When evaluating clients in the urgent care center, which client should be seen first? The client:.
with a large laceration on the left scapula.
with a compound fracture of the right tibia.
who is unable to breastfeed her 4 week old.
with a labored respiratory rate of 28.
The Correct Answer is D
The client with a labored respiratory rate of 28 should be seen first because this indicates respiratory distress, which is a life-threatening condition that requires immediate intervention. Respiratory rate is one of the vital signs that are used to assess the severity of a patient’s condition and to triage them accordingly. A normal respiratory rate for an adult is 12 to 20 breaths per minute.
Choice A is wrong because a large laceration on the left scapula is not as urgent as respiratory distress.
A laceration is a wound that involves a cut or tear in the skin, which may cause bleeding, pain, and infection. However, it can be managed with wound care and suturing in the urgent care center.
Choice B is wrong because a compound fracture of the right tibia is not as urgent as respiratory distress.
A compound fracture is a fracture that breaks through the skin, which may cause bleeding, pain, infection, and nerve or blood vessel damage. However, it can be stabilized with splinting and dressing in the urgent care center before transferring to a hospital for further treatment.
Choice C is wrong because being unable to breastfeed a 4 week old is not as urgent as respiratory distress.
Breastfeeding difficulties may be caused by various factors, such as poor latch, low milk supply, sore nipples, or mastitis. However, they can be managed with education, support, and medication in the urgent care center.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is because mitt restraints can reduce the patient’s mobility and circulation in the hands, and range of motion exercises can help prevent contractures, stiffness, and edema.
Choice A is wrong because removing the mitts when the client is asleep can increase the risk of self-injury or removal of therapeutic equipment.
Choice C is wrong because tying the restraints securely around the wrists and to the bed can impair the patient’s circulation and cause nerve damage.
Choice D is wrong because placing the restraints loosely to allow increased freedom of movement can cause entanglement or strangulation.
Correct Answer is D
Explanation
“I can’t promise that the information won’t be shared if your health or safety is involved.” This response by the nurse would be appropriate because it respects the client’s confidentiality while also acknowledging its limits of it. The nurse has a duty to report any information that may indicate a risk of harm to the client or others.
Choice A is wrong because it dismisses the client’s need to share something and implies that the nurse is not interested or trustworthy.
Choice B is wrong because it gives a false assurance of confidentiality and may lead to ethical dilemmas if the client reveals something that requires reporting.
Choice C is wrong because it does not address the issue of confidentiality and may give the impression that the nurse is trying to avoid the conversation.
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