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.
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Related Questions
Correct Answer is A
Explanation
a. Cutaneous anthrax is typically treated with antibiotics, so preparing to administer antibiotics to the client is the appropriate action.
b. While respiratory protection may be necessary in certain situations, such as when dealing with airborne pathogens, anthrax exposure typically does not require an N95 respirator mask.
c. Anthrax is caused by a bacterium, not a virus, so administering an antiviral medication would not be effective in treating the infection.
d. Placing a surgical mask on the client during transfer may not be necessary unless there are specific concerns about the spread of respiratory droplets. However, the primary treatment for cutaneous anthrax is antibiotics, not respiratory precautions.
Correct Answer is C
Explanation
A. Opened bottles of normal saline should be discarded after 24 hours to prevent contamination, even if stored in a refrigerator. Keeping them longer could increase the risk of infection, making this practice unsafe.
B. Sharps containers should be disposed of when they are three-quarters full, not completely full, to prevent needlestick injuries and ensure staff safety. This is a critical safety measure, not an appropriate cost-containment strategy.
C. Using clean gloves rather than sterile gloves for colostomy care is an appropriate cost-saving measure without compromising care. Clean gloves are sufficient for this procedure and help reduce unnecessary use of sterile supplies, which are more expensive.
D. Unused supplies from the bedside should not be returned to the supply stock due to infection control protocols. Once supplies have been taken to the bedside, they are considered contaminated and should be disposed of, not reused.
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