oxygen therapy. This client is not stable enough to be transferred to a general unit.
Choice C Reason: A renal transplant is a major surgery that involves the replacement of a diseased kidney with a healthy one from a donor. The client may have complications such as rejection, infection, bleeding, thrombosis, or urinary obstruction. The client also needs immunosuppressive therapy, anti-infective therapy, fluid and electrolyte balance, and pain management. This client is not stable enough to be transferred to a general unit.
Choice D Reason: Nephrotic syndrome is a kidney disorder that causes excessive protein loss in the urine, leading to low serum protein levels and edema. The client may have complications such as infection, thromboembolism, or malnutrition. The client needs diuretic therapy, protein replacement, dietary modification, and infection prevention. This client is relatively stable and can be transferred to a general unit.
Correct Answer is D
Explanation
Choice A reason: Demonstrating the proper use of personal protective equipment is important, but not the first action. The charge nurse should first assess the UAP's level of understanding and address any misconceptions or fears about HIV transmission.
Choice B reason: Offering to assist the UAP with the collection of the specimen may be helpful, but not the first action. The charge nurse should first educate the UAP about HIV transmission and infection control measures, and then evaluate the UAP's competence and confidence in performing the task.
Choice C reason: Providing the UAP with the infection control policy is relevant, but not the first action. The charge nurse should first explain the rationale and principles of infection control to the UAP, and then refer to the policy as a guideline and resource.
Choice D reason: Determining the UAP's knowledge about HIV transmission is the first and most appropriate action for the charge nurse to take, as it will help identify any gaps or misinformation that may cause fear or anxiety in the UAP. The charge nurse should then provide accurate and evidence-based information about HIV transmission, prevention, and treatment, and answer any questions or concerns that the UAP may have.
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