A nurse in an emergency department is assessing four clients. Which of the following clients should the nurse see first?
A client who reports a sudden onset of dizziness when sitting up
A client who has new onset urticaria and angioedema
A client who has numerous rectal polyps and blood-tinged stools
A client who has a subluxation of the fifth digit on the left foot
The Correct Answer is B
Rationale:
A. A client who reports a sudden onset of dizziness when sitting up: Although concerning, dizziness on position change may indicate orthostatic hypotension and is not immediately life-threatening. This client requires monitoring but is not the top priority based on airway or circulatory compromise.
B. A client who has new onset urticaria and angioedema: New urticaria and angioedema suggest a potential anaphylactic reaction, which can quickly progress to airway obstruction. This is a life-threatening emergency requiring immediate intervention to secure the airway and administer epinephrine.
C. A client who has numerous rectal polyps and blood-tinged stools: This condition could indicate a colorectal condition such as polyposis or malignancy, but it is not acutely life-threatening. The client needs evaluation, but not before those with airway or circulatory risks.
D. A client who has a subluxation of the fifth digit on the left foot: A subluxation is a partial dislocation, which can be painful but does not involve vital organ systems. This musculoskeletal issue is stable and can be addressed after more urgent needs are met.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. “The client exhibits impulsive behavior.” Impulsivity is a hallmark trait of borderline personality disorder (BPD). Clients may engage in risky behaviors such as substance abuse, binge eating, or reckless driving, often in response to emotional instability and fear of abandonment.
B. “The client is overly concerned about minor details.” This behavior is more characteristic of obsessive-compulsive personality disorder, where clients show perfectionism and a rigid adherence to rules, order, and control over details.
C. “The client might act seductively.” Seductive or provocative behavior is commonly seen in histrionic personality disorder. These clients seek attention and approval through exaggerated emotional expression and flirtatiousness.
D. “The client is exceptionally clingy to others.” Clinginess and an excessive need to be taken care of are features of dependent personality disorder. These individuals have difficulty making decisions independently and fear separation or rejection.
Correct Answer is B
Explanation
Rationale:
A. “I can infuse the medication at a faster rate”: Vancomycin must be infused slowly, typically over 60–120 minutes, to prevent adverse effects such as Red Man Syndrome. Increasing the infusion rate is unsafe and not appropriate.
B. “I can start the medication 30 minutes earlier.” Medications such as IV antibiotics (including vancomycin) must be administered within an acceptable time window to maintain therapeutic drug levels and effectiveness. The standard safe administration window is typically ±30 minutes from the scheduled time. Therefore, giving the medication 2 hours early is not appropriate, but 30 minutes earlier is acceptable and safe.
C. “I have up to 2 hours after the usual scheduled time to give you this medication”: While some medications have extended windows, IV antibiotics like vancomycin require strict timing, and a 2-hour delay is not appropriate.
D. “I can adjust the time and schedule for when it's convenient for you.” While patient preferences are important, antibiotic timing must align with dosing schedules to maintain therapeutic levels. Adjustments must follow clinical guidelines, not personal convenience.
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