An emergency department nurse triages clients who present with chest discomfort. Which client would the nurse plan to assess first?

Client who describes intense squeezing pressure across the chest.

Client who reports moderate pain that is worse on inspiration.

Client who reports cramping substernal pain.

Client who describes pain as a dull ache.

Answer and Explanation

The Correct Answer is A

A. This description is indicative of possible myocardial infarction (MI), a life-threatening emergency. Immediate evaluation and intervention, such as administering oxygen, obtaining an EKG, and providing pain relief, are crucial to prevent further damage to the heart and reduce mortality.

B. Moderate pain worse on inspiration suggests pleuritic pain, often associated with conditions like pleuritis or pulmonary embolism, which are serious but generally not as immediately life-threatening as an MI.

C. Cramping substernal pain may indicate a gastrointestinal issue, such as gastroesophageal reflux disease (GERD), which is less urgent than a potential MI.

D. A dull ache may be related to musculoskeletal or gastrointestinal issues and does not suggest the immediate need for intervention seen in MI.

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Correct Answer is B

Explanation

A. Bleeding precautions are not required as the issue pertains to neutropenia, not thrombocytopenia.

B. Placing the client in a private room is appropriate as the ANC calculation (WBC × [% neutrophils]) indicates severe neutropenia, increasing the risk of infection.

C. Simply documenting findings does not address the client’s increased infection risk.

D. Blood cultures and antibiotics may be needed later but require additional signs of infection to proceed.

A. Client with a blood pressure of 90/50 mm Hg. B. Client with a temperature of 96° F (35.6° C). C. Client with a pulse of 118 beats/min. D. Client with a respiratory rate of 6 breaths/min.

Correct Answer is D

Explanation

A. A blood pressure of 90/50 mm Hg is concerning, but it is less urgent than severe respiratory depression. The nurse should still assess this client promptly.

B. A temperature of 96° F (35.6° C) is mildly low and should be addressed, but it is not as critical as a severely low respiratory rate.

C. A pulse of 118 beats/min is elevated and may require monitoring, but it does not pose as immediate a threat as respiratory depression.

D. A respiratory rate of 6 breaths/min is critically low, which may indicate respiratory depression, particularly after anesthesia. Immediate assessment and intervention are needed to ensure adequate oxygenation and ventilation.

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An emergency department nurse triages clients who present with chest discomfort. Which client would the nurse plan to assess first?

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Naxlex Comprehensive Predictor Exams

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