A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?
A client who reports shortness of breath and left neck and shoulder pain
A client who has active bleeding from a puncture wound of the left groin area
A client who has a raised red skin rash on his arms, neck, and face
A client who reports right-sided flank pain and is diaphoretic
The Correct Answer is B
Choice A reason: A client who reports shortness of breath and left neck and shoulder pain may have a cardiac problem, which is a serious condition. However, this client is not the highest priority, as the symptoms are not life-threatening at the moment.
Choice B reason: A client who has active bleeding from a puncture wound of the left groin area is the highest priority, as this client is at risk of hemorrhage, shock, and infection. The nurse should apply direct pressure to the wound, elevate the leg, and monitor the vital signs.
Choice C reason: A client who has a raised red skin rash on his arms, neck, and face may have an allergic reaction, which is a potential emergency. However, this client is not the highest priority, as the symptoms are not severe enough to indicate anaphylaxis.
Choice D reason: A client who reports right-sided flank pain and is diaphoretic may have a kidney stone, which is a painful condition. However, this client is not the highest priority, as the symptoms are not life-threatening unless there is an obstruction or infection.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Documenting the concern in the nurse's notes is not an appropriate action. The nurse's notes are for recording the client's condition and the care provided, not for expressing the nurse's personal issues. This action does not address the problem or ensure the safety of the clients.
Choice B reason: Requesting help from the personnel on the unit is a good action, but not the best one. The nurse should seek assistance and guidance from experienced staff members, but they should also communicate their concern to the nurse manager, who is responsible for making appropriate assignments and providing support and resources.
Choice C reason: Contacting the nurse manager to discuss the situation is the best action. The nurse manager can evaluate the nurse's competency and experience level, and adjust the assignment accordingly. The nurse manager can also provide feedback, education, and supervision to the nurse to enhance their skills and confidence.
Choice D reason: Refusing to accept the assignment is not an appropriate action. The nurse has a professional and ethical obligation to provide care to the clients, unless there is a clear conflict of interest or violation of standards. The nurse should not abandon the clients or the unit without a valid reason.
Correct Answer is A
Explanation
Choice A reason: The risk of suicide is the highest priority for the charge nurse to assess. The client has several risk factors for suicide, such as major depressive disorder, medication noncompliance, hopelessness, social isolation, and psychomotor retardation. The charge nurse should evaluate the client's suicidal ideation, intent, and plan, and implement safety measures as needed.
Choice B reason: The risk of dehydration is a lower priority than the risk of suicide. The client may be dehydrated due to decreased fluid intake, but this is not a life-threatening condition. The charge nurse should monitor the client's hydration status and encourage oral fluids as appropriate.
Choice C reason: The risk of infection is a lower priority than the risk of suicide. The client does not have any signs or symptoms of infection, such as fever, chills, or leukocytosis. The charge nurse should assess the client's vital signs and laboratory results as indicated, but this is not an urgent issue.
Choice D reason: The risk of seizure is a lower priority than the risk of suicide. The client does not have any history or risk factors for seizure, such as epilepsy, head trauma, or drug withdrawal. The charge nurse should observe the client for any abnormal movements or behaviors, but this is not a likely complication.
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