Nclex Cris Question and answers rated A+ The home care nurse visits a client in a large apartment complex. During the visit, the area experiences a major earthquake. Which of the following clients should the nurse see FIRST?
1. A restless client with a rigid abdomen and absent bowel sounds.
2...
Nclex Cris-3-30
The home care nurse visits a client in a large apartment complex. During the
visit, the area experiences a major earthquake. Which of the following clients
should the nurse see FIRST?
1. A restless client with a rigid abdomen and absent bowel sounds.
2. An unconscious client with left-sided tracheal shift from midline.
3. A client complaining of excruciating pain with an obvious deformity of the
left leg.
4. A client clutching her chest and complaining of severe chest pain - correct
answer ✔Strategy: Determine the most unstable client.
(1) likely has injuries to abdominal organs, resulting in hemorrhage and
severe circulatory compromise and requires emergent evaluation; airway and
breathing take priority
(2) CORRECT—first sign of a tension pneumothorax; airway and breathing
take priority
(3) assess for neurovascular compromise; client with breathing difficulties
takes priority
(4) circulatory problem; airway/breathing problems take priority
The nurse cares for clients in the outpatient clinic. The nurse returns to the
desk to find four phone messages. Which of the following messages should
the nurse respond to FIRST?
, 1. The mother of a 15-year-old reports her son is threatening to jump off a
bridge and has access to a gun.
2. A 20-year-old female reports she has lost 2 lb this week and eats only two
meals a day.
3. A 45-year-old male with a history of depression who is out of Prozac.
4. A 75-year-old male complains of insomnia and irritability after the death of
his wife. - correct answer ✔Strategy: Determine the most unstable client.
(1) CORRECT— using Maslow Hierarchy of Needs theory to prioritize,
physiological issues take priority over psychological issues; patient is at risk
for self harm and must be seen first; observe for safety
(2) does not require immediate attention
(3) does not require immediate attention
(4) may be a normal part of grieving; nurse should assess but is not the
priority
The nurse receives report on the medical/surgical unit. Which of the following
clients should the nurse see FIRST?
1. A client with an IV of normal saline infusing at 125 ml per hour complaining
of slight swelling at the IV insertion site.
2. A client 3 days post right knee replacement complaining of right calf pain
with movement.
3. A client with a respiratory rate of 24 and an oxygen saturation of 94% on
room air.
4. A client 12 hours after a hysterectomy complaining of nausea. - correct
answer ✔Strategy: Determine the most unstable client.
, (1) assess site for client's comfort and to prevent complications associated
with IV infusion, probable DVT takes priority
(2) CORRECT—assessment for possible DVT should be performed and
reported to the physician immediately
(3) respiratory status is stable at present
(4) administer antiemetics; client with calf pain takes priority
The triage nurse at an urgent care center notes that four clients have signed
in, each complaining of a sore throat. Which of the following clients should the
nurse see FIRST?
1. A 7-year-old whose sibling was recently treated for "strep throat."
2. A 10-year-old with a history of chronic allergies.
3. A 21-year-old with a history of chronic sinus infections.
4. A 55-year-old receiving 5-fluorouracil (5-FU). - correct answer ✔Strategy:
Determine the most unstable client.
(1) child has likely contracted strep from his sibling; treatment should begin as
soon as possible; does not take priority
(2) likely experiencing irritation as a result of sinus drainage; does not take
priority
(3) likely experiencing irritation as a result of sinus drainage; does not take
priority
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