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

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A reason: Asking the provider to delay the client's discharge home for a few more days is not an appropriate action for the nurse to take. This would not address the partner's concerns or the client's needs. It would also increase the risk of hospital-acquired infections and complications for the client.

Choice B reason: Seeking out another family member to assist the client's partner with care is not an appropriate action for the nurse to take. This would not respect the partner's autonomy or the client's wishes. It would also assume that there is another family member who is willing and able to provide care.

Choice C reason: Contacting a case manager to discuss hospice options is the appropriate action for the nurse to take. This would provide the client and the partner with information and support regarding end-of-life care. Hospice care focuses on improving the quality of life and comfort of clients with terminal illnesses and their families.

Choice D reason: Advising the partner to place the client in a long-term care facility is not an appropriate action for the nurse to take. This would not respect the partner's feelings or the client's preferences. It would also imply that the nurse is judging the partner's decision or ability to care for the client.

A. A client who has a compromised airway B. A client who has major burns covering 70% of their body C. A client who experienced a brief loss of consciousness D. A client who has fixed pupils

Correct Answer is A

Explanation

Choice A reason: A client who has a compromised airway is in immediate danger of death and requires urgent attention. A red tag indicates that the client has a life-threatening condition and needs the highest priority of care.

Choice B reason: A client who has major burns covering 70% of their body is in critical condition and needs intensive care. However, they are not as urgent as a client who has a compromised airway. A yellow tag indicates that the client has a serious condition and needs the second highest priority of care.

Choice C reason: A client who experienced a brief loss of consciousness may have a concussion or a head injury, but they are not in immediate danger of death. A green tag indicates that the client has a minor condition and needs the lowest priority of care.

Choice D reason: A client who has fixed pupils is likely dead or near death and has no chance of survival. A black tag indicates that the client is deceased or expectant and needs no care.

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A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?

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