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 reports frequent and painful urination
A client who reports left arm pain following a fall
A client who has hypertension and reports a severe headache
A client who has heart failure and received a diuretic 30 min ago
The Correct Answer is C
Rationale:
A. A client who reports frequent and painful urination: This client likely has a urinary tract infection, which requires assessment and treatment but is not immediately life-threatening.
B. A client who reports left arm pain following a fall: Pain from trauma requires evaluation, but unless there are signs of impaired circulation or severe injury, it is lower priority than potential neurologic emergencies.
C. A client who has hypertension and reports a severe headache: A severe headache in a client with hypertension may indicate a hypertensive crisis or impending stroke. Immediate assessment is required to prevent life-threatening complications, making this the highest priority.
D. A client who has heart failure and received a diuretic 30 min ago: Monitoring is necessary to assess diuretic effects, but this client is stable and does not require immediate intervention compared with the client at risk for hypertensive emergency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
Rationale for Correct Choices
• Endometritis: The client’s postpartum course—cesarean delivery, prolonged rupture of membranes, and postpartum Day 3 fever—places her at high risk for endometritis, a uterine infection. Signs include uterine tenderness, boggy fundus, and foul-smelling lochia.
• Uterus and lochia assessment: The firm but tender uterus with boggy areas and moderate dark brown, foul-smelling lochia are classic indicators of endometritis. These assessment findings directly reflect the infection within the uterine cavity and help guide immediate intervention.
Rationale for Incorrect Choices
• Mastitis: While the client reports firm, warm breasts with nipple discomfort, these symptoms alone without localized redness, unilateral involvement, or systemic malaise are not sufficient to diagnose mastitis. The uterine and lochia findings are more indicative of endometritis.
• Postpartum hemorrhage: Although uterine atony can cause bleeding, the client’s fundus is firm after massage and the lochia is moderate, making hemorrhage less likely at this point. Hemoglobin remains within normal limits, further reducing the likelihood of acute postpartum hemorrhage.
• Fever: Fever is a symptom rather than a diagnosis. While present (38.2° C), it supports the presence of infection but does not specify which type, so it is not the best standalone choice for the evidence used to identify the condition.
• Elevated WBC (markedly 33,000/mm3) confirm a systemic infection, it is a general sign of infection that could apply to any source (e.g., wound or mastitis). The assessment of the uterus and lochia specifically localizes the infection to the reproductive tract.
Correct Answer is ["A","D","E"]
Explanation
Rationale:
A. Assess the client's lung sounds prior to the infusion: Baseline lung assessment helps detect early signs of fluid overload or transfusion-associated circulatory overload (TACO), which is especially important in older adults.
B. Prime the infusion tubing with 0.45% sodium chloride: Only 0.9% sodium chloride (normal saline) is compatible with blood products. Hypotonic solutions such as 0.45% sodium chloride can cause hemolysis of red blood cells.
C. Don sterile gloves to prepare the blood administration setup: Clean gloves are sufficient for preparing and administering blood transfusions. Sterile gloves are not required unless performing a sterile procedure.
D. Verify with another nurse that the unit of blood is compatible with the client's blood type: Double verification of the client’s identity and blood compatibility prevents hemolytic transfusion reactions due to mismatched blood.
E. Infuse the blood over 4 hr: Each unit of packed RBCs should be transfused within no more than 4 hours to reduce the risk of bacterial contamination and hemolysis from prolonged infusion.
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