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When triaging emergency room clients, which client should the nurse assess first?
- A. A child who has had a cold for two days and now is coughing up green sputum.
- B. A male adolescent who has been vomiting for the past 12 hours and describes himself as very weak.
- C. A female client with severe right lower abdominal pain who is febrile and vomiting.
- D. An elderly client with peripheral vascular disease who is complaining of severe leg pain when ambulating.
Correct Answer: C
Rationale: Severe abdominal pain with fever and vomiting suggests a potentially life-threatening condition like appendicitis, requiring immediate assessment.
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The nurse obtains verbal prescriptions from the healthcare provider for an antianginal, telemetry, and STAT serum analysis for cardiac isoenzymes, after reading back the prescriptions to the healthcare provider of a client's upper gastric burning, left jaw pain, and nausea. Which intervention is most important for the nurse to implement?
- A. Initiate telemetry and assess the client's cardiac rhythm.
- B. Document description of nausea and administer the antiemetic.
- C. Submit electronic prescriptions to the pharmacy and laboratory.
- D. Obtain the client's 10-point score for radiating jaw pain.
Correct Answer: A
Rationale: Initiating telemetry addresses potential myocardial infarction, a priority given the client's symptoms.
An adult male is transferred from post anesthesia care unit (PACU) to the postoperative unit following an internal fixation of a fractured tibia and fibula that occurred during a motor vehicle collision (MVC). The nurse reports that the client received morphine 2 mg intravenously 45 minutes ago and is currently experiencing pain relief of 7 from a previous report of 10. Postoperative prescriptions include, start patient-controlled analgesia (PCA) using hydromorphone 0.2 mg on demand and 0.2 mg/hour basal rate. Which client information should the nurse provide to complete this report?
- A. Police department wants to be notified when the client is alert.
- B. Neurovascular assessments below the fracture are normal.
- C. No nausea or vomiting during the PACU recovery stay.
- D. The family is requesting a private room when one is available.
Correct Answer: B
Rationale: Normal neurovascular assessments are critical to ensure no complications post-surgery.
A male client who fell at home and experienced a brief loss of consciousness becomes increasingly confused after admission to the medical unit. The family provides the client's signed power of attorney and a home medication list. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?
- A. Client's healthcare power of attorney.
- B. Increasing confusion of the client.
- C. Currently prescribed medications.
- D. Fall at home as reason for admission.
Correct Answer: B
Rationale: Increasing confusion is the urgent situation, indicating potential neurological deterioration.
An adult woman with metastatic pancreatic cancer has requested that no heroic measures are implemented to save her life. Instructions from the healthcare provider have been received to transfer the client to a palliative care room. Which action is most important for the nurse to take?
- A. Ensure transfer of the client's electronic chart code.
- B. Give a detailed report to accepting nurse.
- C. Give client written information about end-of-life care.
- D. Take the family to the client's new room.
Correct Answer: B
Rationale: A detailed report ensures continuity of care, critical for the client's palliative needs.
The charge nurse is making client assignments in the Intensive Care Department. The healthcare team consists of one nurse with 10 years experience, one nurse with 5 years experience, and a new graduate nurse who just completed a 12-week internship. Which client should the nurse assign to the new graduate nurse?
- A. A client with chest tubes secondary to a stab wound to the chest.
- B. A client in end-stage liver failure who is experiencing esophageal bleeding.
- C. A client with multisystem failure secondary to a motor vehicle collision.
- D. A client with Adult Respiratory Distress Syndrome who is on a ventilator.
Correct Answer: A
Rationale: The client with chest tubes has a stable condition suitable for the new graduate's skills.