The nurse receives four clients in the emergency department from triage at the same time. Which client requires the nurse's immediate attention?

Client with an acute allergic reaction

Client with lung cancer reports ongoing cough

Client with dyspnea on exertion

Client with sinus infection with nasal discharge

Answer and Explanation

The Correct Answer is A

A. An acute allergic reaction, especially if involving airway compromise, can be life-threatening and requires immediate attention.

B. The client with lung cancer and a cough is concerning but not as urgent as an acute allergic reaction.

C. Dyspnea on exertion needs evaluation but is not as urgent as a possible airway issue.

D. A sinus infection with nasal discharge is typically not an emergency.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D"]

Explanation

A. Immobile patients are at high risk for developing pressure ulcers due to prolonged pressure on the skin, leading to tissue breakdown.

B. Contractures of the extremities can occur as a result of muscle atrophy and lack of movement in immobilized patients.

C. Immobility increases the risk of venous stasis, leading to the development of deep vein thrombosis (DVT).

D. Crackles in the lungs may result from immobility due to fluid accumulation or atelectasis, particularly in patients who are not moving or changing position frequently.

E. Polyuria is not commonly associated with immobility.

F. Diarrhea is not commonly associated with immobility.

Correct Answer is "{\"xRanges\":[89.96875,99.96875],\"yRanges\":[232.87109375,242.87109375]}"

Explanation

The posterior tibial pulse is typically palpated just behind the medial malleolus, which is the bony prominence on the inner side of the ankle. To locate this pulse, one should place their fingers in the groove between the medial malleolus and the Achilles tendon.

While checking the client's medication administration record, it was determined the client

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The nurse receives four clients in the emergency department from triage at the same time. Which client requires the nurse's immediate attention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse has been assigned four patients of which one of the patients is completely immobile. Which complication should the nurse expect as a result of immobility? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse? (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

Correct Answer is "{\"xRanges\":[89.96875,99.96875],\"yRanges\":[232.87109375,242.87109375]}"

Explanation

A nurse in the outpatient clinic is caring for a client with a serum calcium level of 7.5 mg/dL (8.5-10.2 mg/dL). What nursing intervention is most important when providing care for this client? (Select All That Apply).

A client is to receive enoxaparin 30 mg subcutaneously. Available is enoxaparin 40 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is assessing for cyanosis in a client who has dark skin. Which part of the body should the nurse examine to identify cyanosis in this client?

A nurse in the community clinic is providing care to a client who is anxious and hyperventilating. What should the nurse do to reduce the risk of respiratory alkalosis?

While checking the client's medication administration record, it was determined the client received the wrong medication. Which action should the nurse implement first?

During a physical examination of a client's breast, which finding would the nurse recognize as a possible indication of a malignant tumor?

The nurse is caring for a client on the neurologic medical-surgical unit who was admitted for a new onset of cerebrovascular attack. The client has a medical history of hypertension and diabetes. While conducting a neurologic assessment, how should the nurse assess the oculomotor nerve?