A client assigned the category of nonurgent in the emergency department, begins to have shortness of breath and is dizzy. What should be done to assist this client?

Immediately reassess the client and assign the category of urgent.

Remind the individual to be client and wait to be seen.

Immediately reassess the client and begin resuscitation.

Immediately reassess the client and assign the category of emergent.

Answer and Explanation

The Correct Answer is D

Rationale:

A. “Urgent” indicates the client needs timely evaluation but is not at immediate risk of life or limb. Shortness of breath and dizziness suggest a potentially life-threatening deterioration, requiring a higher priority than urgent.

B. This is unsafe. The client is showing new signs of acute distress, and waiting could result in further deterioration or death. Immediate reassessment and escalation are required.

C. While resuscitation may be needed if the client is hemodynamically unstable, the first step is to reassess and triage appropriately. Resuscitation is initiated based on findings from reassessment, not automatically for all clients with shortness of breath and dizziness.

D. The client’s new symptoms of shortness of breath and dizziness indicate potential life-threatening complications. In the triage system, the category of emergent is reserved for clients whose conditions could rapidly worsen or threaten life or limb. Immediate reassessment allows the nurse to identify vital sign changes, begin interventions if needed, and escalate care appropriately, ensuring the client is seen promptly.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. Applying moisturizer is a non-invasive, routine hygiene measure that falls within the scope of practice of unlicensed assistive personnel (UAP). It helps relieve pruritus by reducing skin dryness and can be safely delegated.

B. This is incorrect because applying prescription medications requires nursing judgment and knowledge of the medication, dose, and timing. This task must be performed by a licensed nurse.

C. This is incorrect because increasing room temperature may actually worsen pruritus, as heat can aggravate itching. Additionally, adjusting environmental controls for therapeutic purposes is part of the nurse’s assessment and planning, not a delegated task.

D. This is incorrect because hot baths can worsen pruritus and damage already sensitive skin. Bathing interventions should be guided by the nurse to ensure safety and appropriate temperature and products are used.

A. New onset of lightheadedness B. Complaints of right shoulder pain C. Heart rate of 116 beats per minute D. Requesting more water to drink E. A wide pulse pressure F. Respiratory rate of 28 breaths per minute

Correct Answer is ["A","B","C","F"]

Explanation

Rationale:

A. New onset of lightheadedness is a key sign of hypovolemia due to internal bleeding. Blood loss decreases circulating volume, leading to decreased perfusion to the brain and dizziness or syncope. This supports the suspicion of internal hemorrhage from liver trauma.

B. Complaints of right shoulder pain (Kehr’s sign) can indicate referred pain from diaphragmatic irritation due to blood in the peritoneal cavity, commonly associated with liver or spleen trauma. This is an important clinical cue supporting internal bleeding.

C. Heart rate of 116 beats per minute indicates tachycardia, a compensatory response to hypovolemia. The body increases heart rate to maintain cardiac output when blood volume decreases, which is consistent with bleeding.

D. Requesting more water to drink is not directly related to liver trauma or internal bleeding. While thirst may occur with mild fluid loss, it is nonspecific and not a reliable cue for acute hemorrhage.

E. A wide pulse pressure (the difference between systolic and diastolic BP) is not typically associated with acute hemorrhage. In early blood loss, blood pressure is often normal or low-normal, and pulse pressure may narrow, not widen.

F. Respiratory rate of 28 breaths per minute indicates tachypnea, which can occur as a compensatory mechanism for hypovolemia and tissue hypoxia. Increased respiratory rate helps improve oxygen delivery when perfusion is compromised due to bleeding.

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A client assigned the category of nonurgent in the emergency department, begins to have shortness of breath and is dizzy. What should be done to assist this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses a client with severe pruritus as a complication of cirrhosis. Which intervention should the nurse delegate to the unlicensed assistive personnel?

Correct Answer is A

Explanation

The nurse suspects that a client who presented to the emergency department is experiencing bleeding from liver trauma, Which cues support the nurse's suspicion? Select all that apply.

Correct Answer is ["A","B","C","F"]

Explanation

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