A nurse is triaging clients in the emergency department. Which client should be considered "urgent"?

A client with chest pain and cool, clammy skin.

A client with severe abdominal pain.

A client who is dyspneic with audible wheezing.

A client with a localized macular rash to wrist.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Chest pain accompanied by cool, clammy skin is a classic sign of a potentially life-threatening cardiac event, such as myocardial infarction. These clients require immediate intervention to prevent death or severe complications. In triage systems, this type of patient is categorized as emergent or red, indicating the highest priority for care.

B. Severe abdominal pain indicates a serious medical condition that needs timely evaluation, such as appendicitis, bowel obstruction, or pancreatitis, but it is not necessarily immediately life-threatening if the patient is stable with normal vital signs. In triage, this client would be categorized as urgent or yellow, meaning they require prompt assessment and intervention to prevent complications but do not require immediate resuscitation.

C. Dyspnea with audible wheezing may indicate acute airway compromise, such as severe asthma or anaphylaxis, which is potentially life-threatening. These clients are prioritized as emergent (red) because any delay could result in respiratory failure or death.

D. A localized rash without other systemic symptoms is generally a minor, non-urgent problem. This client can safely wait for care and would be triaged as non-urgent (green).

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Correct Answer is B

Explanation

Rationale:

A. Neurological status is important to assess, as hypoxemia can lead to confusion or altered mental status. However, this is a secondary assessment after identifying and addressing the primary cause of hypoxemia. It is not the first action.

B. Lung sounds should be assessed first because the client is experiencing shortness of breath with a low oxygen saturation (88%, below the normal 95–100%). In acute pancreatitis, respiratory complications such as pleural effusion or acute respiratory distress syndrome (ARDS) can develop. Assessing lung sounds immediately helps determine the cause of hypoxemia, guides oxygen therapy, and identifies the need for urgent interventions like supplemental oxygen or respiratory support.

C. Abdominal girth and tenderness are relevant for monitoring pancreatitis progression and ascites, but these assessments do not directly address the acute respiratory compromise. They are not the first priority in a client with hypoxemia.

D. Vital signs for hypotension and tachycardia are important because circulatory instability can worsen oxygen delivery. While vital signs should be checked promptly, auscultating lung sounds provides more specific information about respiratory compromise, which is the immediate priority in a client with low oxygen saturation.

A. Call the hospital social worker. B. Recommend grief counseling groups C. Recommend starting antidepressant medications D. Call the mother's religious leader for support.

Correct Answer is C

Explanation

Rationale:

A. Social workers are trained to provide emotional support, help the family navigate practical matters after a death, and connect them with grief resources. This is a supportive and professional intervention.

B. Support groups can provide comfort, normalize the grieving process, and allow the mother to share experiences with others who have faced similar losses. This is a non-invasive and helpful intervention.

C. Recommending antidepressants immediately is inappropriate because normal grief is not a psychiatric disorder and does not automatically require pharmacologic treatment. Prescribing or suggesting medication without a thorough assessment by a qualified provider can be harmful and may pathologize a natural grieving process.

D. Spiritual support can provide comfort, guidance, and coping strategies in accordance with the mother’s beliefs. It is an acceptable and culturally sensitive intervention.

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A nurse is triaging clients in the emergency department. Which client should be considered "urgent"?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client with acute pancreatitis who reports increased shortness of breath and has an oxygen saturation level of 88%. What should the nurse assess first?

Correct Answer is B

Explanation

A client dies in the emergency department. The client's mother states that she is overwhelmed and doesn't know how to proceed since she has never had a death in the family before. Which action should the nurse avoid?

Correct Answer is C

Explanation

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