A nurse in the emergency department is triaging four clients. Which of the following clients should the nurse recommend to be examined first?
An adolescent client who has an injured ankle and reports a pain level of 8 on a scale from 0 to 10
A toddler who has a 2 cm (0.79 in) head laceration oozing dark red blood
An older adult client who has dyspnea and a respiratory rate of 26/min
An adult client who has large ecchymoses on both legs
The Correct Answer is C
A. An ankle injury with pain is painful but not life-threatening. This client can safely wait.
B. A 2 cm head laceration with dark red blood suggests venous bleeding and is not emergent unless signs of more serious head injury are present.
C. An older adult client with dyspnea and a respiratory rate of 26/min should be examined first. Dyspnea (shortness of breath) and elevated respiratory rate indicate possible respiratory distress or a life-threatening condition such as pulmonary embolism, heart failure, or pneumonia. Airway and breathing issues always take priority.
D. Ecchymoses (bruising) could suggest a bleeding or clotting disorder but are not immediately life-threatening without other symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The first step in conflict resolution is to assess and understand the situation fully. This includes gathering facts from all parties involved before taking action or proposing solutions.
B.Meeting with a committee may be a helpful step later in the process, but not before the manager has all relevant information.
C.While encouraging autonomy is valuable, unresolved conflicts often need structured intervention—especially when affecting team dynamics across shifts.
D.Acknowledging the conflict is important, but doing so without first understanding the root causes may lead to ineffective or superficial resolution.
Correct Answer is A
Explanation
A.Pouching an established ostomy is a routine, non-invasive task that can be safely delegated to an assistive personnel.
B.Updating family members about a client’s condition requires nursing knowledge and communication skills and should not be delegated.
C.Reinforcing teaching involves nursing judgment and is not appropriate to delegate to assistive personnel.
D.Demonstrating use of an incentive spirometer requires teaching skills and should be performed by the nurse.
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