A nurse in an emergency department is receiving report for four clients. Which of the following clients should the nurse see first?

A client who has heart failure and received a diuretic 30 min ago

A client who has hypertension and reports a severe headache

A client who reports frequent and painful urination

A client who reports left arm pain following a fall

Answer and Explanation

The Correct Answer is B

Rationale:

A. A client who has heart failure and received a diuretic 30 min ago: While this client should be monitored for urine output and signs of dehydration or electrolyte imbalance, there is no indication of acute distress requiring immediate attention.

B. A client who has hypertension and reports a severe headache: This could indicate a hypertensive crisis or impending stroke, both of which are life-threatening and require urgent assessment and intervention to prevent neurological damage or organ failure.

C. A client who reports frequent and painful urination: These are signs of a urinary tract infection, which, while uncomfortable, is not typically emergent unless accompanied by fever, flank pain, or systemic symptoms.

D. A client who reports left arm pain following a fall: The arm pain may indicate a fracture, but it is less urgent than potential end-organ damage from a hypertensive emergency, assuming no deformity or vascular compromise is described.

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Correct Answer is D

Explanation

Rationale:

A. "Every so often, I think about whether or not to have this surgery.": This statement suggests the client is still ambivalent or uncertain, which means informed consent has not yet been fully achieved. Clients must be sure and fully informed before agreeing to proceed.

B. "I will talk with the doctor about my surgery when I get into the operating room.": Informed consent must be obtained well before the procedure begins. Waiting until the operating room is inappropriate, as the client may be under stress or sedation.

C. "Can you tell me more about the surgery I am having?": This indicates the client lacks essential information about the procedure. Informed consent requires that the client already understand the nature, risks, benefits, and alternatives before signing.

D. "Signing this form indicates that I give my permission for the surgery, right?": This reflects an understanding that the consent form gives legal authorization for the procedure. It shows the client knows their signature confirms informed agreement to the surgery.

A. Administer the medication as prescribed. B. Discuss the prescription with the health care provider. C. Call the pharmacist for clarification of the medication contraindications. D. Place an incident report in the medical record.

Correct Answer is B

Explanation

Rationale:

A. Administer the medication as prescribed: Administering amoxicillin to a client with a penicillin allergy can result in serious allergic reactions, including rash, hives, or anaphylaxis. Amoxicillin is a penicillin derivative, it is contraindicated in patients with penicillin allergies.

B. Discuss the prescription with the health care provider: The nurse must clarify potentially harmful prescriptions directly with the provider. This ensures patient safety by verifying if the medication should be changed, considering the client’s documented allergy to penicillin.

C. Call the pharmacist for clarification of the medication contraindications: While pharmacists can verify drug classes and potential reactions, they do not have the authority to discontinue or modify a prescription. Only the healthcare provider can make necessary changes to an order.

D. Place an incident report in the medical record: Incident reports are meant for internal documentation and are never placed in the client’s medical record. Since the error has not occurred yet, prevention through provider consultation is the priority action.

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A nurse in an emergency department is receiving report for four clients. Which of the following clients should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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