A nurse is prioritizing client care after receiving a change-of-shift report. Which of the following clients should the nurse plan to see first?
A client who told an assistive personnel he is short of breath
A client who has a prescription for discharge
A client who received oral pain medication 30 minutes ago
A client who is scheduled for an abdominal x-ray and is awaiting transport
The Correct Answer is A
Choice A reason (client care): A client reporting shortness of breath may be experiencing a life-threatening situation that aligns with the ABCs (Airway, Breathing, Circulation) of patient prioritization. This client requires immediate assessment and intervention.
Choice B reason (client care): While discharge is important, it does not take precedence over a client with potential respiratory distress.
Choice C reason (client care): A client who received pain medication 30 minutes ago is likely stable and can be seen after more urgent cases are addressed.
Choice D reason (client care): A client waiting for an abdominal x-ray is not a priority over a client with respiratory issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
Choice A reason: This description is too clinical and not the simplest explanation.
Choice B reason: This statement is medically accurate but not the most simplistic description.
Choice C reason: Comparing Crohn's disease to a second-degree burn is not accurate as it does not only affect the colon and rectum.
Choice D reason: Describing Crohn's disease as having the appearance of a patchwork quilt with some areas clear and some with sores provides a simple visual that is easy to understand without medical knowledge.
Correct Answer is A
Explanation
Choice A reason: Stopping the transfusion immediately is the first and most critical action in response to signs of a possible transfusion reaction, which can be life-threatening.
Choice B reason: While informing the provider is a necessary step, it should come after stopping the transfusion to prevent further harm to the patient.
Choice C reason: Calling the lab is an appropriate action but not the first priority. The immediate concern is the patient's safety.
Choice D reason: Obtaining a urine specimen may be part of the diagnostic process for a transfusion reaction, but it is not the first action to take.
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