a nurse working in the emergency department is assessing several clients which of the following clients is the highest priority
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Leadership and Management HESI Quizlet

1. A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?

Correct answer: D

Rationale: The correct answer is D because shortness of breath with referred pain may indicate a serious condition, such as a cardiac event or pulmonary embolism, making this the highest priority. Option A, flank pain with diaphoresis, could suggest kidney-related issues but is not as immediately life-threatening as compromised breathing. Option B, active bleeding, though serious, can usually be controlled with proper interventions. Option C, a raised red skin rash, may indicate an allergic reaction but is not as urgent as respiratory distress with neck and shoulder pain.

2. A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should the nurse recommend for further evaluation and possible intervention?

Correct answer: C

Rationale: A biophysical profile of 6 at 35 weeks of gestation indicates a need for further evaluation and possible intervention. A negative Coombs titer at 28 weeks gestation (Choice A) is within normal limits. A negative contraction stress test at 39 weeks gestation (Choice B) is expected as the pregnancy nears term. An L/S ratio of 2:1 at 37 weeks of gestation (Choice D) is consistent with fetal lung maturity.

3. A nurse is preparing to complete an incident report regarding a medication error. Which of the following actions should the nurse plan to take?

Correct answer: B

Rationale: The correct answer is to identify the medication name and dosage administered to the client in the incident report. This information is crucial for accurate documentation and investigation of the medication error. Choice A is incorrect because incident reports are usually kept confidential and not for personal keeping. Choice C is incorrect as obtaining an order from the client's provider is not necessary to complete an incident report. Choice D, while important, is not the only essential information needed for the incident report.

4. Dr. Shrunk orders intravenous (IV) insulin for Rita, a client with a blood sugar of 563. Nurse AJ administers insulin lispro (Humalog) intravenously (IV). What does the best evaluation of the nurse reveal? Select one that does not apply.

Correct answer: C

Rationale: The best evaluation of the nurse reveals that she should have used regular insulin (Humulin R) for IV administration. Regular insulin is the only insulin approved for intravenous administration due to its pharmacokinetic properties. Insulin lispro (Humalog) is not suitable for IV use. Choice A is incorrect because giving insulin intravenously is necessary in this case of high blood sugar. Choice B is incorrect because administering a different insulin without consulting the physician is not appropriate. Choice D is incorrect because the nurse used the incorrect insulin, which could pose risks to the client's health.

5. A client diagnosed with type 1 diabetes receives insulin. He asks the nurse why he can't just take pills instead. What is the best response by the nurse?

Correct answer: B

Rationale: The correct answer is B because insulin cannot be taken orally as it gets destroyed by stomach acid. Choice A is incorrect as the speed of action is not the reason why insulin can't be in pill form. Choice C is incorrect as it doesn't address the nature of insulin. Choice D is incorrect as it doesn't provide a factual reason why insulin can't be in pill form.

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