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 of the left groin area

A client who has a raised red skin rash on his arms, neck, and face

A client who reports right-sided flank pain and is diaphoretic

A client who reports shortness of breath and left neck and shoulder pain

Answer and Explanation

The Correct Answer is D

A. A client who has active bleeding from a puncture wound of the left groin area – Although this client is at risk for significant blood loss, the immediate priority is to assess and address any potential cardiac issues in clients with respiratory distress.

B. A client who has a raised red skin rash on his arms, neck, and face: While a rash may indicate an allergic reaction or infection, it is not immediately life-threatening compared to active bleeding.
C. A client who reports right-sided flank pain and is diaphoretic: Flank pain and diaphoresis could indicate various serious conditions such as kidney stones or myocardial infarction, but active bleeding requires more immediate intervention.

D. A client who reports shortness of breath and left neck and shoulder pain – This client is experiencing symptoms that may indicate a serious cardiac event, such as a myocardial infarction or pulmonary embolism, which requires urgent evaluation and intervention. The combination of shortness of breath and pain in these areas raises the highest concern for potential life-threatening conditions.

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Correct Answer is B

Explanation

A. The client's preferred time for bathing: While this information may be relevant to the client's care, it is not typically included in a change-of-shift report unless it directly impacts the client's medical condition or care plan.
B. The time the client received his last dose of pain medication: This information is crucial for ensuring continuity of care and managing the client's pain appropriately during the transfer to the rehabilitation facility.
C. The belief that the client has a difficult relationship with his son: While psychosocial factors can impact a client's care, this information may not be relevant to the client's immediate medical needs or the transition to the rehabilitation facility.
D. The steps to follow when providing wound care: While wound care instructions are important, they are typically documented in the client's medical record and may not need to be included in a change-of-shift report unless there are specific wound care concerns that need to be addressed during the transfer.

A. Determine how current practice will affect future performance within the facility. B. Compare practices within the facility against other high-performing facilities. C. Establish work initiatives to promote a positive environment. D. Use root cause analysis to identify gaps in meeting standards.

Correct Answer is B

Explanation

A. Determine how current practice will affect future performance within the facility: While this is an important consideration for improving performance, it does not directly involve benchmarking against external standards or practices.
B. Compare practices within the facility against other high-performing facilities: This is the correct answer. Benchmarking involves comparing the organization's practices, processes, and performance metrics against those of other high-performing organizations or industry standards to identify areas for improvement and best practices.
C. Establish work initiatives to promote a positive environment: While promoting a positive work environment is important for organizational success, it is not directly related to benchmarking as control criteria.
D. Use root cause analysis to identify gaps in meeting standards: Root cause analysis is a method used to identify underlying causes of problems or failures. While it may be part of a quality improvement process, it is not specifically related to benchmarking.

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A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is B

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