A nurse in an emergency department is performing triage on a group of clients.
Which of the following clients should the nurse see first?
A client who has heart failure and peripheral edema.
A client who has cirrhosis of the liver and bruising on their arms.
A client who reports urinary burning and a temperature of 39.2° C (102.5° F).
A client who has a new onset of atrial fibrillation and a heart rate of 152/min.
The Correct Answer is D
Atrial fibrillation with a rapid heart rate can lead to decreased cardiac output and compromised blood flow, which can have serious consequences, including stroke and heart failure. Therefore, this client requires immediate attention to assess and manage the cardiac rhythm.
While the other clients also have significant health concerns, they are not as acutely life-threatening as a new onset of atrial fibrillation with a high heart rate. Prioritizing care based on the urgency and severity of the condition is crucial in the emergency department setting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Standards of care for monitoring clients with a history of blood pressure elevation are important, but they are not the best resource for health promotion activities for clients with hypertension. This choice is more focused on monitoring and care standards.
Choice B rationale:
A critical pathway for clients who have had a stroke is specific to a different condition and not related to health promotion for clients with hypertension. It does not provide the information needed for the presentation.
Choice C rationale:
Acute care facility protocol for clients experiencing a hypertensive crisis is important for managing emergencies, but it is not the best resource for health promotion activities. It deals with crisis management rather than prevention.
Choice D rationale:
Clinical practice guidelines for the management of high blood pressure are the most appropriate resource for the nurse's presentation on health promotion activities for clients with hypertension. These guidelines provide evidence-based recommendations for managing and preventing high blood pressure, making them the best choice for the presentation. .
Correct Answer is C
Explanation
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