Nokea
A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?
- A. A client who has a raised red skin rash on his arms, neck, and face
- B. A client who has active bleeding from a puncture wound of the left groin area
- C. A client who reports right-sided flank pain and is diaphoretic
- D. A client who reports shortness of breath and left neck and shoulder pain
Correct Answer: B
Rationale: The correct answer is B, a client with active bleeding from a puncture wound of the left groin area. This is the highest priority because active bleeding can lead to severe blood loss, shock, and death if not controlled promptly. Immediate intervention is needed to stop the bleeding, assess for further injuries, and ensure the client's stability. Choices A, C, and D describe concerning symptoms that require attention but do not pose immediate life-threatening risks like uncontrolled bleeding. Therefore, they are of lower priority. It is crucial for the nurse to prioritize clients based on the severity and urgency of their conditions to provide timely and appropriate care.
You may also like to solve these questions
A client scheduled for a tubal ligation procedure starts to cry as she is wheeled into the surgical suite. Which of the following nursing statements is an appropriate nursing response?
- A. It's not too late to cancel the surgery if you want to.
- B. This won't take long and it will be over before you know it.
- C. Why did you make the decision to have this procedure?
- D. You shouldn't be worried because the procedure is very safe.
Correct Answer: A
Rationale: Correct Answer: A. "It's not too late to cancel the surgery if you want to."
Rationale: This response acknowledges the client's emotions and empowers her to make a decision based on her feelings. It shows empathy and respect for her autonomy in making choices about her own body.
Summary of Other Choices:
B: This response dismisses the client's emotions and may come off as insensitive.
C: Asking why the client made the decision can be perceived as judgmental and may increase anxiety.
D: This response invalidates the client's feelings and may not provide reassurance effectively.
A nurse is teaching a newly licensed nurse about the role of nurses during a facility disaster. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
- A. A nurse should communicate with the performance improvement committee during a disaster to improve client outcomes.
- B. A nurse can recommend clients who are stable for discharge during a disaster.
- C. A unit nurse has the authority to prescribe emergency medications during a disaster.
- D. A unit nurse can provide information to the media during a disaster.
Correct Answer: B
Rationale: The correct answer is B because a nurse can recommend clients who are stable for discharge during a disaster to free up resources for more critical patients. This shows an understanding of prioritizing care and resource allocation in emergency situations. Choice A is incorrect because the performance improvement committee is not directly involved in disaster response. Choice C is incorrect because prescribing medications is outside the scope of a nurse's authority. Choice D is incorrect because providing information to the media is usually handled by designated spokespersons, not unit nurses.
A charge nurse notices that staff nurses are having difficulty using new IV infusion pumps for medication administration. Which of the following is the priority action by the charge nurse?
- A. Assess the staff nurses' knowledge deficit.
- B. Demonstrate use of the pump during medication administration.
- C. Plan an in-service education program on the unit.
- D. Pair an inexperienced nurse with an experienced nurse.
Correct Answer: A
Rationale: The correct answer is A: Assess the staff nurses' knowledge deficit. This is the priority action because it helps identify the root cause of the difficulty with the new IV infusion pumps. By assessing the staff nurses' knowledge deficit, the charge nurse can determine if additional training, education, or support is needed. This step is crucial in addressing the problem effectively and ensuring safe medication administration.
Other choices:
B: Demonstrating the use of the pump during medication administration may be helpful but should come after assessing the knowledge deficit.
C: Planning an in-service education program is important but should be based on the assessment of the staff nurses' knowledge deficit.
D: Pairing an inexperienced nurse with an experienced nurse may be beneficial but does not directly address the underlying issue of knowledge deficit.
A nurse is providing care for a client who has terminal cancer and is refusing chemotherapy. Which of the following actions should the nurse take?
- A. Request the client sign an informed consent.
- B. Encourage the client to reconsider their decision
- C. Communicate the client's decision to the provider.
- D. Provide care for the client using a sympathetic approach.
Correct Answer: C
Rationale: The correct answer is C: Communicate the client's decision to the provider. This is the most appropriate action as it ensures the client's wishes are respected while also involving the healthcare provider in the decision-making process. By communicating the client's decision, the nurse is upholding the client's autonomy and promoting patient-centered care. Option A is incorrect as the client's refusal of chemotherapy does not require informed consent. Option B is inappropriate as it undermines the client's autonomy by pressuring them to reconsider. Option D is not the best choice as it focuses on the nurse's approach rather than facilitating communication between the client and the provider.
A nurse is planning discharge for a client who has rheumatoid arthritis. Which of the following statements by the client should the nurse identify as an indication that a referral to an occupational therapist is necessary?
- A. I'm having difficulty climbing the stairs at my house.
- B. I am tired of having pain in my joints all the time.
- C. I will need assistance with bathing.
- D. I need some help planning my meals to maintain my weight.
Correct Answer: C
Rationale: Difficulty with bathing, an activity of daily living, indicates a need for occupational therapy to address functional limitations.