which client should be seen by the emergency department nurse first
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Nursing Elites

NCLEX-PN

NCLEX Question of The Day

1. Which client should be seen first by the Emergency Department nurse?

Correct answer: C

Rationale: The priority in the emergency department is to assess and manage clients based on the severity of their condition. In this scenario, the three-year-old with wheezes in the right lower lobe should be seen first because respiratory distress takes precedence over other conditions. Wheezing indicates potential airway compromise, which requires immediate attention to ensure adequate oxygenation. The other options are important but do not pose an immediate threat to the client's airway and breathing. A femur fracture, fever, or a dislodged gastrostomy tube can be addressed after ensuring the child with respiratory distress is stable.

2. When dressing a severe burn to the right hand, it is important for the nurse to:

Correct answer: B

Rationale: When dressing a severe burn to the hand, it is crucial to wrap each digit individually to prevent webbing, which can lead to contractures and impaired function. Applying a wet-to-dry dressing for debridement is not recommended for burn wounds as it can cause trauma to the wound bed during removal. Opening blisters can increase the risk of infection and delay healing. Allowing the client to perform the dressing change may not ensure proper care and can lead to complications.

3. The nurse is obtaining a health assessment from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the physician?

Correct answer: B

Rationale: The most important statement for the nurse to report to the physician is that the client had rheumatic fever when they were 10 years old. This information is crucial as individuals who have had rheumatic fever require pre-medication with antibiotics before any surgical or dental procedure to prevent bacterial endocarditis. Reporting this history ensures the client's safety during the hip replacement surgery. The other options, such as having chickenpox in the past, a family history of gastric cancer, or experiencing hip pain, are important for the client's overall health assessment but do not have the same immediate implications for the upcoming surgery as the history of rheumatic fever.

4. For which adverse effect of the block does the postpartum nurse monitor the woman after receiving a subarachnoid (spinal) block for a cesarean delivery?

Correct answer: A

Rationale: The correct answer is 'Headache.' Postdural headache is a common adverse effect associated with a subarachnoid block due to cerebrospinal fluid leakage at the site of dural puncture. This headache worsens when the woman is upright and may improve when she lies flat. To manage this headache, bed rest and adequate hydration are recommended. Pruritus, vomiting, and hypertension are not typically associated with subarachnoid blocks. Pruritus, nausea, and vomiting are more commonly linked to the use of intrathecal opioids.

5. While assessing a patient who has undergone a recent CABG, the nurse notices a mole with irregular edges and a bluish color. What should the nurse do next?

Correct answer: C

Rationale: In this scenario, the nurse should note the location of the mole and follow up with the attending physician through the medical record and a phone call. This action is appropriate because a mole with irregular edges and a bluish color raises concern for melanoma, a type of skin cancer. Recommending a dermatological consult (Choice A) might delay the evaluation and management of the mole. Contacting the physician via telephone (Choice B) may not provide a documented record of the observation. Removing the mole without proper evaluation (Choice D) could be dangerous and is not within the nurse's scope of practice.

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The test used to differentiate sickle cell trait from sickle cell disease is:
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