A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?
A client who has active bleeding from a puncture wound to the groin area
A client who has a raised red skin rash on his arms, neck, and face
A client who reports shortness of breath and left shoulder and neck pain
A client who reports right-sided flank pain
The Correct Answer is C
A. A client who has active bleeding from a puncture wound to the groin area is urgent but not immediately life-threatening compared to a potential heart attack. Active bleeding requires immediate intervention, but this is often manageable with pressure and quick action.
B. A client who has a raised red skin rash on his arms, neck, and face could indicate an allergic reaction or infection, but it's generally not as life-threatening as signs of a myocardial infarction.
C. A client who reports shortness of breath and left shoulder and neck pain is the highest priority. These are classic signs of a myocardial infarction (heart attack), which is a life-threatening emergency. Shortness of breath and pain in the left shoulder and neck indicate a need for immediate assessment and intervention to prevent cardiac arrest or other complications.
D. A client who reports right-sided flank pain is likely experiencing kidney stones, which can cause significant pain, but it is generally not life-threatening and can be managed after a more urgent situation like a heart attack is addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) An asymmetrical thorax suggests a potential life-threatening condition such as a tension pneumothorax, which can lead to respiratory distress and requires immediate intervention.
B) While an open fracture of the femur is serious and requires medical attention, it is not immediately life-threatening if properly immobilized and the patient's vitals are stable.
C) Preorbital edema may indicate trauma to the facial area, but it is not typically considered an emergent condition unless it is affecting the airway, vision, or there are signs of a more serious underlying condition.
D) A deep-partial thickness burn on the lower extremities, although painful and requiring treatment, is not prioritized as emergent over airway, breathing, or circulation concerns.
Correct Answer is B
Explanation
a. Measuring oxygen saturation for a client with dyspnea requires clinical judgment and assessment skills typically performed by licensed nursing staff.
b. Performing nasal hygiene for a client with an NG tube is within the scope of practice for an assistive personnel (AP) and does not require advanced nursing skills.
c. Pouching a client's ostomy bag for a new colostomy requires specialized training and should be performed by licensed nursing staff.
d. Inserting a rectal suppository for a vomiting client involves administering medication and assessing the client's condition, tasks that should be performed by licensed nursing staff.
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