A nurse working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first?

An older adult client who reports constipation of 4 days

A preschooler who has a skin rash

An adolescent who has a closed fracture

A middle adult client who has unstable vital signs

Answer and Explanation

The Correct Answer is D

- A. This choice is incorrect because an older adult client who reports constipation of 4 days is not an urgent situation that requires immediate attention. The nurse should assess the client's hydration status, bowel habits, and medication use, and provide education on dietary and lifestyle modifications to prevent constipation.

- B. This choice is incorrect because a preschooler who has a skin rash is not an urgent situation that requires immediate attention. The nurse should assess the type, location, and distribution of the rash, as well as any history of allergies, exposure, or infection, and provide appropriate treatment and education.

- C. This choice is incorrect because an adolescent who has a closed fracture is not an urgent situation that requires immediate attention. The nurse should assess the site of injury, neurovascular status, pain level, and immobilization device, and provide analgesia and education on fracture care.

- D. This choice is correct because a middle adult client who has unstable vital signs is an urgent situation that requires immediate attention. The nurse should assess the client's level of consciousness, airway, breathing, circulation, and possible causes of instability, and initiate lifesaving interventions.

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Correct Answer is C

Explanation

Choice A rationale:

This statement implies that the nurse attempted the dressing change but was unsuccessful. However, the information about the dressing not being soiled is irrelevant to the incident report. The key issue is the omission of the prescribed procedure.

Choice B rationale:

This statement acknowledges the omission but lacks specificity. It does not state the nature of the omission or the potential consequences, making it less informative for future prevention strategies.

Choice C rationale:

This statement clearly and concisely states the situation, indicating that the prescribed dressing change was omitted. It provides essential information for understanding what happened, allowing for appropriate investigation and preventive measures.

Choice D rationale:

This statement confirms the completion of the incident report but does not provide details about the incident itself. Without specific information about the omission, this statement is insufficient for understanding the nature of the error and implementing preventive actions.

A. Decreased blood pressure B. Decreased hallucinations C. Decreased cholesterol D. Decreased esophageal reflux

Correct Answer is B

Explanation

- A: Incorrect. Decreased blood pressure is not an indication of chlorpromazine effectiveness, but rather a potential adverse effect that should be monitored and reported.

- B: Correct. Decreased hallucinations are an indication of chlorpromazine effectiveness, as this medication is an antipsychotic that blocks dopamine receptors in the brain and reduces psychotic symptoms such as hallucinations, delusions, and paranoia.

- C: Incorrect. Decreased cholesterol is not an indication of chlorpromazine effectiveness, but rather a potential benefit that may occur due to its effect on lipid metabolism.

- D: Incorrect. Decreased esophageal reflux is not an indication of chlorpromazine effectiveness, but rather a potential adverse effect that should be avoided by taking the medication with food or water and avoiding lying down after administration.

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A nurse working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is creating an incident report due to an accidental omission of a client's dressing change during the previous shift. Which of the following statements should the nurse document on the incident report form?

Correct Answer is C

Explanation

A nurse is caring for a client who has a prescription for chlorpromazine. Which of the following findings should the nurse identify as an indication that the medication is effective?

Correct Answer is B

Explanation

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