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. Assault: Assault is the threat of harm to another individual, such as threatening to administer the injection against the client's will. However, since the nurse actually administers the injection, it does not constitute assault.
b. Libel: Libel refers to a false statement that is written and published, which is not relevant in this scenario.
c. Battery: Battery involves the unauthorized or harmful physical contact with another individual, such as administering the injection without the client's consent.
d. False imprisonment: False imprisonment occurs when an individual is unlawfully restrained or confined. While the client's movement may be restricted by administering the injection, the primary issue here is the unauthorized physical contact, making battery the more appropriate choice.
Correct Answer is A
Explanation
a. Postoperative care, especially for a client with a PCA pump (Patient-Controlled Analgesia), requires skills commonly found in medical-surgical units, making it suitable for an RN with experience in that area.
b. Managing preeclampsia and labor induction involves obstetric-specific knowledge and skills, which are better suited for a nurse with experience in obstetrics.
c. Gestational diabetes management and nonstress tests are part of routine obstetrical care and do not necessarily require specialized medical-surgical skills.
d. A client with premature rupture of membranes at 32 weeks gestation requires close monitoring and potentially specialized obstetric care, not typically provided by medical-surgical nurses.
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