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 with active bleeding from a puncture wound to the groin area requires immediate attention; however, the priority is determined by assessing the severity and potential complications associated with each condition.
B. A raised red skin rash could indicate an allergic reaction or infection, but it is not life-threatening compared to respiratory distress.
C. A client who reports shortness of breath and left shoulder and neck pain is the highest priority because these symptoms can indicate a serious condition, such as a myocardial infarction or pulmonary embolism. Both conditions require urgent assessment and intervention to prevent deterioration.
D. Right-sided flank pain can indicate kidney stones or other issues but is less critical than the risk of respiratory compromise present in option C.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a. While telehealth may facilitate communication between providers, its primary objective is often to assess and address the needs of clients remotely.
b. Developing client treatment protocols may be a component of telehealth, but it is not its primary objective.
c. One of the main objectives of telehealth is to assess client needs remotely, allowing for the provision of healthcare services without the need for an in-person visit.
d. Providing medication reconciliation may be a component of telehealth services, but it is not its primary objective.
Correct Answer is D
Explanation
a. A client at 37 weeks gestation with an L/S ratio of 2:1 is likely nearing term and may not require an interdisciplinary care conference solely based on this result.
b. A negative Coombs's titer at 28 weeks gestation does not typically warrant an interdisciplinary care conference.
c. A client at 39 weeks gestation with a negative contraction stress test may not require an interdisciplinary care conference unless there are other concerning factors.
d. A biophysical profile of 6 at 35 weeks gestation suggests potential fetal compromise and warrants further evaluation and discussion among interdisciplinary team members in a care conference.
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