A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?
A client who has a raised red skin rash on his arms, neck, and face
A client who has active bleeding from a puncture wound of the left groin area
A client who reports shortness of breath and left neck and shoulder pain
A client who reports right-sided flank pain and is diaphoretic
The Correct Answer is B
Choice A reason: A client who has a raised red skin rash on his arms, neck, and face may have an allergic reaction or a skin infection, which are not life-threatening conditions. The nurse should monitor the client for signs of anaphylaxis or systemic infection, but this client is not the highest priority.
Choice B reason: A client who has active bleeding from a puncture wound of the left groin area is the highest priority because they are at risk of hemorrhage and shock. The nurse should apply direct pressure to the wound, elevate the affected leg, and monitor the client's vital signs and hemoglobin level.
Choice C reason: A client who reports shortness of breath and left neck and shoulder pain may have a cardiac or pulmonary problem, such as angina, myocardial infarction, or pulmonary embolism, which are serious conditions. The nurse should obtain an electrocardiogram, administer oxygen, and prepare for further diagnostic tests and interventions, but this client is not the highest priority.
Choice D reason: A client who reports right-sided flank pain and is diaphoretic may have a renal or urinary problem, such as kidney stones, pyelonephritis, or renal colic, which are painful but not life-threatening conditions. The nurse should administer analgesics, encourage fluid intake, and collect a urine sample, but this client is not the highest priority.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is not the correct choice because the Good Samaritan Act is a law that protects health care providers and other individuals from legal liability when they provide emergency care to someone who is injured or ill outside of a health care facility. The act does not apply to the staff in the emergency department, who are expected to follow the standards of care and obtain consent for treatment.
Choice B reason: This is the correct choice because implied consent is a type of consent that is assumed when a client is unable to give verbal or written consent due to their condition, and the treatment is necessary to save their life or prevent further harm. The staff can proceed with emergency surgery based on implied consent, as the client is unconscious and has extensive internal injuries that require immediate intervention.
Choice C reason: This is not the correct choice because a living will is a document that expresses a client's wishes regarding their end-of-life care, such as whether they want to receive life-sustaining treatments or not. A living will does not apply to the client in this scenario, who is not terminally ill or in a persistent vegetative state, and who may recover from their injuries with surgery.
Choice D reason: This is not the correct choice because nonmaleficence is an ethical principle that means to do no harm or prevent harm to the client. Nonmaleficence does not permit the staff to proceed with emergency surgery, as it does not override the need for consent. The staff should also consider the principle of beneficence, which means to do good or promote the well-being of the client.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice because this client has the most urgent and potentially life-threatening problem. Urinary retention after spinal surgery can lead to bladder distension, infection, renal damage, or autonomic dysreflexia (a dangerous rise in blood pressure and heart rate). The nurse should assess the client's bladder, catheterize the client if indicated, and notify the surgeon.
Choice B reason: This is not the correct choice because this client has a serious but not urgent problem. Pancreatic cancer is a malignant tumor that can affect the function of the pancreas and other organs. IV chemotherapy is a treatment that uses drugs to kill cancer cells. The nurse should provide emotional support, education, and symptom management to this client, but they are not the highest priority.
Choice C reason: This is not the correct choice because this client has a chronic but not acute problem. Peripheral vascular disease is a condition that affects the blood vessels outside the heart and brain, causing reduced blood flow to the limbs. An absent pedal pulse indicates poor circulation in the foot, which can lead to pain, numbness, or tissue damage. The nurse should monitor the client's pulses, skin temperature, and color, and teach the client how to prevent complications, but they are not the highest priority.
Choice D reason: This is not the correct choice because this client has a stable but not critical problem. MRSA is a type of bacteria that is resistant to many antibiotics and can cause skin or systemic infections. An axillary temperature of 38°C (101°F) indicates a mild fever, which is a common sign of infection. The nurse should administer antibiotics as prescribed, observe the client for signs of sepsis, and follow infection control precautions, but they are not the highest priority.
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