The nurse cares for a group of clients in the emergency department. Which client should the nurse see first?

A client with dementia who refuses to have the pulse oximeter on their finger.

A client with a blood pressure of 138/86 mmHg who is experiencing acute pain.

A client with delirium who is confused and has a temperature of 101.8 F (38.8 C).

A client with a heart rate of 112 who is experiencing elevated levels of anxiety.

Answer and Explanation

The Correct Answer is C

A. A client with dementia who refuses to have the pulse oximeter on their finger: While monitoring oxygen saturation is important, the client is currently stable and not showing signs of acute distress. This situation can be addressed after more urgent needs are met. Refusal does not immediately threaten life or safety.

B. A client with a blood pressure of 138/86 mmHg who is experiencing acute pain: Mildly elevated blood pressure is expected with pain and is not immediately life-threatening. Pain management is important but does not take priority over a potential infection or acute physiologic instability.

C. A client with delirium who is confused and has a temperature of 101.8 F (38.8 C): Fever in a delirious client may indicate infection or sepsis, which can rapidly deteriorate. Delirium combined with hyperthermia signals acute physiologic compromise requiring immediate assessment and intervention. This client has the highest priority.

D. A client with a heart rate of 112 who is experiencing elevated levels of anxiety: Mild tachycardia associated with anxiety is usually self-limiting and not immediately life-threatening. Anxiety can be managed after addressing clients with potential systemic compromise.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Perform exercises until you feel pain in the joint: Active ROM exercises should not cause pain, as pain can indicate joint injury, inflammation, or overextension. Exercising into pain may worsen tissue damage and reduce adherence. Discomfort signals the need to stop or modify movement.

B. Move each joint until there is resistance and then stop: Active ROM exercises are performed to the point of resistance, which reflects the joint’s normal anatomic limit. This maintains joint flexibility, circulation, and muscle function without stressing ligaments or joint capsules. Stopping at resistance helps prevent injury.

C. Expose the entire body to observe overall movement: Only the joint being exercised needs to be exposed to preserve client comfort and dignity. Full-body exposure is unnecessary for ROM instruction. Observation can be effectively performed one joint at a time.

D. Perform exercises rapidly to increase muscle strength: Rapid movements increase the risk of joint strain and muscle injury, especially in clients with limited mobility. Active ROM focuses on maintaining flexibility and joint motion rather than building strength. Movements should be slow, controlled, and deliberate.

A. Sit the client up in High Fowler's B. Call the rapid response team C. Monitor respiratory rate and depth D. Prepare for possible intubation

Correct Answer is B

Explanation

A. Sit the client up in High Fowler's: Elevating the head of the bed can improve lung expansion and oxygenation, but it does not immediately address the critically low respiratory rate and oxygen saturation. This action is supportive but not the highest priority.

B. Call the rapid response team: A respiratory rate of 6 breaths per minute and oxygen saturation of 71% indicate severe hypoxemia and impending respiratory failure. Immediate activation of the rapid response team ensures rapid, coordinated intervention to prevent cardiac or neurologic compromise. Life-threatening instability requires prompt action.

C. Monitor respiratory rate and depth: Ongoing assessment is important, but monitoring alone does not intervene in a life-threatening situation. The client’s condition is critical, and delaying active intervention could result in deterioration. Assessment must be accompanied by emergency response.

D. Prepare for possible intubation: Preparation for intubation is appropriate, but initiating the rapid response team first ensures timely support, equipment, and personnel are available. Immediate coordination is required before advanced procedures.

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The nurse cares for a group of clients in the emergency department. Which client should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning client education about active range of motion (ROM) exercises. Which instruction should the nurse plan to include in the teaching?

Correct Answer is B

Explanation

A nurse cares for a client with a respiratory rate of 6 breaths per minute and an oxygen saturation of 71% What action should the nurse take first?

Correct Answer is B

Explanation

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