When triaging emergency room clients, which client should the nurse assess first?
A male adolescent who has been vomiting for the past 12 hours and describes himself as very weak.
A female client with severe right lower abdominal pain who is febrile and vomiting.
An elderly client with peripheral vascular disease who is complaining of severe leg pain when ambulating.
A child who has had a cold for two days and now is coughing up green sputum.
The Correct Answer is B
Choice A Reason: This is not the first priority because it is not a life-threatening condition. The male adolescent may have gastroenteritis or food poisoning, which can cause dehydration and electrolyte imbalance. The nurse should monitor his vital signs and fluid intake, but he can wait for further assessment.
Choice B Reason: This is the first priority because it is a potential surgical emergency. The female client may have appendicitis, which can cause peritonitis and sepsis if left untreated. The nurse should assess her pain level, vital signs, and abdominal signs, and prepare her for diagnostic tests and possible surgery.
Choice C Reason: This is not the first priority because it is a chronic condition that does not require immediate intervention. The elderly client may have intermittent claudication, which is a symptom of peripheral arterial disease. The nurse should educate him on leg care and exercise, but he can wait for further assessment.
Choice D Reason: This is not the first priority because it is a common condition that can be treated with antibiotics. The child may have a bacterial infection, such as bronchitis or pneumonia, which can cause productive cough and fever. The nurse should auscultate his lungs and check his temperature, but he can wait for further assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: Waiting until the end of the second week to see if the orientee is able to complete her assignments is not the best action for the charge nurse to take. This would delay providing feedback and support to the orientee, who may feel frustrated and discouraged by her performance. The charge nurse should intervene as soon as possible to help the orientee improve her skills and confidence.
Choice B Reason: Assigning the orientee to work with an experienced nurse who is a long-time, efficient employee is the best action for the charge nurse to take. This would provide the orientee with a role model and a mentor who can guide her through the daily tasks, share tips and tricks, and offer constructive feedback and encouragement. The orientee would benefit from learning from someone who has mastered the workflow and expectations of the unit.
Choice C Reason: Informing the supervisor that for client safety this nurse should be assigned to a slower-paced unit is not the best action for the charge nurse to take. This would imply that the orientee is incompetent and unsuitable for the unit, which may damage her self-esteem and motivation. The charge nurse should first try to help the orientee adjust to the unit and develop her competencies before considering a transfer.
Choice D Reason: Talking to the orientee and asking her if she has considered working in a less stressful environment is not the best action for the charge nurse to take. This would suggest that the charge nurse has given up on the orientee and does not believe in her potential. The charge nurse should first try to understand the challenges and needs of the orientee and provide appropriate guidance and support before suggesting alternative career options.
Correct Answer is B
Explanation
Choice A Reason: This is not the best action because it is a medication error that can be corrected and prevented by following the rights of medication administration. The nurse manager should counsel the staff nurse and provide education on safe medication practices.
Choice B Reason: This is the best action because it is a serious breach of professional ethics and standards. The nurse manager should report the staff nurse to the PRC for falsifying documentation and compromising client care.
Choice C Reason: This is not the best action because it is a mistake that can be rectified by removing the diet tray and notifying the healthcare provider. The nurse manager should reprimand the staff nurse and review the policy on NPO status.
Choice D Reason: This is not the best action because it is a minor issue that can be resolved by communicating with the charge nurse and other staff members. The nurse manager should remind the staff nurse of the importance of teamwork and collaboration.
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