A client arrives in the Emergency Department via ambulance with the following signs: central cyanosis, HR 42, BP 80/50. What priority level should the nurse identify for this client?
Third level priority
First level priority
Routine
Second level priority
The Correct Answer is B
A. This category refers to non-urgent problems, which does not apply here as the client is showing signs of severe distress and requires immediate attention.
B. Central cyanosis, a low heart rate (bradycardia), and low blood pressure are life-threatening signs that necessitate immediate intervention to stabilize the patient.
C. This is not a routine or minor situation. The client is in critical condition and requires urgent intervention.
D. While second-level priorities are important, this patient has life-threatening signs requiring first-level priority, immediate action, and stabilization.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A tear in the rotator cuff usually results in pain and limited range of motion, but it doesn't typically cause a length discrepancy in the arms.
B. Also known as frozen shoulder, this condition is characterized by limited range of motion but would not cause a discrepancy in arm length.
C. While joint effusion involves fluid accumulation and can cause pain and swelling, it doesn't cause arm length discrepancy or the sudden inability to move the shoulder.
D. A dislocated shoulder often results in an obvious deformity, such as a length discrepancy between the arms, and could prevent movement due to pain.
Correct Answer is D
Explanation
A. While this can be uncomfortable and may require attention, it is not typically considered an emergency unless accompanied by severe pain, vomiting, or other concerning symptoms.
B. Insomnia or difficulty sleeping can significantly impact a person's quality of life, but it is not usually an immediate threat to health.
C. While it is important to assess and manage the underlying cause, it is not usually an immediate emergency unless it is accompanied by other severe symptoms like shortness of breath or chest pain.
D. This finding suggests the early stages of pressure ulcer development, which can rapidly progress if not addressed promptly. Immediate intervention is crucial to prevent further tissue damage and complications.
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