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: A unit nurse does not have the authority to prescribe emergency medications during a disaster, unless they have an advanced practice license and a collaborative agreement with a provider. The nurse should follow the facility's protocol and the provider's orders for administering medications.
Choice B reason: A nurse should not communicate with the performance improvement committee during a disaster, as this is not a priority at that time. The nurse should focus on providing safe and effective care to the clients and collaborating with the disaster response team.
Choice C reason: A nurse can recommend clients who are stable for discharge during a disaster, as this can help to free up beds and resources for more critical clients. The nurse should use their clinical judgment and the facility's criteria to identify the clients who are eligible for discharge.
Choice D reason: A unit nurse should not provide information to the media during a disaster, as this can violate the clients' privacy and confidentiality. The nurse should refer any media inquiries to the facility's designated spokesperson or public relations officer.
Correct Answer is D
Explanation
Choice A reason: Closing the fire doors and the doors to the room is an appropriate action, but not the first one that the nurse should take. The nurse should first activate the fire alarm to alert the fire department and the facility staff.
Choice B reason: Extinguishing the fire is an appropriate action, but not the first one that the nurse should take. The nurse should first activate the fire alarm to alert the fire department and the facility staff. Then, the nurse should use the fire extinguisher to put out the fire, following the RACE protocol (rescue, alarm, contain, extinguish).
Choice C reason: Removing clients from nearby rooms is an appropriate action, but not the first one that the nurse should take. The nurse should first activate the fire alarm to alert the fire department and the facility staff. Then, the nurse should evacuate the clients who are in immediate danger, following the RACE protocol (rescue, alarm, contain, extinguish).
Choice D reason: Activating the fire alarm is the first and most appropriate action that the nurse should take. The nurse should activate the fire alarm to alert the fire department and the facility staff. Then, the nurse should follow the RACE protocol (rescue, alarm, contain, extinguish) to protect the clients and the facility.
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