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 B
Rationale
B. Active bleeding site is part of the ABCs of basic life support (Circulation and hemorrhage contro) and should be addressed first
A. Client maybe having an allergic reaction which is urgent but not priority
C. Client could be having a kidney stone which is not a priority
D. The client could be experiencing a heart attack which is important but not priority
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
A. Pipe cleaners are not typically used for tracheostomy care. However, tracheostomy care kits may include brushes or other cleaning devices designed for cleaning the inner cannula of the tracheostomy tube.
B. A portable oxygen tank may be necessary for a client with a tracheostomy, particularly if the tracheostomy was placed due to respiratory insufficiency or if the client needs supplemental oxygen to maintain appropriate oxygen saturation.
C. An obturator is used to insert the tube in the case of dislodgement at home.
D. Cotton balls are generally not recommended for tracheostomy care. They can leave fibers behind and may pose a risk of aspiration. They do not serve a significant purpose in the management of a tracheostomy.
B. An oxygen tan is unsafe for use at home as it increases the risk of fire.
E- Petroleum jelly is useful in the later stages when hyper granulation occurs.
Correct Answer is B
Explanation
Using a sterile pair of forceps to pack a sterile gauze maintains sterility to reduce risk of wound contamination and infection.
A. The back of the sterile gown is considered unsterile and using sterile gloves to touch it breaches sterility.
C. Any part of the sterile field that is within 1 inch from the edge is considered contaminated D. Prolonged exposure of sterile tools to airborne microorganisms can lead to contamination.
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