A nurse is triaging clients in the emergency department. Which of the following clients should the nurse ask the healthcare provider to care for first?

A client who has acute tonsillitis, is drooling, and has difficulty swallowing

A client who sustained a deep laceration to their leg and is complaining of dizziness and weakness

A client who has chronic obstructive pulmonary disease (COPD) with a pulse oximetry reading of 88%

A client who has lower left abdominal pain and bloody stools

Answer and Explanation

The Correct Answer is A

A. A client who has acute tonsillitis, is drooling, and has difficulty swallowing: This client is likely experiencing severe swelling or an airway obstruction, which requires immediate attention to ensure the airway is not compromised.
B. A client who sustained a deep laceration to their leg and is complaining of dizziness and weakness: While this client has concerning symptoms, airway compromise is prioritized in triage.
C. A client who has chronic obstructive pulmonary disease (COPD) with a pulse oximetry reading of 88%: This client is hypoxic and requires prompt intervention, but airway issues take precedence.
D. A client who has lower left abdominal pain and bloody stools: This client may have a serious condition but does not require as immediate intervention as a compromised airway.

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Correct Answer is B

Explanation

A. Extreme abdominal pain with intercourse: This is less specific for endometrial cancer and more indicative of conditions such as pelvic inflammatory disease or endometriosis.
B. Postmenopausal bleeding: This is correct. Postmenopausal bleeding is a common symptom of endometrial cancer and warrants further evaluation.
C. Decreased white blood cell count: This is incorrect. Endometrial cancer does not typically present with a decreased white blood cell count; it may present with normal or elevated levels depending on the stage and presence of infection.
D. Bilateral swelling on the posterior of the vulva: This is incorrect. Swelling of the vulva is not characteristic of endometrial cancer but may be associated with other gynecological issues.

A. Instruct the client to change clothing before arriving. B. Inform the client that photographs of any injuries will be mandatory for a police report. C. Ask the client to repeat the information obtained during admission. D. Obtain a history of the incident from the client.

Correct Answer is D

Explanation

A. Instruct the client to change clothing before arriving: This is incorrect. The client should keep the clothing worn during the assault as it may contain crucial evidence.
B. Inform the client that photographs of any injuries will be mandatory for a police report: This is incorrect. While evidence collection is important, it should be done with the client’s consent and consideration of their emotional state.
C. Ask the client to repeat the information obtained during admission: This is incorrect. Asking the client to repeat information can be traumatic. The history should be obtained sensitively and only as needed.
D. Obtain a history of the incident from the client: This is correct. The nurse needs to gather information to provide appropriate care and ensure evidence is collected properly. This should be done in a supportive and respectful manner.

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A nurse is triaging clients in the emergency department. Which of the following clients should the nurse ask the healthcare provider to care for first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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