Try Naxlex NCLEX-RN (Free-Trial)

A nurse is assessing a group of clients. Which of the following clients should be categorized as Emergency Severity Index Level 1?

Client D ran out of diuretics yesterday. The client's blood pressure is 136/84, heart rate is 88/min, respiratory rate is 18/min, and pulse oximetry is 95%

Client B is obese and has right lower leg pain and swelling. The client's heart rate is 76/min and regular, blood pressure is 126/78, respiratory rate is 18/min, and pulse oximetry is 96%.

Client A reports dizziness and confusion. The client's heart rate is 120/min and irregular, blood pressure is 88/52, respiratory rate is 26/min, and pulse oximetry is82%

Client C reports a urinary tract infection (UTI). The client's heart rate is 72/min, blood pressure is 110/70, respiratory rate is 15/min, and pulse oximetry is 98%.

Answer and Explanation

The Correct Answer is C

A. Client D ran out of diuretics yesterday. The client's blood pressure is 136/84, heart rate is 88/min, respiratory rate is 18/min, and pulse oximetry is 95%: This client is stable with normal vital signs and does not show evidence of immediate life-threatening conditions. Although running out of diuretics may require prompt attention, it does not qualify as ESI Level 1.
B. Client B is obese and has right lower leg pain and swelling. The client's heart rate is 76/min and regular, blood pressure is 126/78, respiratory rate is 18/min, and pulse oximetry is 96%: This presentation could indicate a deep vein thrombosis, which is serious but not immediately life-threatening. The client is hemodynamically stable and does not meet the criteria for ESI Level 1.
C. Client A reports dizziness and confusion. The client's heart rate is 120/min and irregular, blood pressure is 88/52, respiratory rate is 26/min, and pulse oximetry is 82%: This client shows signs of hemodynamic instability, including hypotension, hypoxia, altered mental status, and an irregular, rapid heart rate. These findings indicate a critical condition requiring immediate life-saving interventions, qualifying the client for ESI Level 1.
D. Client C reports a urinary tract infection (UTI). The client's heart rate is 72/min, blood pressure is 110/70, respiratory rate is 15/min, and pulse oximetry is 98%: This client is stable with no signs of systemic or life-threatening complications. UTI symptoms can be uncomfortable but are not immediately life-threatening if vital signs are normal.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","C","D","E"]

Explanation

A. Maintain ventriculostomy at the correct position: It is critical to ensure the ventriculostomy drainage system is maintained at the prescribed height (usually at the level of the external auditory meatus) to accurately measure intracranial pressure (ICP) and safely drain cerebrospinal fluid. Incorrect positioning can lead to over- or under-drainage, which could worsen the client’s neurological status.
B. Elevate the head of the bed to 15%: Elevation of the head of the bed is recommended to promote venous drainage and reduce ICP, but 15% is too low to be effective. The recommended elevation is generally 30 degrees, not 15%, for optimal ICP management in clients with TBI. Elevating it only 15% may not sufficiently reduce intracranial pressure.
C. Maintain enteral feedings: Clients with TBI are at high risk for malnutrition due to increased metabolic demands. Early enteral nutrition supports healing, maintains gut integrity, and prevents complications such as infection or poor wound healing. It is an essential part of TBI care.
D. Administer pain medication as needed: Pain and agitation can increase ICP. Administering pain medications as needed helps control these stressors, thereby maintaining a more stable intracranial environment. Proper pain control is a key aspect of neuroprotection.
E. Maintain the neck in the midline position: Keeping the neck in a neutral midline position helps promote cerebral venous drainage and reduces the risk of increased ICP. Neck flexion or rotation can obstruct venous outflow and worsen intracranial hypertension, making this a vital positioning intervention.

A. Anxiety, unintended weight loss, palpitations B. Fatigue, constipation, weight gain C. Increased thirst, increased urine output, and weight los D. Shakiness, sweating, nausea

Correct Answer is B

Explanation

A. Anxiety, unintended weight loss, palpitations: These symptoms are consistent with hyperthyroidism, where excess thyroid hormone speeds up metabolism. Hyperthyroidism is typically associated with low TSH levels due to negative feedback suppression of the pituitary gland.
B. Fatigue, constipation, weight gain: These are classic symptoms of hypothyroidism, where a deficiency of thyroid hormones slows metabolic processes. An elevated TSH level reflects the pituitary's response to low circulating thyroid hormone, attempting to stimulate the thyroid to produce more.
C. Increased thirst, increased urine output, and weight loss: These symptoms point to hyperglycemia or conditions like diabetes mellitus, not thyroid dysfunction. They are due to glucose imbalances rather than altered thyroid hormone or TSH levels.
D. Shakiness, sweating, nausea: These symptoms are typically seen in hypoglycemia or acute adrenal issues, where blood glucose or cortisol levels drop. They do not correspond with thyroid hormone imbalances or elevated TSH.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assessing a group of clients. Which of the following clients should be categorized as Emergency Severity Index Level 1?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a traumatic brain injury (TBI). Which of the following nursing interventions should be added to the plan of care? (Select All that Apply.)

Correct Answer is ["A","C","D","E"]

Explanation

A nurse is reviewing laboratory results and notes that a client has an elevated thyroid-stimulating hormone (TSH) level. Which of the following assessment findings would the nurse expect?

Correct Answer is B

Explanation

A nurse is providing a presentation to colleagues on emphysema. Which of the following subtypes should the nurse identify as having a complication of pneumothorax?

A nurse is assessing a client who has tension pneumothorax. Which of the following findings should the nurse expect following tracheal deviation?

A nurse is caring for a client who has acute respiratory distress syndrome (ARDS). The nurse should identify which of the following changes are characteristic of cellular damage to the pulmonary epithelium? (Select All that Apply.)

A nurse is providing teaching to a client who has a new diagnosis of Crohn's disease. Which of the following statements by the nurse provides the most simplistic and non-medical description of the disorder?

Which of the following could the nurse expect to observe in an older adult client who has a pneumothorax?

A nurse is preparing to discharge a client who was treated for sexual assault. Prior to discharge, which of the following actions should the nurse plan to take?

A nurse is caring for a client who has a cerebral aneurysm. In the event of a ruptured cerebral aneurysm, which of the following manifestations would be present in the client? (Select all that Apply.)

A nurse is providing discharge teaching for a client who has hyperosmolar hyperglycemic syndrome (HHS). Which of the following topics should be prioritized for teaching?