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

Explore the client's reasons for refusing the treatment.

A. Documenting the client's refusal in the medical record is an important action, but not the first one. The nurse should first try to understand the client's perspective and address any concerns or misconceptions they might have about the blood transfusion. This choice is incorrect.
B. Honoring the client's decision to refuse the blood transfusion is a respectful and ethical action, but not the first one. The nurse should first attempt to educate and persuade the client about the benefits and risks of the treatment, and respect their autonomy only after ensuring that they have made an informed decision. This choice is incorrect.
C. Exploring the client's reasons for refusing the treatment is the first action that the nurse should take. The nurse should use effective communication skills to elicit the client's beliefs, values, fears, and preferences regarding the blood transfusion, and provide factual and evidencebased information to address any knowledge gaps or misconceptions. The nurse should also assess the client's decision-making capacity and determine if they are competent to refuse the treatment. This choice is correct.
D. Discussing the client's refusal with the provider is an appropriate action, but not the first one. The nurse should first try to resolve the issue with the client directly, and involve the provider only if they are unable to do so or if there are legal or ethical implications that require further consultation. This choice is incorrect.

A. Chest x-ray B. Serum liver enzyme levels C. ABGS D. Urine culture and sensitivity

Correct Answer is B

Explanation

- A. Chest x-ray is not correct because it is not related to valproic acid therapy or its adverse effects.

- B. Serum liver enzyme levels is correct because valproic acid can cause hepatotoxicity and liver function tests should be monitored regularly.

- C. ABGS is not correct because it is not indicated for valproic acid therapy or its adverse effects.

- D. Urine culture and sensitivity is not correct because it is not related to valproic acid therapy or its adverse effects.

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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

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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