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 right-sided flank pain and is diaphoretic
A client who reports shortness of breath and left neck and shoulder pain
The Correct Answer is A
A. The client with active bleeding from a puncture wound in the groin is the highest priority because of the risk of severe blood loss, which can lead to hypovolemic shock. The nurse should quickly apply pressure to the wound, assess the extent of the bleeding, and prepare for emergency interventions.
B Active bleeding is part of crculation in the ABCs that comes after airway and breathing
C. Client could be having a kidney stone which is not a priority
D. These symptoms could indicate a pulmonary embolism or heart attack, but they may not be as immediately life-threatening as active bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
decreased level of consciousness indicate that the inflammatory process is spreading to the brain with increasing intracranial pressure. This may lead to herniation which is life threatening.
B. Photophobia is a normal feature of meningitis
C. Increased temperature is expected due to the infectious process
D. Generalized rash over the trunk is a common sign due to some causative organisms
Correct Answer is D
Explanation
The client with slurred speech and confusion could be experiencing a stroke. Recognition of a stroke is an emergency as some forms of stroke requires immediate intervention that is only amenable within a specific time period.
A. A closed femur fracture may have bleeding and other neurovascular damage but this is not as life threatening as a stroke
B. Superficial burns of 10% is likely to have severe pain. The extent of dehydration is minimal
C. Severe vomiting and diarrhea with tachycardia is a sign that the body is compensating for the fluid loss at this point and, therefore, not of highest priority.
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