The nurse reviews a list of clients and their reasons for seeking care in the emergency department. Based on the listed reason for seeking care, which client should the nurse prioritize?

A client with a "sprained ankle from playing tennis"

A client with "stomach pain after eating oatmeal"

A client with a "cough and fever for two days"

A client with a "headache and anxiety for an hour"

Answer and Explanation

The Correct Answer is D

A. A client with a "sprained ankle from playing tennis": A sprained ankle is generally a minor musculoskeletal injury and is not life-threatening. While it requires care for pain and mobility, it is lower priority compared to conditions that may indicate acute or serious illness.

B. A client with "stomach pain after eating oatmeal": Mild stomach discomfort is typically non-urgent unless accompanied by severe or alarming symptoms. This condition is lower priority compared with clients exhibiting potential acute neurological or cardiovascular issues.

C. A client with a "cough and fever for two days": While fever and cough may indicate infection, the short duration without severe distress usually does not require immediate life-saving interventions. This client is important but is less urgent than acute neurological concerns.

D. A client with a "headache and anxiety for an hour": Sudden-onset headache can signal serious conditions such as intracranial hemorrhage or stroke, particularly if accompanied by anxiety or neurological changes. This client requires immediate assessment to rule out life-threatening causes, making it the highest priority.

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Correct Answer is D

Explanation

A. Document by adding the date and time to the end of every entry: While dating and timing entries is required, it is only part of proper documentation practice. Accurate, timely recording of findings as they occur is more critical for safe care and communication.

B. Document data in a subjective manner to ensure accuracy: Subjective documentation captures the client’s reported experiences, but objective data from physical assessment should be recorded factually, without interpretation, to ensure accuracy and reliability.

C. Document information the previous nurse provided during report: Information from prior shifts is useful for continuity of care but should not replace the nurse’s own assessment. Documentation must reflect the current nurse’s direct findings and observations.

D. Document assessment findings as client care is provided: Recording findings in real-time ensures accuracy, timeliness, and completeness. It provides a reliable account of the client’s status, supports clinical decision-making, and facilitates safe, coordinated care.

A. A client with a burn on their forearm sustained from boiling water B. A client with a right ankle fracture unable to place any weight on it C. A client with severe abdominal pain who is pale and diaphoretic D. A client with a head laceration being controlled with pressure

Correct Answer is C

Explanation

A. A client with a burn on their forearm sustained from boiling water: While burns require assessment and care, a forearm burn without signs of systemic compromise is not immediately life-threatening and can wait after more urgent cases.

B. A client with a right ankle fracture unable to place any weight on it: An isolated fracture causes pain and limited mobility but is not life-threatening, making it lower priority in triage compared to clients with potential systemic compromise.

C. A client with severe abdominal pain who is pale and diaphoretic: Pallor and diaphoresis indicate possible shock or serious internal pathology. This client is at highest risk for rapid deterioration and requires immediate assessment and intervention.

D. A client with a head laceration being controlled with pressure: If bleeding is controlled and the client is stable, this is urgent but not immediately life-threatening, so the client can be assessed after those showing signs of shock or systemic compromise.

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The nurse reviews a list of clients and their reasons for seeking care in the emergency department. Based on the listed reason for seeking care, which client should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse conducts a physical assessment. What action should the nurse take when documenting a client's physical assessment?

Correct Answer is D

Explanation

The nurse is triaging a group of clients in the emergency department. Which client should be assessed first?

Correct Answer is C

Explanation

The nurse notices that a client is wearing a hearing aid and does not respond to answers promptly. Which action should the nurse take to conduct the interview?

Which is included in the general survey?

The nurse is evaluating the client's assessment within their electronic health record. For each finding, click to specify whether the assessment finding was collected as part of the health history interview or the physical exam.

A nurse is conducting several health assessments. Which action(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

A nurse is assessing the abdomen of a client by using a tapping technique over the client's skin with short, sharp strokes to assess the density of underlying structures. What assessment technique is the nurse using?

During a client interview, which is an example of an active listening technique a nurse can use to improve communication?

What assessment(s) are included in the physical appearance portion of the general survey? Select all that apply.

A nurse is preparing to collect health history data during a client's admission. Which question(s) should the nurse ask? Select all that apply.